2017-08-012024-05-14https://scholars.lib.ntu.edu.tw/handle/123456789/657093摘要：近年來台灣地區末期腎臟病(end-stage renal disease)之盛行率、發生率及死亡率，均不斷 攀升，已逐漸與高血壓、糖尿病等慢性病同列為國人之重要疾病。許多不同的腎臟疾病都有 可能演變為末期腎臟病，台灣地區則是目前全世界末期腎臟病新生率最高以及盛行率第二的 地方。腎絲球腎炎(glomerulonephritis)為常見的末期腎病變致病原因之一。造成腎絲球腎炎的 原因很多，其病理變化明顯觀察到腎絲球巨噬細胞的聚集、腎腸細胞(mesangial cells)的增生 及細胞外間質蛋白堆積。另外，近年來儘管醫療水準大幅提昇，急性腎損傷(acute kidney injury) 患者的死亡率仍然居高。有許多毒物或藥物能透過多種機制引發腎毒性，進而誘發急性腎損 傷包括急性腎小管細胞損傷和壞死或是在腎間質引起發炎反應。除藥毒物外，腎臟缺血/再灌 流（ischemia/reperfusion)亦為常見造成急性腎損傷的原因，其造成的傷害常發生於腎臟移植、 腎臟動脈血管狹窄或是其他原因所導致;臨床上迄今仍缺乏有效的藥物來治療急性腎損傷。毒 藥物或疾病例如糖尿病和高血壓也可能導致慢性腎臟病(chronic kidney disease)的產生，像是 慢性腎絲球腎炎和慢性腎間質纖維化，最終都可能會導致末期腎臟病的發生。大多數末期腎 病變的治療方法包括了血液透析、腹膜透析和腎臟移植，這些都所費不貲，且唯有腎臟移植 可使患者腎功能恢復到近似正常人。臨床上迄今仍缺乏有效的藥物來治療腎臟疾病。因此， 如何防治及尋找有效治療腎臟疾病的策略是一項需要積極解決的重要課題。另一方面，超音 波是作為診斷用的即時造影設備或侵入性治療時即時定位；但近年來，超音波也被發現可以 做為治療疾病的一種方法，其主要應用有兩個方面，一種是高強度聚焦式超音波(high-intensity focused ultrasound, HIFU)，另一種是低強度脈衝式超音波(low-intensity puled ultrasound, LIPUS)。高強度聚焦式超音波可引發熱效應，造成聚焦區域溫度升高，燒灼破壞蛋白質或引 起組織内細胞凋亡及傷害等，此種大能量的累積可以應用在腫瘤細胞的熱燒灼治療上。但是 以上的治療方法只能利用高溫的熱治療來切除病灶發生的區域，可能無法達到完全治癒效果， 通常對周圍的正常細胞也會有所影響。而低強度脈衝式超音波(LIPUS)相較於HIFU，所造成 傷害的可能性較低也可以恢復，所以應用的範圍也可更為廣泛，例如已有許多有關LIPUS用 於神經性疾病或骨骼疾病治療有效之動物或臨床試驗報告。目前尚未有利用低強度脈衝式超 音波治療腎臟病變之研究報告。本研究計晝之目的乃擬利用細胞及動物模式來探討LIPUS應 用於腎臟疾病治療之可能性及可能之作用機制，以期其能成為臨床上預防(高危險群患者)或 治療或輔助治療腎臟疾病之有用技術。初步預試驗結果可支持本計晝之可行性。計晝分三年 進行：第一年:腎絲球腎炎細胞及動物模式：利用細胞激素或細菌内毒素刺激培養之腎絲球 腎膈細胞模式及anti-thy-1抗體腎絲球腎炎大鼠模式探討低強度脈衝式超音波對於腎絲球腎 炎預防或治療效果及可能作用機制。第二年：急性腎損傷細胞及動物模式：利用培養之腎臟 近端腎小管細胞缺氧/再灌流模式及缺血/再灌流之小鼠模式探討低強度脈衝式超音波對於急 性腎損傷預防或治療效果及可能作用機制。第三年：慢性腎臟病細胞及動物模式：利用轉化 生長因子-P1刺激培養之腎臟近端腎小管細胞模式及單侧輸尿管阻塞大鼠模式探討低強度脈 衝式超音波對於慢性腎臟病預防或治療效果及可能作用機制。本計晝為一新的概念，利用非 侵入性之低強度脈衝式超音波嘗試用於腎臟疾病之治療的研究，若細胞及動物模式實驗可以 證明此方法對於預防或治療腎臟疾病的可能性，則未來進行臨床試驗或甚至應用於臨床預防 或治療上將是可預期或期待的。<br> Abstract: Taiwan is currently the world's highest incidence of end-stage renal disease (ESRD), as well as the world's second highest prevalence. Glomerulonephritis (GN) is still the most common cause of ESRD. GN is an immune-related inflammatory disease of glomeruli characterized by inflammatory cell infiltration, excess glomerular cell proliferation, and mesangial matrix deposition in response to phlogistic stimulation. Moreover, there are a lot of poisons or drugs through a variety of mechanisms to induce renal toxicity and cause acute kidney injury (AKI), including acute renal tubular cell injury and necrosis or acute renal interstitial nephritis. Chronic kidney disease (CKD) is a worldwide public health problem. There is an increasing incidence and prevalence of patients with kidney failure requiring replacement therapy, with poor outcomes and high cost. Tubulointerstitial fibrosis, regardless of the initial renal insults, is a common pathological presentation of CKD. The most important feature of ESRD is renal interstitial fibrosis, which is characterized by normal