【作者】 金永堂；

【导师】 张学军； 杨森；

【作者基本信息】 安徽医科大学 ， 皮肤性病学， 2008， 博士

【摘要】 第一部分HLA-Cw6及其亲代单倍型与寻常型银屑病的关系背景银屑病具有复杂的遗传背景,与多个遗传易感位点和多个基因相关。不同人群的多个研究反复证实HLA-Cw6是寻常型银屑病发病的主要危险因子。而且HLA-Cw6相关的单倍型,尤其是HLA-I类基因相关的单倍型,对寻常型银屑病的影响,引起了人们高度关注。但研究报道很少,结果也不完全一致。几个国内外研究相继比较了HLA-Cw6携带者与非携带者银屑病临床特征的差异,然而,寻常型银屑病患者遗传异质性对临床异质性的影响至今尚不清楚。目的分析我国汉人HLA-Cw6、HLA-B57和HLA-B13对寻常型银屑病的影响,以及HLA-Cw6-B57与HLA-Cw6-B13两单倍型与寻常型银屑病发病的关系;比较HLA-Cw6携带者与非携带者间、HLA-Cw6-B57与HLA-Cw6-B13两单倍型间寻常型银屑病临床临床特征的差异;探讨寻常型银屑病患者遗传异质性对临床异质性的影响。方法临床皮肤病学、遗传流行病学和分子遗传学相结合。采用单纯病例研究和病例-对照研究方法确定研究对象、开展流行病学问卷调查、收集血液样本并用改良盐析法提取DNA、运用序列特异引物PCR方法(polymerase chain reactionsequence specific primer,PCR-SSP)进行基因检测。利用EPI和SAS程序软件分别对资料进行处理与分析;通过分层分析和Logistic回归分析估算相对危险度(odds ratio,OR)及95%可信限。结果分析结果显示:①HLA-Cw6和HLA-B57等位基因分别使银屑病的危险性增加6.44倍和2.43倍(p值均＜0.01);HLA-Cw6对女性银屑病的影响较大(OR,7.45vs 5.73,p值均＜0.01)而HLA-B57对男性的影响较大(OR,3.07 vs 2.00,p值均＜0.01)。而且前者对早发型银屑病的影响明显大于迟发型银屑病(OR,7.16 vs5.12,p值均＜0.01)。未见HLA-B13对寻常型银屑病的显著影响。②HLA-Cw6分别与HLA-B57和HLA-B13间均存在显著的连锁不平衡,HLA—Cw6-B57和HLA-Cw6-B13均是寻常型银屑病的危险单倍型,相对危险度(OR)分别为6.84和3.17(p值均＜0.01)。HLA-Cw6-B57对男性银屑病的影响较大(8.85 vs 5.71,p＜0.01),HLA-Cw6-B13对女性的影响较大(3.54 vs 2.89,p＜0.01)。两单倍型对早发型银屑病的影响均大于迟发型银屑病。③HLA-Cw6携带者与非携带者相比,除了女性寻常型银屑病发病年龄均显著早于男性之外(p值均＜0.05),HLA-Cw6携带者寻常型银屑病呈现早发、更广泛、更严重、冬季发病更多的趋势,但差异无统计学显著意义。HLA-Cw6-B57与HLA-Cw6-B57两单倍型相比,未见明显的寻常型银屑病的临床特征差异。结论(1)HLA-Cw6和HLA-B57等位基因是寻常型银屑病的危险基因,但未见HLA-B13对寻常型银屑病的显著影响。(2)HLA-Cw6分别与HLA-B57和HLA-B13间均存在显著的连锁不平衡且HLA-Cw6-B57和HLA-Cw6-B13均是寻常型银屑病的危险单倍型,均使银屑病的危险性显著增加。(3)HLA-Cw6携带者寻常型银屑病呈现早发、更广泛、更严重、冬季发病更多的趋势,而HLA-Cw6-B57与HLA-Cw6-B57两单倍型者未见明显的寻常型银屑病的临床特征差异。第二部分HLA-Ow6与体内外环境因素对寻常型银屑病的交互影响背景寻常型银屑病是常见的慢性炎症性皮肤病,是多种环境与遗传因素共同作用的结果。大量研究表明HLA-Cw6等位基因、吸烟、精神紧张等与寻常型银屑病密切相关。近期的研究还表明腰臀比(Waist hip ratio,WHR)和体质指数(bodymass index,BMI)也可能增加寻常型银屑病的危险性。但是,HLA-Cw6与环境因素间交互作用是认识银屑病病因机制的关键问题之一,目前尚不清楚。目的在前期大量研究的基础上,本研究将着重分析HLA-Cw6分别与BMI、WHR和吸烟之间交互作用对寻常型银屑病发病的影响,为从预防医学和临床医学角度深入认识银屑病的病因及发病机制,提供科学依据。方法采用医院为基础的病例-对照研究方法,对466例寻常型银屑病病例与178例对照的资料进行成组1:1病例对照分析。在此基础上,利用178对病例与对照的资料分析吸烟与HLA-Cw6间的交互作用。利用非条件Logistic回归模型对所有资料进行资料处理与分析,估算OR(odds ratio,OR)和95%CI(confidenceintervals)。结果研究结果表明,BMI和WHR与寻常型银屑病间存在正相关关系。与WHR为0.80及0.80以下者相比,WHR为0.80-0.85者银屑病的OR值是2.36(p＜0.01),而WHR为0.85以上者的OR值为2.74(p＜0.01)。BMI为20-25和25以上者患银屑病的危险性,分别是BMI为20或者20以下者的1.20倍(p＞0.05)和1.84倍(p＜0.01)。466病例与178对照分析结果显示HLA-Cw6携带者患银屑病的危险性是非携带者的8.33倍(p＜0.01),而且,携带HLA-Cw6的超重者(BMI＞25)是非携带HLA-Cw6体重正常者的近35倍(p＜0.01)。与WHR为0.80及0.80以下的HLA-Cw6非携带者相比,WHR为0.80以上的HLA-Cw6携带者的OR值为17.24,具有高度显著性统计学意义(p＜0.01)。此外,显示了HLA-Cw6与BMI、WHR间在寻常型银屑病发病过程中的交互作用。1:1成组病例-对照研究结果显示,吸烟者患寻常型银屑病的危险性是不吸烟者的2.07倍(p＜0.01),并且吸烟量及吸烟时间与银屑病间存在剂量-反应关系。同时还表明精神紧张与WHR增加银屑病的危险性。调整了潜在混杂因素后,HLA-Cw6携带者增加患寻常型银屑病的危险性,是非携带者的9.93倍(p＜0.01),而HLA-B57携带者患银屑病的OR值为2.41(p＜0.05)。而且还发现HLA-Cw6与HLA-B57在银屑病发病过程中存在交互作用(OR=10.51,p＜0.01)。很明显,携带HLA-Cw6的吸烟者的危险性是非携带HLA-Cw6的非吸烟者的11倍,具有显著性统计学意义(p＜0.01),同时表明了两者在银屑病发病过程中的交互作用。结论HLA-Cw6、吸烟、BMI和WHR均是寻常型银屑病的危险因素,并且在寻常型银屑病发病过程中HLA-Cw6分别与BMI、WHR间呈现出交互作用,而且HLA-Cw6与吸烟间的交互作用在寻常型银屑病发病过程中可能发挥了重要作用。更多还原

【Abstract】 PartⅠ:The Association of HLA-Cw6 and Related Haplotypes with Psoriasis VulgarisBackground Psoriasis is a disease based on complex genetic background and is related to many susceptible locus and genes.The results from various populations verified that HLA-Cw6 is a major risk factor in psoriasis vulgaris.Further,the haplotypes related to HLA-Cw6,specially in HLA-I gene,may also play an important role in psoriasis vulgaris,which was hardly studied.Although several researches suggested the differences of clinic features between