颈动脉粥样硬化与非酒精性脂肪肝的胰岛素抵抗_脂联素异常相关机制及与中医证型关系分.pdf

2009年9月第26卷第5期September 2009,Vol126,No15收稿日期:2009-04-07作者简介:张毅(1983-),男,硕士研究生通讯作者:徐尚华,E2mail:xshanghua1631com基金项目:福建省南平市科技局科研基金(编号:2008Z21)文章编号:1007-3213(2009)05-0499-06颈动脉粥样硬化与非酒精性脂肪肝的胰岛素抵抗、脂联素异常相关机制及与中医证型关系分析张 毅,徐尚华(福建省南平市第一医院心内科一区,福建南平 353000)摘要:【目的】探讨颈动脉粥样硬化(CAS)与非酒精性脂肪肝(NAFLD)的相关机制 胰岛素抵抗(IR)、血清脂联素(APN)异常及与中医证型的关系。【方法】筛选CAS伴NAFLD(联合患病组)74例及单纯CAS(对照组)25例,分别测定其空腹血糖(FBG)、血清胰岛素(FI)、血清脂联素(APN),用自身稳态模型评估法(HOMA)评估I R、APN,并进一步在联合患病组进行指标间双变量相关分析;对比联合患病组各中医证型HOMA2I R、APN的差异并分析其辨证论治的参考指标。【结果】(1)联合患病组与对照组比较,HOMA2I R显著升高、APN显著降低(均P 0101)。(2)联合患病组的APN与HOMA2IR值呈显著负相关(=-01447,P0101)。(3)联合患病组的中医证型构成比不同,与湿热内蕴证组和痰瘀互结证组比较,脾虚痰湿证组的HOMA2I R显著升高、APN显著降低(均P0105),具有可比性,见表1。74例联合患病组的中医证型分布见图1,显示4个中医证型构成比从大到小依次排列为脾虚痰湿证(45195%)湿热内蕴证(32143%)痰瘀互结证(16122%)肝肾阴虚证(5141%)。脾虚痰湿证为本次病例收集中最多见的证型。表1 两组一般资料均衡性比较Table 1Comparison of general status and complicated diseases in both groups组别 N性 别N男N女N年龄/(xs)岁合并疾病N冠心病N高血压N高脂血症N糖尿病对照组 2515106514619142568联合患病组7034366211111124621630图174例联合患病组的中医证型分布Figure 1Percentage of TCM syndromes in 74 CASpatients complicated w ith NAFLD112 研究方法11211 血标本的采集及保存 采集资料并运用表格法记录相关资料(包括颈动脉I MT),联合患病组和对照组分别抽取禁食12 h后的清晨空腹肘静脉血3 mL,待自然凝固后3 h内在KDC21042低速离心机3 000 r/min离心10 min后分离血清,于-90 低温冰箱(青岛海尔公司)保存待测,按收集时间顺序分批次检测。11212 血清标本的测定 血清空腹血糖(FBG)采用葡萄糖氧化酶法使用LX220全自动生化分析仪测定(美国库尔特贝克曼公司产品);血清胰岛素(FI)采用日本东曹全自动荧光微粒酶免分析仪A I A21800成批测定。IR采用自身稳态模型评估法(HOMA),其 计 算 公 式 为:胰 岛 素 抵 抗 指 数(HOMA2IR)=FI(U/mL)FBG(mmol/L)/2215。血清脂联素(APN)采用酶联免疫吸附试验(EL ISA)法使用酶标仪测定(试剂盒由北京中杉金桥生物科技有限公司提供的美国R&D System公司进口产品)。试剂使用前在恒温水浴箱平衡至室温,严格按照试剂盒内的操作说明书进行操作:准备试剂、加样,全自动洗板机Z MX2988B洗板3次,奥地利全自动酶标仪anthos2010在450 nm处测吸光度(D)值,用计算机软件画出标准曲线,用读出的D值减去空白对照的D值即为样品的D值,在标准品的D值曲线上查出相应的样品APN浓度。113 统计学方法 采用SPSS 1310统计学软件进行统计分析。计量资料采用均数 标准差(xs)表示,计数资料采用例数或百分比表示;两组计量资料间比较采用t检验,多组计量资料间比较采用单向方差分析;计数资料采用卡方检验;各因素之间的相关关系用Spearman相关分析。2 结果211 两组APN、HOMA2I R比较 表2结果显示,联合患病组与对照组比较,HOMA2IR水平显著升高、APN水平显著降低(均P0101)。212联合患病组APN与HOMA2I R的关系 经Spearman相关分析,联合患病组的HOMA2IR与APN呈显著的负相关关系(=-01447,P=01000),见图2。213 联合患病组中医证型与APN、HOMA2IR的关005广州中医药大学学报第5期系 表3结果显示,各中医证型组的HOMA2I R均大于对照组(P 0101),APN水平均小于对照组(P 0105)。与湿热内蕴证组和痰瘀互结证组比较,脾虚痰湿证组的HOMA2I R显著升高、APN显著降低(均P0105)。各中医证型组的HOMA2I R水平由高到低的顺序为脾虚痰湿证组痰瘀互结证组湿热内蕴证组,APN水平由高到低的顺序为痰瘀互结证组湿热内蕴证组脾虚痰湿证组。表2 两组APN、HOMA2IR比较Table 2Comparison ofAPN level andHOMA2I R in both groups(xs)组别 NAPN/(mgL-1)IHOMA2I R对照组 259100219311570184联合患病组705141212231361114P0101,与对照组比较图2 联合患病组APN与HOMA2I R的相关性分析Figure 2Correlation of HOMA2I R w ith APN in CASpatients complicated w ith NAFLD表3 联合患病组中医证型与APN、HOMA2IR的关系Table 3Relationship of TCM syndromes w ith APN andHOMA2I R in CAS patients complicated with NAFLD(xs)组别 NAPN/(mgL-1)IHOMA2I R对照组 259100215311570184脾虚痰湿证组344111112941021113湿热内蕴证组246154213521620177痰瘀互结证组126181210621970159 P0105,P0101,与对照组比较;P0101,与脾虚痰湿证组比较3 讨论作为亚临床全身AS的一个安全指标,颈动脉I MT和斑块形成在NAFLD的病人中显著增加3-4。