【作者】 李琛；

【导师】 张碧丽；

【作者基本信息】 天津医科大学 ， 儿科学， 2010， 硕士

【摘要】 目的：观察儿童原发性肾病综合征(primary nephrotic syndrome, PNS)治疗过程中糖皮质激素受体(glucocorticoid receptor, GR)亚型GRa、GRβ的mRNA表达水平,探讨GRα和GRβ与儿童PNS的关系。通过GRα和GRβ的mRNA表达变化及各项临床指标的变化来评价三种糖皮质激素(glucocorticoid, GC)类药物对儿童PNS的疗效。方法：研究对象为天津市儿童医院2008年11月-2009年10月收治的55例初治PNS患儿,随机分为三组,泼尼松组(A组n=17),曲安西龙组(B组n=20),甲基泼尼松龙组(C组n=18)；以20名儿童为对照。PNS组分别在GC应用0周、4周、8周时取血,通过半定量逆转录-聚合酶链反应(RT-PCR)方法检测外周血单个核细胞(PBMCs)中GRα和GRβ的mRNA表达水平,同时检测PNS组血浆胆固醇(Cho)、血浆白蛋白(Alb)、24小时尿蛋白定量(24hUP)的变化,监测患儿体重、血压、睡眠、饮食等各项临床指标,并记录激素治疗反应,随访转归情况。结果：1.GRα和GRβ的mRNA表达水平的变化1)PNS组和对照组相比GRα和GRβ的mRNA水平变化a)GC治疗0周时,PNS患儿GRα低于正常儿童,差异有统计学意义(P<0.05)；GRβ高于正常儿童,差异有统计学意义(P<0.05)。b)PNS患儿GRα表达在GC治疗4周比0周降低,治疗8周比4周升高,差异有统计学意义(P<0.05)；随着GC的治疗,PNS患儿GRβ表达在治疗4周比0周升高,治疗8周比4周升高,差异有统计学意义(P<0.05)。2)各PNS组GRα和GRβ的mRNA水平的变化a) GC治疗0周时,A、B、C三组的GRα和GRβ的mRNA水平比较差异无统计学意义(P＞0.05)。b)GC治疗4周时,A组和B组的GRα比较差异无统计学意义(P＞0.05),C组高于A组和B组,差异有统计学意义(P<0.05)；GC治疗8周,A组和B组的GRα比较差异无统计学意义(P>0.05),C组高于A组和B组,差异有统计学意义(P<0.05)。c)GC治疗4周时,C组和B组的GRβ比较差异无统计学意义P>0.05)；C组和B组均低于A组,差异有统计学意义(P＜0.05)；GC治疗8周,C组和B组的GRβ比较差异无统计学意义(P>0.05)；C组和B组均低于A组,差异有统计学意义(P<0.05)。3)PNS患儿GC耐药6例,在GC治疗0、4、8周时,其GRα均低于GC敏感患儿,GRβ均高于GC敏感患儿,差异有统计学意义(P＜0.05)。2.各项生化指标的变化随着GC治疗,所有PNS患儿的血浆胆固醇均降低；血浆白蛋白上升；24小时尿蛋白定量降低,差异有统计学意义(P<0.05)。1)Cho：三组PNS组差异无统计学意义(P＞0.05)。2) Alb:GC治疗4周时,C组和B组比较差异无统计学意义(P＞0.05)；C组和B组均高于A组,差异有统计学意义(P<0.05)；GC治疗8周,C组和B组差异无统计学意义(P>0.05)；C组和B组均高于A组,差异有统计学意义(P＜0.05)。3) 24hUP:GC治疗4周时和治疗8周时,C组和B组比较差异无统计学意义(P>0.05)；C组和B组均低于A组,差异有统计学意义(P<0.05)。结论：1.PNS患儿,PBMCs中GRα和GRβ的mRNA表达存在异常,其表达的紊乱可能是造成GC耐药的原因之一。2.GC对PNS患儿的治疗,可以调节PBMCs中GRα和GRβ的mRNA表达,不同的GC调节其变化的程度不同,可根据调节水平来评价GC的疗效。3. RT-PCR方法可应用于临床检测PBMCs中GRα和GRβ的mRNA表达,指导PNS患儿的GC选择,评价治疗效果,预测治疗反应及转归。4.口服甲基泼尼松龙片可应用于初治PNS患儿的治疗；甲基泼尼松龙,曲安西龙对PNS患儿的治疗疗效优于泼尼松。更多还原

