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医药导报, 2021, 40(1): 90-93
doi: 10.3870/j.issn.1004-0781.2021.01.016
二肽基肽酶4及其抑制剂在新型冠状病毒肺炎防治中的研究进展*
Research Progress of Dipeptidyl Peptidase 4 and Its Inhibitors in the Prevention and Treatment of Coronavirus Disease 2019
陈志会1,2,, 杨艳3, 凃玲1, 徐西振2

摘要:

新型冠状病毒肺炎(COVID-19)全球大流行给世界健康造成巨大威胁,然而到目前为止尚没有临床证实有效的治疗方法。最近研究显示二肽基肽酶4(DPP4)可能是新型冠状病毒的功能受体,然而DPP4是否直接参与新型冠状病毒与靶细胞的黏附与感染,抑制或者调节DPP4的表达与活性能否阻止COVID-19的发生发展尚需要进一步研究。以往研究显示DPP4抑制剂具有抗炎和抗纤维化作用,因此推测DPP4抑制剂可能具有抑制COVID-19患者高炎症反应状态、改善患者肺纤维化的作用,尚需临床试验加以证实。

关键词: 二肽基肽酶4抑制剂 ; 新型冠状病毒 ; 新型冠状病毒肺炎

Abstract:

The pandemic of coronavirus disease 2019 (COVID-19) poses a huge threat to the world health,however,no clinical proven effective methods of treatment of COVID-19 were currently available.Recent study indicated that dipeptidyl peptidase 4 (DPP4) may be a potential receptor for the SARS-CoV-2,however,whether DPP4 directly participated in the adhesion or infection of SARS-CoV-2 to the target cells,and whether inhibition or modulation of DPP4 activity or expression could prevent the progression of COVID-19 still remain unclear.Previous studies revealed the anti-inflammatory and anti-fibrotic effects of DPP4 inhibitors.Thus,it is speculated that DPP4 inhibitors may play a protective role in inhibiting inflammatory response and pulmonary fibrosis in patients with COVID-19,but it still needs to be further confirmed.

Key words: Dipeptidyl peptidase 4 inhibitors ; Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ; Coronavirus disease 2019

开放科学(资源服务)标识码(OSID)

新型冠状病毒(severe acute respiratory syndrome coronavirus 2,SARS-CoV-2)给社会和经济造成了巨大冲击[1]。流行病学调查显示老龄和男性是新型冠状病毒肺炎(coronavirus disease 2019,COVID-19)患者预后不良的主要危险因素[2]。我国早期队列研究显示约50%的COVID-19患者至少合并存在一种慢性疾病,如心血管系统疾病、糖尿病、慢性阻塞性肺疾病、陈旧性脑梗死等,其中糖尿病是COVID-19患者预后不良的主要危险因素之一[3]。另外,约19%重型COVID-19患者同时患有糖尿病[3],占COVID-19患者死亡数量的约2/3[4]

由于SARS-CoV-2的快速传播和高致病性,寻找有效的预防和治疗方法刻不容缓。然而到目前为止没有临床证实有效的抗病毒药物以及疫苗用以治疗和预防COVID-19[5]。RNA聚合酶抑制药瑞德西韦及SARS-CoV-2疫苗目前尚处于临床试验阶段[6]。尽管疫苗和抗病毒药物的研发对COVID-19的预防和治疗至关重要,老药新用或者寻找新的治疗靶点是快速探索COVID-19治疗方法的有效策略。目前有研究提示二肽基肽酶4(dipeptidyl peptidase 4,DPP4)可能是COVID-19治疗的一个潜在的靶点,笔者拟就DPP4抑制剂在COVID-19治疗中的应用前景进行文献复习和系统综述。

1 DPP4概述

DPP4又称CD26,是细胞表面的跨膜糖蛋白[7]。DPP4有一个大的C端胞外端、跨膜段和一个小的胞内段,其中C端胞外端具有催化活性,能水解多种底物从而影响其生物学活性[7]。DPP4有两种存在形式:膜绑定型和游离型。膜绑定型DPP4,作为细胞表面糖蛋白存在于多种组织和细胞表面,如肺脏、肾脏、肝脏、肠道、免疫细胞等;游离型DPP4(soluable DPP4,sDPP4),具有DPP4酶活性,主要存在于血清和其他组织液。DPP4能够降解胰高血糖素样肽-1(glucagon like peptide 1,GLP-1)和葡萄糖依赖的促胰岛素肽(insulinotropic peptide,GIP)[7]。临床应用DPP4抑制剂如西格列汀、沙格列汀等抑制DPP4活性,抑制其对GLP-1和GIP的降解从而达到控制血糖的目的。除了GLP-1和GIP,DPP4还具有多种生物活性底物,包括生长因子、趋化因子、神经肽、血管活性肽等,因此DPP4参与机体多种病理生理过程[7]

