Expression and clinical significance of exosomal miR-93-5p in patients with chronic kidney disease

Chen Xiao, Shi Jiaqi, Nie Anqi, Lu Yuqing, Liu Jing, Chen Xiaolan

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Chinese Journal of Nephrology ›› 2021, Vol. 37 ›› Issue (10) : 835-838. DOI: 10.3760/cma.j.cn441217-20210204-00124
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Expression and clinical significance of exosomal miR-93-5p in patients with chronic kidney disease

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Chen Xiao. , Shi Jiaqi. , Nie Anqi. , Lu Yuqing. , Liu Jing. , Chen Xiaolan. Expression and clinical significance of exosomal miR-93-5p in patients with chronic kidney disease[J]. Chinese Journal of Nephrology, 2021, 37(10): 835-838. DOI: 10.3760/cma.j.cn441217-20210204-00124.
慢性肾脏病(chronic kidney disease,CKD)是全球公认的高发病率和高死亡率的公共卫生问题,在疾病的早期没有明显的临床症状,因此寻找CKD发展的新型生物标志物进行早期诊断尤为重要[1]。外泌体是由细胞内多泡体与细胞膜融合后,释放到细胞外基质中的一种直径30~100 nm的膜性囊泡,参与细胞间通信、免疫应答、神经修复再生、肿瘤转移等重要的病理生理过程。其表面含有的多种跨膜蛋白可以介导外泌体识别靶细胞,内部含有的微小RNA(microRNA,miRNA,miR)等遗传信息可通过膜融合的方式被传递给受体细胞,miRNA参与调节包括CKD在内的多种疾病[2-3]。我们课题组在前期的研究中通过高通量基因测序发现,CKD患者骨髓间充质干细胞外泌体miR-93-5p表达与健康人有差异,所以本研究拟探讨miR-93-5p在CKD患者血清、尿液外泌体及肾组织中的表达及临床意义,旨在为CKD早期诊断提供途径。

