充血性心力衰竭患者细胞粘附分子与B型钠利尿肽的相关性研究

充血性心力衰竭患者细胞粘附分子与B型钠利尿肽的相关性研究作者：陈礼平，韦铁民    作者单位：丽水市中心医院心内科，浙江 丽水    【摘要】  目的 探讨CHF患者细胞粘附分子与B型钠利尿肽的相关性。方法 CHF患者35例，其中扩张性心肌病19例、高血压性心脏病11例、冠心病5例；正常对照组18例,分别测定sICAM_1、白细胞表面CD18的阳性表达率和BNP；采用Accuson Sequoia 512超声诊断仪测定左房大小、左室舒张末内径、左室收缩末内径、左室射血分数。结果 1.CHF组与正常对照组年龄对比无显著性差异(P＞0.05)，两组在左房内径、左室舒张末内径、左室收缩末内径、左室EF、sICAM_1、CD18的阳性表达率、BNP值对比有显著性差异(P＜0.01)；2.CHF组中心功能Ⅱ级、Ⅲ级和Ⅳ级组三组，sICAM_1、CD18经方差分析无显著性差异（P＞0.05）；心功能Ⅳ级组与Ⅱ级组比较BNP有显著性差异（P＜0.01）；3.sICAM_1与CD18的阳性表达率及BNP水平呈正相关，Pearson指数分别为0.355(P=0.036)和0.531(P=0.001)；4.BNP、CD18与LVEF呈负相关：Pearson指数分别为-0.542(P=0.001)和-0.502(P=0.002)；5.BNP值＞450pg/ml组（n=18）sICAM_1值及CD18分别为387.61±21.39μg/L和64.73±2.91%，＜450pg/ml组（n=17）为314.47±24.10μg/L和52.60±3.91%，两组比较P=0.029和0.017，有显著性差异。结论 CHF患者血清sICAM-1及白细胞表面CD18的阳性表达率增加；sICAM_1浓度与BNP呈正相关，提示慢性炎症可能是充血性心力衰竭的发病机制之一。心功能分级各组sICAM_1和CD18无显著性差异。根据BNP值分组显示sICAM_1及CD18有显著性差异。    【关键词】  充血性心力衰竭；细胞粘附分子；B型尿钠肽     Relationship between Cell Adhesion Molecules and B_type Natriuretic Peptide in Patients with Congestive Heart Failure. CHEN Li_ping, WEI Tie_min.Department of cardiology, Lishui Center Hospital，Zhejiang 323000， China   ［Abstract］ Objective To explore the changes of levels of serum soluble intercellural adhesion molecule_1(sICAM_1), the diurnal variation of leukocyte CD18 expression in peripheral blood and the concentration of serum B_type natriuretic peptide(BNP) in the patients with chronic congestive heart failure(CHF), and to explore the relationship between cell adhesion molecules and heart failure degrees. Methods Study included 35 CHF patients ［19 cases of idiopathic dilated cardiomyopathy, 11 cases of hypertension, 5 cases of coronary heart disease (CHD)］ and 18 healthy subjects. Serum sICAM_1 was measured by enzyme_linked immmunosorbent assay (ELISA). Diurnal variation of leukocyte CD18 expression in peripheral blood was assayed by flow cytometer. Serum BNP was measured by chemiluminescence. The diameter of left atrium (LA), left ventricle end_diastolic (LVED) and left ventricle end_systolic (LVES) and the left ventricular function were assessed by Doppler echocardiography Accuson Sequoia 512. Results There was no significant difference in the age between CHF group and control group (P＞0.05). However, the LA, LVEDV, LVESV, LVEF, sICAM_1, the leukocyte CD18 expression and the concentration of serum BNP were significantly higher in CHF patients than those in control group(P＜0.01). CHF patients were divided into three subgroups: NYHA Fc II,III and Ⅳ group. There was no significant difference in sICAM_1 and the leukocyte CD18 