2 DPP4与冠状病毒感染

历史上,感染人的冠状病毒包括几种温和的普通感冒病毒,如 hCoV-OC43、HKU、229E[6]。近二十年来,高致病性人冠状病毒的出现对人类健康造成巨大威胁。2003年严重急性呼吸窘迫综合征冠状病毒(severe acute respiratory syndrome coronavirus,SARS-CoV)导致全世界约8000人感染,其死亡率约10%[6]。2012年中东呼吸综合征冠状病毒(Middle East respiratory syndrome coronavirus,MERS-CoV)导致全球约2500人感染,其死亡率高达36%[6]。SARS-CoV-2是冠状病毒科的一种有包膜的、阳性单链RNA倍他卡病毒,与SARS-CoV和MERS-CoV相比,SARS-CoV-2致死率低,传染性强,导致其难以控制。

DPP4是MERS-CoV的功能受体,MERS-CoV的刺突蛋白与DPP4受体结合区域结合,影响T细胞及核转录因子如核转录因子κb(nuclear factor kappa b,NF-κB),进而导致机体炎症反应失调[8]。体外实验显示,特异性DPP4抗体能够抑制MERS-CoV对人原代支气管上皮细胞的感染[8]。此外,表达人DPP4的糖尿病小鼠更易感染MERS-CoV,表现为体质量下降,重症及恢复期延长,肺脏C D 4 + T细胞聚集减少等[9]。小鼠体内人DPP4外显子敲入促进其肺脏中MERS-CoV的增殖[10]。DPP4为MERS-CoV的功能受体,高表达DPP4加重MERS-CoV的感染和疾病严重程度,而抑制DPP4则阻止MERS-CoV的感染。那么,DPP4是否参与SARS-CoV-2的感染与疾病进程?目前有一些研究报道,但仍未完全阐明。

2.1 DPP4与SARS-CoV-2的直接结合

最近有研究显示DPP4可能是治疗COVID-19的潜在靶点[11]。与其他冠状病毒相似,SARS-CoV-2通过刺突糖蛋白N端S1区域与细胞蛋白结合,如血管紧张素转化酶2(angiotensin converting enzyme 2,ACE2)等。VANKADARI等[11]的研究显示SARS-CoV-2的S1区域与DPP4存在紧密相互作用。DPP4绑定片段K267、T288、A289、A291、L294、I295、R317、Y322及D542与MERS-CoV存在相互作用。尽管SARS-CoV-2与MERS-CoV的刺突蛋白S1区域存在差异,VANKADARI等的预测模型显示这些DPP4绑定片段与SARS-CoV-2的S1区域相毗邻。此外,作者预测DPP4片段Q286、I287、 N338、V341、 R336通过范德华力或者氢键与SARS-CoV-2的刺突糖蛋白S1区域结合。然而与VANKADARI等推测不同,TAI等[12]研究显示,SARS-CoV-2的受体绑定区域可以与表达人ACE2的293T细胞结合,而不与表达人DPP4的293T细胞结合。到目前为止尚无直接证据证明DPP4为SARS-CoV-2的受体,DPP4是否直接参与SARS-CoV-2的黏附和感染,抑制或者调节DPP4是否能够抑制SARS-CoV-2感染、改善新型冠状病毒肺炎的疾病进程尚不清楚。

2.2 循环sDPP4在SARS-CoV-2感染中的作用

流行病学调查显示肥胖、2型糖尿病、代谢性疾病及年龄等是COVID-19患者死亡的重要危险因素[2]。研究显示,循环中sDPP4的水平在肥胖、2型糖尿病患者及老年人中明显增加[13,14]。BARCHETTA等[15]提出循环sDPP4可能是临床COVID-19患者严重性的驱动因子:一方面,DPP4在多个组织广泛表达可以解释SARS-CoV-2有多个靶器官,而非只攻击表达ACE2的器官;另一方面,机体DPP4水平可能决定新型冠状病毒肺炎的严重性,反映SARS-CoV-2对靶细胞、组织、器官的感染性等。循环sDPP4水平可能是预测COVID-19患者疾病进程及对治疗反应性的有效指标。检测循环sDPP4水平可能是对SARS-CoV-2感染患者,特别是伴随糖尿病及其他代谢性疾病患者,进行危险分层的简易手段。

然而,以往研究显示,感染MERS-CoV的患者循环中sDPP4水平明显降低,增加循环中sDPP4的含量可以抑制50%的MERS-CoV感染[16]。其可能原因是循环中sDPP4竞争性结合病毒从而阻止病毒进入细胞。另一方面,可能是MERS-CoV与受体结合之后导致受体下调[17],已有研究显示SARS-CoV及SARS-CoV-2感染导致其受体ACE2表达下调[18]

