【作者】 赵伟；

【导师】 黄烽；

【作者基本信息】 中国人民解放军军医进修学院 ， 内科学， 2003， 博士

【摘要】 目的： 本研究拟通过检测RANKL、OPG和CD68蛋白在强直性脊柱炎(AS)外周关节滑膜组织中的表达，并以类风湿关节炎(RA)、骨关节炎(OA)患者和健康对照者的外周关节滑膜组织为对照，了解细胞核因子кB受体活化因子配基(RANKL)、护骨素(OPG)和代表单核/巨噬细胞标记的CD68蛋白表达与AS患者炎性关节病理改变及疾病活动性的相关性，试图从炎性关节局部RANKL/OPG平衡调节这一角度进一步探讨AS关节炎症及骨质破坏的发病机制，为AS病情评判与治疗提供理论基础。 方法： 应用单克隆抗体，通过免疫组织化学方法检测13例AS、16例RA、17例OA及6例健康对照关节滑膜组织中RANKL、OPG、CD68蛋白表达及分布状况；鉴于抗酒石酸酸性磷酸酶(TRAP)是破骨细胞或前体细胞的一种标志酶，本研究还采用酶组织化学法分析各组滑膜组织TRAP染色阳性细胞表达及分布状况，通过计算机辅助图象分析系统和半定量分析方法确定RANKL、OPG、CD68以及TRAP在各滑膜组织中表达量之间的差异，分析各因子表达与炎性指标及关节X线分期之间的相关性。 结果： (1)OPG蛋白在所有13例AS滑膜组织中均有阳性表达，阳性细胞主要分布于滑膜衬里层、衬里下层区域，滑膜软骨交界区OPG表达明显低于滑膜衬里层和衬里下层；2例健康对照滑膜组织中有 军医进修学院博土学位论文RANKL10pe在牙直性脊柱 周关节骨质玻坏痛理机删中的作用 阳性表达，但明显低于AS患者组。RA及OA患者组未见OPG阳 性表达。 （2）AS患者组滑膜组织RANKL表达水平明显升高，阳性细胞 主要见于滑膜组织衬甩层和滑膜软骨交界区。AS 患者组RANKI。 蛋白与RA患者组无明显差异刀A患者组和健康对照组滑膜织织中 未见阳性表达信号。 （3）AS和 RA滑膜组织中 RANKL表达量与关节 X线分州呈小 十 关（十 关系数 r分别为 0．7 3，0．41，P值分别为 0．0 0 3，0．0 ZI）。 （4）CD68蛋白在各组滑膜组织中滑膜细胞中均有表达，主要 表达于滑膜衬里层，AS及RA 患者组滑膜组织中表达强度显著高 于OA和健康对照组。 （5）TRAP染色结果表明，RANKL丰富表达的 AS和 RA i A· 滑膜组织中，TRAP 染色阳性细胞数量增加，AS 患者组滑腴组织 TRAP 阳性细胞百分数显著低于RA 组。在滑膜－软骨交界区域， ＊＊＊P着色强度明显增加，＊A及正常对照组滑膜中 ＊＊AP阳忖细 胞少见。 （6）RA组RANKL表达与滑膜组织中的TRAP阳性细胞百分 数呈正相关（十关系数r—0．442，P＝0．043）。 结论： （l）AS患者组滑膜组织中OPG表达水平明显高于健康对照组 （P＜0刀01），而＊A、＊A滑膜组织中未见＊PG表达，说明＊PG的 高水平表达是滑膜组织对炎症反应／关节破坏所特有的表现，OPG 的局部表达是维持AS关节骨代谢稳定的重要因素，这可能是大多 数AS患者外周关节受累预后好于RA的原因之一。 （2）AS患者组滑膜软骨交界区中OPG表达量显著减少可能是 4军医进修学院博士学位论文RANKL10PG在羹盅性存柱 周关节骨质玻坏病 制中的作用导致关节骨质破坏的重要原因，提示关节局部应用 O P G治疗有 l。J能改善受累关节的骨质破坏状况。 （3）AS患者组受累关节滑膜组织中RANKL表达量明显Ifti十木出现关节破坏的AS患者，其表达量与关节骨质破坏程度密切川关，说明RANKL在AS患者骨质破坏病理机制中起重要作用，AS思K滑膜组织中RANKL表达模式与RA相似，提示AS思者骨质破坏的病理机制可能与RA类似。 （4） 炎性关节滑膜组织CD68阳性细胞及TRAP阳性细胞数＿量增加为破骨细胞的生成提供了细胞数量基础，这些均是RANKL过度表达的结果。RANKL 表达与骨质破坏的密切相关提示抑制RANKL活性就可能有效阻断破骨细胞前体细胞向破骨细胞的转化，达到对炎性关节疾病的骨质破坏的治疗。更多还原

