原发性高血压病患者血清瘦素、可溶性瘦素受体及沉默信息调节因子相关酶3水平与动脉粥样硬化的关系研究

胡迪聃，徐彤彤，王文艳，顾婉红



·论著·

原发性高血压病患者血清瘦素、可溶性瘦素受体及沉默信息调节因子相关酶3水平与动脉粥样硬化的关系研究

胡迪聃，徐彤彤，王文艳，顾婉红

目的探讨原发性高血压病(EH)患者血清瘦素(LP)、可溶性瘦素受体(SLR)及沉默信息调节因子相关酶3(SIRT3)水平与动脉粥样硬化(AS)之间的关系。方法选取2015年7月—2016年1月在桂林医学院附属医院心血管内科及特需病区住院的EH患者60例为EH组，及同期在本院进行体检的健康成年人60例为对照组。根据高血压分级将EH组患者分为高血压1、2、3级，各20例。根据颈动脉内膜-中层厚度(cIMT)将所有受试者分为cIMT正常组55例、cIMT增厚组52例和颈动脉斑块形成组13例。采用ELISA检测所有受试者血清LP、SLR及SIRT3水平，以cIMT来评估AS程度，同时检测空腹血糖(FPG)、总胆固醇(TC)、三酰甘油(TG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、尿素氮(BUN)、肌酐(Cr)等相关指标。结果EH组患者血清LP、SIRT3水平及cIMT均高于对照组，血清SLR水平低于对照组，差异有统计学意义(P<0.05)。不同高血压分级患者血清LP、SLR、SIRT3水平及cIMT间差异均有统计学意义(P<0.05)，其中高血压3级患者血清LP、SIRT3水平及cIMT高于高血压1、2级患者，血清SLR水平低于高血压1、2级患者；高血压2级患者血清LP、SIRT3水平高于高血压1级患者，血清SLR水平低于高血压1级患者。不同cIMT分组患者血清LP、SLR、SIRT3水平间差异均有统计学意义(P<0.05)，其中颈动脉斑块形成组患者血清LP、SIRT3水平高于cIMT正常组、增厚组，血清SLR水平低于cIMT正常组、增厚组；cIMT增厚组患者血清LP、SIRT3水平高于cIMT正常组，血清SLR水平低于cIMT正常组。cIMT与LP、SIRT3呈直线正相关(r值分别为0.725、0.683，P<0.05)，与SLR呈直线负相关(r=-0.720，P<0.05)。多元Logistic回归分析结果显示，LP、SIRT3是cIMT增厚的独立危险因素(P<0.05)，而SLR是cIMT增厚的独立保护因素(P<0.05)。结论血清LP、SLR、SIRT3水平与高血压及cIMT密切相关，说明瘦素抵抗、SIRT3可能参与了EH及AS的形成和发展。

瘦素；受体,瘦素；沉默信息调节因子相关酶3；高血压；动脉粥样硬化

胡迪聃，徐彤彤，王文艳，等.原发性高血压病患者血清瘦素、可溶性瘦素受体及沉默信息调节因子相关酶3水平与动脉粥样硬化的关系研究[J].中国全科医学，2016，19(22)：2676-2680.[www.chinagp.net]

HU D D,XU T T,WANG W Y,et al.Correlation between serum leptin,soluble leptin receptor as well as silent information regulator related enzyme 3 levels and atherosclerosis in patients with essential hypertension[J].Chinese General Practice，2016，19(22)：2676-2680.

