大剂量rHuEPO对肾性贫血患者血液和骨髓红系作用的研究

[摘要] 目的：探讨应用大剂量重组人促红细胞生成素（rHuEPO）治疗肾性贫血的效果及机制。方法：对68例处于慢性肾脏病（CKD）3~5期的贫血患者给予佳林豪12 000 IU皮下注射，每周1次，连续12周，同时补充铁剂、叶酸和维生素B12；取血检测未成熟网织红细胞组分（IRF）、网织红细胞组分（Ret）、红细胞压积（Hct）、红细胞（RBC）、血红蛋白（Hb），并行骨髓穿刺进行骨髓显微图像分析，部分骨髓标本行电镜观察，观察治疗前后骨髓形态学变化，评价治疗效果。结果：治疗过程中大部分患者在EPO注射48 h后IRF、Ret升高（P

[关键词] 重组人促红细胞生成素；肾性贫血；红细胞系；未成熟网织红细胞组分

[中图分类号] R556[文献标识码]A [文章编号]1673-7210（2009）06（c）-015-03

Effect of high dose rHuEPO on blood and bone marrow erythrocytic series of patients with renal anemia

GUO Zhentao, XIAO Qing, LI Xiangling, CHEN Jing

(Department of Nephrology, the Affiliated Hospital of Weifang Medical College, Weifang261031, China)

[Abstract] Objective: To study the effect and mechanism of high dose rHuEPO in the treatment of renal anemia. Methods: 68 patients with renal anemia and 3-5 stage CKD received 12 000 IU per week of Jialinhao by hypodermic injection for 12 weeks, meanwhile, they were administered with folic acids, vitamin B12 and chalybeates. A sample of blood was obtained to test IRF, Ret, Hct, RBC and Hb, after that, bone marrow puncture and bone marrow micrograph analysis were performed. A part of bone marrow samples were observed by electron microscope. The change of bone marrow morphology before and after treatment was observed, and the therapeutic effect was analyzed. Results: 48 h after treatment, most of the patients had a marked improvement in IRF and Ret (P＜0.05), and IRF showed a more significant increase. Moreover, the value before treatment and 48 h after treatment of IRF had no overlap; IRF and Ret were further increased after 1 week; after 12 weeks IRF%, Hct, Ret, RBC and Hb were significantly increased than before treatment, bone marrow erythrocytic series proliferation was more active than that before treatment, each kind of erythroblast ratio and the percentage of total erythrocytic series (E) were significantly increased, especially late erythroblasts proliferation. Conclusion: High dose rHuEPO shows obvious therapeutic effect in the treatment of renal anemia, IRF may become an effective index for the early monitor of rHuEPO in treating patients with renal anemia.

[Key words] Recombined human erythropoietin; Renal anemia; Erythrocytic series; IRF%

重组人促红细胞生成素是目前治疗肾性贫血的主要药物，本研究应用大剂量rHuEPO对68例肾性贫血患者进行治疗，对骨髓和血液红系变化进行研究，现报道如下：

1 资料与方法

1.1 一般资料

按美国国家肾脏病基金会的“肾脏病生存质量指导”（K/DOQI）中分期标准均为3~5期、住院超过12周的患者68例，其中，男性44例，女性24例；年龄18~77岁。肾小球滤过率（GFR）

1.2 方法

1.2.1药品及给药方案采用rHuEPO皮下注射，每次12 000 IU，每周给药1次，连用12周。同时补充铁剂，右旋糖酐铁50 mg（25 mg/片），bid，叶酸20 mg，tid和维生素B12 500 μg，im，qod。

1.2.2 观察指标

1.2.2.1血象用药前和用药后48 h及第1、2、4、6、8、10、12周末分别取静脉血，应用Sysmex R-3000血细胞计数仪自动检测红细胞计数（RBC）、Hb、Hct、网织红细胞组分（Ret）、未成熟网织红细胞组分（IRF）。

1.2.2.2骨髓象用药前及用药后第12周末分别行骨髓穿刺检查，常规涂片，瑞氏染色，经骨髓显微图像分析，观察计算总红系所占百分数（E），并对早幼红、中幼红及晚幼红细胞分别进行分类计数，计算粒/红系（G/E）比值；同时留取适量骨髓液送电镜室，制作电镜样本后在透射电子显微镜（H-7500型，加速电压80 kV）下观察红细胞形态并拍照。

