Clinical And Immunological Mechanism Research Of Primary Biliary Cirrhosis

Part one:The Clinical analysis of primary biliary cirrhosis and primary biliary cirrhosis complicating Sj(o|¨)gren syndromeObject To analyze the relations of primary biliary cirrhosis(PBC), primary biliary cirrhosis complicating Sj(o|¨)gren syndrome(PBC with SS)and Primary Sj(o|¨)gren syndrome(pSS),Further to identify the features of SS in PBC.Materials and methods Randomly collected 64 patients of PBC without SS,93 patients of PBC with SS,20 patients of autoimmune hepatisis(AIH)with SS,and 57 patients of pSS according to their respective diagnostic criteria.In addition the patients of pSS with abnormal levels of hepatic function were ruled out.To analyze their basic conditions(including age and sex etc),clinical symptoms,the markers of liver function and immunological indexes.Results Compared the basic conditions of PBC and PBC with SS,the age in the group of PBC with SS was older than of the PBC's group(P=0.035);the leucocyte(P=0.015) and the platelet(P=0.002) was lower in the group of PBC with SS.For the indexes which indicated the severity such as Mayo risk score and esophageal varices,there was no difference between the two groups.There was also no difference in the prognosis.In clinical symptoms,the group of PBC with SS had more obviously dry mouth(P=0.000) and dry eyes(P=0.003), and the incidence rate of rampant caries(P=0.006),Raynaud phenomenon(P=0.016) and parotitis(P=0.000) was also higher in the group of PBC with SS.For other symptoms such as fatigue,jaundice and pruritus,there was no difference between the two groups.There was no difference in the liver function between two groups(p＞0.05).The level of IgG of PBC with SS was higher than the group of PBC(P=0.006), but the level of IgM and IgA was no difference;When compared the autoantibodies,we found the positive rate of Anti-SSA increased in the group of PBC with SS,but the positive rate of Anti-SSB was no difference.Their pathology of liver was very similarity.When we compared the group and the group of pSS,we also found the age of PBC with SS was older than the group of pSS(P=0.016).For clinical symptoms there was no difference between the two groups(P＞0.05). Compared the autoantibodies between two groups,the positive rate of Anti-SSA (P=0.000) and Anti-SSB(P=0.000) was lower in the group of PBC with SS.But the anticentromere antibody(ACA)(P=0.002) was higher in the group of PBC with SS.Among the three immunoglobulin,the level of IgG in pSS was higher than in the PBC with SS,and the level of IgM and IgA was no difference between two groups. When compared the group of PBC with SS to the group of AIH with SS,they expressed the different features of hepatic lesion,and the character of two kind of SS were different too.CONCLUSIONS There was no essential difference in clinical symptoms,the biochemical markers of liver and pathology between two groups.SS in PBC was a kind of secondary SS,the primary disease was PBC;the hepatic lesion of PBC with SS was different from the lesion of pSS,maybe ACA resembled with Anti-mitochondrial antibodies(AMA),it was also the index which can distinguished PBC from other hepatic lesions.ACA could make as an additional antibody when anti-SSA or anti-SSB was negative in SS,ACA had the same value in PBC when AMA was negative.Maybe the PBC with positive ACA was a subtype of PBC,and it was an reference index for PBC complicating SS. Part two:The significance of T regulatory cells in primary biliary cirrhosis and primary biliary cirrhosis complicating Sj(o|¨)gren syndromeObject To study the character of T regulatory cells(Treg) in peripheral blood and target organ,Further to analyze the significance of Treg in PBC,PBC with SS and pSS.Materials and methods Sixty-eight patients came from the prospective and random samples in the first part of thesis,including PBC 27 persons,PBC with SS 23 persons and pSS 23 patients.Separated peripheral blood mononuclear cell(PBMC) from venous blood,and detected CD4+CD25+FOXP3+T cells in peripheral blood through tricolour flowcytometry technique.Simultaneously messenger RNA(mRNA) of FOXP3,transforming growth factor-β(TGF-β)and interleukin-10(IL-10) was determined by real-time RT-PCR assay,analyzed the difference of expression in different groups.From the aspect of pathology,we detected the expression of CD4,TGF-βand FOXP3 in livers,meanwhile the expression of CD4,TGF-βand FOXP3 in labial gland was determined by immunohistochemistry.Results The percent of CD4+CD25+highT and CD4+CD25+FOXP3+T in peripheral blood were lower in PBC(P=0.001,P=0.000), PBC with SS(P=0.008,P=0.006) and pSS(P=0.045,P=0.036) than in healthy control group,moreover there was correlation in CD4+CD25+FOXP3+T and ESR. The mRNA expression of FOXP3,TGF-βand IL-10 wasn't different from the healthy control