一、 对象与方法

1. 研究对象: 选取2018年12月至2020年12月于南通大学附属医院诊断为CKD的患者及同期健康志愿者,分为CKD组(160例,CKD 1期42例,2期27例,3期25例,4期37例,5期29例)与对照组(70例),其中CKD组行肾活检者60例(包括糖尿病肾病、IgA肾病、膜性肾病各20例),以20例行肾切除手术的肾癌患者癌旁正常肾组织作为对照。CKD组患者纳入标准:年龄满18周岁;根据2012年改善全球肾脏病预后组织(KDIGO)指南确诊为CKD;临床资料保存完整;不存在其他类型肾功能不全,如急性肾衰竭、急性肾小球肾炎、急进性肾小球肾炎等;不合并严重心脑血管疾病、感染、肿瘤的患者;同意加入研究的患者。对照组纳入标准:年龄与CKD组差异无统计学意义;近3个月内未行药物治疗;不伴有血尿、蛋白尿、肾功能异常;不伴有冠心病、糖尿病、原发性高血压等基础疾病。本研究所涉及的患者及对照组血清、尿液、肾组织,均经过患者或家属同意,符合医学伦理委员会要求,并获得南通大学附属医院伦理委员会同意批准[伦理审批文编号:通大附院伦理审查(科研)2016-141]。
2. 临床资料: 包括血尿素氮(BUN)、血肌酐(Scr)、估算肾小球滤过率(eGFR)、24 h尿蛋白量、血红蛋白、血白蛋白、血胱抑素C(Cys-c)、尿纤维蛋白降解产物(FDP)、尿β2微球蛋白(β2-MG)、尿免疫球蛋白G、尿N-乙酰-β-D-氨基葡萄糖苷酶(NAG)、尿渗透压(Osm)、血清β2微球蛋白(β2-MG)、血钾、血钠、血钙、血磷、甲状旁腺素(PTH)、超敏C反应蛋白(hs-CRP)、红细胞沉降率。
3. 方法: 采用超速离心法提取血清、尿液外泌体,实时定量PCR方法检测血清、尿液外泌体miR-93-5p水平。荧光原位杂交技术(FISH)对60例行肾活检的CKD患者和20例对照组肾组织miR-93-5p表达进行定位和定量分析。对肾组织石蜡切片进行Masson染色,在光学显微镜下,观察肾组织病理图片判断肾间质纤维化(renal interstitial fibrosis,RIF)严重程度。RIF指数评估方法[4]:每例样本在光学显微镜200倍视野下选取10个不重复肾皮质区进行拍照,采用IPP 6.0图像分析软件计算每个视野小管间质纤维化面积与同视野小管间质总面积的百分比:0分,无损伤(≤5%);1分,轻度损伤(6%~25%);2分,中度损伤(26%~50%);3分,重度损伤(>50%);每例样本10个视野取平均分为RIF指数。
4. 统计学处理: 采用SPSS 22.0统计软件进行统计分析。对连续性变量行正态分布、方差齐性检验,用x¯±s形式表示符合正态分布的数据,用MP25P75)表示非正态分布的数据。采用Spearman秩相关分析法行双变量之间的相关性分析。采用Graphpad Prism 8散点图比较两组间血清、尿液外泌体miR-93-5p的表达水平。诊断分析采用受试者工作特征(ROC)曲线。P<0.05 视为差异有统计学意义。
表1 慢性肾脏病患者血清、尿液外泌体miR-93-5p相对表达水平与临床指标的相关性
临床指标 慢性肾脏病组
(n=160)
血清外泌体miR-93-5p 尿液外泌体miR-93-5p
Spearman秩相关系数 P Spearman秩相关系数 P
24 h尿蛋白量(g) 2.41(1.29,5.09) -0.33 0.38 -0.72 0.11
血尿素氮(mmol/L) 8.10(4.90,17.62) -0.25 0.95 -0.14 0.76
血肌酐(μmol/L) 98.00(68.00,554.00) -0.57 0.03 0.11 0.82
eGFR 63.50(17.92,98.94) 0.17 0.67 -0.21 0.65
血红蛋白(g/L) 113.26±28.77 0.70 0.04 -0.86 0.87
血白蛋白(g/L) 32.30±10.07 0.37 0.33 0.68 0.09
血胱抑素C(mg/L) 1.81±0.92 -0.71 0.02 0.26 0.06
尿FDP(mg/L) 0.70(0.28,1.70) -0.24 0.17 0.82 0.32
尿β2微球蛋白(mg/L) 1.21±3.06 -0.33 0.13 0.54 0.03
尿免疫球蛋白G(mg/L) 93.27(68.80,171.31) -0.40 0.51 0.17 0.37
尿NAG(U/mmol·Cr) 2.97±2.08 -0.16 0.07 0.35 0.02
尿渗透压(mOsm/kg·H2O) 352.00(262.00,661.00) 0.42 0.07 0.16 0.75
血清β2微球蛋白(mg/L) 3.14(2.05,18.07) -0.23 0.03 0.89 0.01
血钾(mmol/L) 4.16±0.69 -0.02 0.99 0.60 0.15
血钠(mmol/L) 138.77±2.77 -0.31 0.42 -0.21 0.65
血钙(mmol/L) 2.12±0.24 0.53 0.14 0.69 0.09
血磷(mmol/L) 1.33±0.44 -0.05 0.89 0.05 0.92
甲状旁腺素(ng/L) 48.26(31.73,112.83) -0.88 0.84 -0.50 0.31
超敏C反应蛋白(mg/L) 3.24(1.97,4.88) -0.35 0.40 -0.58 0.23
红细胞沉降率(mm/h) 33.41±25.99 -0.13 0.76 -0.64 0.17
注:eGFR:估算肾小球滤过率,单位为ml·min-1·(1.73 m2)-1;FDP:纤维蛋白降解产物;NAG:N-乙酰-β-D-氨基葡萄糖苷酶;正态分布数据以x¯±s形式表示,非正态分布数据以MP25P75)形式表示

二、 结果

1. CKD患者血清、尿液外泌体中miR-93-5p相对表达水平与临床指标的相关性: CKD患者血清外泌体miR-93-5p相对表达水平与血红蛋白呈正相关,与血肌酐、血Cys-C、血清β2-MG呈负相关;尿液外泌体miR-93-5p相对表达水平与血清β2-MG、尿β2-MG、尿NAG呈正相关(均P<0.05),见表1
2. miR-93-5p在CKD组和对照组血清、尿液外泌体中的水平比较: CKD组血清外泌体miR-93-5p表达低于对照组,尿液外泌体miR-93-5p表达高于对照组,见图1
图1 对照组和慢性肾脏病组患者血清、尿液外泌体中miR-93-5p水平比较
注:A:血清外泌体;B:尿液外泌体

Full size|PPT slide

3. 血清、尿液外泌体miR-93-5p诊断CKD的价值: 血清外泌体miR-93-5p、尿液外泌体miR-93-5p诊断CKD的ROC曲线下的面积(AUC)分别为0.627(P<0.05)和0.741(P<0.05),AUC均>0.5,说明两者对CKD有诊断价值。血清外泌体miR-93-5p的AUC大于0.5,小于0.7,尿液外泌体miR-93-5p的AUC大于0.7,小于0.9,表明血清外泌体miR-93-5p对CKD的诊断价值相对较低,尿液外泌体miR-93-5p对CKD的诊断价值中等,见图2
图2 血清、尿液外泌体miR-93-5p诊断慢性肾脏病的价值
(受试者工作特征曲线)