renal structure replaced by abnormal accumulation of extracellular matrix proteins, tubular atrophy, tubular expansion and glomerular sclerosis. The methods for ESRD treatment include hemodialysis, peritoneal dialysis, and kidney transplantation, which are costly and can only kidney transplant patients return to approximately normal renal function. On the other hand, ultrasound is widely used for diagnostic medical imaging, and is a safe and effective modality to visualize pathological lesions in human body. In recent years, ultrasound has also been found to be used as a method for treating a disease, its main application has two aspects, one is a high intensity focused ultrasound formula (HIFU), and the other is a low-intensity pulsed ultrasound (LIPUS). HIFU can lead to thermal effects style, with good penetration in human tissues, energy can be transferred to the deep tissue, the focus area can cause the temperature rises, burning causing damage to proteins or cell injury/apoptosis within tissues. Accumulation of such large energy can be applied to the thermal cautery treatment of tumor cells. However, the HIFU method using high-temperature heat treatment usually might damage the surrounding normal cells or tissues. LIPUS, as compared to HIFU, is less likely to cause harm and can be restored, so the range of applications can be more extensive, for example, LIPUS effectively alleviated bone disease. However, the therapeutic effects of LIPUS on kidney diseases are still unclear. The aims of this research project are to investigate the preventive and therapeutic effects of LIPUS on kidney diseases using cell and animal models. The results of our preliminary experiments can support the ideas of this project. This is a three-year project. First year: To investigate the preventive and therapeutic effects and possible mechanisms of LIPUS on cytokines/lipopolysaccharide-treated mesangial cell model and anti-thy-1 rat model of GN. Second year: To investigate the preventive and therapeutic effects and possible mechanisms of LIPUS on hypoxia/reperfusion-exposed renal tubule cell model and ischemia/reperfusion-exposed mouse mnodel of AKI. Third year: To investigate the preventive and therapeutic effects and possible mechanisms of LIPUS on TGF-pi-treated renal tubule cell model and unilateral ureteral obstruction (UUO) rat model of CKD. This project is a new concept. The non-invasive LIPUS, which intensity is in the range of diagnostic ultrasound, will be used to test its effects on acute and chronic renal injury. If these cell and animal model experiments can prove that this method is work for the preventive or treatment of kidney diseases, the clinical trials or even used in clinical preventive or treatment will be expected or anticipated in the future.