張慧云，錢久榮，沈道明，張應(yīng)愛，何韶衡

(1.蘇州市相城人民醫(yī)院中心實(shí)驗(yàn)室，江蘇蘇州 215131；2.海南醫(yī)學(xué)院病理生理學(xué)教研室，海南?？?571101；3.?？谑腥嗣襻t(yī)院中心實(shí)驗(yàn)室，海南海口 570000；4.南京醫(yī)科大學(xué)第一附屬醫(yī)院臨床實(shí)驗(yàn)研究中心，江蘇南京210029)

·綜述·

肥大細(xì)胞在哮喘氣道損傷及重塑中的作用機(jī)制

張慧云1，2，錢久榮1，沈道明1，張應(yīng)愛3，何韶衡4

(1.蘇州市相城人民醫(yī)院中心實(shí)驗(yàn)室，江蘇蘇州 215131；2.海南醫(yī)學(xué)院病理生理學(xué)教研室，海南?？?571101；3.?？谑腥嗣襻t(yī)院中心實(shí)驗(yàn)室，海南?？?570000；4.南京醫(yī)科大學(xué)第一附屬醫(yī)院臨床實(shí)驗(yàn)研究中心，江蘇南京210029)

過敏性哮喘是機(jī)體將原本正常的免疫識別過程無限放大的過敏性炎癥反應(yīng)所導(dǎo)致的疾病。由于氣道的損傷及重塑既是哮喘的特征又直接關(guān)系到哮喘的發(fā)展和預(yù)后。本文就過敏性炎癥效應(yīng)階段的核心細(xì)胞-肥大細(xì)胞在哮喘時(shí)氣道損傷和重塑中的作用機(jī)制做一綜述。

肥大細(xì)胞；哮喘；氣道重塑；過敏

過敏性哮喘的病理生理學(xué)基礎(chǔ)是過敏性炎癥，而發(fā)生過敏性炎癥的一個(gè)重要原因就是機(jī)體將原本正常的免疫識別過程無限的放大，從而導(dǎo)致疾病甚至迅速死亡。過敏性炎癥傳統(tǒng)的免疫識別過程(圖1)為：過敏原→抗原提呈細(xì)胞→T細(xì)胞活化→B細(xì)胞活化→特異性IgE分泌增加→IgE與肥大細(xì)胞(嗜堿性粒細(xì)胞？)表面的FCεRI受體結(jié)合|←誘導(dǎo)階段‖效應(yīng)階段→|再次進(jìn)入體內(nèi)的過敏原與肥大細(xì)胞表面的IgE結(jié)合→肥大細(xì)胞脫顆?！鷨?dòng)病理過程。從這個(gè)過程來看，只有效應(yīng)細(xì)胞被激活，過敏性疾病才會(huì)發(fā)生，而肥大細(xì)胞無可爭議的是過敏性炎癥效應(yīng)階段的核心細(xì)胞，被稱為初始效應(yīng)細(xì)胞(Primary effector cells)。

圖1 過敏性炎癥傳統(tǒng)的免疫識別過程

1 氣道的損傷及重塑在哮喘發(fā)病機(jī)制中的作用

氣道的損傷及重塑在哮喘氣道過敏性炎癥發(fā)生過程中的重要作用早在20年前就已經(jīng)被發(fā)現(xiàn)。損傷主要由初始效應(yīng)細(xì)胞即肥大細(xì)胞、次級效應(yīng)細(xì)胞嗜酸性粒細(xì)胞及中性粒細(xì)胞、巨噬細(xì)胞、激活的T細(xì)胞，及“結(jié)構(gòu)”細(xì)胞如上皮細(xì)胞、成纖維細(xì)胞、平滑肌細(xì)胞等釋放出的炎癥性介質(zhì)、細(xì)胞因子、趨化因子引起；主要表現(xiàn)為血管通透性增強(qiáng)、黏液分泌增加、上皮脫落、氣道狹窄[1]。重塑主要表現(xiàn)在支氣管黏膜增厚、上皮下纖維化、血管增生、平滑肌層增厚，從而引起不可逆的肺功能喪失和氣道高反應(yīng)性[2-3]。但迄今為止人們對哮喘氣道損傷及重塑的發(fā)生發(fā)展過程及機(jī)制的認(rèn)識還十分有限。

