Glucocorticoids-induced osteonecrosis of the femoral head: adipogenic differentiation and treatment progress

doi:10.3969/j.issn.2095-4344.2014.29.024

Abstract

Abstract:

BACKGROUND: Glucocorticoids may induce local bone trabecular and bone marrow necrosis, femoral head collapse and deformation, thus resulting in hip dysfunction. However the pathological mechanisms and treatment of glucocorticoids-induced osteonecrosis of the femoral head remain unclear, and the pathogenesis mechanisms are controversial. The current studies focus on the understanding of the pathological mechanisms.

OBJECTIVE: To summary the research progress of adipogenic differentiation theory of glucocorticoids-induced osteonecrosis of the femoral head and the treatment.

METHODS: The first author searched literature from CNKI and PubMed database from 1988 to 2010, by using the key words is “Glucocorticoids, osteonecrosis of femoral head, bone marrow stromal stem cells, adipogenic differentiation, differentiation factors, treatment, choices” in English, and “glucocorticoids induced osteonecrosis of femoral head, adipogenic differentiation, treatment, research progress” in Chinese. Articles regarding the adipogenic differentiation theory of glucocorticoids-induced osteonecrosis of the femoral head and the treatment were included.

RESULTS AND CONCLUSION: A total of 112 literatures were screened out, according to inclusion and exclusion criteria for literature screening, 54 articles were included. Modern researches emphasize the cell and molecular biology level, and show that the biological base of glucocorticoids-induced osteonecrosis of the femoral head is abnormal adipogenic differentiation of bone cells, glucocorticoids cause the variations of adipogenic differentiation factors, leading to adipogenic differentiation of bone marrow stromal cells. But glucocorticoids affects multiple differentiation factors, it may cause great error in the evaluation of the pathogenesis of glucocorticoids-induced osteonecrosis of the femoral head purely from one factor. The abuse of glucocorticoids is the leading cause for the osteonecrosis of femoral head. Further studies are needed to investigate the pathogenesis of osteonecrosis of the femoral head and treatment programs.

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

全文链接：

Key words: hormones, femur head necrosis, bone marrow, adipogenesis

CLC Number:

R318

Liu Bin, Li Gang, Xu Bo, Liu Guo-yan. Glucocorticoids-induced osteonecrosis of the femoral head: adipogenic differentiation and treatment progress[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(29): 4730-4735.