NAFLD与早期的AS密切相关,是AS形成早期的独立标志物,并且这个联系是独立于典型的危险因素,如I R、腹型肥胖等MetS特征。2005年Brea等【5】首次发现NAFLD独立于其他典型的MetS特征(如IR等)与颈动脉I MT、斑块形成存在紧密的联系。而在Targher等【6】的观察中,NAFLD的诊断以肝组织学检查为标准,同样发现NAFLD病人的颈动脉I MT增加是独立于NAFLD的危险因素MetS组分,并且这种增加是伴随着病情进展而进展的。311 颈动脉粥样硬化与非酒精性脂肪肝的相关机制 胰岛素抵抗、脂联素异常 本研究发现,与单纯CAS对照组比较,CAS伴NAFLD联合患病组的HOMA2IR水平显著升高、APN水平显著降低(P0101)。I R以及腹型肥胖可能是NAFLD与加速性AS的一个联结点7-9。IR和内脏型肥胖是MetS的两个主要的根本的危险因素,对于NAFLD病情预后起决定作用,并能预测心血管疾病(CVD)事件,是NAFLD和AS进展的枢纽。IR时血中游离脂肪酸(FFA)、非对称性二甲基精氨酸和肿瘤坏死因子 2(TNF2)增多,而内皮源性一氧化氮(NO)合酶的辅酶四氢叶酸减少,使内皮细胞结构和功能受损从而导致内皮功能障碍。内皮功能障碍与IR呈恶性循环,两者相互促进,影响AS的发生发展。因此,可以认为腹型肥胖和胰岛素抵抗是CAS与NAFLD相关联的一个机制。脂联素(adiponection,APN)是一种在人类血浆中大量流通的蛋白质,并且是与胰岛素抵抗密切相关的细胞因子,主要由脂肪细胞分泌,脂联素与受体结合后具有增强胰岛素敏感性,以及抗动脉粥样硬化、抗高血糖等生物效应10-12。研究证实高浓度的脂联素还可通过抑制TNF2 降低单核细胞的黏附,减少平滑肌细胞的增殖和迁移以及抑制清道夫受体表达减少泡沫细胞的形成,终止炎症反应、改善脂代谢等途径发挥抗AS的作用。同时亦有研究证实:腹型肥胖7、血脂紊乱13-14、炎症反应15-16 均可能是联系NAFLD与AS进展的生物机制。本研究还显示,经相关分析,CAS伴NAFLD联合患病组的HOMA2IR与APN呈显著的负相关关105张毅,等.颈动脉粥样硬化与非酒精性脂肪肝的胰岛素抵抗、脂联素异常相关机制及与中医证型关系分析2009年第26卷系。研究表明17-19,IR形成初期引发大量细胞(内皮细胞、巨噬细胞、脂肪细胞)分泌I L21、I L26、TNF2 等前炎症细胞因子,引起肝脏合成急性期蛋白(纤维蛋白原、C反应蛋白、血浆胰淀素A等)。此时脂联素维持较高浓度,发挥抗炎作用,与炎症因子相对抗。机体进行自限调节,以期恢复被干扰的稳态,同时通过肌肉组织局部产生脂联素,满足炎症过程的过多能量消耗。但持续慢性应激可引发细胞因子级联反应,使炎症反应扩大和慢性化;同时脂联素的生物合成受到炎症因子的抑制,形成了低脂联素血症,进一步促进炎性因子的释放和炎症过程慢性化,从而加重了I R。312 联合患病组中医证型与HOMA2I R、APN的相关性 本研究表明,各中医证型组的HOMA2I R均大于对照组(P 0101),APN水平均小于对照组(P0105)。与湿热内蕴证组、痰瘀互结证组比较,脾虚痰湿证组HOMA2IR显著升高、APN显著降低(P痰瘀互结证组湿热内蕴证组,APN水平由高到低的顺序为痰瘀互结证组湿热内蕴证组脾虚痰湿证组。中医学无NAFLD之病名,根据文献资料认为其主要病因是由于饮食失节,过食肥甘厚腻、情志失调导致肝失疏泄、脾失健运,水湿不能正常输布而致痰湿内聚。痰湿蕴久又可化热而成湿热蕴结,痰湿、湿热可阻滞脉道而导致血行不畅,久之化瘀,最终形成痰湿瘀阻,痹阻肝脉。同时合并血压升高、肥胖以及代谢异常可致气血亏虚、肝失调养、肾精亏耗,最终导致肝肾阴虚。整个病变过程有从脾虚痰湿 湿热内蕴 痰瘀互结 肝肾阴虚发展的趋势。在本研究的74例联合患病组的证型分布中脾虚痰湿证34例(45195%)、湿热内蕴证24例(32143%)、痰瘀互结证12例(16122%)、肝肾阴虚证4例(5141%),尤以脾虚痰湿证为多见,肝肾阴虚证最少,符合NAFLD的发病病因和病机。NAFLD的中医证型与CT分度【20】以及B超分度的关系同样证实:脾虚痰湿证以轻度脂肪肝为主,湿热内蕴证以中度脂肪肝为主,痰瘀互结证以中度以上脂肪肝为主,肝肾阴虚证以重度脂肪肝为主。从胰岛素抵抗和脂联素指标显示不同证型间CAS伴NAFLD患病者均有不同程度的I R及APN降低现象,尤以脾虚痰湿型明显,提示联合患病者IR、APN异常的主要证候特点是脾虚痰湿。由于脾虚失运,痰湿内聚,同时使肝疏泄失司,脾转运失常,导致胰液分泌紊乱,从而促使或加重IR,影响机体的脂肪代谢,造成APN降低。提示脾虚失运,痰湿内聚可能是联合患病者IR、脂联素异常的主要病机,而健脾化痰利湿可能是减轻或逆转联合患病者IR、脂联素异常的主要治法。总之,CAS与NAFLD的相关机制显示胰岛素抵抗、脂联素异常,可以认为NAFLD是动脉粥样硬化的一个新的危险因素。近年来,评估NAFLD病人的CVD危险已经被逐渐重视。虽然目前对于改善NAFLD是否将最终阻止CVD的进展还不是很清楚,但是积极治疗CVD的危险因素(如MetS组分),如合理减肥、习惯性锻炼,治疗IR(如二甲双胍和噻唑烷二酮类),调节血脂代谢(如贝特类和他汀类)等被相信能同时改善NAFLD和AS。根据CAS伴NAFLD患病组的中医证型构成不同,HOMA2IR、APN可以作为中医辨证论治的参考,尤其对脾虚痰湿证更具参考意义。