骨膜蛋白在支气管哮喘诊治中的作用
2016/07/07
史玉婷 黄茂
南京医科大学第一附属医院（江苏省人民医院） 210029
南京医科大学第一附属医院（江苏省人民医院） 210029
骨膜蛋白最初是在鼠成骨细胞分泌的蛋白中被发现和鉴定的[1]，并被命名为成骨细胞特异性因子2，后因其在骨膜和牙周韧带组织中高表达，故易名为骨膜蛋白（periostin）[2]。随后的研究表明骨膜蛋白是一种由结缔组织细胞分泌的细胞外基质蛋白，广泛存在于正常成人组织和胎儿组织中，包括胚胎骨膜、牙周韧带、胎盘、心脏、肾上腺、肺、甲状腺等组织[3]，具有十分广泛的生理和病理生理作用，例如组织修复，心脏损伤，肿瘤性疾病等[4-5]。在肺组织中，骨膜蛋白则主要存在于上皮下区域，由气道上皮细胞、成纤维细胞分泌[6]。近来研究将其列为支气管哮喘（哮喘）的潜在生物学标志物之一[7]。
一、骨膜蛋白在哮喘发病机制中的研究
哮喘是由多种细胞和细胞成分参与的气道炎症性疾病，以气道炎症、气道高反应性（AHR）和气道重塑为特征。IL-13是一种作用于免疫性B细胞、巨噬细胞、嗜酸性粒细胞、嗜碱性粒细胞和肥大细胞以及非免疫性的上皮细胞、内皮细胞、成纤维细胞和平滑肌细胞的多功能细胞因子[8-9]。大量证据显示IL-13对支气管上皮细胞的作用增加了哮喘病人的气道高反应性[10-11]。为了明确这种作用的机制，人们利用DNA 微阵列的方法对IL-13诱导的基因进行了全面的研究，结果发现骨膜蛋白基因是表达最多的基因之一[12]。随后Takayama等[13]通过对哮喘患者成纤维细胞进行体外培养，应用RT-PCR、Western blotting技术证实，IL-4和1L-13能够不依赖TGF-β独立诱导肺成纤维细胞分泌骨膜蛋白。在哮喘患者、卵清蛋白致敏的小鼠均可发现骨膜蛋白与其他细胞外基质蛋白共同参与导致（I、Ⅲ、Ⅳ）胶原蛋白、纤连蛋白、肌糖蛋白-C及其他细胞外基质蛋白在基底膜网状板区产生沉积，但是IL-4和IL-13敲除的小鼠未出现上述现象。Sidhu等[8]进行了进一步的相关研究，气道上皮细胞被激活后分泌大量骨膜蛋白于细胞外基质中，随后又通过自分泌方式再次作用于气道上皮细胞，促使气道上皮细胞通过金属基质蛋白酶-2（MMP-2）及MMP-9途径激活TGF-β，从而促进成纤维细胞分泌I型胶原蛋白。以上研究均证明骨膜蛋白参与了哮喘上皮下纤维化过程。
除此以外，对骨膜蛋白在气道炎症中作用的相关研究发现在以真菌提取物致敏的野生型小鼠支气管肺泡灌洗液（BALF）中嗜酸粒细胞明显增多，而骨膜蛋白缺陷小鼠BALF中细胞数明显低于野生型组，但是两组小鼠血中嗜酸粒细胞都有明显升高，并且能够通过调节嗜酸粒细胞趋化蛋白调节嗜酸粒细胞的黏附，说明在过敏性炎症性疾病中骨膜蛋白能够调节嗜酸粒细胞的聚集[14]。为了进一步了解骨膜蛋白在Th2介导的哮喘病中的作用，Sehra等[15]通过动物实验证实骨膜蛋白缺失的小鼠与野生型小鼠相比，外周血中Th2升高，气道阻力增加，杯状细胞黏液分泌增加，提示骨膜蛋白在过敏性肺部炎症中起着负性调节作用。
二、骨膜蛋白作为哮喘生物标志物的实用性
1.骨膜蛋白作为生物标志物的优势
首先，骨膜蛋白较容易从受损组织向附近的血管迁移。在支气管哮喘中上皮细胞、成纤维细胞及内皮细胞是其可能来源，产生于上皮细胞和成纤维细胞的骨膜蛋白易于向血管迁移，而来自于内皮细胞的骨膜蛋白很可能直接被分泌至外周血中。有趣的是，极少量甚至完全没有骨膜蛋白被分泌至支气管腔中[16]。其次，血清骨膜蛋白的基础含量（约50 ng/ml）使其适于作为血清中的生物标志物。其他细胞外基质蛋白如纤连蛋白、玻连蛋白等的血清基础含量（约100 ng/ml）较骨膜蛋白高出许多，意味着如果相同量的细胞外基质蛋白迁移至血管中，骨膜蛋白的增加能更为灵敏地反映在血清含量中。而细胞因子如IL-13（约100pg/ml）的血清基础含量与其相比明显减少，因此尽管骨膜蛋白是IL-13信号通路的下游分子，却更加适合应用于哮喘病人的血清学检测[17]。