Figures/Tables 1

2.1 纳入资料基本概况纳入的文献包括激素性股骨头坏死成脂分化学说机制类文章20篇[1-20]，成脂因子在激素性股骨头坏死的作用类文章14篇[21-34]，激素性股骨头坏死治疗方案进展类文章20篇[34-54]。以此为依据对激素性股骨头坏死及治疗研究进展进行了归纳和总结。 2.2 纳入资料的研究结果特征 2.2.1 激素性股骨头坏死成脂分化学说相关研究骨髓基质干细胞具有多向分化潜能，可分化为脂肪细胞、成骨细胞和血管内皮细胞等。下面是激素促进骨髓基质干细胞成脂分化方面研究进展：激素促骨髓基质干细胞成脂分化作用研究：Tan等[2]实验研究发现糖皮质激素对骨髓基质干细胞分化调节，是通过激活或抑制成骨和成脂细胞相关转录调控实现的。在激素的刺激下，骨髓基质干细胞来源的脂肪细胞会增加惊人的体积，造成成骨细胞明显下降，最终因为脂肪代谢紊乱继而引起一系列病理生理变化导致股骨头坏死。Bujalska等[3]发现脂肪细胞的分化有赖于糖皮质激素和羟类固醇脱氢酶的作用，这些结果表明，糖皮质激素局部代谢可以通过一个特定站点的方式控制脂肪组织的分化。Campbell等[4]通过研究发现：慢性糖皮质激素暴露刺激内脏脂肪组织的脂肪分解和脂肪细胞分化，且主要促进前脂肪细胞分化脂肪细胞，通过细胞分化而不是脂肪细胞肥大形成脂肪。Lin等[5]发现糖皮质激素通过拮抗外源Runt-related transcription factor 2 (Runx2)诱导原代培养的骨髓间充质干细胞向脂肪细胞。其实验中地塞米松治疗作用含诱导成脂分化和抑制增殖，而外源Runx2能够拮抗地塞米松对成骨细胞分化抑制的影响。Ortiz-Colon等[6]研究发现牛肌内，皮下及肾间质血管细胞表达类似的糖皮质激素受体亚型，具有不同的成脂能力，但是成脂活性和糖皮质激素受体的数量或功能之间没有关系。Pantoja等[7]通过地塞米松处理前脂肪细胞研究得出结论：糖皮质激素驱动前脂肪细胞成为一种中间状态的细胞，并且脂肪细胞因子(preadipocyte factor-1，Pref-1)抑制可决定前脂肪细胞的细胞命运。Shi等[8]揭示新的糖皮质激素拮抗机制：糖皮质激素诱导的亮氨酸拉链蛋白(GC-induced leucine-zipper protein，GILZ)抑制骨髓间充质干细胞成脂分化。Cook等[9]发现糖皮质激素可诱导脂肪酸结合蛋白分化基因的表达。激素影响骨细胞分化的研究：激素抑制骨细胞分化，变相的改善成脂分化。Weinstein等[10]研究发现糖皮质激素应用过量后，破骨细胞存活量以及成骨细胞和骨细胞凋亡增加引起骨骼的不良影响。但是骨保护素诱导后可增强骨细胞活力保存骨强度。Eijken等[11]研究表明糖皮质激素诱导刺激参与骨形成基因的表达和抑制负调控骨形成和矿化的基因表达。Ito等[12]阐明糖皮质激素诱导骨髓基质干细胞分化为脂肪细胞和成骨细胞，但不能诱导终端成骨细胞的分化。实验研究发现地塞米松连续治疗可刺激脂肪细胞的形成，但未能诱导成骨相关转录因子抗体Osterix的表达和矿化基质的形成，这表明地塞米松不促进终端成骨细胞分化。Rauch等[13]发现糖皮质激素通过单体糖皮质激素受体减少成骨细胞分化以抑制骨形成，糖皮质激素抑制单体糖皮质激素受体二聚化从而减弱成骨细胞的分化。Rodriguez等[14]发现骨质疏松患者骨髓间充质干细胞产生的Ⅰ型胶原缺乏的细胞外基质有利于脂肪细胞的分化。这说明来自骨质疏松症绝经后妇女的生成和维护Ⅰ型胶原蛋白的细胞外基质减少，促进了骨髓间充质干细胞成脂分化的能力。另外Derfoul等[15]发现糖皮质激素可增强软骨细胞外基质基因表达，进而促进人骨髓间充质干细胞向软骨细胞分化。