妊娠肝内胆汁淤积症发生的分子机制研究进展

妊娠肝内胆汁淤积症(Intrahepatic cholestasis of pregnancy,ICP)是发生在妊娠中晚期,以皮肤瘙痒、黄疸、血清胆汁酸升高,伴轻度肝功能损害为特征的妊娠并发症,严重影响母儿健康。ICP的发病机制尚未完全阐明,但有研究表明在遗传易感性妇女中,性激素及其代谢产物导致胆汁酸代谢异常与本病的发生密切相关。现就目前国内外有关ICP发病机制的研究进展做一综述,一方面为探寻更深层次的机制提供理论基础,另一方面为临床治疗ICP提供思路和方法。     

妊娠肝内胆汁淤积症胎儿猝死发病机制的研究进展

妊娠肝内胆汁淤积症（ICP）妊娠晚期胎儿猝死,难以预料和准确监测,具有高风险性。目前其机制不明。孕妇和胎儿高胆汁酸水平对胎盘功能的影响和对胎儿的损伤是当前研究的主要方向。特别是一系列胆汁酸对心肌细胞毒性作用的实验,提示胆汁酸对胎儿心脏的毒性作用可能是引起胎儿猝死的重要原因。     

胆汁酸受体在非酒精性脂肪性肝病中的作用

非酒精性脂肪性肝病(non-alcoholic fatty liver disease, NAFLD)作为一种慢性肝病,在全球的发病率逐年递增。胰岛素抵抗和脂质代谢紊乱,以及随后的炎症反应和纤维化的激活,在其发生发展过程中发挥重要作用。但是对其认识仍很欠缺,且临床尚缺乏有效的药物。科研人员正极力探索NAFLD的相关病因及治疗的新的突破口。胆汁酸是在肝中合成的众多代谢产物之一。除帮助脂肪消化吸收外,胆汁酸还作为信号分子激活胆汁酸受体,一种重要的转录调节因子而发挥效应,对维持机体正常生理代谢至关重要。越来越多的证据表明,胆汁酸受体的功能与NAFLD的发生发展关系密切,研究其相关的作用与功能可为治疗NAFLD提供新见解和药物治疗靶点。本文就胆汁酸受体包括核受体,诸如法尼醇X受体 (farnesoid X receptor, FXR)、孕烷X受体 (pregnane X receptor ,PXR)等,和细胞表面受体,诸如跨膜G蛋白偶联胆汁酸受体5(transmembrane G protein-coupled receptor 5, TGR5)、鞘氨醇-1-磷酸受体2(phingosine-1-phosphate receptor 2, S1PR2)和毒蕈碱胆碱受体3 (M3 muscarinic receptor, M3R)通过调节胆汁酸稳态、脂质和糖代谢、能量代谢、肝的炎症和纤维化等参与NAFLD发病机制的研究进展进行总结,并进一步阐述了胆汁酸受体激动剂对NAFLD的治疗现状,以期更全面地了解NAFLD的发病机制以及为治疗找到更有效的途径。     

FXR与糖尿病相关性研究进展

国际糖尿病联盟(IDF)最新数据表明目前中国糖尿病患者在剧增。糖尿病是以胰岛素分泌相对或和绝对不足导致的慢性高血糖为特征的代谢性疾病,法尼醇X受体(farnesoid X receptor,FXR,NR1H4)是能被胆汁酸激活的转录因子,FXR能对胆汁酸的代谢进行调节,胆汁酸代谢与糖尿病相关,胆汁酸代谢在β细胞的功能是通过FXR介导的,本文回顾国内外有关法尼醇X受体通过抑制肝糖原异生、增加肝糖原储存、影响胰岛素信号、增加胰岛素的分泌和增强胰岛素的敏感性等机制发挥调节血糖平衡作用的研究,意在探索FXR与糖尿病的相关性,为糖尿病的发病机制提供新的理论依据。     

