临床药师在制定免疫球蛋白制剂治疗原发性免疫缺陷性疾病合理用药方案中的作用

对于接受某些药物治疗久治不愈、欲更换免疫球蛋白治疗方案的原发性免疫缺陷性疾病患者进行用药分析,是临床药师在制定和更换治疗方案中的重要职能.由于临床药师既能分析不同免疫球蛋白给药途径的差异,在治疗方案确立中通过分析患者的病史和用药史、不同剂型的药物特性、患者个体差异、药物剂量控制和因人而异的药物免疫耐受程度、患者的经济条件及患者个人喜好等因素来确立合理用药方案,因而临床药师在完善治疗方案、用药监测和更改治疗方案后的用药指导方面具有重要作用.因为临床药师参与治疗并能使治疗效果显著提升,所以免疫球蛋白的个性化治疗是未来抗体治疗的发展趋势,抗体治疗方案的制定过程离不开专业药学人员的参与.     

Detection and purification of antiidiotypic antibody against anti-DNA in intravenous immune globulin

Pooled normal human IgG for therapeutic use, following depletion of anti-DNA, anti-Fc, and anti-F(ab)₂ of normal IgG, expressed antiidiotypic activity against anti-DNA derived from lupus sera. The antiidiotype enriched by elution from anti-DNA affinity columns bound directly to anti-DNA IgG and inhibited the binding of lupus sera to DNA but did not bind to normal IgG or inhibit the binding of anti-tetanus toxoid to tetanus toxoid. Antiidiotypes in pooled normal sera may have a role in the clinical improvement seen in patients with autoimmune diseases receiving intravenous immune globulin.     

T cell receptor VB repertoire diversity in patients with immune thrombocytopenia following splenectomy

In recent years, a pathophysiological role for T cells in immune thrombocytopenia (ITP) has been established. We applied cDNA size distribution analysis of the T cell receptor (TCR) beta-variable (VB) complementarity-determining region 3 (CDR3) in order to investigate T cell repertoire diversity among immune thrombocytopenia patients who had either responded or not responded to splenectomy, and compared them to normal controls. ITP patients who had had a durable platelet response to splenectomy showed a mean 2.8 +/- 2.1 abnormal CDR3 size patterns per patient, similar to healthy volunteers (2.9 +/- 2.0 abnormal CDR3 size patterns). In contrast, patients unresponsive to splenectomy demonstrated evidence of significantly more clonal T cell expansions than patients who had responded to splenectomy or controls (11.3 +/- 3.3 abnormal CDR3 size patterns per patient; P < 0.001). Of the VB subfamilies analysed, VB3 and VB15 correlated with response or non-response to splenectomy, each demonstrating oligoclonality in non-responding patients (P < 0.05). These findings suggest that removal of the spleen may lead directly or indirectly to reductions in T cell clonal expansions in responders, or that the extent of T cell clonality impacts responsiveness to splenectomy in patients with ITP.     

The IgG molecule as a biological immune response modifier: mechanisms of action of intravenous immune serum globulin in autoimmune and inflammatory disorders

Intravenous immune globulin (IVIG) is an important treatment modality in patients with humoral or B-cell immune deficiency as replacement therapy. Soon after its introduction in the early 1980s for the treatment of patients with immune deficiency, IVIG was used in the treatment of children with idiopathic thrombocytopenia purpura. Presently, more commercial IVIG is used for the treatment of autoimmune and inflammatory disorders than as replacement therapy in patients with immune deficiency. Understanding the mechanisms of action of IVIG in these autoimmune and inflammatory disorders has occupied investigators over the past 3 decades. A number of mechanisms for the immune modulation and anti-inflammatory actions of IVIG have been described, including Fc receptor blockade, inhibition of complement deposition, enhancement of regulatory T cells, inhibition or neutralization of cytokines and growth factors, accelerated clearance of autoantibodies, modulation of adhesion molecules and cell receptors, and activation of regulatory macrophages through the FcγRIIb receptor. It can now be appreciated that IVIG affects many different pathways to modulate the immune and inflammatory response. Further delineation of these pathways might lead to new treatment strategies.     

