【作者】 李桂芳；

【导师】 刘会兰；

【作者基本信息】 安徽医科大学 ， 内科学， 2015， 硕士

【摘要】 目的急性移植物抗宿主病(Acute graft-versus-host disease,aGVHD)是异基因造血干细胞移植后早期主要并发症和死亡原因,但目前还没有可信的方法来预测它的发生及其对预后的影响,本研究通过监测清髓性非血缘脐血移植后患者外周血生物标记物ST2、elafin和REG-3α血清水平来对照分析临床aGVHD发生情况。方法本研究选择2013年7月至2014年7月在安徽医科大学附属省立医院血液科接受非血缘脐血移植的恶性血液病患者作为研究对象,采用清髓性预处理方案,收集患者移植后5天、14天和30天的外周血标本各5ml,样本收集后1500RPM离心8min,储存于-80℃冰箱中备用。用ELISAs方法检测患者外周血血清中的生物学标记物ST2、elafin和REG-3α的浓度变化,并对照患者移植后aGVHD的发生情况,并根据aGVHD在各时间点发生与否将患者分为两组,分别比较这两组患者生物标记物的浓度有无统计学意义。结果1.总共有43例患者接受脐血移植,植入43例。中性粒细胞植入时间为脐血移植术后18天。血小板植入的中位时间为脐血移植后46天。43例患者中,有23例于脐血移植术后15到96天之间发生aGVHD,发生率为53.5%。在发生aGVHD的23例患者中,Ⅰ-Ⅱ度有14人,Ⅲ-Ⅳ度有9人,中位发生时间为脐血移植术后27天。在发生急性移植物抗宿主病的这23例患者中,14/23例(61%)患者对激素治疗反应良好,9/23例(39%)患者对激素抵抗采用了二线治疗。移植后早期并发症如血流感染、迟发型出血性膀胱炎、移植相关微血管病(HSCT-associated thrombotic microangiopathy,TMA)和巨细胞病毒感染率分别为30.2%、34.9%、4.7%和65.1%。2.ST2的浓度于脐血移植术后第5天、14天和30天进行监测。发生aGVHD的患者在脐血移植术后第14天(发生组280pg/ml,未发生组90pg/ml)和第30天(发生组340pg/ml,未发生组130pg/ml)血清中ST2水平较为发生者明显升高(P=0.022和P=0.007);然而,两组在脐血移植术后第5天ST2水平(发生组128pg/ml,未发生组203pg/ml)与急性移植物抗宿主病之间无统计学意义(P=0.38)。按照aGVHD发生的严重程度将其分为3组:I-II度、III-IV度和未发生组。研究发现,脐血移植后第14天和第30天ST2浓度在III-IV级组分别为600pg/ml和500pg/ml,比另外两组均高,脐血移植术后第14天ST2水平III-IV级组显著高于I-II级组(P=0.001),I-II级组和未发生组之间均无统计学差异(P=0.301,P=0.092)。脐血移植术后第14天高ST2组与低ST2组移植后6个月非复发死亡率分别为32.6%和4.4%(P=0.003)。3.14/21例脐血移植患者发生皮肤aGVHD。移植后第5天、第14天和第30天患者血清elafin的水平分别为13.8pg/ml,12.05pg/ml,6.65pg/ml。移植后第14天发生皮肤aGVHD患者血清elafin水平明显升高(P=0.028),但是移植后第5天和第30天两组之间血清elafin水平无统计学意义(P=0.185,P=0.732)。4.11/43例患者发生肠道aGVHD,移植后第5天、第14天和第30天患者血清中REG-3α水平分别为0.4ng/ml,1.65 ng/ml,0.9 ng/ml。研究发现,在每个时间点发生肠道aGVHD和未发生的患者REG-3α水平分别为0.4ng/ml和0.9ng/ml,1.65ng/ml和1.2ng/ml,0.9 ng/ml和0.8ng/ml。在三个时间段两组比较均无统计学意义(P=0.698,P=0.07和P=0.502)。而发生肠道aGVHD患者组在移植后第14天血清REG-3α水平较未发生者有升高趋势。REG-3α水平与发生肠道aGVHD的等级无统计学意义。结论1.清髓性非血缘脐血移植术后患者外周血血清中ST2、elafin水平可以作为预测急性移植物抗宿主病的发生的生物学标记;移植后第14天患者血清REG-3α水平在发生肠道aGVHD的患者中有升高趋势,但需要扩大病例数进一步证实。2.非血缘脐血移植术后第14天患者外周血血清中ST2水平与移植后6个月非复发死亡相关。更多还原