2.骨膜蛋白与2型免疫反应的关系
KiHAC[18]研究发现，哮喘病人的血清骨膜蛋白水平明显高于正常对照组（哮喘病人n=224，中位数86.0 ng/mL，平均值92.8 ng/mL，范围22-312 ng/mL；正常对照n=66，中位数33.0 ng/mL，平均值39.1 ng/mL，范围1-114 ng/mL）。进一步分析发现哮喘的迟发性、血嗜酸粒细胞计数、血清IgE和嗜酸细胞阳离子蛋白水平及伴随性的鼻窦炎与血清骨膜蛋白水平具有很好的相关性。后续研究显示阿司匹林不耐受的病人血清骨膜蛋白水平高于正常[19]，将重度哮喘病人按血清骨膜蛋白水平分为高中低三组，阿司匹林不耐受的发生率依次降低。研究发现，阿司匹林不耐受和慢性鼻窦炎是嗜酸粒细胞性重度哮喘的常见并发症[20]。最近的研究发现，按照“哮喘全球创议”（GINA）方案中4-5级治疗的哮喘病人，其FeNO值与血清骨膜蛋白水平存在较强的相关性[21]，而FeNO是2型免疫反应的另一个生物标志物。上述结果显示骨膜蛋白水平与2型免疫反应之间存在一定的相关性，提示血清骨膜蛋白水平升高的哮喘病人对基于2型免疫反应的药物治疗可能具有更好的效果，如抗IL-13治疗[21-22]。
3.骨膜蛋白对ICS低反应性的预测作用
上文已提及骨膜蛋白促进了哮喘病人的气道重塑和纤维化，而纤维化是导致哮喘病人激素抵抗的原因之一[21-22]。为鉴别血清骨膜蛋白是否能预测哮喘病人对ICS的抵抗或低反应性，KiHAC等[18]将哮喘病人分为肺功能快速下降组和非快速下降组。快速下降组FEV1下降值大于30ml/年，表明此类哮喘病人对ICS存在不同程度的抵抗，非快速下降组FEV1下降值小于30ml/年，表明对ICS疗效较好；快速下降组病人的血清骨膜蛋白高于非快速下降组，证明骨膜蛋白与哮喘病人对ICS的低反应性存在一定的相关性。随后的研究显示，嗜酸性粒细胞为主的哮喘病人中，血清骨膜蛋白高的病人使用ICS疗效较差，而血清骨膜蛋白水平较低的病人对ICS反应较好[23]。根据上述试验结果，结合外周血嗜酸粒细胞、中性粒细胞及血清骨膜蛋白水平可以很好的预测哮喘病人对于ICS治疗的反应，其中以嗜酸性粒细胞性炎症为主且骨膜蛋白增多的病人，ICS对其治疗效果较差，针对2型免疫反应的治疗药物或许是更为合理的选择。
三、展望
骨膜蛋白在哮喘病理生理中的作用机制正在被逐步阐明，评估其与现有的生物学指标如嗜酸粒细胞、FeNO等之间关系或可帮助我们完善哮喘的分类诊疗。未来可能开展更多的临床研究以证实血清骨膜蛋白做为支气管哮喘和2型免疫反应生物标志物的有效性，并借此预测不同患者对哮喘治疗药物的反应性。随着骨膜蛋白研究的深入，也有望为寻找哮喘治疗的新靶点提供思路。
参考文献
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14.Blanchard C, Mingler MK, Mcbride M, et a1. Periostin facilitates eosinophil tissue infiltration in allergic lung andesophageal responses[J]. Mueosal Immunol, 2008, 1(4):289-296．
15.Sehra S, Yao W, Nguyen ET, et a1．Periostin regulates goblet cell metaplasia in amodel of allergic airway inflammation[J]. J Immunol, 2011, 186(8):4959-4966.