group.Compared the CD4 positive cells in liver tissue,the result showed the infiltration of CD4 T cell in normal liver was almost seen.The infiltration of CD4 T cell in PBC liver and PBC with SS liver highly increased than in normal liver,but there was no difference between PBC and PBC with SS(P=0.797).When compared these two groups with pSS liver,the latter was almost no infiltration of CD4 positive T cell(p＜0.05).the infiltration of FOXP3 T cell was not seen in normal liver,it highly increased in the liver of PBC and PBC with SS than in normal liver, there was no difference bwteen two groups.But the infiltrating extent of FOXP3 positive T cell was different in different pathological stage and different inflammatory extent of portal area,the infiltration of FOXP3 positive T cell was extensive in severity of inflammation portal area.No infiltration of FOXP3 positive T cell was in pSS liver.The expression of TGF-β1 was no difference between the 1 iver of PBC and the liver of PBC with SS.the expression of TGF-β1 in these two groups was no difference in early stage with the normal liver,but in the late stage when the pseudo-lobules of liver formed,the expression of TGF-β1 was mainly expressed in the space of fibrosis especially near to the space of pseudo-lobules.When compared the CD4 T cell in labial gland,it showed that the patient of PBC without SS was similarity with the normal liver,but the infiltration of CD4 T cells was highly extensive in PBC with SS and pSS.There was almost no FOXP3 positive cells in normal labial gland,the labial gland in PBC without SS was the same as normal labial gland,there was obviously increased more FOXP3 positive cells in PBC and PBC with SS labial gland than normal labial gland.When compared the TGF-βin PBC with the TGF-βin mormal labial gland,there was no difference.But in the labial gland of SS(including PBC with SS and pSS),it's expression in the ductal epithelial cell is less than in the normal labial gland.CONCLUSIONS Maybe the reason of Treg decreasing in peripheral blood of PBC and Treg increasing in local inflammatory portal area of liver was the result of local inflammatory in autoimmunity,this resulted the migration of peripheral Treg so as to deal with the incipient inflammation in local target organ of autoimmunity.PBC is the most common hepatic lesion in SS,there was no difference of Treg in liver and labial gland when compared PBC with SS to PBC.Maybe the decreasing Treg in pSS group was similar with PBC,it was the self-regulatory process which was caused by the imbalance between systemic immunity and local inflammation. Part three:Prospective study of three different therapy for primary biliary cirrhosis and primary biliary cirrhosis complicating Sj(o|¨)gren syndromeObject To evaluate the effects of the combination therapy with prednisonlone/azatharaprine and ursodeoxycholic acid(UDCA) for PBC and PBC with SS,compared to UDCA monotherapy,this study would get result by comparing symptoms,biochemical markers and Ig in pre- therapy and post- therapy,hoping to find better therapy.Materials and methods Ninety-three patients were divided randomly into three groups:group U(only use UDCA),group UP(use UDCA combination with prednisonlone) and group UA(use UDCA combination with azatharaprine).PBC with SS meeting demands had 79 patients,among these patients: group U 29 persons,group UP 37 persons,group UA 13 persons.The clinical and laboratory data was followed after 3,6 and 12 months,and finished the examination about SS in the department of stomatology and ophthalmology as far as possible, anti-ENA antibodies was also finished.Disease progression and medicine side effect was descriptived.Result The basic condition of three groups before therapy was no difference.Fatigue and pruritus were improved in three groups,there was no statistical difference.The P value was respectively group U(P=0.037 and P=0.036),group UA(P=0.046 and P=0.042),group UP(P=0.035 and P=0.037).the symptom of dry mouth was no obviously improved,The P value was respectively group U (P=0.055),group UA(P=0.057),group UP(P=0.067).There was no difference in improving biochemical indexes and Ig among these three groups,and these groups had disease progression during therapy.CONCLUSIONS The therapy of PBC with SS should treat PBC mainly.They could improve the hepatic biochemical markers.There are no difference between three groups for improve biochemical data of liver.There was not difference in progression among three groups.The combination with prednisonlone or azatharaprine did not surpass UDCA monotherapy. The side effect could not avoid completely.There are no statistical difference between three groups for improve three kinds of Ig,but the improving trend was more obviously compared the combination therapy UDCA with prednisonlone or azatharaprine to UDCA monotherapy.