The immune system's role in sepsis progression,resolution, and long-term outcome

Sepsis occurs when an infection exceeds local tissue containment and induces a series of dysregulated physiologic responses that result in organ dysfunction. A subset of patients with sepsis progress to septic shock, defined by profound circulatory, cellular, and metabolic abnormalities, and associated with a greater mortality. Historically, sepsis-induced organ dysfunction and lethality were attributed to the complex interplay between the initial inflammatory and later anti-inflammatory responses. With advances in intensive care medicine and goal-directed interventions, early 30-day sepsis mortality has diminished, only to steadily escalate long after “recovery” from acute events. As so many sepsis survivors succumb later to persistent, recurrent, nosocomial, and secondary infections, many investigators have turned their attention to the long-term sepsis-induced alterations in cellular immune function. Sepsis clearly alters the innate and adaptive immune responses for sustained periods of time after clinical recovery, with immune suppression, chronic inflammation, and persistence of bacterial representing such alterations. Understanding that sepsis-associated immune cell defects correlate with long-term mortality, more investigations have centered on the potential for immune modulatory therapy to improve long-term patient outcomes. These efforts are focused on more clearly defining and effectively reversing the persistent immune cell dysfunction associated with long-term sepsis mortality.     

急性免疫性血小板减少动物模型的实验研究

目的：制备急性免疫性血小板减少动物模型。方法：采用洗涤小鼠血小板免疫家兔获得抗小鼠血小板血清（APS）;将74只BALB／c小鼠随机分为3组：对照组（10只）、APS组（32只）、正常家兔血清（NRS）组（32只）。对照组经尾静脉注射灭菌生理盐水100ul,APS组经尾静脉注射1：4浓度抗小鼠血小板血清APS100ul,NRS组经尾静脉注射正常家兔血清100ul。每组均于注射前和注射后第3、6、12小时取小鼠尾静脉血,进行血小板。白细胞及红细胞计数,并测定每个时间点断尾出血时间。结果：APS组外周血象显示各时间点血小板计数进行性减少,出血时间进行性延长,第3、6、12小时所测血小板计数值与NRS组及对照组比较亦差异显著（p〈0．01）,而红细胞和白细胞计数无显著变化（p〉0．05）。NRS组、对照组各时间点及组间血小板计数、出血时间、白细胞计数、红细胞计数均无显著差异。结论：用免疫血清法制备急性免疫性血小板减少模型方法可行,可靠,成功率高。     

妊娠合并血小板减少的病因及治疗

目的探讨妊娠合并血小板减少的病因及围生期处理。方法回顾性分析青岛大学医学院附属医院1995年至2005年间106例妊娠合并血小板减少患者的病因及临床处理方法。结果106例患者中妊娠相关性血小板减少(PAT)40例(37.74%),子痫前期25例(23.58%),特发性血小板减少性紫癜(ITP)13例(12.26%)。血小板减少出现最早孕周为20+3周,<28周出现25例(23.58%),>28周出现81例(76.42%)。阴道分娩25例,剖宫产81例。产后出血13例(12.26%)。结论妊娠合并血小板减少有多种病因,以妊娠相关性血小板减少最多见,对血小板<50×109L或有明显出血倾向者,用糖皮质激素或(和)免疫球蛋白治疗;分娩前后使用血小板制剂,预防产时或产后出血。PAT一般不作特殊处理。     

Treatment of aplastic anemia with cyclosporin A,methylprednisolone, and antithymocyte globulin

Summary Twenty-three patients with aplastic anemia (18/23 with severe aplastic anemia) were treated with an immunosuppressive regimen consisting of cyclosporin A (CsA) and methylprednisolone (MP) (n=7) or CsA, MP, and antithymocyte globulin (ATG;n=16). Nineteen patients are alive with a follow-up of 4 to 25 months; three patients died of infections and one of a gastrointestinal hemorrhage. Within 3 months, improvement of hematopoiesis was seen in 14 patients (61%). First signs of a response after 23 to 88 days were followed by complete remission in eight patients, partial remission in three patients, and minimal improvement in three patients. Two of the patients with only minimal improvement were treated with a second course of immunosuppression and reached a complete remission and partial remission. Interestingly, remission proved to be dependent on the continued administration of CsA in four of five patients with partial or complete remission who could be evaluated up to now. Thus, CsA must have been effective in the induction and/or maintenance of remission in three patients. This observation is a very strong argument for the role of T cells in the pathogenesis of at least some cases of aplastic anemia and warrants further evaluation of the role of CsA in the treatment of aplastic anemia.Abbreviations ALG Antilymphocyte globulin - ATG Antithymocyte globulin - CR Complete remission - CsA Cyclosporin A - MI Minimal Improvement - MP Methylprednisolone - NR No response - PR Partial remission - SAA Severe aplastic anemia - SGPT Serum alanine aminotransferase     

Foxp3 methylation status in children with primary immune thrombocytopenia

Aim

To investigate the status of DNA methylation in the Foxp3 promoter in pediatric ITP patients and assess the role of DNA methylation of Treg cells in the pathogenesis of ITP.

