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1、关木通肾毒性机制的实验研究关木通肾毒性机制的实验研究马红梅,张伯礼,徐宗佩,孙静美,李苓史红,王同胜,王津生,戴品忠,杜文复(天津中医学院,天津300193摘要:目的研究揭示关木通肾毒性的组织、细胞学机制。方法建立体内短期肾毒理动物模型和体外培养牛肾间质成纤维细胞模型,分别观察关木通(9g/kg)及其复方(30g/kg)对体内动物模型、关木通鼠血清和关木通主要毒性成分马兜铃酸及其鼠血清对体外细胞模型的毒性影响,并进一步采用高效液相色谱法检测马兜铃酸鼠血清中马兜铃酸及其代谢产物的含量。结果关木通组动物体重明显减轻(P0.05)。2.2.3马兜铃酸鼠血清对体外培养牛肾成纤维细胞的影响(图3):参加
2、AA鼠血清第2天时,成纤维细胞的生长遭到明显抑制(P0.05),服药后3h和5h时抑制率分别达52%和57%,可见其作用持续。2.3物的含量(图4)从测定结果初步断定样品中含有马兜铃酸I(AristolochicacidI,AAI),马兜铃酸II(AristolochicacidII,AAII)、部分样品中含有马兜铃内酰胺I(AristololactamI,ALI).其中AAI含量最高,于服药后1h即达峰值,且血药浓度随服药后时间延长而呈递减趋势,T1与T6相差约4倍,提示其吸收转化的代谢速度快;T2血药浓度骤减可能与大鼠个体差异或AA混悬液不匀有关。AAII含量最低,且血药浓度波动、不稳定。
3、提示其吸收较差。马兜铃内酰胺I从已检出的血药浓度揣测在一定时间内应相对稳定,T1、T5未检出,可能与方法不成熟,进样次数少有关。3讨论分析国内外报道的关木通肾毒性病例1发现:关木通的服药剂量和时间不同,所产生的肾毒性病变也有别,提示关木通急性与慢性中毒的肾损害机制可能是不同的。国内既往曾报道过短期(110d)大量(25200g/d)服用关木通导致急性肾衰甚至死亡的病例,其病理特征为中毒型肾小管坏死;日本临床报告的小剂量(1g/d)长期(661036d)服用关木通复方肾毒性病例的病理特征为近端肾小管上皮细胞显著变性、萎缩、坏死,伴间质纤维化,肾小球病变稍微或基本正常。我们建立了体内短期肾毒理动物
4、模型并观察短期(7d)内大量(相当临床成人用量20g/d)服用关木通及其复方对该模型的毒性影响。结果显示关木通及其复方均出现肾毒性,肾组织病理表现为皮质浅层近端肾小管上皮细胞变性、脱落,间质血管瘀血,肾小球基本正常或有轻度基膜皱缩,进而在动物模型上确证大量短期服用关木通及其复方呈现急性肾小管上皮细胞损伤为主而不伴肾间质纤维化的组织病理学特点。另据周方钧等报道:给小白鼠关木通用量相当成人口服200g时,连续1周后,杀检肾脏发现肾小管弥漫性变性坏死,大部分远端肾小管上皮细胞坏死、脱落,远端肾小管管腔明显扩张,管腔内可见多种管型,以蛋白、细胞管型为主;间质充血、血管周围水肿,淋巴细胞浸润7。同时,我
5、们还建立了体外培养牛肾间质成纤维细胞模型,观察关木通鼠血清和关木通主要毒性成分马兜铃酸及其鼠血清对该模型的毒性影响,并进一步采用高效液相色谱法检测马兜铃酸鼠血清中马兜铃酸及其代谢产物的含量。结果表明:(1)关木通及其主要成分马兜铃酸的鼠血清均对牛肾间质成纤维细胞的生长明显抑制,这与慢性马兜铃酸肾病寡细胞性肾间质纤维化的特点相一致8;且大鼠服用马兜铃酸后1h6h内作用持续,各时相血药间无显著性差异。(2)体外马兜铃酸溶液在实验浓度范围内,连续3天均未见对肾成纤维细胞的生长有显著影响。HPLC检测结果:马兜铃酸鼠血清中含量最高的马兜铃酸,其吸收转化的代谢速度快,随服药后时间延长血药浓度呈递减趋势;
6、而含量最低的马兜铃酸,吸收较差,血药浓度不稳定;只要马兜铃内酰胺在一定时间内血药浓度相对稳定。可见马兜铃酸鼠血清对肾成纤维细胞的抑制并不随马兜铃酸I血药浓度的递减而减弱,提示不同时相马兜铃酸鼠血清对肾成纤维细胞的持续抑制可能与血药浓度相对稳定的马兜铃酸代谢产物马兜铃内酰胺有关。至此我们考虑:关木通真正的肾毒性成分还有其固有的和体内代谢生成的马兜铃内酰胺,其作用位点并不局限于肾小管上皮细胞,至少还有肾间质成纤维细胞。目前以为关木通的主要毒性成分是马兜铃酸,研究表明马兜铃酸对小鼠、大鼠、家兔、山羊和人体均有毒性作用,十分对啮齿类动物有强致癌作用;药代动力学研究提示马兜铃酸在人体内有蓄积;马兜铃酸对
7、肾脏的损害存在量-毒依靠关系,主要特征是肾小管坏死。最近国际上对中药安全性问题的报道,其焦点本质集中于马兜铃酸的肾毒性上。日本和比利时学者分别从当归四逆加吴茱萸生姜汤颗粒剂(KM-38旧方)和进口中药材防已样品中检出马兜铃酸成分,这一最直接的证据促使他们以为马兜铃酸是上述中药制剂招致肾损害的罪魁,其肾损害的作用位点主要是肾小管上皮细胞920。然而,关木通和其它马兜铃科马兜铃属植物中药材一样,不但含致癌活性成分马兜铃酸,而且还含有硝基菲类有机酸衍生物或内酰胺(Aristololac2tam)成分。最新的体内药代动力学数据表明:马兜铃酸在肾脏分布较高,在体内分布与消失较快,不易积蓄,大鼠口服后未能
8、明显测出其在血液中的含量,讲明其生物利用度较低。有学者进一步研究发现,中草药肾病的机理至少不完全是直接毒性,可能与马兜铃酸代谢产物马兜铃内酰胺贴附于肾小管上皮细胞上并最终进入细胞核构成DNA加成物使癌基因序列发生碱基置换有关,Cosyns等则发现马兜铃酸可引起癌变但不伴小管-间质病变。以上这些研究至少对马兜铃酸独立而直接的肾毒性作用提出质疑。我们根据实验结果揣测马兜铃内酰胺可能也是关木通真正的肾毒性成分。至于肾毒性的作用位点则存在三种假讲:其一是毒物直接损害肾小管上皮细胞,十分是近端小管,引起肾小管上皮细胞转分化为成纤维细胞,进而导致间质纤维化及间质瘢痕;其二是原发病在间质血管,导致缺血、间质
9、纤维化及肾小管继发性毁坏;其三是毒物直接刺激间质,引起间质纤维化进而导致间质血管和小管病变8-9,21-29。我们根据肾间质在肾脏所占比例较大,且中药肾毒性的病理特征往往伴不同程度的间质病变如纤维化,十分是Depierreux等在研究所谓中草药肾病的病理特征时提出假讲,以为其原发病变可能还包括间质成纤维细胞8,18,并在本实验中被证明。另据基础毒理学研究指出:绝大多数有机毒物的毒性,主要是由于其代谢产物引起的,芳香族硝基化合物在体内代谢时,皆可诱发大量活性氧30,关木通肾毒性机理可能也是如此,这与细胞毒作用机理类似,其确切机制有待进一步研究揭示。参考文献:1马红梅,张伯礼.关木通肾毒害及其防治