Wei等[16]通过去卵巢大鼠模型研究发现糖皮质激素受体拮抗剂影响其骨髓间充质干细胞增殖、分化能力。Matsumoto等[17]研究发现雌激素和糖皮质激素通过差异性调节骨形态发生蛋白、Smad和肿瘤坏死因子α信号方式参与成骨细胞分化。其中骨形态发生蛋白2增加雌激素和糖皮质激素的敏感性。Carcamo-Orive等[18]通过研究发现人骨髓间充质干细胞糖皮质激素受体在高浓度的糖皮质激素刺激下，通过减少c-Jun表达和人骨髓间充质干细胞增殖，抑制成骨来支持脂肪细胞分化；相反，低浓度的糖皮质激素，允许人骨髓间充质干细胞增殖，有利于正常骨矿化。这揭示了一种以c-Jun为中心的新的控制骨髓间充质干细胞成骨和成脂分化增殖的信号调节网络。Wang等[19-20]发现激素性股骨头坏死与骨髓间充质干细胞骨保护素和RANKL 基因表达水平相关，中药淫羊藿预防机制可能就是通过拮抗糖皮质激素引起RANKL和骨保护素的异常表达。 2.2.2 激素性股骨头坏死促成脂分化因子及研究进展关于脂肪细胞标记基因过氧化物酶增殖物激活受体(peroxidase proliferator-activated receptorγ，PPARγ2)的相关研究：Kang等[21]在实验研究中有2个重要发现：PPARγ2经过骨形态发生蛋白诱导后，不仅增加骨髓基质干细胞的成脂分化，还明显增加成骨分化；相反PPARγ2敲出的骨髓基质干细胞成脂分化减少、成骨细胞分化及矿化作用均减弱。这表明PPARγ2可能在成骨细胞和成脂细胞分化诱导中均发挥了重要作用；另外还发现Runx2表达受抑制后，骨形态发生蛋白诱导骨形成的减少，同时伴有体内脂肪的积累减少。Lu等[22]通过实时RT-PCR检测分析PPARγ2，脂蛋白脂酶和脂肪酸结合蛋白4后，发现细胞密度对人骨髓间充质干细胞的成脂分化没有明显的影响。Guo等[23]发现肌肉生长抑制素可介导骨髓基质干细胞成脂分化。肌肉生长抑制素主要通过关联信号通路交叉通信介导下调PPARγ的表达，从而抑制人骨髓间充质干细胞向脂肪细胞分化。Zhang等[24]通过MTT法、细胞周期、ALP活性成骨胶原蛋白活性和油红O染色法等方法，发现在10 d内锰(Mn2+)在所有测试浓度中均可促进骨髓间充质干细胞成脂分化，但延长培养时间没有效果。You等[25]通过Western blot、油红O染色和Alamar法等方法，最终发现K+离子通道包括Kv通道亚单位Kv2.1和Kv3.3子集在人骨髓间充质干细胞分化为脂肪细胞过程中发挥重要的作用。Ciciarello等[26]研究发现ATP在特定培养条件下，同过显著增加脂质积累和成脂肪细胞掌控基因(PPARγ)表达水平促进成脂分化，此外，ATP也促进成骨细胞矿化相关基因Runx2的表达刺激成骨细胞分化。Rajalin等[27]发现脂肪细胞培养条件下ERRalpha (orphan nuclear receptor estrogen-related receptor- alpha)缺乏培养液条件下脂肪细胞分化可减少。其他关于成脂分化的较为重要的因子：Lee等[28]通过实验发现表明远端不同源盒Dlx5 (Distal-less homeobox 5)是测定骨髓基质干细胞向成骨细胞分化的重要的调节因素，远端不同源盒5直接刺激作用可抑制脂肪细胞分化以及促成骨分化。Chen等[29]研究结果表明c-myb基因，一种调节造血细胞分化的重要转录因子，在骨髓基质干细胞分化过程中起重要作用。Chiu等[30]研究发现Ⅱ型胶原蛋白对骨髓基质干细胞在成骨细胞和脂肪细胞分化中产生了不同影响。Ⅱ型胶原在骨髓基质干细胞分化早期可以促进骨形成和抑制脂肪细胞。这些结果激发了Ⅱ型胶原在骨组织工程中新策略应用。