醫(yī)學(xué)免疫學(xué)課件：TNF和TNFR與類風(fēng)濕關(guān)節(jié)炎

1、TNF和TNFR與類風(fēng)濕關(guān)節(jié)炎目錄1基本概念2類風(fēng)濕關(guān)節(jié)炎3TNF-與RA的聯(lián)系4RA治療5參考文獻(xiàn)Tumor Necrosis FactorTNF-Tumor Necrosis Factor ReceptorTNF-傳導(dǎo)通路基本概念1.1 Tumor Necrosis Factor分類tnf-：?jiǎn)魏艘蜃樱?lps、ifn-（干擾素-）、m-csf（巨噬細(xì)胞集落刺激因子）、gm-csf（粒細(xì)胞巨噬細(xì)胞集落刺激因子）可刺激單核細(xì)胞、巨噬細(xì)胞產(chǎn)生tnf-。而pge（前列腺素E）則有抑制作用。tnf-：淋巴因子，抗原和絲裂原可刺激t淋巴細(xì)胞分泌tnf-。1.2 TNF-人的TNF-基因長(zhǎng)約2.76k

2、b，小鼠為2.78kb，結(jié)構(gòu)非常相似，均由4個(gè)外顯子和3個(gè)內(nèi)含子組成，與MHC基因腫瘤壞死因子群密切連鎖，分別定位于第6對(duì)和第17對(duì)染色體上。人TNF-前體由233個(gè)氨基酸殘基組成，含76個(gè)氨基酸殘基的信號(hào)肽，切除信號(hào)肽后成熟型TNF-為157氨基酸殘基，非糖基化，第69位和101位兩個(gè)半胱氨酸形成分子內(nèi)二硫鍵。TNF-是一個(gè)非螺旋、富含B折疊的蛋白多肽，每個(gè)單體由反向平行的B折疊組成。通常以二聚體、三聚體或五聚體的形式存在于體內(nèi)，具有生物學(xué)活性的TNF-分子是緊密連接的三聚體。TNF-基因是RA發(fā)病遺傳因素的一個(gè)重要候選基因。TNF增強(qiáng)子238位GG基因型與RA進(jìn)展性關(guān)節(jié)破壞程度相關(guān)且不依賴

3、于DR4的存在，TNF區(qū)域多態(tài)性可能與DR等位基因存在交互作用從而影響疾病易感性。1.3 Tumor Necrosis Factor Receptortnf-r的分型：型tnf-r，55kda，cd120a，439氨基酸殘基，此型受體可能在溶細(xì)胞活性上起主要作用；型tnf-r，75kda，cd120b，426氨基酸殘基，此型受體可能與信號(hào)傳遞和t細(xì)胞增殖有關(guān)。兩型tnf-r均包括胞膜外區(qū)、穿膜區(qū)和胞漿區(qū)三個(gè)部分，胞膜外區(qū)有28%的同源，但在有胞漿區(qū)無同源性，可能與介導(dǎo)不同的信號(hào)轉(zhuǎn)導(dǎo)途徑有關(guān)。tnf-r屬于神經(jīng)生長(zhǎng)因子受體（ngfr）超家族。tnf-和tnf-的受體可能是同一的?？扇苄詔nfr：

4、tnf結(jié)合蛋白（tnf-bp）是tnfr的可溶性形式，有sTNf R（TNF-BPI）和sTNFR（TNF-BP）兩種。一般認(rèn)為stnfr具有局限tnf活性，或穩(wěn)定tnf的作用，在細(xì)胞因子網(wǎng)絡(luò)中有重要的調(diào)節(jié)作用。tnf-bp可與tnf特異結(jié)合，抑制tnf活性，如抑制其細(xì)胞毒活性和誘導(dǎo)IL-1產(chǎn)生，可促進(jìn)皮下接種meth a肉毒的生長(zhǎng)，可見于正常妊娠尿中。炎癥、內(nèi)毒素血癥、腦膜炎雙球菌感染、 SLE、HIV感染、腎功不全時(shí)以及腫瘤時(shí)可升高?？扇苄詔nfr可有效地減輕佐劑性關(guān)節(jié)炎的病理改變以及敗血癥休克。1.4 TNF-傳導(dǎo)通路Figure1. TNF- pathwayEva AV Moelant