Methods

Quantitative DNA methylation levels of Foxp3 promoter in pediatric ITP patients were detected by MassARRAY EpiTYPER. Methylation levels of Foxp3 promoter were analyzed in ITP patients and normal controls.

Results

Significantly higher expression of CpG-2, CpG-3 and CpG-11.12 was observed in ITP patients compared to the controls. A subgroup analysis revealed that persistent and chronic ITP patients exhibited significantly higher CpG-6 expression than in the subgroup of newly diagnosed ITP patients. All patients who represented newly diagnosed ITP at admission were reclassified at later follow-up. In this follow-up subgroup analysis, there were significantly higher levels of CpG-6 in the persistent ITP group than that in the newly diagnosed ITP group.

Conclusions

Our results indicate that defective Treg cell activity identified in ITP might be partially mediated through hypermethylation of CpG sites in the promoter region of Foxp3.     

射频消融治疗顽固性免疫性血小板减少症

目的探讨脾脏射频消融术治疗顽固性免疫性血小板减少症（ITP）的安全性和有效性。方法回顾分析我院开展的国际首例脾脏射频消融治疗ITP的疗效。结果 1例43岁女性食管癌患者,经反复外周血计数、血涂片和骨髓穿刺等检查证实合并原发性重症ITP,其血小板计数小于（5~10）×109/L,经规范抗幽门螺旋杆菌治疗、静滴人免疫球蛋白、甲基强的松龙、长春新碱和输注血小板等治疗无效。患者接受腹腔镜下脾脏射频消融术治疗,术后第22天血小板计数恢复正常,无围手术期并发症;随访超过8个月,患者呈完全应答。结论脾脏射频消融术治疗顽固性ITP安全、有效,值得扩大临床试验进一步验证其疗效。     

ITP患者脾切除前后外周血Th亚群细胞因子的变化及意义

目的: 探讨辅助性T淋巴细胞(T helper lymphocyte,Th)亚群细胞因子在原发性免疫性血小板减少症(ITP)患者脾切除术前后的表达及意义。方法: 采用QuantiGene Plex (QGP)方法检测22例ITP患者腹腔镜脾切除术前后外周血Th1(IL-2和IFN-γ)、Th2(IL-4、IL-5、IL-6和IL-10)、Th3(TGF-β₁)和Th17(IL-17)细胞因子mRNA表达水平的变化。30例健康体检者作为对照组。结果: (1)术前组IL-2表达水平较对照组明显降低(P<0.05),IL-17表达水平较对照组明显升高(P<0.05),其它细胞因子表达水平在术前组和对照组之间无显著差异(P>0.05)。术后组TGF-β₁表达较术前组和正常对照组均明显升高(P<0.05);术后组IL-2 表达较术前有所升高(P<0.05),但仍低于对照组(P<0.05)。其它细胞因子表达水平在术前组和术后组之间无显著性差异(P>0.05)。(2)术前IL-2与IFN-γ之间成正相关(r=0.647,P<0.01),术前其它细胞因子之间均无明显相关性(P>0.05)。术后3对细胞因子之间成正相关,分别是IL-2与IFN-γ(r=0.787, P<0.01),IL-17与IL-2(r=0.554,P<0.01),IL-17与IFN-γ(r=0.461,P<0.05);术后其它细胞因子之间均无明显相关性(P>0.05)。 结论: ITP患者存在Th亚群细胞因子失衡,脾切除术可改善ITP患者部分Th亚群细胞因子的失衡。     