近年來台灣地區末期腎臟病(end-stage renal disease)之盛行率、發生率及死亡率，均不斷 攀升，已逐漸與高血壓、糖尿病等慢性病同列為國人之重要疾病。許多不同的腎臟疾病都有 可能演變為末期腎臟病，台灣地區則是目前全世界末期腎臟病新生率最高以及盛行率第二的 地方。腎絲球腎炎(glomerulonephritis)為常見的末期腎病變致病原因之一。造成腎絲球腎炎的 原因很多，其病理變化明顯觀察到腎絲球巨噬細胞的聚集、腎腸細胞(mesangial cells)的增生 及細胞外間質蛋白堆積。另外，近年來儘管醫療水準大幅提昇，急性腎損傷(acute kidney injury) 患者的死亡率仍然居高。有許多毒物或藥物能透過多種機制引發腎毒性，進而誘發急性腎損 傷包括急性腎小管細胞損傷和壞死或是在腎間質引起發炎反應。除藥毒物外，腎臟缺血/再灌 流（ischemia/reperfusion)亦為常見造成急性腎損傷的原因，其造成的傷害常發生於腎臟移植、 腎臟動脈血管狹窄或是其他原因所導致;臨床上迄今仍缺乏有效的藥物來治療急性腎損傷。毒 藥物或疾病例如糖尿病和高血壓也可能導致慢性腎臟病(chronic kidney disease)的產生，像是 慢性腎絲球腎炎和慢性腎間質纖維化，最終都可能會導致末期腎臟病的發生。大多數末期腎 病變的治療方法包括了血液透析、腹膜透析和腎臟移植，這些都所費不貲，且唯有腎臟移植 可使患者腎功能恢復到近似正常人。臨床上迄今仍缺乏有效的藥物來治療腎臟疾病。因此， 如何防治及尋找有效治療腎臟疾病的策略是一項需要積極解決的重要課題。另一方面，超音 波是作為診斷用的即時造影設備或侵入性治療時即時定位；但近年來，超音波也被發現可以 做為治療疾病的一種方法，其主要應用有兩個方面，一種是高強度聚焦式超音波(high-intensity focused ultrasound, HIFU)，另一種是低強度脈衝式超音波(low-intensity puled ultrasound, LIPUS)。高強度聚焦式超音波可引發熱效應，造成聚焦區域溫度升高，燒灼破壞蛋白質或引 起組織内細胞凋亡及傷害等，此種大能量的累積可以應用在腫瘤細胞的熱燒灼治療上。但是 以上的治療方法只能利用高溫的熱治療來切除病灶發生的區域，可能無法達到完全治癒效果， 通常對周圍的正常細胞也會有所影響。而低強度脈衝式超音波(LIPUS)相較於HIFU，所造成 傷害的可能性較低也可以恢復，所以應用的範圍也可更為廣泛，例如已有許多有關LIPUS用 於神經性疾病或骨骼疾病治療有效之動物或臨床試驗報告。目前尚未有利用低強度脈衝式超 音波治療腎臟病變之研究報告。本研究計晝之目的乃擬利用細胞及動物模式來探討LIPUS應 用於腎臟疾病治療之可能性及可能之作用機制，以期其能成為臨床上預防(高危險群患者)或 治療或輔助治療腎臟疾病之有用技術。初步預試驗結果可支持本計晝之可行性。計晝分三年 進行：第一年:腎絲球腎炎細胞及動物模式：利用細胞激素或細菌内毒素刺激培養之腎絲球 腎膈細胞模式及anti-thy-1抗體腎絲球腎炎大鼠模式探討低強度脈衝式超音波對於腎絲球腎 炎預防或治療效果及可能作用機制。第二年：急性腎損傷細胞及動物模式：利用培養之腎臟 近端腎小管細胞缺氧/再灌流模式及缺血/再灌流之小鼠模式探討低強度脈衝式超音波對於急 性腎損傷預防或治療效果及可能作用機制。第三年：慢性腎臟病細胞及動物模式：利用轉化 生長因子-P1刺激培養之腎臟近端腎小管細胞模式及單侧輸尿管阻塞大鼠模式探討低強度脈 衝式超音波對於慢性腎臟病預防或治療效果及可能作用機制。本計晝為一新的概念，利用非 侵入性之低強度脈衝式超音波嘗試用於腎臟疾病之治療的研究，若細胞及動物模式實驗可以 證明此方法對於預防或治療腎臟疾病的可能性，則未來進行臨床試驗或甚至應用於臨床預防 或治療上將是可預期或期待的。Taiwan is currently the world's highest incidence of end-stage renal disease (ESRD), as well as the world's second highest prevalence. Glomerulonephritis (GN) is still the most common cause of ESRD. GN is an immune-related inflammatory disease of glomeruli characterized by inflammatory cell infiltration, excess glomerular cell proliferation, and mesangial matrix deposition in response to phlogistic stimulation. Moreover, there are a lot of poisons or drugs through a variety of mechanisms to induce renal toxicity and cause acute kidney injury (AKI), including acute renal tubular cell injury and necrosis or acute renal interstitial nephritis. Chronic kidney disease (CKD) is a worldwide public health problem. There is an increasing incidence and prevalence of patients with kidney failure requiring replacement therapy, with poor outcomes and high cost. Tubulointerstitial fibrosis, regardless of the initial renal insults, is a common pathological presentation of CKD. The most important feature of ESRD is renal interstitial fibrosis, which is characterized by normal renal structure replaced by abnormal accumulation of extracellular matrix proteins, tubular atrophy, tubular