James等[31] 研究发现骨诱导分子Nell-1是一种有效的抗脂剂，其可能通过刺猬蛋白依赖性机制抑制成脂分化。其中骨髓基质干细胞成脂分化有随着年龄的增加而增加的偏爱。Iwata等[32]通过研究基本螺旋-环-螺旋转录因子basic helix-loop-helix transcription factor(Dec1)对骨髓基质干细胞分化成骨细胞和脂肪细胞表达的影响，发现在成骨诱导培养基中，Dec1表达增强可促进骨桥蛋白和碱性磷酸酶的表达并诱导基质钙化。Dec1基因敲出后可抑制成骨细胞的表型，而Dec1过表达可以抑制成脂分化。Wang等[33]研究发现Wnt信号抑制剂Dickkopf-1 (DKK1)改良体具有防止糖皮质激素诱导的骨质疏松的治疗潜力。DKK1改良体可以减弱糖皮质激素诱导的成骨细胞凋亡、脂肪细胞分化和骨量丢失。DKK1改良体似乎是通过β-连环素调节糖皮质激素对成骨细胞和脂肪细胞的活动影响，增强保护骨组织细胞。Wang等[34]通过再生障碍性贫血患者和健康志愿者骨髓间充质干细胞的形态、体外增殖能力、细胞表型及分化过程中的基因表达的比较，发现前者骨髓间充质干细胞成脂能力增加，而成骨能力的降低。 2.2.3 激素性股骨头坏死最新治疗方案现在医学对股骨头缺血性坏死治疗仍然是有争议的。Phan等[35]研究发现成骨细胞通过骨保护素/RANKL，RANK/RANKL调节破骨细胞功能，成骨细胞分化生成减少，失去成骨细胞抑制作用的破骨细胞功能活跃，骨吸收加快，骨修复相对不足，因而骨修复的研究成为治疗该类疾病的重要途径。Weinstein等[10]发现骨保护素可抑制糖皮质激素诱导的小鼠细胞凋亡。糖皮质激素过量引起的骨骼不良改变是通过增加破骨细胞存活量，下降细胞产量以及成骨细胞和骨细胞凋亡增加实现的，这可能是骨强度下降的主要原因，而骨保护素诱导至少可部分保存骨强度的骨细胞活力。 Kerachian等[36]实验研究糖皮质激素在股骨头坏死的作用机制认识到激素敏感性的个体差异和潜在的额外机制。同时使用直接糖皮质激素可促成骨细胞、骨细胞凋亡增加及对破骨细胞和内皮细胞凋亡的寿命的延长。Kang等[37]研究多个钻芯减压联合全身阿仑膦酸钠作为股骨头坏死治疗方案。探索比较应用减压合并阿仑膦酸钠是否可以延缓或预防股骨头坏死的结果发现：多头小直径钻芯减压联合全身阿仑膦酸钠能减少疼痛和延迟早期股骨头坏死的进展。这种方案的优点至少是可以适当延迟全髋关节置换时间。Zhao等[38]报道早期的股骨头坏死的治疗联合自体髂嵴包含成千上万的骨髓内骨髓间充质干细胞移植，可取得有前途的结果。自体骨髓间充质干细胞体外扩增结合髓心减压治疗干预是安全和有效的，同样可延缓或避免本需行全髋关节置换的塌陷股骨头时间。陈炳鹏等[39]利用髓芯减压联合自体骨髓基质干细胞骨髓基质干细胞移植治疗兔激素性股骨头坏死，并通过检测骨陷窝率、骨髓坏死面积、骨小梁体积的方法同样发现该方法对兔早期激素性股骨头坏死有治疗作用，并且取得了良好的效果，可为临床提供一定的参考价值，该方法简便安全性高，但具体治疗机制等问题还须更进一步的研究加以探讨。Hang 等[40]通过成年杂种狗研究评估血管内皮生长因子(vascular endothelial growth factor 165，VEGF165)转基因骨髓基质干细胞对早期股骨头坏死的修复疗效。实验表明接收植入VEGF转基因骨髓基质干细胞动物中观察到明显的排列规则的再生骨小梁，新生成的毛细血管数量明显增加。Esmail等[41]发现地塞米松联合脉冲电磁场可上调胰岛素生长因子1 mRNA的表达。在早期阶段的，细胞经脉冲电磁场刺激后，胰岛素生长因子1 mRNA的表达上调；在后期阶段经脉冲电磁场刺激后，地塞米松诱导后下降环氧化酶2 mRNA的表达量可增加。