5、s, et al. Regulation of TNF- with a focus on rheumatoid arthritis. Immunology and Cell Biology. 2013; 91: 393-401.1.4 TNF-傳導(dǎo)通路 核轉(zhuǎn)錄因子kappaB( NF-B) ：細(xì)胞中重要的轉(zhuǎn)錄調(diào)節(jié)因子，通常以p50-p65 異二聚體的形式與其抑制性蛋白( inhibitor kappaB，IB) 結(jié)合而呈非活化狀態(tài)。NF-B 通過刺激因子( 病毒、腫瘤壞死因子、B 細(xì)胞活化因子、淋巴毒素等) 的活化進(jìn)而誘導(dǎo)多種基因的表達(dá)，產(chǎn)生多種細(xì)胞因子參與炎癥反應(yīng)。Table 1. Cand

6、idate Genes with Single-Nucleotide Polymorphisms (SNPs) Linked to Rheumatoid Arthritis and Their Potential Function in Pathogenesis.Iain B. McInnes, Georg Schett. The Pathogenesis of Rheumatoid Arthritis. N Engl J Med 2011; 365(23): 2205-2219類風(fēng)濕關(guān)節(jié)炎Gary S. Firestein. Evolving concepts of rheumatoid a

7、rthritis. Nature 2003; 423: 356-361 2 類風(fēng)濕關(guān)節(jié)炎發(fā)病機(jī)制不明：分子模擬:病原體的某些成分與自身抗原有相似的抗原表位。表位擴(kuò)展:T細(xì)胞或B細(xì)胞在免疫應(yīng)答早期對(duì)個(gè)別表位的應(yīng)答擴(kuò)展到對(duì)其他表位的應(yīng)答。模糊識(shí)別:同一種抗原可被多個(gè)HLA表型識(shí)別，而同一種HLA分子可分別結(jié)合不同抗原。類風(fēng)濕關(guān)節(jié)炎的發(fā)生可能通過T細(xì)胞受體以及HLA-DRB1之間的模糊識(shí)別。遺傳因素：與類風(fēng)濕關(guān)節(jié)炎發(fā)病相關(guān)的易感基因包括HLA-DR、PADI4和PTPN22等。環(huán)境因素：某些病毒和細(xì)菌感染可能作為始動(dòng)因子，啟動(dòng)攜帶易感基因的個(gè)體發(fā)生免疫反應(yīng)，進(jìn)而導(dǎo)致類風(fēng)濕關(guān)節(jié)炎的發(fā)病。病原體包括EB

8、病毒、結(jié)核分枝桿菌等。Figure2. A proposed model implicating multiple pathogenic mechanisms in RA.Gary S. Firestein. Evolving concepts of rheumatoid arthritis. Nature 2003; 423: 356-361 2 類風(fēng)濕關(guān)節(jié)炎特征：滑膜組織增生慢性炎癥骨質(zhì)侵蝕自身抗體、趨化因子、細(xì)胞因子類風(fēng)濕因子(RF)抗變性IgG的自身抗體，主要為19S的IgM，也可見7S的IgG及IgA。它能與人或動(dòng)物的變性IgG結(jié)合，而不與正常IgG發(fā)生凝集反應(yīng)。RF主要出現(xiàn)在類風(fēng)濕

9、性關(guān)節(jié)炎患者，約7090的血清中和約60的滑漠液中可檢出IgG類RF，這很可能是自身IgG變性所引起的一種自身免疫應(yīng)答的表現(xiàn)抗瓜氨酸化蛋白抗體(ACPA)：抗瓜氨酸化蛋白抗體是一類針對(duì)含有瓜氨酸化表位的自身抗體的總稱，對(duì)類風(fēng)濕關(guān)節(jié)炎的診斷具有很高的敏感性和特異性，并與類風(fēng)濕關(guān)節(jié)炎的病情和預(yù)后密切相關(guān)。各種抗瓜氨酸化蛋白抗體對(duì)類風(fēng)濕關(guān)節(jié)炎的敏感性和特異性RA中TNF-的表達(dá)RA中TNF-的作用TNF-通過促進(jìn)其他細(xì)胞產(chǎn)生細(xì)胞因子發(fā)揮作用關(guān)節(jié)骨損傷RA與TNF-的聯(lián)系3.1 RA中TNF-的表達(dá)Marinova-Mutafchieva L, et al. Dynamics of proinflam