16.Nakamura Y, Nagashima H, Ohta S, et al. Periostin in the bronchial lavage fluid of asthma patients[J]. Allergol Int, 2015, 64:209e10.
17.Matsusaka M, Kabata H, Fukunaga K, et al.Phenotype of asthma related with high serum periostin levels[J]. Allergol Int, 2015, 64:175e80.
18.Kanemitsu Y, Matsumoto H, Izuhara K, et al. Increased periostin associates with greater airflow limitation in patients receiving inhaled corticosteroids[J]. J Allergy Clin Immunol, 2013, 132:305e12.
19.Kim MA, Izuhara K, Ohta S, et al. Association of serum periostin with aspirin-exacerbated respiratory disease[J]. Ann Allergy Asthma Immunol, 2014, 113(3):314-320.
20.Choi JH, Kim MA, Park HS. An update on the pathogenesis of the upper airways in aspirin-exacerbated respiratory disease[J]. Curr Opin Allergy Clin Immunol, 2014, 14(1):1-6.
21.Corren J, Lemanske RF, Hanania NA, et al. Lebrikizumab treatment in adults with asthma[J]. N Engl J Med, 2011, 365:1088-1098.
22.Scheerens H, Arron JR, Zheng Y, Putnam WS, Erickson RW, Choy DF, et al. The effects of lebrikizumab in patients with mild asthma following whole lung allergen challenge[J]. Clin Exp Allergy 2014;44:38-46.
23. Nagasaki T, Matsumoto H, Kanemitsu Y, et al. Using exhaled nitric oxide and serum periostin as a composite marker to identify severe/steroid-insensitive asthma[J]. Am J Respir Crit Care Med, 2014;190:1449e52.
24.Chung KF, Godard P, Adelroth E, et al. Difficult/therapy-resistant asthma: the need for an integrated approach to define clinical phenotypes, evaluate risk factors, understand pathophysiology and find novel therapies[J]. ERS task force on Difficult/Therapy-Resistant Asthma. European respiratory Society. Eur Respir J, 1999;13:1198e208.
25.Wenzel S. Severe asthma in adults. Am J Respir Crit Care Med, 2005;172:149e60.
26.Nagasaki T, Matsumoto H, Kanemitsu Y, et al. Integrating longitudinal informetionon pulmonary function and inflammation using asthma phenotypes[J]. J Allergy Clin Immunol, 2014;133:1474e7.
2.Ducy P, Zhang R, Geoffroy V, et a1. Osf2/Cbfal: atranscriptional activator of osteoblast differentiation[J]. Cell, 1997, 89(5):747-754.
3.Nuzzo PV, Buzzatti G, Ricci F, et al. Periostin: a novel prognostic and therapeutic target for genitourinary cancer? Clin Genitourin Cancer, 2014, 12:301-311.
4.Hamilton DW. Functional role of periostin in development and wound repair: implications for connective tissuediseaseI-J. J Cell Commun Signal, 2008, 2(1-2):9-17.
5.Norris RA, Moreno-Rodriguez R, Hoffman S, et a1. The many facets of the matricelluar protein periostin during cardiac development remodeling and pathophysiology[J]. J Cell Commun Signal, 2009, 3(3-4):275-286.
6.Woodruff PG, Boushey HA, Dolganov GM, et a1. Genome-wide profiling identifies epithelial cell genes associated with asthma and with treatment response to eortieosteroids[J]. Proc Natl Acad Sci USA, 2007, 104(40): 15858-15863.
7.Matsumoto H. Serum periostin: a novel biomarker for asthma management[J].Allergol Int, 2014, 63:153e60.
