2015-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/645802摘要：從isoniazid (INH)及rifampicin (RIF)在1950及1970年代開發成功後，結核病已有很有效的藥物可治療。然而目前結核病在台灣之發生率仍居高不下，其原因固然很多，但抗結核藥物引起肝炎，使得結核病患者易中斷治療，無疑是治療失敗的重要原因。主持人曾於2007至2008年執行一前瞻性之計畫，研究我國結核病患者發生治療中肝炎之危險因子。結果顯示，我國結核病病人發生治療中肝炎之百分比為18.9%，其中16.4%是抗結核藥物引起的藥物性肝炎。發生藥物性肝炎之危險因子為： 1)女性；2) N-acetyl transferase 2 (NAT2)基因之slow acetylator; 3) 有B型肝炎且病毒量高者；4) 末期腎衰竭且未作透析。為了瞭解為什麼我國女性發生抗結核藥物性肝炎之危險性遠高於男性(24% vs. 12%)，主持人遂研究pregnane X receptor (PXR) 基因調控區之單核苷酸多型性(SNP)與抗結核藥物性肝炎之間的關係。結果發現，PXR 基因調控區之rs2461823，其基因型若為AA，則在女性其發生抗結核藥物性肝炎之風險為其他基因型之6.87倍，但在男性則無此現象。PXR 基因調控區之rs7643645，其基因型若為AA，則在女性其發生抗結核藥物性肝炎之風險為其他基因型之7分之1，但在男性則無此現象。然而抗結核藥物性肝炎最終之傷害，究竟發生在肝細胞之哪個分子機轉，至今尚不清楚，女性發生肝細胞最終傷害之風險是否較高亦不清楚。近年來由於粒線體科學之發展，科學家發現，抗結核藥物INH或其代謝物hydrazine，會抑制粒線體複合體II，但通常不會引起明顯的粒線體功能異常，因為粒線體的儲備功能很大。然而當同時有粒線體複合體I (即NADH去氫酶)抑制物存在時，就會因嚴重的能量(ATP)缺乏造成大量的肝細胞壞死。粒線體複合體I的突變或基因多型性，已有報告與女性乳癌之風險及女童氣喘病之風險有關(亦即與女性疾病有關)。因此主持人假設，女性發生INH或其他抗結核藥物性肝炎之風險較高，有一部分是因為粒線體複合體I (即NADH去氫酶)基因之SNP造成。亦即，INH之有毒代謝物hydrazine (本身是粒線體複合體II抑制劑)或其他的抗結核藥物，即使蓄積在體內，但若沒有特定的粒線體複合體I (即NADH去氫酶)基因多型性造成NADH去氫酶受抑制，則並不會造成嚴重的INH或其他的抗結核藥物性肝炎。然而若此病人有某些特定的NADH去氫酶基因多型性，造成NADH去氫酶受抑制，則因粒線體複合體I與II同時受抑制，會引起嚴重的INH或其他的抗結核藥物性肝炎。本計畫為期三年，研究方法為，分析300位肺結核病人及300位健康受試者白血球粒線體DNA中複合體I (即NADH去氫酶)基因之多型性，包括位於此基因之ND1、ND2、ND3、ND4、ND4L、ND5、ND6等7個subunit中之9個SNP，經PCR增量後作DNA定序。比較肺結核病人與健康成人9個SNP之基因型(genotype)與單套型(haplotype)，以及有發生INH或其它抗結核藥物性肝炎與未發生肝炎者，其9個SNP之genotype與haplotype。分析NADH 去氫酶基因中，此9個SNP之genotype與haplotype，與女性之INH或其他抗結核藥物性肝炎之風險較高有無相關性。<br> Abstract: Hepatitis during anti-tuberculosis (TB) treatment (HATT) is the most important adverse event of anti-TB chemotherapy. In 2007 to 2008 we conducted a prospective study to investigate risk factors of HATT. We found that HATT developed in 18.9% of our TB patients, of whom 16.5% were due to anti-TB drugs (drug-induced HATT). We discovered that risk factors for drug-induced HATT were: 1) women; 2) N-acetyl transferase 2 (NAT2) slow acetylator; 3) High HBV viral load, and 4) end-stage renal disease. To explore why women have higher risk of drug-induced HATT than men (24 vs. 12%), we conducted a study in 2013 to investigate the influence of single nucleotide polymorphisms (SNPs) in the regulatory region of pregnane X receptor (PXR) gene on drug-induced HATT. We found that female with genotype AA at rs2461823 of PXR was 6 times more risky of developing drug-induced HATT than those having other genotypes. No such association was found in males.However, the exact molecular mechanisms leading to final steps of hepatic necrosis in drug-induced HATT remain unknown. Whether females have higher risk in the final steps of hepatic necrosis is also unknown. Recently it was discovered that INH and its metabolite hydrazine (both being mitochondrial complex II inhibitors) may interfere with mitochondrial function. Yet such changes of mitochondria usually won’t cause overt liver damage, because mitochondria have large reserve. Yet when there is coexisting genetic or pharmacologic inhibitors of mitochondria complex I, the inhibition of both complex I and complex II would lead to severe ATP shortage and massive hepatic necrosis. In the literature, mitochondrial complex I (i.e. NADH dehydrogenase) gene SNPs were associated with breast cancer and asthma in girls, but not in boys. These gender-specific associations prompt us to set our hypothesis as: Mitochondrial complex I (or NADH dehydrogenase) SNPs are associated with mitochondrial complex I deficiency and could trigger INH-induced, or other drug-induced HATT, because INH metabolite hydrazine itself is a known mitochondrial complex II inhibitor . The genotype/haplotype distribution of NADH dehydrogenase SNPs might be different in females than in males, contributing to the higher risk of INH- or other drug-induced HATT in females.We’ll enroll 300 TB patients and 300 healthy controls in 3 years. We’ll sample peripheral blood and sequence 9 SNPs in NADH dehydrogenase gene (in subunit ND1, ND2, ND3, ND4, ND4L, ND5, ND6), compare genotype/haplotype distribution between TB patients and controls, patients with INH- or other drug-induced HATT and those without, and analyze if SNPs in NADH dehydrogenase could contribute to the higher risk of INH- or other drug-induced HATT in females than males.結核病抗結核藥物性肝炎isoniazid (INH)hydrazine女性粒線體NADH去氫酶基因複合體I複合體II單核苷酸多型性基因型單套型tuberculosishepatitis during anti-TB treatment (HATT)INHhydrazinemitochondria complex I or complex II deficiencyNADH dehydrogenasesingle nucleotide polymorphism (SNP)genotypehaplotypefemalemale