10、matory cytokine expression in the joints of mice with collagen-induced arthritis (CIA). Clin Exp Immunol 1997; 107: 5075123.1 RA中TNF-的表達(dá)炎癥初期：滑膜細(xì)胞產(chǎn)生TNF-，吸引巨噬細(xì)胞和中性粒細(xì)胞T細(xì)胞通過活化其它細(xì)胞促進(jìn)產(chǎn)生TNF-:T細(xì)胞和相鄰巨噬細(xì)胞和滑膜成纖維細(xì)胞的接觸活化這些細(xì)胞，誘導(dǎo)TNF-釋放炎癥中期：巨噬細(xì)胞1. Eva AV Moelants, et al. Regulation of TNF- with a focus on rheumatoi

11、d arthritis. Immunology and Cell Biology ,2013; 91: 3934012. McInnes IB, et al. Interleukin-15 mediates T cell-dependent regulation of tumor necrosis factor-alpha production in rheumatoid arthritis. Nat Med 1997; 3: 189195.3.1 RA中TNF-的表達(dá)骨質(zhì)破壞猜想：ACPAs 結(jié)合破骨細(xì)胞前體細(xì)胞會(huì)促進(jìn)其自分泌TNF-，隨后TNF-又促進(jìn)其向破骨細(xì)胞分化Ulrike Harr

12、e, et al. Induction of osteoclastogenesis and bone loss by human autoantibodies against citrullinated vimentin. The Journal of Clinical Investigation. 2012; 122: 1791-1802.Figure3. Bone loss elicited by MCV-ACPAs is induced by TNF-mediated increase of osteoclast precursor trafficking and differentia

13、tion. 3.2 RA中TNF-的作用Brennan FM, McInnes IB. Evidence that cytokines play a role in rheumatoid arthritis. J Clin Invest 2008; 118: 35373545.Figure4. TNF- actions relevant to the pathogenesis of RA.RA中TNF-的作用RA中TNF-的作用TNF-通過促進(jìn)其他細(xì)胞產(chǎn)生細(xì)胞因子發(fā)揮作用關(guān)節(jié)骨損傷3.3 TNF-通過促進(jìn)其他細(xì)胞產(chǎn)生細(xì)胞因子發(fā)揮作用募集細(xì)胞：TNF-誘導(dǎo)釋放趨化因子：RANTES、MCP-1、

14、IL-8、SDF-1等，發(fā)生趨化作用：例如：T細(xì)胞遷移。TNF-促進(jìn)內(nèi)皮細(xì)胞表達(dá)整合素（integrins）和粘附分子（adhesion molecules），募集白細(xì)胞，被吸引的細(xì)胞繼續(xù)表達(dá)TNF-，形成正反饋。促進(jìn)血管翳生成：TNF-誘導(dǎo)產(chǎn)生釋放多種細(xì)胞因子：例如：組織因子、細(xì)胞間黏附分子1(ICAM-1)、血管細(xì)胞黏附分子1(VCAM-1)、環(huán)氧化酶(COXII)和血管內(nèi)皮生長(zhǎng)因子(VEGF)。這些分子作用于血管內(nèi)皮細(xì)胞，促進(jìn)滑膜炎癥和血管翳的形成。1. Rossol, M., et al. Tumor necrosis factor receptor type I expression

15、 of CD4+ T cells in rheumatoid arthritis enables them to follow tumor ne- crosis factor gradients into the rheumatoid synovium. Arthritis & Rheumatism, 2013; 65: 1468-1476.2. Bevilacqua MP. Endothelial-leukocyte adhesion molecules. Annu Rev Immunol 1993; 11: 767804.3. 厲彥山. 腫瘤壞死因子及其受體在類風(fēng)濕關(guān)節(jié)炎中的作用. 復(fù)旦學(xué)

16、報(bào), 2010; 37(2): 245-249. 炎性反應(yīng)：TNF-誘導(dǎo)表達(dá)前炎性因子IL-1、 IL-6、粒細(xì)胞巨噬細(xì)胞集落刺激因子2,109111，促進(jìn)炎性反應(yīng)。慢性炎癥：巨噬細(xì)胞和滑膜成纖維細(xì)胞巨噬細(xì)胞初始，滑膜成纖維細(xì)胞維持炎癥？3.3 TNF-通過促進(jìn)其他細(xì)胞產(chǎn)生細(xì)胞因子發(fā)揮作用3.3 TNF-通過促進(jìn)其他細(xì)胞產(chǎn)生細(xì)胞因子發(fā)揮作用慢性炎癥Lee, A., et al. Tumor necrosis factor alpha induces sustained signaling and a prolonged and unremitting inflammatory response