Full size|PPT slide

4. CKD患者血清、尿液外泌体miR-93-5p相对表达水平与RIF指数的相关性: CKD患者血清外泌体miR-93-5p相对表达水平与RIF指数呈负相关(r=-0.57,P=0.03),尿液外泌体miR-93-5p相对表达水平与RIF指数呈正相关(r=0.65,P=0.03)。
5. miR-93-5p在肾组织的表达: FISH检测结果显示,不同病理类型CKD患者肾组织中,miR-93-5p表达均高于对照组,并且miR-93-5p表达于肾小管内,见图3
图3 对照组和不同病理类型慢性肾脏病组肾组织miR-93-5p的表达与分布(荧光原位杂交技术 ×200)
注:白色箭头显示miR-93-5p呈阳性染色;黄色箭头显示细胞核DAPI染色阳性;Merge表示肾组织中miR-93-5p与细胞核共表达

Full size|PPT slide

三、 讨论

CKD的主要组织学表现是肾小球硬化和小管间质纤维化。血清、尿液外泌体miRNA作为CKD诊断的生物标志物,有着一定的优势。血清中的miRNA主要富集于外泌体内,外泌体的脂质双分子的外膜结构可以保护其中的miRNA不被RNA酶降解,稳定性较高[5],甚至可以在室温放置24 h后反复冻融而不影响其稳定性[6-7],有助于实验过程中样本的收集与储存。一般情况下,血外泌体无法通过肾小球滤过孔进入尿液[8],所以尿液外泌体被认为来源于肾脏细胞,而肾脏细胞分泌的外泌体可以通过miRNA参与病理生理过程[9],因此理论上,尿液外泌体分泌的miRNA水平更能反映肾脏的病理生理状态[10]
在对催乳素瘤的研究中发现,miR-93-5p可以激活转化生长因子β(TGF-β)/Smad3信号介导的纤维化[11]。而TGF-β在CKD发展过程中被认为是一个重要的中介者,其可以介导肾小球硬化和肾小管间质纤维化的形成。因此本研究通过检测CKD患者血清、尿液外泌体miR-93-5p的表达发现,与对照组相比,CKD组血清外泌体miR-93-5p表达降低,尿液外泌体miR-93-5p表达升高,并且血清外泌体miR-93-5p、尿液外泌体miR-93-5p诊断CKD的ROC曲线下的面积均大于0.5,证实两者对CKD有诊断价值。
在临床指标中,肾小球滤过、肾小管重吸收的小分子物质血肌酐、Cys-C、血清β2-MG、尿NAG、尿β2-MG水平可以间接反映肾脏功能损伤的程度[12-13]。本研究发现CKD患者血清外泌体miR-93-5p相对表达水平与血红蛋白呈正相关,与血肌酐、Cys-C、血清β2-MG呈负相关,尿液外泌体miR-93-5p相对表达水平与血清β2-MG、尿β2-MG、尿NAG呈正相关,提示血清、尿外泌体miR-93-5p表达水平可以反映肾组织损伤程度。
RIF是导致终末期肾病的病理变化,其发生发展的机制尚未明确,目前缺乏有效的治疗方案[14]。本研究发现CKD患者血清外泌体miR-93-5p相对表达水平与RIF指数呈负相关,尿外泌体miR-93-5p相对表达水平与RIF指数呈正相关,可以一定程度反映肾间质纤维化。FISH不仅可以准确地检测到miRNA在组织中的表达位置,还可以检测到相对表达量。为了进一步探究miR-93-5p在CKD患者肾组织内的表达水平,本研究在包括糖尿病肾病、IgA肾病、膜性肾病在内的不同病理类型的CKD患者肾组织内发现,miR-93-5p表达均高于对照组,同时可以看到miR-93-5p的表达位于肾小管内,与上述尿液外泌体miR-93-5p在CKD组高表达相一致,证实了尿液外泌体miRNA可以反映肾脏的病理生理状态,同时与肾小管的损伤存在相关性。
综上所述,血清、尿液外泌体miR-93-5p对CKD诊断有价值,并且血清、尿液外泌体miR-93-5p的表达水平与肾小管间质损伤相关,对CKD的早期诊断有一定参考价值。关于CKD的进展及预后与血清、尿液外泌体、肾组织miR-93-5p表达水平的关系,及miR-93-5p在CKD发生发展中的作用机制,有待进一步明确。