expression between three groups（P＞0.05）, serum BNP was markedly higher in patients with NYHA Fc IV than in patients with NYHA Fc Ⅱ（P＜0.01）. There was positive correlation between sICAM_1, CD18 and BNP (r=0.355, P=0.036; r=0.531, P=0.001, respectively). There was negative correlation between BNP, CD18 and LVEF (r=-0.542,P=0.001; r=-0.502,P=0.002, respectively). BNP value ＞450 pg/ml, sICAM_1 and CD18 in this subgroup（n=18） were 387.61±21.39μg/L and 64.73±2.91%, respectively; in another subgroup （BNP value ＜450 pg/ml n=17）were 314.47±24.10μg/L and 52.60±3.91%, respectively. There was significant difference between two subgroups (P=0.029 and 0.017, respectively). Conclusions Elevated levels of sICAM_1 and CD18 were found in the patients with CHF. Meanwhile, there was a positive correlation between levels of sICAM_1 and BNP, which indicated that chronic inflammation might be one of mechanisms in the development of CHF. Adhesion molecules might play an important role in the progression of CHF. We found poor correlation associated in sICAM_1 and the leukocyte CD18 expression in different heart function classes of CHF, While, referring to BNP, there was positive correlation between sICAM_1 and CD18 in different heart function classes of CHF.   ［Key words］ Congestive heart failure； Cell adhesion molecules； B_type natriuretic peptide    CHF时存在多种细胞因子的激活，白细胞表面的整合素CD11a/CD18表达增加，其血浆可溶性细胞间黏附分子（sICAM_1）水平增高。研究表明，CAM在血栓形成、动脉粥样硬化形成及心肌缺血-再灌注损伤中的作用发挥重要作用［1］。sICAM_1与心力衰竭程度呈正相关。    B型钠利尿肽（B_type natriuretic peptide，BNP）在心室容量和压力负荷增加时分泌，具有利钠利尿扩血管作用［2］。BNP与NYHA心功能分级具有很好的相关性，心功能越差BNP值越高［3，4］。本研究用BNP对CHF患者进行分组，观测CAM与BNP及与心功能的关系。1  资料与方法    1.1  一般资料：2005年9月至2006年3月入院的未经正规治疗的CHF患者，超声心动图示左室舒张末期内径＞55mm且左室射血分数＜55%，HAYA心功能II～IV级，剔除合并慢性肝肾功能不全，坏疽，大量心包积液，全身免疫性疾病，恶性肿瘤等，共35例CHF组。年龄22～78岁，平均60±3岁，其中男20例（66.7%），女15例（33.3%）。根据病史、体格检查、胸片、超声心动图，心脏核素检查及冠状动脉造影确定基础心脏病，分为：扩张性心肌病19例：排除其他心脏疾病引起的心腔扩大和EF下降。高血压性心脏病11例：高血压诊断附合WHO高血压诊断标准并随病程逐渐出现心腔扩大，排除其它可能合并存在的病因。冠心病5例：有心绞痛或心肌梗死病史，心脏扩大，心功能不全，经核素心肌灌注显像或冠状动脉造影确诊。进一步按NYHA心功能分级标准，分为三个亚组：心功能Ⅱ级组11例，Ⅲ级组13例，Ⅳ级组11例。按BNP值分为两个亚组：BNP≥450pg/ml组18例，BNP＜450pg/ml组17例，两组年龄、性别比无显著性差别。正常对照组共18例，均来自同期本院健康体检者，经询问病史，心电图，X线胸片，超声心动图，常规生化检查等未发现器质性疾病，其中男10例，女8例，年龄21～74岁，平均51±3岁。    1.2  方法    1.2.1  超声心动图检查：由两位有经验的超声心动图医师先后单独进行检查，每位医师测3次取平均值给出结果，再取两位医师给出结果的平均值。采用Accuson Sequoia 512超声诊断仪，探头频率2.5～3.5MHz，进行标准长轴切面，短轴切面，心尖二腔心和四腔心切面扫描。左室舒张末期内径测量方法：在腱索水平左室长轴切面测量舒张末室间隔心内膜面和左室后壁心内膜面长度。    1.2.2  CD18阳性表达率检查：测定前以标准荧光微球校正流式细胞仪光路系统，使流式细胞仪检测变异系数＜2%，进样速率约5000～10000/分钟，分析10000个白细胞的CD18的阳性表达率。    1.2.3  sICAM_1测定：采用夹心酶联免疫吸附法（ELISA）测定。    1.2.4  BNP测定：采用化学发光法测定。    