肠道菌群与胆汁酸代谢在代谢相关脂肪性肝病的发生发展中的作用CSCD

代谢相关脂肪性肝病(metabolic-dysfunction-associated fatty liver disease,MAFLD)已成为我国慢性肝病的主要病因之一,其发病率呈逐年上升趋势。MAFLD是代谢综合征累及肝脏的表现,其发生发展与肠道菌群失调和代谢功能障碍等密切相关。由于发病机制尚不明确,目前依旧缺乏有效的药物治疗方法。肠道菌群与胆汁酸代谢密切相关,胆汁酸可靶向法尼醇X受体(farnesoid X receptor,FXR)信号通路负反馈调控肠道菌群,同时肠道菌群通过一系列复杂的生化反应影响胆汁酸代谢。大量研究发现MAFLD的免疫应答受损及全身低度慢性炎症可导致胆汁酸代谢紊乱。此外,MAFLD常伴随肠道菌群失调。本文就肠道菌群与胆汁酸代谢在MAFLD发生发展中的作用作一综述,以期探寻治疗MAFLD潜在的新的靶点。     

妊娠期肝内胆汁淤积症患者血管内皮祖细胞生物学变化

目的:研究妊娠期肝内胆汁淤积症(Intrahepatic Cholestasis of Pregnancy,ICP)患者血管内皮祖细胞(Endothelial Progenitor Cells,EPC)的生物学变化并探讨其意义.方法:40例28-40周孕妇分为ICP组(n=20)、正常组(n=20).用酶联免疫吸附试验法测定两组血胆汁酸浓度;用密度梯度离心法从外周血分离两组单个核细胞培养后进行EPC数量、增殖率、黏附及迁移能力测定并对胆汁酸与EPC相关性进行分析.结果:ICP组孕妇的EPC黏附、增殖和迁移能力明显受损;数量较正常组减少(P=0.00).结论:ICP患者血管内皮祖细胞功能受损,可能与高胆汁酸造成的细胞膜损伤有关.     

从肠道微生物出发探讨其代谢产物与心血管疾病的关系

肠道菌群在维护人类的健康以及在疾病发展中起到重要的作用。随着对肠道菌群的逐步了解,人们发现肠道菌群结构和功能的紊乱与动脉粥样硬化和冠心病等心血管疾病的发生密切相关。肠道菌群的代谢产物例如氧化三甲胺、短链脂肪酸、胆汁酸和脂多糖的增多被认为是影响心血管疾病发生、发展和预后的危险因素。本文将阐述肠道菌群及其代谢产物在心血管疾病发病机制中的作用,从"心血管-肠道-肠道菌群"的角度,为心血管疾病的个体化辨证防治提供新的思路和方法。     

熊脱氧酸治疗妊娠期肝内胆汁淤积症的临床效果分析

目的:探讨熊脱氧酸治疗妊娠期肝内胆汁淤积症(ICP)的临床效果及其可能机制。方法:选择2013年8月到2018年2月在我院诊治的ICP患者105例作为研究对象,根据治疗方法分为对照组50例和研究组55例,对照组给予腺苷蛋氨酸治疗,研究组给予腺苷蛋氨酸联合熊脱氧酸治疗,检测和比较两组的临床总有效率,治疗前后的血清肿瘤坏死因子α(TNF-α)、白细胞介素12(IL-12)、甘胆酸(CG)和总胆汁酸(TBA)水平的变化及妊娠结局。结果:所有患者都顺利分娩,无死亡产妇与胎儿。研究组的总有效率为98.2%,显著高于对照组(88.0%),差异有统计学意义(P0.05)。两组治疗后的血清CG、TBA、IL-12及TNF-α水平均显著低于治疗前(P0.05),且研究组以上指标均明显低于对照组(P0.05)。研究组的剖宫产、早产、新生儿窒息、产后出血、羊水粪染等发生率显著低于对照组(P0.05)。结论:熊脱氧酸治疗ICP能有效提高治疗效果,改善妊娠结局,这可能与其降低血清患者TNF-α、IL-12、CG、TBA水平有关。     