2 肥大細(xì)胞在哮喘中氣道損傷與重塑中的作用

2.1 肥大細(xì)胞在氣道損傷中的作用由于氣道的損傷及重塑直接關(guān)系到哮喘的發(fā)展和預(yù)后，基于了解其發(fā)生機(jī)制而開發(fā)必要的干預(yù)策略的研究成為受關(guān)注的熱點(diǎn)。近年來，多項(xiàng)研究成果使人們認(rèn)識到肥大細(xì)胞在哮喘的慢性氣道炎癥、重塑、臨床癥狀形成中起重要作用[4]。人們先后發(fā)現(xiàn)[2，5-36]，肥大細(xì)胞的數(shù)量在哮喘氣道中明顯增加，且有脫顆?，F(xiàn)象；肥大細(xì)胞特異性分泌產(chǎn)物肝素、組胺、類胰蛋白酶、類糜蛋白酶、白三烯C4、前列腺素D2以及非特異性分泌產(chǎn)物血小板活化因子(PAF)、激肽酶原等均具有強(qiáng)力的增強(qiáng)血管通透性的作用；組胺、類胰蛋白酶、類糜蛋白酶、PAF、前列腺素D2以及肥大細(xì)胞分泌的多種細(xì)胞因子IL-3、4、5、8、13、17、22、25、29、31、33，腫瘤壞死因子(TNF)，胸腺間質(zhì)來源的淋巴生成素(TSLP)，粒-巨噬細(xì)胞集落刺激因子(GM-CSF)，嗜酸細(xì)胞活化趨化因子(Eotaxin)，正常T細(xì)胞表達(dá)和分泌因子(RANTES)，基質(zhì)金屬蛋白酶(MMP)能誘導(dǎo)嗜酸性粒細(xì)胞、中性粒細(xì)胞等炎癥性細(xì)胞募集；類糜蛋白酶、組胺、白三烯C4具有刺激支氣管上皮細(xì)胞間杯狀細(xì)胞黏液分泌增強(qiáng)的作用；類胰蛋白酶和類糜蛋白酶具有誘導(dǎo)上皮損傷的作用。上述研究表明肥大細(xì)胞積極參與哮喘時(shí)氣道損傷的病理生理過程，見表1。

表1 肥大細(xì)胞介質(zhì)、細(xì)胞因子促進(jìn)氣道損傷的作用

2.2 肥大細(xì)胞在哮喘氣道重塑中的作用

2.2.1 肥大細(xì)胞參與哮喘氣道重塑的病理生理過程有關(guān)肥大細(xì)胞參與哮喘氣道重塑的研究[2，36-43]顯示，肥大細(xì)胞具有促進(jìn)過敏原誘導(dǎo)的哮喘鼠氣道黏膜下組織纖維化的作用，并能刺激人皮膚纖維細(xì)胞增殖、膠原合成增加，提示在肥大細(xì)胞與哮喘的氣道重塑間有密切的聯(lián)系。哮喘患者氣道平滑肌間肥大細(xì)胞的浸潤與氣道功能障礙有關(guān)；與非哮喘者相比，死于哮喘的患者氣道平滑肌間有明顯肥大細(xì)胞浸潤和肥大細(xì)胞脫顆粒；哮喘患者黏膜下腺體間脫顆粒的肥大細(xì)胞數(shù)量增加與腺體增大有關(guān)。上述研究提示肥大細(xì)胞與氣道平滑肌增生、黏液腺增大有直接聯(lián)系。同時(shí)，肥大細(xì)胞分泌的多種產(chǎn)物如介質(zhì)、細(xì)胞因子等都積極參與哮喘氣道重塑的病理生理過程(見表2)。