脉冲电磁场可有益于改善地塞米松诱导的骨质流失和骨质疏松症。Moriya等[42]提出双极人工股骨头置换是治疗特发性股骨头坏死(股骨头坏死)的一个较好的选择。但全髋关节置换患者需要严格置换指征，其推荐进行股骨头坏死ARCO分期Ⅳ或年龄在40岁以下的患者。Qi等[43]发现通过桃红四物汤治疗腹腔注射醋酸泼尼松龙加间断性股骨头缺血性坏死大鼠模型后可增加转化生长因子β1的转录和表达。Erken 等[44]研究发现用于外周血管和脑血管对血液循环疾病的己酮可可碱似乎可减少类固醇的影响和减少股骨头坏死的发病率。临床中糖皮质激素多用于治疗重症炎性和自身免疫性疾病，但使用激素常会产生严重不良反应。早期系统性红斑狼疮患者应用糖皮质激素治疗前后，通过动态磁共振成像检测股骨头病变及血流恢复情况[45]，利用多元回归分析数据得出：皮质类固醇激素应用天数和开始动态MRI的年龄可决定股骨头的血液变化情况[46]。 Okazaki等[47]通过采用甲基强的松龙注射动物模型及组织病理学分析研究，发现表明负重不助于大鼠非创伤性股骨头坏死的发展。Qi等[48]发现活血化瘀中药可以通过促进血管内皮生长因子的表达，改善糖皮质激素诱导的股骨头缺血性坏死兔股骨头微循环。Li等[49]研究发现中药顾傅声胶囊提高糖皮质激素诱导的股骨头缺血性坏死家兔一氧化氮(无)表达量，保护血管内皮细胞和改善纤溶活性。He等[50]研究复方生脉成骨胶囊能，保护血管内皮细胞，恢复TXB2和6-keto-pgf1alpha平衡抑制股骨头坏死。中药活血化瘀可以预防股骨头坏死的发展。Zhang等[51]研究表明，木豆叶水提物对骨的保护作用可能是通过减少骨髓间充质干细胞成脂肪细胞的形成，介导，可促进成骨细胞增殖、分化和矿化功能。激素过度使用导致脂肪代谢紊乱继而引起一系列病理生理变化最终导致股骨头缺血性坏死，他汀类药物可以调节血脂在一定程度上可预防激素性股骨头坏死。郑立强等[52]利用经大鼠双侧臀大肌注射地塞米松磷酸钠制备大鼠早期激素性股骨头缺血坏死模型，通过对股骨头的一般标本形态、骨密度、组织病理形态学分析发现辛伐他汀可能通过多种机制促进早期激素性股骨头坏死的修复，其作用机制可能与调节血脂阻止病变进展促进骨质生成增加骨密度修复骨组织显微结构改善激素性股骨头坏死患者循环内皮祖细胞的功能状态促进血管再生等有关。PPAR是骨髓基质细胞向脂肪细胞分化的关键转录因子，在股骨头坏死发病中起着非常重要的作用，刘文刚等[53]在探讨健骨方对激素性股骨头坏死兔股骨头局部PPAR影响时发现，主要由何首乌、泽泻、山楂、骨碎补、枸杞子、黄芪、地黄、丹参、当归、党参、女贞子和甘草等药物组成的具有补肾活血、健脾化痰作用的临床经验效方健骨方在治疗激素性股骨头坏死可能通过降低PPAR含量抑制股骨头局部成脂分化达到防治激素性股骨头坏死的作用。Xu等[54]研究发现淫羊藿黄酮类化合物增加碱性磷酸酶和早期成骨细胞分化因子基因的表达水平，如Runx2、骨钙素和Ⅰ型胶原基因的表达水平，并剂量依赖性的方式减少脂肪生成的标记因子，如PPARγ2和增强子结合蛋白α表达，且可以通过激活Wnt/β-catenin信号通路，上调β-连环蛋白，低密度脂蛋白LRP5和T细胞因子TCF蛋白基因的表达水平，调节去卵巢大鼠骨髓基质干细胞成骨和成脂的分化之间的平衡，这可能是在其治疗绝经后骨质疏松症的重要分子机制。这些研究证明中药在治疗激素性股骨头坏死方面发挥了越来越多的分量，中医中药或许是未来研究治疗激素性股骨头的风向标。"

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