原发性高血压病(essential hypertension,EH)是最常见的由多种因素导致的持续进展状态的心血管疾病，长期高血压可引起心脏结构和功能的改变，导致严重的心血管并发症，是增加血管病变、动脉粥样硬化(atherosclerosis,AS)的主要危险因素。当AS发展到一定程度，尤其是有明显血管狭窄或闭塞，并引起相应器官病变时，诊断并不困难，但早期诊断并不容易。目前可通过颈动脉超声技术检测颈动脉内膜-中层厚度(carotid intima media thickness,cIMT)及斑块形成，以cIMT作为早期评估AS病变程度的指标[1]。高血压所致的AS是由血管内皮损伤导致的慢性炎性反应，同时神经体液因素也是重要机制之一。本研究通过探讨EH患者血清瘦素(leptin,LP)、可溶性瘦素受体(soluble leptin receptor,SLR)及沉默信息调节因子相关酶3(silent information regulator factor related enzyme 3,SIRT3)水平与cIMT的相关性，为评估和防治AS提供有益线索。

1　资料与方法

1.2方法

1.2.1血压测量待测者坐位安静休息至少10 min后，选择经校准的台式水银柱血压计连续测量右上肢肱动脉血压2次，每次至少间隔1～2 min，取平均值，分别以Korotkof第1音和第5音确定收缩压(systolic blood pressure,SBP)和舒张压(diastolic blood pressure,DBP)水平。若2次测量的SBP或DBP读数相差≥5 mm Hg(1 mm Hg=0.133 kPa)，则相隔5 min后再测量，取3次测量的平均值并记录，作为被测者的血压值。

1.2.2血清LP、SLR及SIRT3水平检测所有受试者禁食12 h以上，于次日清晨空腹抽取肘静脉血2 ml，离心半径13 cm，3 000 r/min离心10 min后，分离上层清夜置-70 ℃冰箱中保存待测。血清LP、SLR及SIRT3水平均采用ELISA测定，试剂盒购自上海一基实业有限公司，按说明书具体步骤操作，测定吸光度，由标准曲线计算血清LP、SLR及SIRT3水平。

1.2.3相关指标检测应用7600型全自动生化分析仪测定空腹血糖(fasting plasma glucose,FPG)、总胆固醇(total cholesterol,TC)、三酰甘油(triacylglycerol,TG)、高密度脂蛋白胆固醇(high density lipoprotein cholesterol,HDL-C)、低密度脂蛋白胆固醇(low density lipoprotein cholesterol,LDL-C)、尿素氮(blood urea nitrogen,BUN)、肌酐(creatinine,Cr)、尿酸(uric acid,UA)、同型半胱氨酸(homocysteine,Hcy)及超敏C反应蛋白(high sensitivity C reactive protein,hs-CRP)水平。测身高、体质量、腰围、臀围，计算BMI、腰臀比(waist-to-hip ratio,WHR)；腰臀比=腰围(cm)/臀围(cm)。

1.2.4颈动脉多普勒彩超检查及分组使用德国西门子Acuson Sequoia 512型多普勒彩超诊断仪，由本院超声科同一资深专业医师操作，采用7.5～10 MHz探头。检查对象取去枕仰卧位，头偏向检查侧对侧，充分暴露颈部，分别探查双侧颈总动脉、颈动脉分叉及双侧颈内、外动脉。为观察血清LP、SLR及SIRT3水平与cIMT的关系，根据血管超声检查指南中cIMT分组标准，将所有患者分为cIMT正常组55例(cIMT<1.0 mm)、cIMT增厚组52例(cIMT≥1.0 mm) 和颈动脉斑块形成组13例(局限性cIMT≥1.5 mm)[3]。对照组中47例进入cIMT正常组，13例进入cIMT增厚组；EH组中8例进入cIMT正常组，39例进入cIMT增厚组，13例进入斑块形成组。

2　结果

2.1两组患者观察指标比较两组患者BMI、WHR、FPG、TC、TG、LDL-C、BUN、Cr间差异无统计学意义(P>0.05)；而SBP、DBP、LP、SLR、SIRT3、cIMT、HDL-C、UA、Hcy、hs-CRP间差异有统计学意义(P<0.05，见表1) 。

表1　两组患者观察指标比较±s)