但是由于时间、经费、技术等原因,本研究未能得出不同证型与指标的相关性程度及相对应的具体参考值。今后还将多中心、多渠道收集较大样本数,引进相关技术,得出不同证型与指标的相关性程度及相对应的具体参考值,为判断证型提供更为客观、临床实用的证据,并进行动物实验,制作动物模型,验证这些指标的可靠程度。参考文献:1 范建高,徐铭益 1脂肪肝与动脉粥样硬化和冠心病的关系J.中华肝脏病杂志,2002,10(2):15012魏华凤,季光,邢练军 1脂肪肝辨证分型规律的初探J 1辽宁中医杂志,2002,11:65513 Targher G,BertoliniL,Padovani R,et al1Nonalcoholic fatty liverdisease is associated with carotid artery wall thickness in diet2controlled type 2 diabetic patients J 1J Endocrinol Invest,2006,29:5514 FracanzaniA L,Burdick L,Rasselli S,et al1Risk of early athero2sclerosis evaluated by carotid artery 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H,Oktenli C,et al1Systemic markers of lipidperoxidation and antioxidants in patientswith nonalcoholic fatty liverdisease J 1Am J Gastroenterol,2005,100:850117 Hotta K,Funahashi T,Bodkin N L,et al1Circulating concentra2tions of the adipocyte protein adiponectin are decreased in parallelwith reduced insulin sensitivity during the progression to type 2diabetes in rhesus monkeys J 1Diabetes,2001,50(5):1126118 Ishii T,Yamakita T,Yamagami K,et al1Plasma adiponectin levelare associated with insulin sensitivity improved by exercise trainingin type 2 diabetes J 1Diabetes,2002,51(Suppl 2):A2481119崔丽娟,都健 1脂联素与炎症及胰岛素抵抗关系的研究进展J 1国际内分泌代谢杂志,2006,34(6):44120王嵩,李琼,王夕富,等 1CT定量诊断与脂肪肝中医证型的相关性J 1中西医结合学报,2007,3(5):1261PathogenicMechanism Associ ated with Insuli n Resistance and AdiponectinAbnormality in Carotid Atherosclerosis Patients Complicated withNonalcoholic Fatty L iver D isease and Their Relationships withTraditional ChineseMedical Syndrome TypesZHANG Yi,XU Shanghua(The First Section of CardiologyDept.,the First Hospital ofNanping,Nanping 353000 Fujian,China)Abstract:ObjectiveTo explore the pathogenic mechanis m associated with insulin resistance(I R)and adiponetin(APN)abnor mality in carotid atherosclerosis(CAS)patients complicated with nonalcoholic fatty liver disease(NAFLD),and to study their relationships with traditional Chinese medical(TCM)syndrome types.M ethodsSeventy2fourCAS patients complicatedwithNAFLD(group A)and 25 CAS patients(group B)were enrolled into thestudy.Fasting blood glucose(FBG),fasting serum insulin(FI),and serum APN levels were measured.I R andAPN were evaluated by the homeostasis assess ment(HOMA)method.HOMA2I R andAPN in group A were comparedwith those in group B,and bivariate correlation analysis was made between the two indexes in group A.Therelationship of HOMA2I R and APN with TCM syndrome types was analyzed in group A.Results(1)HOMA2I Rwas obviously increased,and APN was obviously decreased in group A(P0101 compared with those in group B).