HLA-Cw6~+ and HLA-Cw6~- cases,it is completely unclear that effect of the genetic heterogeneity on clinic heterogeneity in psoriasis vulgaris. Objective To explore the effects of HLA-Cw6,HLA-B57 and HLA-B13 on psoriasis vulgaris and the relationship of HLA-Cw6-B57 and HLA-Cw6-B13 haplotypes with psoriasis vulgaris;To compare various clinic features between HLA-Cw6 and HLA-Cw6,HLA-Cw6-B57 and HLA-Cw6-B13 haplotype,presenting the effects of the genetic heterogeneity on clinic heterogeneity in psoriasis vulgaris.Methods With only-case study and tradition case-control study,the case and control were selected and the collected data including questionnaires,and sample of peripheral venous blood from which the DNA was extracted by improved method.The genes were tested and typed by PCR-SSP method(polymerase chain reaction sequence specific primer,PCR-SSP).To explore role of HLA-Cw6,HLA-Cw6-B57 and HLA-Cw6-B13 haplotype in the development of psoriasis,the relationship between psoriasis and each factor was assessed in contingency tables,with T-test or X~2-test used to determine statistical significance.Mantel-Haenszel test for homogeneity was used to compute odds ratios(OR) and 95%confidence intervals(CI) for psoriasis after stratification by selected factors,or if the data were sparse,a Fisher exact test was used.With psoriasis as a dependent variable,non-condition logistic regress model in SAS statistical software package,version 9.0(SAS Institute Inc,Cary,North Carolina) was used in the multivariate analyses to adjust for potential confounding factors.ORs and 95%CIs were calculated as estimates of the relative risk for variables.The statistical significant level is a two-sided a of 0.05 for all tests.Results The results display that both of HLA-Cw6 and HLA-B57 increased the risk of psoriasis vulgaris,OR is 6.44 and 2.43(all p＜0.01),respectively,the effect of HLA-Cw6 on psoriasis is greater in female than male(OR,7.45 vs 5.73,all p＜0.01) while the effect of HLA-B57 on psoriasis is greater in male than female(OR,3.07 vs 2.00,all p＜0.01),and the effect of HLA-Cw6 is greater on earlier psoriasis than later psoriasis(7.16 vs 5.12,all p＜0.01).However,the effect of HLA-B13 on psoriasis vulgaris is not found.The linkage disequilibrium is declared between HLA-Cw6 and HLA-B57 or HLA-B13,and both of HLA-Cw6-B57 and HLA-Cw6-B13 were the risk haplotypes of psoriasis vulgaris,OR is 6.84 and 3.17(all p＜0.01),respectively.The effect of HLA-Cw6-B57 on psoriasis is greater for male than female(OR,8.85 vs 5.71, all p＜0.01),in contrast,the effect of HLA-Cw6-B13 on psoriasis in female than male(OR,3.54 vs 2.89,all p＜0.01),but the effect of two risk haplotypes were all greater on earlier psoriasis than later psoriasis.Compared with HLA-Cw6~- cases,the onset age of psoriasis with HLA-Cw6 is significantly earlier in female than male(p＜0.05).The psoriasis vulgaris with HLA-Cw6 shown those features for earlier onset,more many affected positions,more serious,much more in winter but those difference is not significant in statistics(all p＞0.05),the difference of clinic features between HLA-Cw6-B57 and HLA-Cw6-B13 haplotype is not significant(p＞0.05).Conclusions First,HLA-Cw6 and HLA-B57 were the risk genes of psoriasis vulgaris, but the effect of HLA-B13 genes on psoriasis vulgaris is not obvious.Second,the linkage disequilibrium between HLA-Cw6 and HLA-B57 or HLA-B13 was validated, all increasing the risk of psoriasis