新生儿血小板减少症46例临床分析

目的分析新生儿血小板减少的临床特点及可能原因,探讨其预防和治疗措施。方法回顾性分析本院2008年1月～2009年7月诊断新生儿血小板减少症所有患儿的临床资料。结果早发型血小板减少患儿临床上多无特殊表现,预后较好;迟发型血小板减少症多发生于早产儿,小于胎龄儿,通常由于合并严重感染所致,病情严重,需要输注血小板来治疗。结论围产期有高危因素母亲,其新生儿出生后要常规监测血常规,对于宫内发育不良或低出生体质量儿生后一旦合并感染要警惕血小板减少,甚至DIC的发生。     

妊娠合并血小板减少238例临床分析

目的探讨妊娠合并血小板减少症的病因及治疗。方法对238例妊娠合并血小板减少患者的临床资料进行回顾性分析。结果单纯由妊娠引起的血小板减少171例(71.85%),特发性血小板减少性紫癜(ITP)引起20例(8.40%),合并肝脏疾病18例(7.56%),重度妊高征引起25例(10.50%),Rh血型不合及病毒感染各2例(各占0.84%)。对血小板<50×109/L者用强的松治疗,分娩前后使用血小板制剂,同时考虑剖宫产。结论妊娠期血小板减少是最常见的妊娠合并血小板减少症类型。有合并症的血小板减少程度严重,大多<70×109/L,半数ITP有临床症状。糖皮质激素是治疗严重血小板减少的有效手段,术前血小板仍<50×109/L可输注浓缩血小板。     

急性免疫性血小板减少症患儿IgG-Fc受体表达变化

目的 探讨小儿急性免疫性血小板减少症(aITP)外周血单核细胞(MC) IgG-Fc受体(FcγR)表达变化.方法 急性ITP患儿组27例,同龄健康对照组25例,流式细胞术检测单核细胞表面活化型受体FcγR Ⅰ及FcγRⅢ表达;荧光定量PCR( real-time PCR)检测MC活化型FcγRⅡa及抑制型FcγRⅡb mRNA表达;酶联免疫吸附法(ELISA)检测血浆IFN-γ、IL-4和IL-10浓度.结果 (1)急性ITP患儿组MC FcγR Ⅰ和FcγRⅢ表达明显高于对照组(P＜0.05);FcγRⅡa mRNA及FcγRⅡa/FcγRⅡb mRNA比值显著高于对照组及治疗后,经地塞米松治疗后,活化型FcγR Ⅰ、FcγRⅢ、FcγRⅡa mRNA表达下降,抑制型FcγRⅡb mRNA表达增加,FcγR活化型/抑制型平衡逐渐恢复.(2)血浆炎症细胞因子IFN-γ浓度较对照组显著增高;抗炎因子IL-4显著低于对照组.IFN-γ浓度水平与MC FcγRⅡa mRNA表达显著正相关(r=0.79,P＜0.05),IL-4与FcγRⅡb mRNA表达正相关(r=0.84,P＜0.05).结论 单核细胞活化型FcγRs过度表达,抑制型FcγRⅡb表达降低,活化型/抑制型FcγRs表达失衡可能参与儿童急性ITP免疫发病机制,MC FcγRs异常表达可能与细胞因子IFN-γ、IL-4的改变有关,地塞米松治疗可恢复FcγRs活化型/抑制型平衡表达.     

Alloimmunization to the platelet antigen human platelet antigen-1a and characterization of the helper T-cell responses in fetomaternal alloimmune thrombocytopenia

The major cause of severe FMAIT in Caucasians is fetal-maternal incompatibility for the human platelet antigen HPA-1a, which leads to the production of maternal anti-HPA-1a alloantibodies that cross the placenta and cause thrombocytopenia. The estimated incidence of severe FMAIT is approximately 1 in 1100 neonates, and the clinical manifestations range from mild purpura to intracranial hemorrhage and death. At present, there are no preventative measures or antenatal routine screening procedures in place to identify women at risk of HPA-1a alloimmunization, nor reliable predictors of severe fetal disease, although maternal responsiveness is associated with DR52a (DRB3*0101). Anti-HPA-1a production depends on antigen specific T helper lymphocytes that recognize HPA-a peptides bound to MHC molecules on antigen-presenting cells (APC). The core epitope on HPA-1a responsible for the alloimmune response has been identified by a combination of functional studies with immune lymphocytes and helper T cell clones, peptide binding and antigen processing studies. This dominant epitope has the potential to prevent or reverse the anti-HPA-1a response in women if used to induce tolerance.