96例妊娠期肝内胆汁淤积症患者的妊娠结局分析及护理对策

目的:探讨妊娠合并肝内胆汁淤积症(ICP)对妊娠结局的影响,并探索相对应的护理策略.方法:选取在我院治疗的ICP患者96例,根据ICP分度标准分为轻度与重度型,分别观察其妊娠.结果:重型组患者新生儿窒息、羊水污染、剖宫产的发生率都明显高于轻型组患者(P＜0.05);而两组围产儿死亡率和产后出血率相比,差异无显著性意义(P＞0.05).结论:ICP对孕妇妊娠结局具有重要的不良影响作用,针对其可能导致的不良妊娠结局采取针对性的护理策略具有重要的临床意义.     

胆汁酸和肠道菌群相互作用对非酒精性脂肪性肝病的影响

近年来,大量研究发现胆汁酸与肠道菌群相互作用对非酒精性脂肪性肝病的发生和发展有重要影响。胆汁酸主要在肝脏中合成,分泌进入肠道后不仅可以促进脂类物质的消化和吸收,还具有重要的生理信号和代谢调节作用,其能通过参与能量代谢和炎症反应影响非酒精性脂肪性肝病的进程。肠道菌群的代谢产物(如胆汁酸、短链脂肪酸、内生性乙醇和三甲胺等)对宿主的代谢表型、免疫稳态、炎症反应和病程进展等都有重要调节作用。本文主要综述了胆汁酸的合成、转运代谢与肠道菌群结构变化之间的互相作用和对话交流机制,揭示了肠道菌群结构紊乱和胆汁酸代谢异常对非酒精性脂肪性肝病的推动作用,以期为临床上治疗非酒精性脂肪性肝病提供全新的策略和方法。     

The Reversed Feto-Maternal Bile Acid Gradient in Intrahepatic Cholestasis of Pregnancy Is Corrected by Ursodeoxycholic Acid

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disorder associated with an increased risk of adverse fetal outcomes. It is characterised by raised maternal serum bile acids, which are believed to cause the adverse outcomes. ICP is commonly treated with ursodeoxycholic acid (UDCA). This study aimed to determine the fetal and maternal bile acid profiles in normal and ICP pregnancies, and to examine the effect of UDCA treatment. Matched maternal and umbilical cord serum samples were collected from untreated ICP (n = 18), UDCA-treated ICP (n = 46) and uncomplicated pregnancy (n = 15) cases at the time of delivery. Nineteen individual bile acids were measured using HPLC-MS/MS. Maternal and fetal serum bile acids are significantly raised in ICP compared with normal pregnancy (p = <0.0001 and <0.05, respectively), predominantly due to increased levels of conjugated cholic and chenodeoxycholic acid. There are no differences between the umbilical cord artery and cord vein levels of the major bile acid species. The feto-maternal gradient of bile acids is reversed in ICP. Treatment with UDCA significantly reduces serum bile acids in the maternal compartment (p = <0.0001), thereby reducing the feto-maternal transplacental gradient. UDCA-treatment does not cause a clinically important increase in lithocholic acid (LCA) concentrations. ICP is associated with significant quantitative and qualitative changes in the maternal and fetal bile acid pools. Treatment with UDCA reduces the level of bile acids in both compartments and reverses the qualitative changes. We have not found evidence to support the suggestion that UDCA treatment increases fetal LCA concentrations to deleterious levels.     