17、 in rheumatoid arthritis synovial fibroblasts. Arthritis & Rheumatism, 2013; 65: 928-938.Figure5a. Sustained induction of IL-6, chemokines, and MMPs in FLS by TNF Figure5b. Transient inflammatory response to TNF in human macrophages. RA中TNF-的作用RA中TNF-的作用TNF-通過促進(jìn)其他細(xì)胞產(chǎn)生細(xì)胞因子發(fā)揮作用關(guān)節(jié)骨損傷3.4 關(guān)節(jié)骨損傷破骨細(xì)胞：Recep

18、tor activator of nuclear factor kappa B ligand （RANKL）和其受體RANK介導(dǎo)TNF-可能促進(jìn)破骨細(xì)胞前體細(xì)胞從骨髓遷移到外周在RANKL存在情況下放大破骨細(xì)胞生成、活化、聚集過程 1. Eva AV Moelants, et al. Regulation of TNF- with a focus on rheumatoid arthritis. Immunology and Cell Biology , 2013; 91: 393401.2. Li P, et al. RANK signaling is not required for TN

19、F- mediated increase in CD11hi osteoclast precursors but is essential for mature osteoclast formation in TNF-mediated inflammatory arthritis. J. Bone Miner. Res. 2004; 19:207213.3. Vis M, et al. Evaluation of bone mineral density, bone metabolism, osteoprotegerin and receptor activator of the NFB li

20、gand serum levels during treatment with infliximab in patients with rheumatoid arthritis. Ann. Rheum. Dis. 2006; 65: 14951499.3.4 關(guān)節(jié)骨損傷Figure6b. RANK blockade has no effect on the increased CD11bhi osteoclast precursor frequency (OCP) in TNF-Tg mice.Figure6a. RANK blockade reduces osteoclast numbers

21、 both within long bones and at rosion sites in joints of TNF-Tg mice treated with RANK:Fc. Li P, et al. RANK signaling is not required for TNF- mediated increase in CD11hi osteoclast precursors but is essential for mature osteoclast formation in TNF-mediated inflammatory arthritis. J. Bone Miner. Re

22、s. 2004; 19:207213.3.4 關(guān)節(jié)骨損傷Eva AV Moelants, et al. Regulation of TNF- with a focus on rheumatoid arthritis. Immunology and Cell Biology (2013) 91, 393401Figure7. TNF-a-mediated signaling in osteoclasts.治療藥物使用原則現(xiàn)存問題治 療 方 法4.1 治療藥物靶向治療代表藥物有corticosteroids 、非甾類抗炎藥主要通過乙?；饔檬弓h(huán)氧酶1（COX-1）和COX-2 失活，從而阻斷花生四

23、烯酸經(jīng)環(huán)氧化酶催化產(chǎn)生前列腺素類物質(zhì)而起到消炎止痛的作用。對(duì)關(guān)節(jié)破壞沒有治療效果Anti-TNF agentsTNF-單抗(e.g., infliximab, adalimumab, golimumab and certolizumabpegol) TNF受體融合蛋白(e.g.,etanercept).Helga Radner, Daniel Aletaha. Anti-TNF in rheumatoid arthritis: an overview. Wien Med Wochenschr. 2015; 165:394.1 治療藥物Infliximab (Remicade)英夫利昔單抗單抗類

24、藥物，3-10 mg/(kg* 6w)作用：減輕炎癥癥狀，抑制骨壞死，提高治療效果毒副作用：TNF正常生理作用被抑制TNF在早期防御反應(yīng)中的抗感染作用被抑制。一項(xiàng)研究顯示infliximab在西班牙的應(yīng)用導(dǎo)致了大規(guī)模爆發(fā)肺結(jié)核感染。可能機(jī)制：ADCC效應(yīng)破壞巨噬細(xì)胞，造成巨噬細(xì)胞內(nèi)細(xì)菌被釋放而感染。 措施：肺結(jié)核篩查，聯(lián)合用藥：isoniazide、methotrexateEtanercept (Enbrel)依那西普融合蛋白：TNF受體+IgG的Fc 段 ,25mg/2w或50 mg/w肺結(jié)核感染率最低 非單抗，無ADCC效應(yīng)Helga Radner, Daniel Aletaha. Ant