表2 肥大細(xì)胞介質(zhì)、細(xì)胞因子促進(jìn)氣道重塑的作用

2.2.2 肥大細(xì)胞與氣道平滑肌相互作用參與哮喘氣道重塑關(guān)于肥大細(xì)胞參與哮喘氣道重塑的機(jī)制研究[36，40，41]發(fā)現(xiàn)人肺肥大細(xì)胞在氣道平滑肌分泌的趨化因子的作用下向氣道平滑肌遷移，哮喘患者肺肥大細(xì)胞表面表達(dá)的最豐富的趨化因子受體是CXCR3 (平滑肌間肥大細(xì)胞表達(dá)率達(dá)100%，黏膜下肥大細(xì)胞表達(dá)率達(dá)47%)，氣道平滑肌培養(yǎng)物能夠通過激活人肺肥大細(xì)胞CXCR3使之遷移。肥大細(xì)胞一旦遷移到氣道平滑肌細(xì)胞間，便與氣道平滑肌細(xì)胞發(fā)生粘附使肥大細(xì)胞停留于此并與氣道平滑肌細(xì)胞發(fā)生相互作用。研究顯示原代培養(yǎng)肥大細(xì)胞緊密地粘附于單層培養(yǎng)的氣道平滑肌細(xì)胞上，且不被ICAM-1、VCAM-1、CD8、整合素α-4和整合素β-1等粘附分子抗體阻斷。

關(guān)于肥大細(xì)胞如何誘導(dǎo)氣道平滑肌細(xì)胞肥大和增生的機(jī)制研究[36]顯示，肥大細(xì)胞特異性分泌產(chǎn)物類胰蛋白酶能夠促進(jìn)氣道平滑肌細(xì)胞增生進(jìn)而參與氣道重塑。哮喘患者肺肥大細(xì)胞分泌的激活素(Activin)能夠促進(jìn)人氣道平滑肌細(xì)胞增生。肥大細(xì)胞產(chǎn)生的血小板源性生長因子(PDGF)和轉(zhuǎn)化生長因子β也能促進(jìn)氣道平滑肌細(xì)胞增生。

2.2.3 肥大細(xì)胞與氣道杯狀細(xì)胞相互作用參與哮喘氣道重塑有關(guān)肥大細(xì)胞促進(jìn)杯狀細(xì)胞增生的機(jī)制研究[42-44]顯示，在小鼠體內(nèi)，過敏原誘導(dǎo)產(chǎn)生的IL-4，13、9，解聚素(Disintegri)，金屬蛋白酶(Metalloprotease)和表皮生長因子(EGF)能夠上調(diào)黏蛋白基因表達(dá)；但在人體內(nèi)，僅肥大細(xì)胞分泌的IL-9和EGF家族成員-雙調(diào)蛋白(Amphiregulin，AREG)能夠上調(diào)上皮細(xì)胞黏蛋白基因表達(dá)，AREG還具有促進(jìn)哮喘患者支氣管黏膜杯狀細(xì)胞增生和人肺成纖維細(xì)胞增生的作用。

3 肥大細(xì)胞激活的自身放大機(jī)制假說

2004年，我們提出了《肥大細(xì)胞激活的自身放大機(jī)制假說》[45]，其具體內(nèi)容為人體內(nèi)肥大細(xì)胞被過敏原激活后，釋放出肥大細(xì)胞特異性類胰蛋白酶和組胺[46]，被釋放出的類胰蛋白酶再通過其特異性受體，蛋白酶激活受體-2激活相鄰的肥大細(xì)胞[47]；而組胺則通過它的H1和H2受體激活相鄰的肥大細(xì)胞，從而產(chǎn)生肥大細(xì)胞脫顆粒的“瀑布效應(yīng)”(圖2)。為解釋微量的過敏原進(jìn)入體內(nèi)即可引起嚴(yán)重的過敏反應(yīng)提供了新的思路。此外，我們還發(fā)現(xiàn)哮喘病人支氣管肺泡灌洗液中的肥大細(xì)胞與非哮喘者肺及大腸的肥大細(xì)胞相比，對過敏原刺激的敏感性增強(qiáng)100倍[48]。從而進(jìn)一步揭示了哮喘易感病人的發(fā)病基礎(chǔ)，為理解肥大細(xì)胞在哮喘發(fā)病機(jī)制中的作用提供了新信息。盡管我們的這篇文章已經(jīng)被他人引用160余次，近年來的研究也越來越多的支持我們的假說，但是到目前為止，這個(gè)假說的內(nèi)容還很膚淺，有待在今后的工作中得到進(jìn)一步證實(shí)。

