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研究生:賈婉伶
論文名稱:血液透析患者氧化壓力狀態之評估與其影響因子
論文名稱(外文):The evaluation of oxidative stress status and causing factors in hemodialysis patients
指導教授:郭志宏郭志宏引用關係
學位類別:碩士
校院名稱:弘光科技大學
系所名稱:營養醫學研究所
學門:醫藥衛生學門
學類:營養學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
論文頁數:150
中文關鍵詞:血液透析氧化壓力發炎DNA 損傷微營養素狀態
外文關鍵詞:hemodialysisoxidative stressinflammationDNA damagemicronutrient
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本論文旨在探討長期接受血液透析之患者 (hemodialysis, HD)的氧化壓力 (oxidative stress) 狀態,進一步評估其洗腎前後的氧化壓力改變之影響因子。收集基本資料與受試者臨床指標外,並分析DNA 損傷程度、氧化壓力指標 (淋巴球細胞 ROS 及 GSH 分佈、血漿中MDA 及ox-GSH/ reduced GSH、紅血球中 H2O2含量及紅血球中抗氧化酵素 GSH peroxidase (GPx) 活性)、微量元素鋅 (zinc) 和鐵 (iron)、紅血球細胞膜 n-3 多元不飽和脂肪酸 (EPA 及 DHA) 組成、維生素 C/維生素E/homocysteine 含量、TNF- 及急性期反應蛋白 C-reactive protein (CRP) 濃度等。結果顯示HD有顯著較健康受試組(CNL) 高的 DNA 損傷程度 (p<0.05)。HD 的淋巴球、血漿或紅血球氧化壓力狀態,皆明顯比 CNL 較高。推測 HD 患者有較高的氧化壓力,可能是增加 DNA 損傷的主因。此外,患者血漿中微營養素 (鋅、維生素 C 及維生素E) 狀態、紅血球細胞膜的 EPA和DHA 含量顯著較 CNL 組低及較高血漿 TNF-、CRP 含量及 homocysteine 濃度,與較高的氧化壓力狀態有關。然而,比較接受不同血液透析 (高透量血液透析、低透量血液透析、血液過濾及血液透析過濾) 方式的氧化壓力狀態,各組間未有明顯差異 (p>0.05)。另一方面,HD 在進行透析後,淋巴球 ROS 比率和紅血球 H2O2 counts 皆較透析前明顯減少。GPx 活性、鋅、鐵、維生素 C、維生素E 及 homocysteine 含量,則明顯較洗腎前低。推測透析治療可以清除患者因體內含氮廢物及同半胱胺酸所產生的氧化壓力,進而消耗體內抗氧化能力伴隨微營養素流失。進一步將洗腎前後的各項氧化指標變化值與洗腎前各項相關因子及臨床生化指標進行相關性分析:(1)鐵含量則和紅血球中H2O2 變化值;(2)ferritin含量與 ROS 比率變化值;(3)尿素移除率 (URR) 和 MDA 變化值,均呈現顯著負相關。(4)鋅和 ROS 變化值;(5)CRP、homocysteine濃度和紅血球中 H2O2 變化值;(6)creatinine含量與 GSSG/GSH 比值變化,亦呈明顯正相關。顯示洗腎前的微營養素含量、發炎反應指標或含氮廢物濃度,明顯影響洗腎後氧化壓力狀態改變。因此,監控洗腎前的 TNF-、hs-CRP、zinc、iron、homocysteine 與臨床生化指標URR 和 ferritin,可能預估出患者洗腎後的氧化壓力狀態,期能減少因氧化壓力增加而造成對患者的氧化傷害或減少死亡率。
The purpose of this investigation was to assess the oxidative stress status of patients with chronic hemodialysis (HD), and further to evaluate the causing factors of oxidatve stress changes during hemodialysis process. The basic characteristics of all subjects were collected, and the DNA damage, oxidative stress, trace elements zinc and iron, the erythrocyte membrane n-3 polyunsaturated fatty acid (EPA and DHA) composition, vitamin C/vitamin E/homocysteine contents, cytokine and high-sensitivity C-reactive protein levels were then analysed. The results showed that HD group has significantly higher DNA damage (DNA in head, tail length, DNA in tail and tail moment parameter) than healthy control (CNL). HD patients have significantly higher oxidative stress in lymphocyte, plasma or erythrocyte compared with CNL, that as a possible major factor in increasing DNA damage. In addition, the plasma levels of zinc, vitamin C and E, erythrocyte membrane's EPA and DHA composition were markedly decreased than CNL. This suggested that these observations were correlated with increased oxidative stress. The markedly higher blood plasma levels of TNF- , the CRP content and homocysteine were also noted. The difference among the four different hemodialysis methods (High flux hemodialysis, low flux hemodialysis, hemofiltration and hemodiafiltration) were not observed. Moreover, the lymphocyte ROS and erythrocyte H2O2 counts were significantly reduced in after HD than before HD in patients. GPx activity, zinc and iron, vitamin C, vitamin E and homocysteine contents were also decreased after HD. Moreover, the significantly negative correlations between (1) Fe level and changes in erythrocyte H2O2 ; (2)ferritin and changes in ROS ratio ; (3) URR and changes in MDA were observed, and (4) zinc and changes in ROS ratio ; (5)CRP on homocysteine and the changes erythrocyte H2O2 change value ; (6) the creatinine content and changes in GSSG/GSH ratio, the positive correlations were also noted. Therefore, levels for TNF-, hs-CRP, zinc, iron and homocysteine, URR and ferritin concentrations in the before hemodialysis, which as a predictior of oxidative stress after hemodialysis. This suggest that the avoiding of increased oxidative stress will decrease the mortality of HD patients.
目錄……………………………………………………………………Ⅰ
表目錄…………………………………………………………………Ⅴ
圖目錄…………………………………………………………………Ⅵ
縮寫表…………………………………………………………………Ⅶ
中英對照表……………………………………………………………Ⅷ
中文摘要………………………………………………………………Ⅸ
英文摘要………………………………………………………………Ⅺ
第一章 緒論……………………………………………………………1
第二章 文獻回顧………………………………………………………3
ㄧ、慢性腎衰竭……………………………………………………3
1. 慢性腎衰竭之併發症………………………………………4
1.1續發性副甲狀腺機能亢進與高磷血症……………………4
1.2貧血…………………………………………………………5
1.3骨病變………………………………………………………7
2. 延緩慢性腎衰竭進展之方法………………………………10
二、血液透析………………………………………………………12
1. 透析膜材質…………………………………………………14
2. 不同血液透析方式……………………………………………16
三、 血液透析所產生之副作用
1. 心血管疾病……………………………………………………16
2. 低血壓…………………………………………………………17
3. 抽筋與電解質不平衡…………………………………………17
4. 氧化壓力增加…………………………………………………18
四、血液透析之危險因子……………………………………………19
1. 白蛋白狀態改變………………………………………………20
2. 免疫力改變……………………………………………………21
3. 發炎反應………………………………………………………22
4. 微營養素分布改變……………………………………………25
4.1維生素………………………………………………………26
4.2同半胱胺酸…………………………………………………27
4.3微量元素……………………………………………………31
5. 紅血球細胞膜上多元不飽和脂肪酸組成改變………………33
6. 抗氧化酵素活性改變…………………………………………35
五、DNA 受損…………………………………………………………37
六、氧化壓力…………………………………………………………38
第三章 材料與方法……………………………………………………46
ㄧ、收案對象………………………………………………46
二、分析項目…………………………………………47
1. 血液分離-淋巴球細胞製備…………………………48
2. 淋巴球之 ROS 及 GSH 含量之分析…………………………48
3. Comet assay……………………………………………49
4. 血漿中脂質過氧化物檢測…………………………51
5. 血漿中 C-反應蛋白…………………………………………53
6. 血漿中腫瘤壞死因子-
7. -tocopherol 含量之分析…………………………………54
8. 血漿中維生素 C之分析…………………………………….56
9. 血漿中 GSH 含量分析…………………………………...…57
10. 血漿中 GSSG 含量分析……………………………………58
11. 血漿中微量元素鋅和鐵的含量分析…………………………59
12. 血漿中同半胱胺酸含量分析…………………………….60
13. 紅血球細胞膜脂不飽和脂肪酸(EPA 和 DHA)組成分析…62
14. 紅血球 luminol 作用產物分析………………………65
15. 紅血球麩胱甘肽過氧化酵素活性分析………………….66
三、統計分析………………………………………………….69
第四章 結果…………………………………………………….70
第五章 討論…………………………………………………………97
第六章 結論…………………………………………………………104
第七章 參考文獻……………………………………………………106
附錄....................................................141
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