1.2.2.3疗效评价标准Hb上升≥30 g/L和（或）Hct上升≥10％，或 Hb达100 g/L、Hct达30％为显效；Hb上升≥15 g/L和（或）Hct上升≥5％为有效；上述指标无变化或恶化为无效。

1.3 统计学处理

数据以均数±标准差（x±s）表示，用SPSS 11.5软件进行统计学分析，定性资料行χ2检验，定量资料行配对t检验，P

2结果

2.1血象结果

治疗过程中大部分患者在佳林豪注射48 h后IRF、Ret显著升高（P

2.2 骨髓象结果

治疗后骨髓红系增生较治疗前明显活跃，各类幼红细胞比率及E均显著升高，其中以晚幼红细胞增生最为明显，粒/红系比值（G/E）明显降低，见表2。

表2 佳林豪治疗前和治疗第12周骨髓红系各指标变化（x±s）

2.3 骨髓红细胞电镜观察结果

中幼红细胞粗面内质网有脱颗粒现象，细胞核周间隙增宽，线粒体内有颗粒样沉积，考虑可能是铁沉积；晚幼红细胞的细胞膜不规则，胞膜厚薄不均匀，核膜不规则，且核固缩不明显。

3 讨论

1906年，Camot证实红系造血受激素调控，这种激素后来被命名为促红细胞生成素（erythropoietin，EPO）。1953年，Erslev等在贫血动物的血液中证实了这种物质的存在。肾性贫血的发病因素主要有肾脏产生促红细胞生成素不足、红细胞寿命缩短、尿毒症血清中一些毒性物质干扰红细胞的生成和代谢等[1-3]。正常人血清EPO浓度为10～12 mU/ml，肾性贫血患者为20～25 mU/ml，而非肾性贫血者血清EPO浓度达100～1 000 mU/ml，说明肾性贫血患者血清EPO相对不足[4]。rHuEPO可通过外源性途径补充EPO，刺激骨髓内红细胞前驱细胞增殖和分化[5]，其治疗肾性贫血的有效性和安全性临床已证实[6-8]。以往治疗肾性贫血往往采用1周2～3次，3 000 IU/次，为了方便患者、减轻患者的经济负担，国外学者先后探讨了1周1次、2周1次等延长间隔的给药方法，每周1次6 000~9 000 IU的方法取得了满意的效果[9-10]。本研究采用每周12 000 IU/次皮下注射的方法，治疗贫血总有效率为88.24%，无一例发生不良反应。本文68例CRF贫血患者治疗后红系各指标均显著上升，骨髓象红系增生明显活跃（以中幼红和晚幼红细胞增生为主），治疗期间血象和骨髓象增生趋势相符，骨髓E增幅越大，Hct增加越多，且E增幅大于Hct增幅，说明rHuEPO促进骨髓造血后骨髓内大量原始红细胞增殖和分化，成熟红细胞释放入血，外周血红细胞相应地增加。关于肾性贫血患者骨髓红系电镜下观察超微结构的变化，国内外报道罕见，本研究对6例贫血患者进行了骨髓电镜观察，与正常人相比，发现中幼红细胞粗面内质网有脱颗粒现象，细胞核周间隙增宽，线粒体内有颗粒样沉积，考虑可能是铁沉积；晚幼红细胞的细胞膜不规则，胞膜厚薄不均匀，核膜不规则，且核固缩不明显，由于各方面因素导致样本数量较少，骨髓电镜观察还需进一步研究。

然而，5%~10%的患者应用rHuEPO以后，Hb不能达到目标值，存在明显的rHuEPO低反应性[11-12]，至于低反应性的原因还有待于进一步研究，然而IRF作为一种新的参数，能准确、敏感地反映患者应用rHuEPO以后骨髓造血状况，本试验中有效组和显效组的患者应用rHuEPO 48 h后即显著升高，早期与Ret相比无重叠区，而无效组IRF变化不大，因此，对那些rHuEPO治疗后反应差的患者能早期作出提示，对肾内科医生是否使用rHuEPO起一定的指导作用，且检测简易、快速、廉价，IRF可成为肾性贫血患者应用rHuEPO后早期疗效监测的有效指标。

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（收稿日期：2009-02-16）