【Abstract】 OBJECTIVESTo detect the RANKL, OPG and CD68 protein levels in synovial tissues from ankylosing spondylitis(AS ) patients and compare the expression levels of RANKL, OPG and CD68 protein in AS , rheumatoid arthritis(RA), and osteoarthritis(OA) and normal synovial tissues. RANKL/OPG expressions were correlated with pathological changes of inflammatory joints to explore the role of RANKL / OPG in the pathogenesis of bone destruction in AS. METHODSImmunohistochemical analysis was performed using monoclonal antibodies to detect RANKL, OPG and CD68 protein expression in 13 AS, 16 RA,17 OA patients and 6 healthy controls. The presence of TRAP positive cells in the synovial tissues of patients with AS and RA was examined by enzyme histochemistry. The labeled synovial tissue sections were quantified by digital image analysis and semiquantitative analysis to compare the expression of RANKL, OPG, CD68 and TRAP positve cells in different patient groups and normal subjects. In addition, RANKL expression and OPG expression were correlated with certain inflammatory indices (including ESR, CRP, blood platelet count) and radiological stage of involved joints respectively. RESULTS(1) Positive staining of OPG was seen in all 13 AS patients. OPG expression was predominantly seen in the synovial lining layer and subling areas. Positive staining of OPG was also found in the synovial tissues of 2 normal subjects, but the OPG levels were significantly lower. No positive staining of OPG was found in synovial tissues from all patients with RA and OA.(2) Positive staining of RANKL was seen respectively in all 13 AS patients and 16 patients with RA, and positive expression was distributed predominantly in the synovial lining layer and at synovium-cartilage junctions. There was no significant difference between levels of RANKL expression in tissues from patients with AS and in tissues from RA. No positive staining of RANKL was observed in 6 normal subjects and all OA patients.(3) Positive correlation was found between RANKL protein expression and X-ray stage of involved joints destruction of patients with AS and RA (r=0.73,0.41, P=0.003,0.021 respectively).(4) Positive staining of CD68 was seen in synovial tissues from all the patients with AS, RA, OA and normal subjects, and the expression levels of CD68 from patients with AS and RA were higher than those from OA patients and healthy subjects. The CD68 positive cells were abundant mainly in lining layer.(5) In areas where elevated RANKL expression levels were present, the number of TRAP positive staining cells were found significantly increased in AS and RA synovium. The percentage of TRAP positive cells in synovium from AS patients was significantly lower than that from RA patients. The intensity of TRAP staining at synovium-cartilage junctions was notably increased. TRAP positive cells were rarely observed in synovium from OA patients and normal controls.(6) There was positive correlation between the number of TRAP positive cells and the RANKL expression (r=0.442, P-0.043) in RA patients. CONCLUSIONS(1) Higher levels of OPG were expressed in synovial tissues from AS patients than in tissues from normal subjects (P<0.001). No OPG was found in synovial tissues from patients with RA and OA, suggesting that OPG expression may be the consequenceof synoviocytes’ reaction to inflammation and that OPG may have a protective effect on bone integrity. This serves a possible explanation for the better prognosis of the peripheral joint involvement in AS patients in comparison with RA patients.(2) Decrease in OPG levels at synovium-cartilage junctions is likely to be the main cause of bone destruction in AS patients. OPG may well have a therapeutic role in preventing bone destruction in AS.(3) Higher levels of RANKL were expressed in synovial tissues from AS patients with bone destruction than in tissues from subjects with healthy joints. RANKL protein expression was closely related with the degree of bone destruction, suggesting that it play a role in更多还原