圖2 肥大細(xì)胞激活的自身放大機(jī)制假說

4 結(jié)語

終上所述，人們對肥大細(xì)胞在哮喘氣道損傷及重塑中的作用已經(jīng)有了一些認(rèn)識，但是遠(yuǎn)遠(yuǎn)沒有發(fā)現(xiàn)其作用的規(guī)律及機(jī)制。掌握肥大細(xì)胞在哮喘氣道損傷及重塑中的作用機(jī)制，有助于對此類疾病的理解，開發(fā)出行之有效的新療法。

[1]Royce SG,Tang ML.The effects of current therapies on airway remodeling in asthma and new possibilities for treatment and prevention[J].Curr Mol Pharmacol,2009,2(2):169-181.

[2]Amin K.The role of mast cells in allergic inflammation[J].Respir Med,2012,106(1):9-14.

[3]Yu M,Tsai M,Tam SY,et al.Mast cells can promote the development of multiple features of chronic asthma in mice[J].J Clin Invest,2006,116(6):1633-1641.

[4]Chiappara G,Gagliardo R,Siena A,et al.Airway remodelling in the pathogenesis of asthma[J].Curr Opin Allergy Clin Immunol,2001, 1(1):85-93.

[5]Carroll NG,Mutavdzic S,James AL.Increased mast cells and neutrophils in submucosal mucous glands and mucus plugging in patients with asthma[J].Thorax,2002,57:677-682.

[6]Ward C,Pais M,Bish R,et al.Airway inflammation,basement membrane thickening and bronchial hyperresponsiveness in asthma [J].Thorax,2002,57(4):309-316.

[7]He S,Walls AF.Human mast cell tryptase:a stimulus of microvascular leakage and mast cell activation[J].Eur J Pharmacol,1997, 328(1):89-97.

[8]He S,Walls AF.The induction of a prolonged increase in microvascular permeability by human mast cell chymase[J].Eur J Pharmacol,1998,352(1):91-98.

[9]Hui Y,Cheng Y,Smalera I,et al.Directed vascular expression of human cysteinyl leukotriene 2 receptor modulates endothelial permeability and systemic blood pressure[J].Circulation,2004,110(21): 3360-3366.

[10]Nishimura H,Tokuyama K,Inoue Y,et al.Acute effects of prostaglandin D2 to induce airflow obstruction and airway microvascular leakage in guinea pigs:role of thromboxaneA2 receptors[J].Prostaglandins Other Lipid Mediat,2001,66(1):1-15.

[11]Schwartz LB.Mediators of human mast cells and human mast cell subsets[J].AnnAllergy,1987,58(4):226-235.

[12]Foster AP,Cunningham FM.Histamine-induced adherence and migration of equine eosinophils[J].Am J Vet Res,1998,59(9): 1153-1159.

[13]He S,Peng Q,Walls AF.Potent induction of a neutrophil and eosinophil-rich infiltrate in vivo by human mast cell tryptase:selective enhancement of eosinophil recruitment by histamine[J].J Immunol,1997,159(12):6216-6225.

[14]He S,Walls AF.Human mast cell chymase induces the accumulation of neutrophils,eosinophils and other inflammatory cells in vivo [J].Brit J Pharmacol,1998,125(7):1491-1500.