Elevated Plasma Levels of Hypermethylated RASSF1A Gene Sequences in Pregnant Women with Intrahepatic Cholestasis

Intrahepatic cholestasis of pregnancy (ICP) is associated with increased perinatal mortality and morbidity. Circulating cell-free fetal DNA has been a useful parameter for monitoring of pregnancy-associated diseases. The purpose of this study was to determine the concentrations of hypermethylated RAS-association domain family 1, isoform A (RASSF1A) gene sequences in the plasma of pregnant women with intrahepatic cholestasis. This study included 56 women in their third trimester of pregnancy, of whom 26 had ICP (study group) and 30 were healthy (control group). Real time PCR was performed to detect RASSF1A concentrations after methylation-sensitive restriction digestion with HinpII and HhaI to measure cell-free fetal DNA. Beta-actin was detected as an internal control to confirm complete enzyme digestion. The data show a significant increase in the circulating hypermethylated RASSF1A levels regarding the pregnancies complicated with ICP as compared with normal pregnancies. Circulating hypermethylated RASSF1A levels in maternal plasma related to total bile acid. Based on these observations, we suggest that the circulating hypermethylated RASSF1A levels in maternal plasma may be used as a diagnostic marker for ICP.     

Roles of PPARγ/NF-κB Signaling Pathway in the Pathogenesis of Intrahepatic Cholestasis of Pregnancy

Background

Intrahepatic cholestasis of pregnancy (ICP) is the most prevalent pregnancy specific liver disease. However, the pathogenesis and etiology of ICP is poorly understood.

Aim

To assess the expression of peroxisome proliferator-activated receptorγ (PPARγ) and nuclear factor kappa B (NF-κB) in placenta and HTR-8/SVneo cell, and evaluate the serum levels of cytokines, bile acids, hepatic function and lipids in control and ICP patients and the fetal outcome, in order to explore the role of PPARγ/NF-κB signaling pathway in the possible mechanism of ICP.

Methods

Clinical data of the pregnant women were collected and serum levels of cytokines, bile acids, hepatic function and lipids were measured. Expressions of PPARγ and NF-κB in placenta and HTR-8/SVneo cell were determined. The new-born information was collected to demonstrate the relationship between PPARγ/NF-κB signaling pathway and ICP.

Results

The serum levels of bile acids, hepatic function, triglycerides (TG), total cholesterol (TC), IL-6, IL-12 and TNF-α in ICP group were significantly increased (P<0.01), and serum level of IL-4 was significantly decreased (P<0.01). PPARγ and NF-κB staining were found in the membrane and cytoplasm of placental trophoblast cell. The expression of PPARγ and NF-κB were significantly higher in ICP group and taurocholate acid (TCA) treated HTR-8/SVneo cell (P<0.01). The new-born information in severe ICP group were significantly different as compared to that in control group (P<0.05), and part of information in mild ICP group were also difference to that in control group (P<0.05).

Conclusions

The higher expressions of PPARγ and NF-κB in ICP placenta and TCA treated HTR-8/SVneo cell, together with the abnormal serum levels of cytokines, might induced by the imbalance of inflammatory and immune reaction, and then disturb placental bile acid and serum lipids transportation, finally result in fatal cholestasis which probably be one of the mechanism of ICP.     

Heart and bile acids – Clinical consequences of altered bile acid metabolism

Cardiac dysfunction has an increased prevalence in diseases complicated by liver cirrhosis such as primary biliary cholangitis and primary sclerosing cholangitis. This observation has led to research into the association between abnormalities in bile acid metabolism and cardiac pathology. Approximately 50% of liver cirrhosis cases develop cirrhotic cardiomyopathy. Bile acids are directly implicated in this, causing QT interval prolongation, cardiac hypertrophy, cardiomyocyte apoptosis and abnormal haemodynamics of the heart. Elevated maternal serum bile acids in intrahepatic cholestasis of pregnancy, a disorder which causes an impaired feto-maternal bile acid gradient, have been associated with fatal fetal arrhythmias. The hydrophobicity of individual bile acids in the serum bile acid pool is of relevance, with relatively lipophilic bile acids having a more harmful effect on the heart. Ursodeoxycholic acid can reverse or protect against these detrimental cardiac effects of elevated bile acids.     