8.Sidhu SS, Yuan S, Innes AL, et a1. Roles of epithelial cell-derived periostin in TGF-beta activation, collagen production and collagen gel elasticity in asthma[J]. Proc Natl Acad Sci USA, 2010, 107(32):14170-14175.
9.McKenzie AN, Spits H, Eberl G. Innate lymphoid cells in inflammation and immunity[J]. Immunity, 2014, 41:366e74.
10.Zhu Z, Homer RJ, Wang Z, et al. Pulmonary expression of interleukin-13 causes inflammation, mucus hypersecretion, subepithelial fibrosis, physiologic abnormalities, and eotaxin production. J Clin Invest, 1999, 103:779e88.
11.Kuperman DA, Huang X, Koth LL, et al. Direct effects of interleukin-13 on epithelial cells cause airway hyperreactivity and mucus overproduction in asthma[J]. Nat Med, 2002, 8:885e9.
12.Yuyama N, Davies DE, Akaiwa M, et al. Analysis of novel disease-related genes in bronchial asthma[J]. Cytokine, 2002, 19:287e96.
13.Takayama G, Arima K, Kanaji T, et a1. Periostin: a novel component of subepithelial fibrosis of bronchial asthma downstream of IL-4 and IL-13 signals[J]．J Allergy Clin Immunol, 2006, 118(1):98-104.
14.Blanchard C, Mingler MK, Mcbride M, et a1. Periostin facilitates eosinophil tissue infiltration in allergic lung andesophageal responses[J]. Mueosal Immunol, 2008, 1(4):289-296．
15.Sehra S, Yao W, Nguyen ET, et a1．Periostin regulates goblet cell metaplasia in amodel of allergic airway inflammation[J]. J Immunol, 2011, 186(8):4959-4966.
16.Nakamura Y, Nagashima H, Ohta S, et al. Periostin in the bronchial lavage fluid of asthma patients[J]. Allergol Int, 2015, 64:209e10.
17.Matsusaka M, Kabata H, Fukunaga K, et al.Phenotype of asthma related with high serum periostin levels[J]. Allergol Int, 2015, 64:175e80.
18.Kanemitsu Y, Matsumoto H, Izuhara K, et al. Increased periostin associates with greater airflow limitation in patients receiving inhaled corticosteroids[J]. J Allergy Clin Immunol, 2013, 132:305e12.
19.Kim MA, Izuhara K, Ohta S, et al. Association of serum periostin with aspirin-exacerbated respiratory disease[J]. Ann Allergy Asthma Immunol, 2014, 113(3):314-320.
20.Choi JH, Kim MA, Park HS. An update on the pathogenesis of the upper airways in aspirin-exacerbated respiratory disease[J]. Curr Opin Allergy Clin Immunol, 2014, 14(1):1-6.
21.Corren J, Lemanske RF, Hanania NA, et al. Lebrikizumab treatment in adults with asthma[J]. N Engl J Med, 2011, 365:1088-1098.
22.Scheerens H, Arron JR, Zheng Y, Putnam WS, Erickson RW, Choy DF, et al. The effects of lebrikizumab in patients with mild asthma following whole lung allergen challenge[J]. Clin Exp Allergy 2014;44:38-46.
23. Nagasaki T, Matsumoto H, Kanemitsu Y, et al. Using exhaled nitric oxide and serum periostin as a composite marker to identify severe/steroid-insensitive asthma[J]. Am J Respir Crit Care Med, 2014;190:1449e52.
24.Chung KF, Godard P, Adelroth E, et al. Difficult/therapy-resistant asthma: the need for an integrated approach to define clinical phenotypes, evaluate risk factors, understand pathophysiology and find novel therapies[J]. ERS task force on Difficult/Therapy-Resistant Asthma. European respiratory Society. Eur Respir J, 1999;13:1198e208.
25.Wenzel S. Severe asthma in adults. Am J Respir Crit Care Med, 2005;172:149e60.
26.Nagasaki T, Matsumoto H, Kanemitsu Y, et al. Integrating longitudinal informetionon pulmonary function and inflammation using asthma phenotypes[J]. J Allergy Clin Immunol, 2014;133:1474e7.
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