[15]Ishiura Y,Fujimura M,Nobata K,et al.In vivo PAF-induced airway eosinophil accumulation reduces bronchial responsiveness to inhaled histamine[J].Prostaglandins Other Lipid Mediat,2005,75(1-4):1-12.

[16]Malaviya R,Abraham SN.Role of mast cell leukotrienes in neutrophil recruitment and bacterial clearance in infectious peritonitis[J]. J Leukoc Biol,2000,67(6):841-846.

[17]Whelan CJ.Evidence that 13-14 di-hydro,15-keto prostaglandin D (2)-induced airway eosinophilia in guinea-pigs is independent of interleukin-5[J].Inflamm Res,2009,58(2):103-108.

[18]Shakoory B,Fitzgerald SM,Lee SA,et al.The role of human mast cell-derived cytokines in eosinophil biology[J].J Interferon Cytokine Res,2004,24(5):271-281.

[19]Ozdemir C,Akdis M,Akdis CA.T-cell response to allergens[J]. Chem ImmunolAllergy,2010,95:22-44

[20]Molfino NA,Gossage D,Kolbeck R,et al.Molecular and clinical rationale for therapeutic targeting of interleukin-5 and its receptor [J].Clin ExpAllergy,2012,42(5):712-737.

[21]Chen R,Ning G,Zhao ML,et al.Mast cells play a key role in neutrophil recruitment in experimental bullous pemphigoid[J].J Clin Invest,2001,108(8):1151-1158.

[22]Venkayya R,Lam M,Willkom M,et al.The Th2 lymphocyte products IL-4 and IL-13 rapidly induce airway hyperresponsiveness through direct effects on resident airway cells[J].Am J Respir Cell Mol Biol,2002,26(2):202-208.

[23]Horvat JC,Starkey MR,Kim RY,et al.Chlamydial respiratory infection during allergen sensitization drives neutrophilic allergic airways disease[J].J Immunol,2010,184(8):4159-4169.

[24]Takahashi K,Hirose K,Kawashima S,et al.IL-22 attenuates IL-25 production by lung epithelial cells and inhibits antigen-induced eosinophilic airway inflammation[J].J Allergy Clin Immunol,2011, 128(5):1067-1076.

[25]Wisniewski JA,Borish L.Novel cytokines and cytokine-producing T cells in allergic disorders[J].Allergy Asthma Proc,2011,32(2): 83-94.

[26]He S,Zhang H,Chen H,et al.Expression and release of IL-29 by mast cells and modulation of mast cell behavior by IL-29[J].Allergy,65(10):1234-1241.

[27]Cornelissen C,Lüscher-Firzlaff J,Baron JM,et al.Signaling by IL-31 and functional consequences[J].Eur J Cell Biol,2012,91 (6-7):552-566.

[28]Eiwegger T,Akdis CA.IL-33 links tissue cells,dendritic cells and Th2 cell development in a mouse model of asthma[J].Eur J Immunol,2011,41(6):1535-1538.

[29]Willart MA,Hammad H.Alarming dendritic cells for allergic sensitization[J].Allergol Int,2010,59(2):95-103.

[30]Nakae S,Suto H,Berry GJ,et al.Mast cell-derived TNF can promote Th17 cell-dependent neutrophil recruitment in ovalbumin-challenged OTII mice[J].Blood,2007,109(9):3640-3648.

[31]Bischoff SC,Ulmer FA.Eosinophils and allergic diseases of the gastrointestinal tract[J].Best Pract Res Clin Gastroenterol,2008,22 (3):455-79.

[32]Ozaki A,Fukushima A,Fukata K,et al.Mast-cell activation augments the late phase reaction in experimental immune-mediated blepharoconjunctivitis[J].Graefes Arch Clin Exp Ophthalmol, 2003,241(5):394-402.

[33]He S,Zheng J.Stimulation of mucin release from airway epithelial cells by mast cell chymase[J].Acta Pharmacol Sin,2004,25(6): 827-832.