注：EH=原发性高血压病，WHR=腰臀比，SBP=收缩压，DBP=舒张压，LP=瘦素，SLR=可溶性瘦素受体，SIRT3=沉默信息调节因子相关酶3，cIMT=颈动脉内膜-中层厚度，FPG=空腹血糖，TC=总胆固醇，TG=三酰甘油，HDL-C=高密度脂蛋白胆固醇，LDL-C=低密度脂蛋白胆固醇，BUN=尿素氮，Cr=肌酐，UA=尿酸，Hcy=同型半胱氨酸,hs-CRP=超敏C反应蛋白；1 mm Hg=0.133 kPa

2.2不同高血压分级患者血清LP、SLR、SIRT3水平及cIMT比较不同高血压分级患者血清LP、SLR、SIRT3水平及cIMT间差异均有统计学意义(P<0.05)，其中高血压3级患者血清LP、SLR、SIRT3水平及cIMT与高血压1、2级患者比较，高血压2级患者血清LP、SLR、SIRT3水平及cIMT与高血压1级患者比较，差异均有统计学意义(P<0.05，见表2)。

表2　不同高血压分级患者血清LP、SLR、SIRT3水平及cIMT比较

注：与高血压1级比较，aP<0.05；与高血压2级比较，bP<0.05

2.3不同cIMT分组患者血清LP、SLR、SIRT3水平比较不同cIMT分组患者血清LP、SLR、SIRT3水平间差异均有统计学意义(P<0.05)。其中颈动脉斑块形成组患者血清LP、SLR、SIRT3水平与cIMT正常组、增厚组比较，cIMT增厚组患者血清LP、SLR、SIRT3水平与cIMT正常组比较，差异均有统计学意义(P<0.05，见表3)。

表3　不同cIMT分组患者血清LP、SLR、SIRT3水平比较

注：与cIMT正常组比较，aP<0.05；与cIMT增厚组比较，bP<0.05

2.4cIMT与其他观察指标的相关性分析cIMT与BMI、WHR、FPG、TC、TG、LDL-C、BUN、Cr无直线相关关系(r值分别为0.113、0.043、0.108、0.178、0.178、0.138、0.117、0.075，P>0.05)；而与SBP、DBP、LP、SIRT3、HDL-C、UA、Hcy、hs-CRP呈直线正相关(r值分别为0.636、0.581、0.725、0.683、0.196、0.181、0.334、0.226，P<0.05)，与SLR呈直线负相关(r=-0.720，P<0.05)。

2.5cIMT影响因素的多元Logistic回归分析以cIMT有无增厚为因变量(赋值：cIMT正常组=0，cIMT增厚组及颈动脉斑块形成组=1)，以SBP、DBP、LP、SLR、SIRT3、HDL-C、UA、Hcy、hs-CRP为自变量，进行多元Logistic回归分析。结果显示，LP、SIRT3是cIMT增厚的独立危险因素(P<0.05)，而SLR、Hcy是cIMT增厚的独立保护因素(P<0.05，见表4)。

表4　cIMT影响因素的多元Logistic回归分析

3　讨论

LP是一种主要由脂肪组织分泌的蛋白质类激素，主要通过与其受体结合而产生生物学效应，其与许多心血管疾病的发生、发展密切相关[4]。在体内，LP过度表达可反馈下调SLR的产生；而LP信号缺陷导致SLR增加，上调LP水平。由于LP和SLR之间反馈调节机制的存在，SLR可作为检测LP生物学活性的重要指标。本研究显示EH组血清LP水平明显高于对照组，血清SLR水平明显低于对照组，且随着高血压分级增高，血清LP水平升高，血清SLR水平下降，说明EH患者存在瘦素抵抗(leptin resistence,LR)现象，且与高血压分级密切相关。已有相关研究认为LR与高血压存在关联性[5]。其引起高血压的原因可能为：(1)高LP血症可引起交感神经系统(sympathetic nervous system,SNS)激活、外周血管收缩及促进肾小管对水、钠的重吸收，导致水钠潴留，致使血压升高[6]；(2)血清LP水平与肾素活性及醛固酮水平相关，提示LP可能介导肾素-血管紧张素-醛固酮系统(renin angiotensin aldosterone system,RAAS)的激活使血压升高[7]；(3)同时，血清LP水平升高，其与受体结合增加，可增强二磷酸腺苷(adenosine diphosphate,ADP)诱导的血小板聚集，引起外周血管收缩，增加外周阻力[8]。由此说明，高血压患者存在LP及LP受体异常，其可通过复杂机制影响EH的进程。