1.3  统计学处理：计量资料以均数±标准差（x－±s）描述，各组间比较采用方差分析（ANOVA）和两样本均数比较t检验。相关系数的计算采用参数法（Pearson法）。采用SPSS10.0软件进行统计学处理，以P＜0.05有统计学意义。2  结果    2.1  CHF组与正常对照组各项目的对比：见表1。可见两组年龄性别对比无显著性差异，其它项目值的对比均有显著性差异。表1  CHF组与正常对照组各项目的对比    2.2  CHF组不同心功能分级sICAM_1、CD18阳性表达率、LVEF、BNP的对比：见表2。可见根据NYHA心功能分级，三组sICAM_1、CD18阳性表达率无显著性差异；心功能Ⅳ级组与Ⅱ级组比较BNP有显著性差异（P＜0.01）；心功能Ⅲ级、Ⅳ级组与Ⅱ级组比较LVEF有显著性差异（P＜0.01），但心功能Ⅲ级、Ⅳ级组比较LVEF无显著性差异。表2  CHF组不同心功能分级sICAM_1、CD18、LVEF、BNP的对比注：与心功能Ⅱ级比较，P＜0.01    2.3  sICAM_1、CD18阳性表达率，BNP及EF的相关性：sICAM_1与CD18的阳性表达率呈正相关：Pearson指数为0.355(P=0.036)。BNP与CD18阳性表达率呈正相关：Pearson指数为0.342(P=0.045)。BNP与sICAM_1呈正相关：Pearson指数为0.531(P=0.001)。BNP与EF呈负相关：Pearson指数为-0.542(P=0.001)。CD18阳性表达率与EF呈负相关：Pearson指数为-0.502(P=0.002)。    2.4  CHF组中BNP值：＞450pg/ml组（n=18）sICAM_1值及CD18分别为387.61±21.39μg/L和64.73±2.91%，＜450pg/ml组（n=17）为314.47±24.10μg/L和52.60±3.91%，两组比较P=0.029和0.017，有显著性差异。3  讨论    3.1  ICAM_1与CD18的关系：ICAM_1于1986年首次被鉴定，又称为CD54，属于免疫球蛋白超家族成员。参与机体的免疫和炎症反应，其增高程度反映炎症的轻重。通常心肌细胞只表达极少量的ICAM_1，但在某些病理因素的刺激下，如心脏遭受致命性损伤，心肌缺血再灌注，心脏移植排斥反应及肿瘤坏死因子-α等细胞因子的作用下，心肌细胞膜的表达可以成倍增加。ICAM_1脱落后以可溶性形式存在于血液中，研究发现血液中可溶性ICAM_1的量与细胞表面ICAM_1的分子数量呈正比［5］。因此，测定血液中sICAM_1可间接反映细胞表面ICAM_1的表达量。CD18属整合素超家族的细胞表面蛋白，只在白细胞表面表达，CD18与ICAM_1互为配体，共同介导白细胞的增加与粘附。本组资料显示，sICAM_1与CD18呈正相关,与以往的报道一致［6］。    3.2  sICAM_1、CD18在CHF发生发展中的作用：内皮细胞表达粘附分子是炎症细胞向血管壁游走和浸润的必要条件［7］。急性心肌梗塞、慢性缺血性心脏病、扩张型心肌病等心力衰竭病人心肌组织ICAM_1含量较正常人明显升高。Yosninori S等［8］发现患柯萨奇B3病毒性心肌炎鼠心肌细胞有明显ICAM_1表达,Devaux B等［9］证实,ICAM_1和VCAM_1在心肌炎、慢性缺血性心脏病、扩张型心肌病心脏各种组织中显著增多。Tsutamoto T等［10］检测了102例CHF患者sICAM_1水平且随访18个月，结果发现血浆sICAM_1水平随CHF严重性而升高。随访期间发现14例经治疗后心功能由Ⅲ级降到Ⅱ级的患者，其血浆sICAM_1水平也明显降低，且左室射血分数和sICAM_1呈显著负相关。Klein等研究71例CHF患者，发现血循环中明显升高，且升高水平与心肌组织中炎症浸润程度相关，并与心衰程度相关。本组研究发现，CHF患者sICAM_1及白细胞表面CD18的阳性表达率明显高于正常对照组（P＜0.01），表明慢性炎症有可能是CHF的发病机制之一。有研究表明［11］，细胞粘附分子的表达先于细胞间的粘附，因此，检测白细胞表面CD18的表达及血浆ICAM_1水平可能对观测CHF患者的病情变化，判断预后具有一定的意义，同时，也可能为临床应用抗粘附分子单克隆抗体预防和治疗CHF提供了理论依据。    3.3  NYHA心功能分级与sICAM_1、CD18的关系：研究发现,CHF患者血浆ICAM_1水平升高，且与病情呈正比［12～14］。Tousoulis D等［15］发现在扩张型心肌病患者中ICAM_1和VCAM_1均升高,且此水平的升高与冠脉的粥样硬化无关,而与患者心功能级别相关。但是，本组资料显示，根据NYHA心功能分级判断的心功能Ⅱ级、Ⅲ级和Ⅳ级组，经方差分析未能显示出各组间sICAM_1、CD18的显著性差异，与段氏和李氏［16，17］报道不同。    3.4  BNP与sICAM_1的关系：BNP是目前临床诊断心力衰竭的主要生化标志物，BNP浓度与心力衰竭严重程度相关，心功能越差，BNP浓度越高，每级心功能之间的BNP浓度几乎相差一倍［4］。本组资料显示，BNP与sICAM_1、CD18呈正相关。以BNP值450pg/ml作为截点，CHF两组的sICAM_1、CD18经t检验有显著性差异（P＜0.01），表明BNP高值者，心肌炎症反应有增强的趋势。    综上所述，CHF患者血清sICAM_1及白细胞表面CD18的阳性表达率增加，而且，sICAM_1浓度与BNP呈正相关，提示慢性炎症可能是充血性心力衰竭的发病机制之一，粘附分子在充血性心力衰竭的发展中扮演重要的角色。本文心功能分级各组sICAM_1和CD18阳性表达率无显著性差异，是否因本组资料样本量偏少，有待今后作进一步研究。【参考文献】  ［1］Jang Y, Lincoff AM, Plow EF, et al. 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