【Abstract】 Objective:Observe the mRNA expression levels of GRa and GRB during the treatment of children PNS to explore the relation between GR subtypes and children PNS, thus evaluate the efficacy of three GC drugs through mRNA expression changes of GR subtypes as well as changes of various clinical indicators.Methods:The research subjects are 55 PNS kid patients. They are randomly divided into three groups, namely, prednisone group (GroupA=17), triamcinolone group (GroupB=20), methylprednisolone group (GroupC=18) to compare with 20 healthy children. After GC application, collect blood after 0 week,4 weeks and 8 weeks; test the mRNA expression levels of the GR subtypes in PBMCs by semi-quantitative RT-PCR; meanwhile, test changes in the Cho,Alb and 24hUP of PNS children, record the response to hormone therapy and make follow-up prognosis.Results:1. Changes in mRNA expression levels of GRa and GRB.1) Comparison of changes in mRNA expression levels of GRa and GRB between PNS children and healthy children, a) In 0 week of receiving GC treatment, the GRa of PNS children is lower than healthy children (P＜0.05); the GRB of PNS children is higher than healthy children and the difference is statistically significant (P＜0.05).b) After 4 weeks’GC treatment, the GRa of PNS children is lower than that of 0 week (P＜0.05);After 8 weeks’ GC treatment, the GRa of PNS children is higher than that of 4 week (P＜0.05).As the treatment time increases, the overall GRβlevel is rising and the difference is statistically significant (P＜0.05).2) Changes of mRNA levels in GRa and GRB of each PNS children group.a) In 0 week of receiving GC treatment, the comparison of changes of mRNA levels in GRa and GRB of the three PNS children groups has no statistical significance (P＞0.05).b) After 4 weeks’ and 8 weeks’ treatment, the GRa comparison difference between Group A and Group B has no statistical significance (P＞0.05), the GRa of Group C is higher than that of Group A and Group B, the difference is statistically significant (P＜0.05).c) After 4 weeks’and 8 weeks’treatment, the GRB comparison difference of Group B and Group C has no statistical significance (P＞0.05);the GRB of Group B and Group C is lower than that of Group A, the difference is statistically significant (P＜0.05);.3) There are 6 cases of PNS children steroid-resistance; in the treatment of 0,4 and 8 weeks, the GRa of them is lower than steroid-sensitive children and GRB is higher(P＜0.05).2. Changes in various biochemical indicators:With GC treatment, cho decreases;Alb increases;24hUP decreases and the difference is statistically significant(P＜0.05).1)Cho:the difference among the three PNS groups has no statistical significance(P＞0.05).2) Alb:after 4 weeks’and 8 weeks’treatment, the comparison difference between Group B and Group C is not statistically significant (P＞0.05); Group C and Group B is higher than Group A(P＜0.05).3)24hUP:after 4 weeks’and 8 weeks’ treatment, the comparison difference between Group B and Group C is not statistically significant (P＞0.05),Group C and Group B is lower than Group A(P＜0.05).Conclusions:1. Abnormities are found in the mRNA expression of GRa and GRB of PNS children, and the mRNA expression disorder of GRa and GRB of PNS children may be one of the reasons causing GC resistance.2. GC treatment on PNS children can adjust the mRNA expression of GRa and GRB. Different GC adjustments have different degrees on mRNA expression of GRa and GRB.and the adjusting level can evaluate the efficacy of GC.3. By semi-quantitative RT-PCR, we can test the mRNA expression levels of the GR subtypes in PBMCs. RT-PCR can be used into clinical test, to evaluate the efficacy of GC drugs and predict the PNS children’s treatment effect and prognosis.4.Oral methylprednisolone can be used in children onset PNS. Methylprednisolone and triamcinolone have a better treatment effect on PNS than that of prednisone.更多还原