vulgaris.Third,The psoriasis vulgaris with HLA-Cw6 showed those features for earlier onset,more many affected positions,more serious, much more in winter but those difference is not significant.PartⅡ:The effects of interaction between HLA-Cw6 and endogenesis and xenobiotic factors on psoriasis vulgarisBackground Psoriasis is a chronic inflammatory skin disease,which results from the common effects of multiply environmental and genetic factors.It was well known that HLA-Cw6,cigarette smoking and life stress events was closely related to psoriasis vulgaris.Further,the recent results declared that higher waist-hip ratio(WHR) and body mass index(BMI) may increase the risk of psoriasis vulgaris.But,to our knowledge,no evidence of interaction between HLA-Cw6 and in turn,BMI,WHR and cigarette smoking are available.Objective To mainly analyzed the interaction between HLA-Cw6 and in turn BMI, WHR and cigarette smoking in psoriasis vulgaris.The data is obvious significance for preventive and clinical medicine.Methods 466 patients and 178 controls received this epidemiological investigation and HLA typing by PCR-SSP based on the hospital-based case-control study,and the data was analyzed by non-condition logistic regress model.Results There was a graded positive association of WHR and BMI with psoriasis vulgaris.Compared with a WHR of 0.80 or less than 0.80,the OR was 2.36(p＜0.01) for WHR 0.80-0.85,and 2.74(p＜0.01) for WHR greater than 0.85.Compared with subjects with a BMI of 20 or less than 20,the multivariate OR of psoriasis were 1.20(p＞0.05) for a BMI of 20-25,1.84(p＜0.05) for a BMI of more than 25 corresponding overweight (p for trend,＜0.01).We found not only the risk of psoriasis for the individual with HLA-Cw6 was 8.33 times greater than that for individual without HLA-Cw6 but also the risk increased approximately 35 times in individuals with HLA-Cw6 and a overweight as compared with one without HLA-Cw6 and a non-overweight,and 17-fold when the individuals with HLA-Cw6 and a WHR of more than 0.80 were compared with individuals without HLA-Cw6 and a WHR of 0.80 or less than 0.80, displaying the combined effect of HLA-Cw6,BMI and WHR(all p＜001).The data of 178 cases and 178 controls showed that the risk of psoriasis was related to smoking,the adjusted OR being 2.07(P＜0.01),and there is a graded positive association between the risk of psoriasis and intensity or duration of smoking.Stressful life events increased the risk of psoriasis(OR=7.87,P＜0.01).We found the waist-hip ratio(WHR) increased the risk of psoriasis vulgaris and OR was 2.67(P＜0.01) in China. Individuals harboring the HLA-Cw6 gene obviously increased the risk of psoriasis,OR being 9.93(P＜0.01) after adjusted for potential confounder factors while the OR of psoriasis for HLA-B57 was 2.41(P＜0.05).Significant interacion between HLA-Cw6 and HLA-B57 for psoriasis was found(OR=10.51,P＜0.01).A striking finding is that the risk of psoriasis for smokers with HLA-Cw6 increased about 11-fold than non-smoker without HLA-Cw6,and the risk increased some 20-fold in individuals with HLA-Cw6 having stressful life events as compared with one without HLA-Cw6 and stressful life events.Conclusions This study suggested that HLA-Cw6,overweight,higher waist-hip ratio and cigarette smoking are material risk factors of psoriasis vulgaris,specially the combined effects of HLA-Cw6 and BMI,WHR,smoking on psoriasis vulgaris in Chinese population.更多还原