Phospholipid metabolism in bile duct-ligated rat plasma and erythrocytes

Incorporation of [32P]orthophosphate into phosphatidylcholine, lysophosphatidylcholine and molecular species of phosphatidylcholine in vivo was observed in liver, plasma and erythrocytes of bile duct-ligated or sham-operated rats. Both the amount and radioactivity of dienoic species of phosphatidylcholine in all tissues examined increased in bile duct-ligated rats as compared to sham-operated rats. The experiments in vivo and in vitro showed that the ratio of lysophosphatidylcholine to phosphatidylcholine transferred to erythrocytes from plasma in sham-operated rats was much higher than that in bile duct-ligated rats. It is suggested that one of the mechanisms by which abnormal erythrocytes appear might be explained by the facilitated and direct transfer of phosphatidylcholine, which is caused by the interaction of erythrocytes with bile acid in bile duct-ligated rat plasma.     

Bile Acid-Induced Arrhythmia Is Mediated by Muscarinic M2 Receptors in Neonatal Rat Cardiomyocytes

Background

Intrahepatic cholestasis of pregnancy (ICP) is a common disease affecting up to 5% of pregnancies and which can cause fetal arrhythmia and sudden intrauterine death. We previously demonstrated that bile acid taurocholate (TC), which is raised in the bloodstream of ICP, can acutely alter the rate and rhythm of contraction and induce abnormal calcium destabilization in cultured neonatal rat cardiomyocytes (NRCM). Apart from their hepatic functions bile acids are ubiquitous signalling molecules with diverse systemic effects mediated by either the nuclear receptor FXR or by a recently discovered G-protein coupled receptor TGR5. We aim to investigate the mechanism of bile-acid induced arrhythmogenic effects in an in-vitro model of the fetal heart.

Methods and Results

Levels of bile acid transporters and nuclear receptor FXR were studied by quantitative real time PCR, western blot and immunostaining, which showed low levels of expression. We did not observe functional involvement of the canonical receptors FXR and TGR5. Instead, we found that TC binds to the muscarinic M₂ receptor in NRCM and serves as a partial agonist of this receptor in terms of inhibitory effect on intracellular cAMP and negative chronotropic response. Pharmacological inhibition and siRNA-knockdown of the M₂ receptor completely abolished the negative effect of TC on contraction, calcium transient amplitude and synchronisation in NRCM clusters.

Conclusion

We conclude that in NRCM the TC-induced arrhythmia is mediated by the partial agonism at the M₂ receptor. This mechanism might serve as a promising new therapeutic target for fetal arrhythmia.     

The role of phosphatidylethanolamine methyltransferase in a mouse model of intrahepatic cholestasis

Intrahepatic cholestasis eventually leads to liver failure. We report here a condition that decreases liver damage in intrahepatic cholestasis based on a mouse model that lacks multiple drug resistant protein 2 (ABCB4). We found that lack of phosphatidylethanolamine N-methyltransferase (PEMT) decreased liver damage in Abcb4(-/-) mice caused by exposure of the liver to excess bile acids. The protective effect was not related to hepatic ratio of phosphatidylcholine to phosphatidylethanolamine or the level of cholesterol. The decreased concentration of bile acids in liver was related to impaired re-absorption of bile acids in intestine and increased disposal of bile acids in feces in Abcb4(-/-)/Pemt(-/-) mice as compared to Abcb4(-/-) mice. PEMT deficiency affected intestinal Na(+) absorption resulting in an impaired Na(+) concentration gradient along the length of the small intestine and abnormal absorption of bile acids mediated by apical sodium-dependent bile acid transporter (ASBT). The findings of this study suggest that inhibition of PEMT and/or reduction of intestinal sodium concentration may be helpful in attenuating liver damage and prolonging hepatic function in intrahepatic cholestasis.