CYP3A4/5,ABCB1,FOXP3以及CCDC22基因多态性对中国肾移植患者环孢素药动学及药效学的影响

【作者】 徐勤霞； 邱晓燕； 焦正； 钟明康；

【Author】 Xiaoyan Qiu;

【机构】 复旦大学附属华山医院临床药学室；

【摘要】 目的:环孢素(CsA)是一种广泛用于预防肾移植排斥反应的一线免疫抑制剂,有效降低了排斥反应发生率,提高了移植存活率。然而,CsA治疗窗窄,并具有较大的药动学和药效学个体差异。而单核苷酸多态性(SNPs)是影响个体差异的重要因素之一。本研究旨在探索CYP3A4、CYP3A5和ABCB1基因多态性与CsA药动学(浓度)以及CYP3A4、CYP3A5、ABCB1、FOXP3和CCDC22基因多态性与CsA药效学(临床终点事件和肾功能变化)之间的关系,为临床个体化给药奠定基础。材料与方法:本研究纳入177名2000年1月至2012年12月间在复旦大学华山医院接受手术的中国汉族肾移植患者。所有患者接受环孢素(CsA),霉酚酸酯(MMF)或霉酚酸钠(MPS)以及强的松三联免疫抑制方案。CYP3A4*1G和CYP3A5*3采用PCR-LDR技术,ABCB1 C1236T、C3435T和G2677T/A采用PCR-RFLP技术,FOXP3rs3761547、rs3761548、rs2232365、rs3761549、rs2280883和CCDC22 rs2294021位点采用TaqMan探针技术进行基因分型。移植后不同时期的环孢素调整谷浓度(CO)及峰浓度(C2)与相应SNP之间的相关性使用方差分析进行检验。通过卡方检验比较临床事件(包括排斥反应、肾毒性和肺炎)发生组和未发生组患者基因型分布的差异,并使用Bonferroni校正进行多重校正。使用Kaplan-Meier生存分析和log-rank检验比较不同基因型患者临床事件发生率的差异。采用Cox比例风险模型比较引入临床混杂因素后,基因型对临床事件发生率的影响。eGFR使用CKD-EPI公式计算。SNP对移植后eGFR变化趋势的影响由线性混合模型(MIXED)进行估算。结果:CYP3A4*1G以及CYP3A5*3等位基因A携带者2-12个月的调整谷浓度高于于非携带者(74.42±76.14 vs 49.34±31.90,P=0.04;73.32±71.55 vs 46.98±32.26,P=0.027)。ABCB1 G2677T/A携带T等位基因的患者15-21天的调整峰浓度高于非携带者(206.78±76.25 vs176.60±75.42,P=0.028)。而ABCB1 C1236T或C3435T基因型对CsA调整浓度没有影响。卡方检验、Kaplan-Meier生存分析和Cox比例风险模型未发现阳性结果。线性混合模型也未发现基因多态性对术后患者的eGFR变化有影响。结论:CYP3A4*1G、CYP3A5*3和ABCB1 G2677T/A基因多态性可能影响肾移植患者术后CsA的血药浓度。但我们并未发现CYP3A4、CYP3A5、ABCB1、FOXP3或CCDC22单核苷酸多态性对预测排斥反应、肾毒性和肺炎的发生风险以及移植后的肾功能有帮助。更多还原

【Abstract】 Introduction:Cyclosporine（CsA） is a first-line immunosuppressant widely used to prevent allograft rejection in renal transplantation,which has reduced rejection rates and increased overall graft survival However,CsA has a narrow therapeutic range and presents a wide interindividual pharmacokinetic and pharmacodynamic variability,which is related to many factors including single nucleotide polymorphisms（SNPs）.In this study,we aim to explore the association between CYP3 A4,CYP3 A5 and ABCB1 polymorphisms and the pharmacokinetics of CsA（plasma concentration） and the association between CYP3 A4,CYP3 A5,ABCB1,FOXP3 and CCDC22 polymorphisms and the pharmacodynamics of CsA（clinical events and renal function of graft）.Materials and methods:A total of 177 Chinese patients who received renal transplantation between January 2000 and December 2012 and were followed up regularly in Huashan Hospital of Fudan University were included in this study.All patients received cyclosporine（CsA）,mycophenolate mofetil（MMF） or mycophenolic acid（MPS） and prednisolone as a triple immunosuppression regimen.Genotyping of CYP3 A4*1 G and CYP3 A5*3 was performed by polymerase chain reaction-ligase detection reaction（PCR-LDR）,ABCB1 C1236 T,C3435 T and G2677 T/A was by Polymerase chain reaction-restriction fragment length polymorphism（PCR-RFLP）,FOXP3 rs3761547,rs3761548,rs2232365,rs3761549,rs2280883 and CCDC22 rs2294021 was by a TaqMan probe technique.The relationships of dose-adjusted pre-dose levels（C₀） and 2 h post-dose levels（C₂） of CsA with corresponding SNPs in different post-transplant periods were investigated using ANOVA.The clinical events incidence（including rejection,nephrotoxicity and pneumonia） among the patients with different genotypes was compared by Chi-square test.Bonferroni correction method was utilized for multiple testing.Time-to-event analysis was performed using Kaplan-Meier estimates and log-rank tests.Multivariate cox regression analysis was further performed to calculate the hazards associated with different SNPs to control potential confounders.The eGFR was computed using the CKD-EPI formula.Linear mixed model（MIXED） was used to evaluate the impact of SNPs on the post-transplant eGFR trend.Results:The dose-adjusted C₀ in the CYP3 A4*1 G A allele carriers in Month 2-12 was higher compared with the non-carriers（74.42±76.14 vs 49.34±31.90,p=0.04;）.And the CYP3 A5*3 A carriers also had a higher dose-adjusted C₀ in Month 2-12 than the non-carriers（73.32±71.55 vs 46.98±32.26,p=0.027）.The dose-adjusted C₂ of patients with ABCB1 2677 T allele during day 15-21 was higher than those noncarriers（206.78±76.25 vs 176.60±75.42,p=0.028）.We did not observe any significant impact of the ABCB1 C1236 T or C3435 T SNPs on the dose-adjusted concentration of CsA.All 11 SNPs invested showed no association with occurrence of allograft rejection,nephrotoxicity and pneumonia by Chi-square test,Kaplan-Meier analysis and multivariate cox regression analysis.There was also no correlation between the studied SNPs and post-transplantation eGFR.Conclusion:This study suggests that polymorphism CYP3 A4*1 G,CYP3 A5*3 and ABCB1 G2677 T/A in kidney transplant recipients may affect the CsA concentration after transplantation.But none of the studied SNPs in CYP3 A4,CYP3 A5,ABCB1,FOXP3 or CCDC22 genes can help to predict the risk of rejection,nephrotoxicity and pneumonia or the renal function after transplant.更多还原