25、i-TNF in rheumatoid arthritis: an overview. Wien Med Wochenschr (2015) 165:39. 4.1治療藥物聯(lián)合用藥Figure8. Forest plot of the risk ratio for attaining clinical remission using combination therapy versus onotherapy at follow-up.Kuriya, B.et al. Efficacy of initial methotrexate monotherapy versus combination

26、therapy with a biological agent in early rheumatoid arthritis: a meta-analysis of clinical and radiographic remission. Ann. Rheum. Dis., 2010, 69, 1298-1304.4.1 治療藥物Infliximab (Remicade)英夫利昔單抗單抗類藥物，3-10 mg/(kg* 6w)作用：減輕炎癥癥狀，抑制骨壞死，提高治療效果毒副作用：TNF正常生理作用被抑制TNF在早期防御反應(yīng)中的抗感染作用被抑制。一項(xiàng)研究顯示infliximab在西班牙的應(yīng)用導(dǎo)致了

27、大規(guī)模爆發(fā)肺結(jié)核感染。可能機(jī)制：ADCC效應(yīng)破壞巨噬細(xì)胞，造成巨噬細(xì)胞內(nèi)細(xì)菌被釋放而感染。 措施：肺結(jié)核篩查，聯(lián)合用藥：isoniazide、methotrexateEtanercept (Enbrel)依那西普融合蛋白：TNF受體+IgG的Fc 段 ,25mg/2w或50 mg/w肺結(jié)核感染率最低 非單抗，無ADCC效應(yīng)Helga Radner, Daniel Aletaha. Anti-TNF in rheumatoid arthritis: an overview. Wien Med Wochenschr (2015) 165:39. 4.2 使用原則使用劑量Binder, N.B.,

28、et al. Tumor necrosis factor-inhibiting therapy preferentially targets bone destruction but not synovial inflammation in a tumor necrosis factor-driven model of rheumatoid arthritis. Arthritis & Rheumatism, 2013; 65: 608- 617.Figure9. Histologic analysis of the tarsal area of the hind paws of WT and

29、 hTNF-transgenic mice after 3 weeks of treatment with different concentrations of adalimumab4.2 使用原則使用劑量肺結(jié)核篩查聯(lián)合用藥：isoniazide、methotrexate4.3 現(xiàn)存問題感染幾率高藥物昂貴，需要長(zhǎng)時(shí)間使用無法修復(fù)受損關(guān)節(jié)使用持續(xù)時(shí)間難以統(tǒng)一，中斷用藥后果不明確盡管沒有研究表明TNF抑制會(huì)使惡性腫瘤惡化長(zhǎng)時(shí)間使用仍然可能帶來風(fēng)險(xiǎn)6. 參考文獻(xiàn)Eva AV Moelants, et al. Regulation of TNF- with a focus on rheumatoid

30、 arthritis. Immunology and Cell Biology. 2013; 91: 393-401.Marinova-Mutafchieva L, et al. Dynamics of proinflammatory cytokine expression in the joints of mice with collagen-induced arthritis (CIA). Clin Exp Immunol 1997; 107: 507512McInnes IB, et al. Interleukin-15 mediates T cell-dependent regulat

31、ion of tumor necrosis factor-alpha production in rheumatoid arthritis. Nat Med 1997; 3: 189195.Ulrike Harre, et al. Induction of osteoclastogenesis and bone loss by human autoantibodies against citrullinated vimentin. The Journal of Clinical Investigation. 2012; 122: 1791-1802.厲彥山. 腫瘤壞死因子及其受體在類風(fēng)濕關(guān)節(jié)炎

32、中的作用. 復(fù)旦學(xué)報(bào), 2010; 37(2): 245-249.Helga Radner, Daniel Aletaha. Anti-TNF in rheumatoid arthritis: an overview. Wien Med Wochenschr. 2015; 165:39Kuriya, B.et al. Efficacy of initial methotrexate monotherapy versus combination therapy with a biological agent in early rheumatoid arthritis: a meta-analysis of clinical and radiographic remission. Ann. Rheum. Dis., 2