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In multicellular organisms, effective communication between cells is a crucial part of cellular and tissue homeostasis. This communication mainly involves direct cell-cell contact as well as the secretion of molecules that bind to receptors at the recipient cells. However, a more recently characterized mode of intercellular communication-the release of membrane vesicles known as exosomes-has been the subject of increasing interest and intensive research over the past decade. Following the discovery of the exosome-mediated immune activation, the pathophysiological roles of exosomes have been recognized in different diseases, including cancer. In this review, we describe the biogenesis and main physical characteristics that define exosomes as a specific population of secreted vesicles, with a special focus on their role in oncogenic transformation and cancer progression.
[11]
Hu B, Mao Z, Du Q, et al. miR-93-5p targets Smad7 to regulate the transforming growth factor-β1/Smad3 pathway and mediate fibrosis in drug-resistant prolactinoma[J]. Brain Res Bull, 2019, 149: 21-31. DOI: 10.1016/j.brainresbull.2019.03.013.
Prolactinoma is a common subtype of pituitary tumors. Dopamine receptor agonists are the preferred treatment for prolactinoma; however, with this therapy, drug resistance often occurs. In our previous work, we found that partial resistant prolactinomas showed increased fibrosis and that the transforming growth factor (TGF)-β1/Smad3 signaling pathway mediated fibrosis and was involved in drug resistance. Additionally, the success of surgery is known to be heavily influenced by the consistency of the pituitary adenoma. Therefore, in this study, we aimed to clarify the mechanisms of fibrosis in prolactinoma. Using high-throughput sequencing for analysis of microRNAs, we found that miR-93-5p was significantly upregulated in prolactinoma samples with a high degree of fibrosis compared with that in samples without fibrosis. Furthermore, we found that miR-93-5p was negatively correlated with the relative expression of Smad7 and positively correlated with the relative expression of TGF-β1 in clinical prolactinoma samples. In addition, luciferase reporter assays showed that miR-93-5p could downregulate the Smad7 gene, an important inhibitor of the TGF-β1/Smad3 signaling pathway, and activate TGF-β1/Smad3 signaling-mediated fibrosis in a feed-forward loop. Moreover, miR-93-5p could enhance the drug resistance of prolactinoma cells by regulation of TGF-β1/Smad3-dependent fibrosis. Taken together, our findings demonstrated that miR-93-5p may be a potential therapeutic target for inhibiting fibrosis and reducing drug resistance in prolactinoma cells.Copyright © 2019 Elsevier Inc. All rights reserved.
[12]
Żychowska I, Suszek D, Dryglewska M, et al. β2-microglobulin as a marker of systemic lupus erythematosus activity[J]. Adv Clin Exp Med, 2018, 27(3): 379-382. DOI: 10.17219/acem/68291.
Systemic lupus erythematosus (SLE) is characterized by alternating periods of activity and remission. A portion of the patients suffers from the chronically active form of the disease. The search for clinically useful markers of its activity is ongoing. At present, it is suggested that β2-microglobulin (β2M) may be useful in assessing SLE activity.The objective of the paper was to investigate the relationship between serum β2M concentration and SLE activity.The study group consisted of 69 SLE patients (62 women and 7 men), aged 34.5 ±11 years (19-69). Patients with kidney failure and infection were excluded from the study group. The concentration of β2M was measured using an ELISA test. SLE activity was assessed with Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), and by measuring the levels of C3 and C4 complement components, anti-double stranded DNA antibodies (anti-dsDNA antibodies) and β2M. The relationship between β2M and the clinical manifestation of SLE was also covered in the study.The study revealed a statistically significant correlation between β2M concentration and SLEDAI-2K disease activity index (p < 0.05; r = 0.6), anti-dsDNA titer (p < 0.05; r = 0.3), and C4 component serum level (p < 0.05; r = -0.3). β2M concentration was significantly higher in patients with arthritis and/or myositis (p = 0.005), vasculitis (p = 0.005), and hematological manifestations of SLE (p = 0.02).Periodical determination of β2M concentration in SLE patients may prove helpful in assessing the disease activity.
[13]
Gluhovschi C, Velciov S, Kaycsa A, et al. The dynamics of urinary N-acetyl-β-D-glucosaminidase (NAG), a marker of renal tubular dysfunction, in patients with lupus nephritis undergoing oral prednisone therapy[J]. Immunopharmacol Immunotoxicol, 2012, 34(1): 163-169. DOI: 10.3109/08923973.2011.585343.
[14]
Farris AB, Colvin RB. Renal interstitial fibrosis: mechanisms and evaluation[J]. Curr Opin Nephrol Hypertens, 2012, 21(3): 289-300. DOI: 10.1097/MNH.0b013e3283521cfa.
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