【Abstract】 Object: Acute graft-versus-host disease is major complications and causes of death after allogeneic hematopoietic stem cell transplantation. However there is no reliable way to predict its occurrence and influence on prognosis. In this study, we monitor the biomarkers of ST2, elafin, and REG-3α in patients’ peripheral blood, then analysis the clinical occurrence of a GVHD.Method: In this research, we choose the patients with hematologic malignancies who received umbilical cord blood transplantation(UCBT) in department of hematology of anhui provincial hospital from July 2013 to July 2014 as participants. Using myeloablative conditioning regimen.Collect 5 ml peripheral blood from patients who received UCBT at day 5, day 14, and day 30. Samples were centrifugal for 8 min under 1500 RPM, then stored in the refrigerator of-80℃. ELISAs method was used through test the ST2, elafin, and REG-3α in patients’ peripheral blood to study the incidence of GVHD after transplantation. To compare the occurrence of GVHD at different timepoints after UCBT, and divide the patients into two groups. Compare the two groups of patients with the concentration of biomarkers.Result: 1. A total of 43 patients were undergoing UCBT, 43 patients achieved engraftment. The median time for neutrophil get engraftment was 18 days. The median time for platelet get engraftment was 46 days after UCBT. Of these 43 patients, 23 patients developed a GVHD between 15 days and 96 days after transplantation(53.5%). Of the total 23 patients with a GVHD, 14 patients had grade Ⅰ- Ⅱa GVHD and 9 patients had Ⅲ-Ⅳa GVHD. The median time was 27 days after UCBT. Among the total 23 patients, 14 patients(61%) had a complete response to corticosteroid treatment, and the 9 steroid-refractory patients(39%) received second-line therapy. The cumulative incidences of the post-transplantation septicemia, hemorrhagic cystitis, TMA, and CMV infection during the follow-up period were 30.2%, 34.9%, 4.7%, and 65.1%, respectively.2. ST2 level was measured on day 5, day 14 and day 30. The increased ST2 levels at day 14(a GVHD 280pg/ml,no a GVHD 90pg/ml) and day 30(a GVHD 340pg/ml,no a GVHD 130pg/ml) were observed in patients who developed a GVHD post-transplantation(P=0.022, and P=0.007). However, no significant association was found between a GVHD and ST2 level at day 5(a GVHD 128pg/ml,no a GVHD 203pg/ml)(P=0.38). According to the classification of a GVHD, we divided the patients into three groups; grade I-II group, grade III-IV a GVHD group, and no a GVHD group. From this study, we can conclude that the level of ST2 in grade III-IV a GVHD group in day 14 and day 30 after UCBT were 600pg/ml and 500pg/ml, respectively, which were higher than the other two groups. However, the ST2 value in grade III-IV a GVHD group was significantly higher than grade I-II group at day 14(P=0.001), there was no relationship between the second group and the third group whether at day 14 or day 30(P=0.301, P=0.092, respectively). Patients with a high and a low ST2 value at day 14 after UCBT, 6-month mortality without relapse was 32.6% and 4.4%, respectively(P=0.003).3. Among a total of 21 cord blood recipients, an amount of 14 patients have developed skin a GVHD. Elafin level was measured on day 5, day 14 and day 30. The study concluded that increased elafin levels at day 14 was observed in patients who developed skin a GVHD post-transplantation(P=0.028). However, no significant association was found between a GVHD and elafin level at day 5 and day 30(P=0.185 and P=0.732).4. A total of 11 patients developed LGI GVHD. REG-3α level was measured on day 5, day 14 and day 30. The study demonstrated that the level of REG-3α at each timepoint were 0.4ng/ml and 0.9ng/ml,1.65 ng/ml and 1.2ng/ml,0.9 ng/ml and 0.8ng/ml between a GVHD and no a GVHD patients. No significant association was found between REG-3α level and patients who developed LGI GVHD at each time point.(P=0.698, P=0.067, and P=0.502, respectively). However, we can observe a trend that REG-3α value was obviously higher in LGI GVHD patients compared with no LGI GVHD patients on day 14. The REG-3α value had no relevant to the grade of LGI GVHD.Conclution: 1. Our results suggest that ST2 and elafin can be a potential plasma biomarker of a GVHD after myeloablative unrelated cord blood transplantation. An trend can be observed that REG-3α value was obviously higher in LGI GVHD patients compared with no LGI GVHD patients on day 14, but it need to expand the number of cases for further conforming.2. Plasma ST2 values at day 14 after UCBT were associated with 6-month mortality without relapse.更多还原