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21、sofToxicology,1998,72:738-743.30江泉观.基础毒理学M.北京:化学工业出版社,1991.83-84.欢迎订阅!欢迎赐稿!欢迎指正!本刊邮发代号:46-210ABSTRACTOFORIGINALARTICLESProspectiveClinicalStudyofNephrotoxicityofCompoundDecoctionofCaulisAristolochiaeManshuriensisMAHongmei,ZHANGBoli(TianjinCollegeofTCM,Tianjin300193)Abstract:ObjectiveToinvestigatethe
22、possiblenephrotoxicityofCompoundDecoctionofCaulisAris2tolochiaeManshuriensis(CDCAM).MethodsBodyweight,bloodpressure,hemoglobinandrenalfunc2tions,especiallyofurinarylow-molecularweightproteininpatientswereobservedbeforeandafterashort-term(0.05).ConclusionThenephrotoxicityofCaulisAristolochiaeManshuri
23、ensismaybeasso2ciatedwiththelong-termover-doseadministrationandwithoutTCMsyndromedifferentiation.Keywords:CaulisAristolochiaeManshuriensis/poisoning;CompoundDecoctionofCaulisAristolochiaeManshuriensis/poisoning;Kidney/physiopathology;Nephrotoxicity;Prospectivestudies(originalarticleonpage400)Experim
24、entalStudiesonNephrotoxicmechanismofCaulisAristolochiaeManshuriensisMAHongmeiZHANGBoliXUZongpei,etal.(TianjinCollegeofTCM,Tianjin300193)AbstractObjectiveTorevealthenephrotoxicmechanismofCaulisAristolochiaeManshuriensis(CAM).MethodsIn-vivomousemodelsofshort-termnephrotoxicityandin-vitrocalfmodelsofre
25、nalfibrob2lastswereestablished.EffectsofCAM(9g/kg)andCompoundDecoctionofCAM(30g/kg)wereobservedinvivo.Andtheeffectsofaristolochicacid(AA),themaintoxiccomponentofCAM,andAA-containedmouseserumaswellasCAM-containedmouseserumonin-vitrocalfmodelswerealsoobserved.Thecon2tentofAAanditsmetaboliteinmouseseru
26、mweredetectedbyHPLC.ResultsTheweightofmousewasdecreasedobviously(P0.01),andurinaryproteinandglucosewerefoundintheCAMgroup.InthegroupofCompoundDecoctionofCAM,theweightwasincreasedslowly(P0.05),andurinaryproteinap2pearedbuturinaryglucosewasnotfound.Degenerationandexfoliationofrenaltubularepithelialcel
27、lsandbloodstasisofinterstitialvesselappearedinthegroupsofCAMandCompoundDecoctionofCAM.Andglomerulusstayednormalormildwrinklingofthebasementmembraneappeared.BothAA-containedmouseserumandCAM-containedmouseserumhadasignificantinhibitiononthegrowthofcalfrenalfibroblasts(P0.01),andtheinhibitionwascorrela
28、tedwiththeserumconcentrationofAristololactamI(ALTI),ametaboliteofAA,whilewasnotcorrelatedwithserumconcentrationofAAI.ConclusionShort-termover-doseadmistrationofCAManditscompounddecoctioncanleadtonephrotoxicitywiththehistopatho2logicalcharacteristicsofacutelesionofrenaltubularepithelialcellsbutwithou