除此之外，LP在AS形成中扮演着重要角色[4]。AS是一种慢性炎性反应，而LP的分泌异常诱导机体产生各种炎性因子参与炎性反应，从而加速AS进程[9-10]。SCHAFER等[8]发现LP可调节血小板功能，促进血小板的黏附、聚集、活化等过程，增加动静脉血栓的形成。CIRILLO等[11]认为LP能增加细胞黏附分子(cell adhesion molecule,CAM)和组织因子的表达，促进凝血反应。王先梅等[12]研究发现EH患者血清LP水平明显升高，且与cIMT存在相关性。本研究结果显示，血清LP水平随cIMT增厚而增高，而血清SLR水平随cIMT增厚而降低；cIMT与LP呈直线正相关，与SLR呈直线负相关；LP是cIMT增厚的独立危险因素，而SLR会降低cIMT增厚的危险性。以上说明LR与AS密切相关，并影响AS的进程。

SIRT3是一类烟酰胺腺嘌呤二核苷酸(nicotinamide adenine dinucleotide,NAD+)依赖性组蛋白去乙酰化酶，在体内分布广泛，与多种心血管疾病，尤其是早期AS形成密切相关，且对心血管系统具有重要保护作用[13]。本研究结果显示，EH组血清SIRT3水平明显高于对照组，且随高血压分级增加，血清SIRT3水平升高。故推测在高血压或交感神经兴奋等应激状态下，心肌细胞代偿性SIRT3表达增加以减轻血流动力学超负荷对机体造成的损伤，从而影响EH的发生发展[14]。研究发现，血管平滑肌细胞中SIRT3随着血管紧张素Ⅱ(Angiotensin Ⅱ,Ang Ⅱ)水平升高而表达增加，抑制由Ang Ⅱ诱导血管平滑肌细胞增殖；而敲除SIRT3基因后，血管平滑肌细胞增殖加快，可诱发AS的发生发展[14]。同时，体内活性氧(reactive oxygen species,ROS)的过度累积与AS发病相关，而SIRT3可直接或间接下调ROS水平，促进内皮型一氧化氮合酶(endothelial nitric oxide synthase,eNOS)生成，以改善血管内皮功能[15-16]。BELL等[17]认为线粒体SIRT3可通过直接去乙酰化激活锰超氧化物歧化酶(manganese superoxide dismutase,MnSOD)及异柠檬酸脱氢酶2(isocitrate dehydrogenase 2,IDH2)等抗氧化因子，启动抗氧化过程降低ROS的蓄积，延缓AS进程。本研究结果显示，血清SIRT3水平随cIMT增厚而增高；cIMT与SIRT3呈直线正相关；SIRT3是cIMT增厚的独立危险因素，说明SIRT3与AS密切相关，对评估AS程度具有一定意义。

综上所述，LR、SIRT3与cIMT密切相关，可能参与了EH及AS的形成和发展，但具体作用机制尚不明确，有待于进一步深入研究。本研究结果提示，血清LP、SLR及SIRT3水平的变化可作为评估EH及AS病情和严重程度的早期预测指标，为EH及AS的诊疗提供新思路，具有一定的临床参考价值。

作者贡献：胡迪聃、徐彤彤负责试验设计与实施、撰写论文、成文并对文章负责；王文艳负责试验实施、评估、资料收集；顾婉红负责质量控制与审校。

本文无利益冲突。

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(本文编辑：崔沙沙)

Correlation Between Serum Leptin,Soluble Leptin Receptor as Well as Silent Information Regulator Related Enzyme 3 Levels and Atherosclerosis in Patients With Essential Hypertension