[34]Takeyama K,Tamaoki J,Nakata J,et al.Effect of oxitropium bromide on histamine-induced airway goblet cell secretion[J].Am J Respir Crit Care Med,1996,154(1):231-236.

[35]Shimizu T,Hirano H,Majima Y,et al.A mechanism of antigen-induced mucus production in nasal epithelium of sensitized rats.A comparison with lipopolysaccharide-induced mucus production[J]. Am J Respir Crit Care Med,2000,161(5):1648-1654.

[36]Okayama Y,Ra C,Saito H.Role of mast cells in airway remodeling [J].Curr Opin Immunol,2007,19(6):687-693.

[37]Oh CK.Mast cell mediators in airway remodeling[J].Chem ImmunolAllergy,2005,87:85-100.

[38]Suzuki R,Miyazaki Y,Takagi K,et al.Matrix metalloproteinases in the pathogenesis of asthma and COPD:implications for therapy[J]. Treat Respir Med,2004,3(1):17-27.

[39]Zanini A,Chetta A,Saetta M,et al.Chymase-positive mast cells play a role in the vascular component of airway remodeling in asthma[J].JAllergy Clin Immunol,2007,120(2):329-33.

[40]Berger P,Perng DW,Thabrew H,et al.Tryptase and agonists of PAR-2 induce the proliferation of human airway smooth muscle cells[J].JAppl Physiol,2001,91(3):1372-1379.

[41]Ceresa CC,Knox AJ,Johnson SR.Use of a three-dimensional cell culture model to study airway smooth muscle-mast cell interactions in airway remodeling[J].Am J Physiol Lung Cell Mol Physiol, 2009,296(6):1059-1066.

[42]Masuda T,Tanaka H,Komai M,et al.Mast cells play a partial role in allergen-induced subepithelial fibrosis in a murine model of allergic asthma[J].Clin ExpAllergy,2003,33(5):705-713.

[43]Margulis A,Nocka KH,Wood NL,et al.MMP dependence of fibroblast contraction and collagen production induced by human mast cell activation in a three-dimensional collagen lattice[J].Am J Physiol Lung Cell Mol Physiol,2009,296(2):L236-247.

[44]Garbuzenko E,Nagler A,Pickholtz D,et al.Human mast cells stimulate fibroblast proliferation,collagen synthesis and lattice contraction:a direct role for mast cells in skin fibrosis[J].Clin Exp Allergy,2002,32(2):237-246.

[45]He S.Key role of mast cells and their major secretory products in inflammatory bowel disease[J].World J Gastroenterol,2004,10(3): 309-318.

[46]He S,Gaca MDA,Walls AF.A role for tryptase in the activation of human mast cells:modulation of histamine release by tryptase and inhibitors of tryptase[J].J.Pharmacol[J].Exp Ther,1998,286: 289-297.

[47]He S,Aslam A,Gaca MD,et al.Inhibitors of tryptase as mast cell-stabilizing agents in the human airway:Effects of trypatse and other agonists of proteinase-activated receptor 2 on histamine release[J].J Pharmacol Exp Ther,2004,309:119-126.

[48]Xie H,He S,Chen P.Selectively enhanced sensitivity of bronchoalveolar lavage fluid(BALF)mast cells to IgE dependent stimulation in mild asthmatics[J].Asian Pac JAllergy,2003,21:83-88.

R562.2+5

A

1003—6350（2014）03—0376—04

2013-07-29)

10.3969/j.issn.1003-6350.2014.03.0144

國家自然科學(xué)基金資助項(xiàng)目(編號：81241135，81060250，81172836，81030054)；蘇州市科技計(jì)劃項(xiàng)目(編號：SYS201272)；海南省自然科學(xué)基金(編號：309115)；?？谑兄攸c(diǎn)科技資助項(xiàng)目編號：(2009-SKG-18-046)

何韶衡。E-mail:shoahenghe@hotmail.com