expansion and glomerular sclerosis. The methods for ESRD treatment include hemodialysis, peritoneal dialysis, and kidney transplantation, which are costly and can only kidney transplant patients return to approximately normal renal function. On the other hand, ultrasound is widely used for diagnostic medical imaging, and is a safe and effective modality to visualize pathological lesions in human body. In recent years, ultrasound has also been found to be used as a method for treating a disease, its main application has two aspects, one is a high intensity focused ultrasound formula (HIFU), and the other is a low-intensity pulsed ultrasound (LIPUS). HIFU can lead to thermal effects style, with good penetration in human tissues, energy can be transferred to the deep tissue, the focus area can cause the temperature rises, burning causing damage to proteins or cell injury/apoptosis within tissues. Accumulation of such large energy can be applied to the thermal cautery treatment of tumor cells. However, the HIFU method using high-temperature heat treatment usually might damage the surrounding normal cells or tissues. LIPUS, as compared to HIFU, is less likely to cause harm and can be restored, so the range of applications can be more extensive, for example, LIPUS effectively alleviated bone disease. However, the therapeutic effects of LIPUS on kidney diseases are still unclear. The aims of this research project are to investigate the preventive and therapeutic effects of LIPUS on kidney diseases using cell and animal models. The results of our preliminary experiments can support the ideas of this project. This is a three-year project. First year: To investigate the preventive and therapeutic effects and possible mechanisms of LIPUS on cytokines/lipopolysaccharide-treated mesangial cell model and anti-thy-1 rat model of GN. Second year: To investigate the preventive and therapeutic effects and possible mechanisms of LIPUS on hypoxia/reperfusion-exposed renal tubule cell model and ischemia/reperfusion-exposed mouse mnodel of AKI. Third year: To investigate the preventive and therapeutic effects and possible mechanisms of LIPUS on TGF-pi-treated renal tubule cell model and unilateral ureteral obstruction (UUO) rat model of CKD. This project is a new concept. The non-invasive LIPUS, which intensity is in the range of diagnostic ultrasound, will be used to test its effects on acute and chronic renal injury. If these cell and animal model experiments can prove that this method is work for the preventive or treatment of kidney diseases, the clinical trials or even used in clinical preventive or treatment will be expected or anticipated in the future.低強度脈衝式超音波腎絲球腎炎急性腎損傷慢性腎臟病low-intensity pulsed ultrasoundglomerulonephritisacute kidney injurychronic kidney disease