29、tinterstitialrenalfibrosis.ALTIwhichistheproductofAAinvivoandthenaturalcomponentofCAMisprovedtobethenephrotoxiccomponentofCAM,anditsnephrotoxicsiteisnotonlylocatedintherenaltubularepithelialcells,butalsointherenalinterstitialfibroblasts.Andthegrowthofrenalfibroblastsbeingsignificantinhibitedwascorre
30、2spondentwithpaucicelluarinterstitialrenalfibrosisinchronicAAnephropathy.Keywords:CaulisAristolochiaeManshuriensis/poisoning;CompoundDecoctionofCaulisAristolochiaeManshuriensis/poisoning;Aristolochicacid/poisoning;Aristololactam/poisoning;Nephrotoxicity;Re2naltubularepithelialcells/physiopathology;C
31、alfrenalinterstitialfibroblasts/physiopathology;Diseasemodels,animal;Cells,cultured(originalarticleonpage404)AMeta-analysisofClinicalTrialsofTripterygiumWilfordiiPreparationsinTreatingRheumatoidArthritisXUWeihua,WENZehuai(DMECenter,GuangzhouUniversityofTCM,Guangzhou,510405)Abstract:ObjectiveToevalua
32、tethetherapeuticeffectofpreparationsofTripterygiumWilfordiiHook.F.intreatingrheumatoidarthritis(RA).MethodsAmeta-analysis,involvingdatafrom7randomizedcontrolledclinicaltrialsofTripterygiumWilfordiiintreatingRAissuedfrom19742000,waspresented.Therandomizedeffectivemodelwasusedtocalculateapooloddsratio
33、.ResultsThedifferenceofthetotalef2fectiveratebetweenthetreatmentgroupandthecontrolwasnotsignificant,theORbeing0.58(95%CI,0.171.94).ConclusionFurtherresearchisneededtoperformfortheevaluationofTripterygiumWil2fordiipreparationsintreatingRA.Keywords:Arthritis,Rheumatoid/TCMtherapy;TripterygiumWilfordii
34、/:/doczj/doc/05004600de80d4d8d15a4f56.htmle;Evaluationstudies;Evidence-basedmedicine(originalarticleonpage410)EffectofNaoxinqingTabletforCerebralAtherosclerosisandAnginaPectorisofCoronaryHeartDisease:AnObservationof60CasesCAIYuedong1,YANGShaofeng2(1.BaiyunshanPharmaceuticalFactory,Guangzhou510515;2.
35、NanfangHospital,theFirstMilitaryMedicalUniversity,Guangzhou510515)Abstract:ObjectiveToassesstheeffectandthesafetyofNaoxinqingTabletintreatingcerebralatherosclerosisandanginapectorisofcoronaryheartdisease.MethodsForty-eightpatientswithcerebralatherosclerosisand12patientswithanginapectorisofcoronaryhe
36、artdiseaseservedastheobjects.ResultsTheeffectiverateswere83.33%and75.00%incerebralatherosclerosisgroupandanginapectorisofcoro2naryheartdiseasegrouprespectively,andthetotaleffectiverateofNaoxinqingTabletwas81.67%,thedif2ferencebeingsignificantascomparedwiththosebeforetreatment(P0.01)ConclusionNaoxinq
37、ingTabletiseffectiveintreatingcerebralatherosclerosisandanginapectorisofcoronaryheartdiseaseandnoob2viousadverseeffectswerefound.Keywords:NaoxinqingTablet/:/doczj/doc/05004600de80d4d8d15a4f56.htmle;Cerebralarteriosclerosis/TCDtherapy;Anginapectorisofcoronarydisease/TCDtherapy(originalarticleonpage414)