(2)APN was negatively correlated with HOMA2I R in group A(=-01447,P0101).(3)In group A,HOMA2I R wasmarkedly increased and APN wasmarkedly decreased in patientswith phlegm2damp acculamtion due to spleendeficiency(P 0101 compared with those in patients with internal accumulation of damp2heat and phlegm305张毅,等.颈动脉粥样硬化与非酒精性脂肪肝的胰岛素抵抗、脂联素异常相关机制及与中医证型关系分析2009年第26卷accumulatingwith stagnation).ConclusionThe pathogenic mechanis m of CAS complicated with NAFLD is relatedwith I R and the abnor mal level ofAPN,and NAFLD can be considered as one of the new risky factors of CAS.InCAS patients complicated with NAFLD,the abnor mal level ofAPN is correlated with I R.HOMA2I R and APN can beused as the reference parameters for the syndrome differentiation of CAS complicated with NAFLD,in particular forthe syndrome of phlegm2damp acculamtion due to spleen deficiency.Key words:CAROTI D ATHEROSCLEROSIS/pathogenesis(TCM);NONALCOHOL I C FATTYL I VER/pathogenesis(TCM);I NSUL I N RESISTENCE;AD IPONETI N/blood(Continued from page 487)Resource Survey ofMedicinal Plant ofM orinda officinalisHow inGuangdong and Fujian Provi ncesL IU Jin1,3,D ING Ping1,3,ZHAN Ruoting1,2,CHEN W ei wen1,2(1.KeyLaboratory of Chinese Herbal Resource Founded by EducationMinistry and Guangdong Province,Guangzhou510006 Guangdong,China;2.Science and Engineer Center for Chinese Herbal Resource,Guangzhou University of TC M,Guangzhou 510006 Guangdong,China;3.School of Chinese HerbalMedicine,Guangzhou University of TCM,Guangzhou 510006 Guangdong,China)Abstract:ObjectiveTo investigate resource status of medicinal plant ofM orinda officinalisHow(MOH)insouthern regions of five ridges,thus to provide scientific evidence for the sustainable development and utilization ofMOH.MethodsThe relevant documentswere reviewed and the specimenswere checked.Field investigationswerecarried out in five counties of Guangdong province and in two counties of Fujian province.ResultsNow wildresource of MOH was rapidly reducing and needed to be protected.The cultivated areas for MOH were mainlyconcentrated in Deqing,Yunan,and Gaoyao counties of Guangdong province,and a few in Fujian province.Thecultivated areas forMOH were shrinking for the soil erosion induced byMOH planting and for the unstable price ofMOH.ConclusionEffective measures should be taken to protect the ecological environment and genetic diversity ofMOH,and to i mprove its planting enviroment.Key words:MORINDA OFFICI NALISHOW;CONSERVATI ON OF NATURAL RESOURCE;DAT A COLLECTI ON405广州中医药大学学报