HUDi-dan,XUTong-tong,WANGWen-yan,GUWan-hong.VIPWard,AffiliatedHospitalofGuilinMedicalUniversity,Guilin541001,China

Correspondingauthor:XUTong-tong,VIPWard,AffiliatedHospitalofGuilinMedicalUniversity,Guilin541001,China;E-mail：xutongtongguilin@163.com

ObjectiveTo analyze the relationship between serum leptin(LP),soluble leptin receptor(SLR) and silent information regulator factor related enzyme 3(SIRT3) with atherosclerosis(AS)in patients with essential hypertension (EH).Methods60 cases with EH,who were hospitalized in Cardiovascular Department of Internal Medicine and VIP Ward of the Affiliated Hospital of Guilin Medical College from July 2015 to January 2016,were selected as the EH group,and 60 cases of healthy adults examined medically during the corresponding period in our hospital were selected as the control group.The 60 cases with EH were divided into the patients with hypertension stage 1,stage 2 and stage 3 according the hypertension grading,with each stage 20 cases respectively.All subjects were divided in accordance with carotid intima media thickness (cIMT) into cIMT normal group with 55 cases,cIMT thickness group with 52 cases and the plaque formation group with 13 cases.Serum LP,SLR and SIRT3 levels were tested by ELISA method,and cIMT was used to measure the degrees of AS and to examine the relative indicators of fasting plasma glucose(FPG),total cholesterol(TC),triacylglycerol(TG),high density lipoprotein cholesterol(HDL-C),low density lipoprotein cholesterol(LDL-C),blood urea nitrogen(BUN) and creatinine(Cr),etc.ResultsThe cIMT and serum LP,SIRT3 levels of EH group were significantly higher than those of the control group,while serum SLR level of the EH group was significantly lower than that of control group,and differences were statistically significant (P<0.05).Differences among cIMT and serum LP,SIRT3 levels of the patients with different hypertension grades were statistically significant (P<0.05).Among them,cIMT and serum LP,SIRT3 levels of the patients with hypertension stage 3 were significantly higher than that of patients with hypertension stage 1 and 2,while serum SLR level was lower than that of patients with hypertension stage 1 and 2;cIMT and serum LP,SIRT3 levels of the patients with hypertension stage 2 were significantly higher than those of patients with hypertension stage 1,while serum SLR level was lower than that of patients with hypertension 1.Differences among serum LP,SIRT3 levels of patients in different cIMT groups were statistically significant (P<0.05),in which serum LP,SIRT3 levels of patients in the plaque formation group were higher than those of patients in cIMT thickness group as well as the normal group,while serum SLR level was lower than that of patients in cIMT thickness group as well as the normal group,serum LP,SIRT3 levels of cIMT thickness group were higher than those of patients in the normal group,while serum SLR level of patients in the former group was lower than that of patients in the latter group.The cIMT level was linearly positive correlated with serum LP and SIRT3 levels(rvalues were 0.725,0.683,P<0.05) and linearly negative correlated with serum SLR level(rvalue was -0.720,P<0.05).Multivariate Logistic regression analysis showed that SIRT3 and LP were independent risk factors for CIMT thickening (P<0.05),while SLR was an independent protective factor for CIMT thickening (P<0.05).ConclusionSerum LP,SLR and SIRT3 levels are closely associated with hypertension and cIMT,which indicates the possible participation of LP resistance and SIRT3 in the development and progression of EH and AS.

Leptin;Receptors,leptin;Silent information regulator factor related enzyme 3;Hypertension;Atherosclerosis

广西科学研究与技术开发计划项目(桂科能1598025-29)；广西医疗卫生适宜技术研究与开发课题(S201316-03)

541001广西桂林市，桂林医学院附属医院特需病区(胡迪聃，徐彤彤，王文艳)；台州市中心医院检验科(顾婉红)

徐彤彤，541001广西桂林市，桂林医学院附属医院特需病区；E-mail：xutongtongguilin@163.com

R 544.1

A

10.3969/j.issn.1007-9572.2016.22.013

2016-04-08；

2016-06-16)