综上所述,循环中sDPP4在SARS-CoV-2感染中的作用需要进一步研究,sDPP4在临床中的应用需要进一步探讨。

2.3 DPP4抑制剂在SARS-CoV-2感染中的作用

DPP4抑制剂如西格列汀、沙格列汀、阿格列汀、维格列汀等已广泛应用于临床2型糖尿病的治疗[7]。DPP4抑制剂与DPP4催化位点结合抑制其活性,进而降低其对GLP-1和GIP的降解,达到控制血糖的目的[7]。与DPP4抑制剂不同,模型预测结果显示SARS-CoV-2及MERS-CoV与DPP4催化位点之外的其他绑定位点结合[11]。DPP4抑制剂西格列汀与DPP4的结合位点与SARS-CoV-2的预测结合位点之一距离较近[19],那么DPP4抑制剂与DPP4结合导致的构象变化是否会影响病毒与DPP4的结合?以往研究显示MERS-CoV与DPP4的结合不依赖于DPP4的活性,抑制DPP4活性并不能阻止MERS-CoV感染[20,21]。然而,调节DPP4表达水平或者作用于DPP4与病毒结合位点的抑制剂可能具有抗病毒作用,例如人抗CD26单克隆抗体YS110可以显著抑制MERS-CoV感染,而不影响免疫功能及DPP4酶活性[22]。因此推测下调DPP4表达或者研发作用于DPP4与SARS-CoV-2结合位点的抑制剂或抗体可能是阻止SARS-CoV-2感染细胞的有效方法。

3 DPP4与炎症反应

炎症风暴是导致重型COVID-19患者死亡的主要原因。尽管DPP4在SARS-CoV-2感染中的作用有待证实,以往研究已经证明抑制DPP4活性具有抑制炎症反应的作用。DPP4通过与细胞外基质蛋白的黏附等多种生理机制,在T细胞成熟、活化及与抗原呈递细胞相互作用中发挥共刺激作用。抑制DPP4活性在一定程度上抑制免疫反应,可能在自身免疫性疾病中发挥作用[23]。例如,药物抑制DPP4活性可降低实验多发性硬化自身免疫性脑脊髓炎的发病率,减轻其临床症状和疾病总体严重程度[24,25]。人群队列研究结果显示DPP4抑制剂降低自身免疫性疾病的发病风险[26]。一项Meta分析结果显示,DPP4抑制剂并不增加上呼吸道感染的风险[27]。因此,推测DPP4抑制剂可能具有抑制COVID-19患者高炎症反应状态的作用,然而需要更多的临床研究证明。此外,由于机体感染病毒后的炎症反应为动态过程,因此在临床使用DPP4抑制剂时应充分考虑患者的疾病进程和综合情况。

4 DPP4与急性呼吸窘迫综合征

肺间质纤维化及因此导致的急性呼吸窘迫综合征是COVID-19患者死亡的主要原因。研究显示抑制DPP4具有抑制肺部损伤及抗纤维化的作用[28,29]。DPP4抑制剂西格列汀通过抑制炎症因子白细胞介素(IL)-1β、肿瘤坏死因子(TNF)-α及IL-6改善急性呼吸窘迫综合征动物肺损伤[28]。抑制DPP4活性或者敲除DPP4改善博来霉素诱导的肺纤维化[29]。笔者推测抑制DPP4可能具有改善COVID-19患者肺损伤及纤维化的作用,尚需要进一步研究。

综上所述,DPP4是否是SARS-CoV-2的功能受体尚不明确,抑制DPP4活性或者调节DPP4表达能否阻止COVID-19的发生发展尚需要进一步研究。DPP4抑制剂可能具有抑制COVID-19患者炎症反应,减轻COVID-19患者肺部损伤和纤维化的作用,然而尚需要临床试验研究加以证实。

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Diabetic retinopathy (DR) is one of the leading causes of blindness worldwide, and the limited availability of qualified ophthalmologists restricts its early diagnosis. For the past few years, artificial intelligence technology has developed rapidly and has been applied in DR screening. The upcoming technology provides support on DR screening and improves the identification of DR lesions with a high sensitivity and specificity. This review aims to summarize the progress on automatic detection and classification models for the diagnosis of DR.
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CD26 or dipeptidyl peptidase IV (DP IV) is expressed on various cell types, including T cells. Although T cells can receive activating signals via CD26, the physiological role of CD26/DP IV is largely unknown. We used the reversible DP IV inhibitor Lys[Z(NO(2))]-pyrrolidide (I40) to dissect the role of DP IV in experimental autoimmune encephalomyelitis (EAE) and to explore the therapeutic potential of DP IV inhibition for autoimmunity. I40 administration in vivo decreased and delayed clinical and neuropathological signs of adoptive transfer EAE. I40 blocked DP IV activity in vivo and increased the secretion of the immunosuppressive cytokine TGF-beta1 in spinal cord tissue and plasma during acute EAE. In vitro, while suppressing autoreactive T cell proliferation and TNF-alpha production, I40 consistently up-regulated TGF-beta1 secretion. A neutralizing anti-TGF-beta1 Ab blocked the inhibitory effect of I40 on T cell proliferation to myelin Ag. DP IV inhibition in vivo was not generally immunosuppressive, neither eliminating encephalitogenic T cells nor inhibiting T cell priming. These data suggest that DP IV inhibition represents a novel and specific therapeutic approach protecting from autoimmune disease by a mechanism that includes an active TGF-beta1-mediated antiinflammatory effect at the site of pathology.
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二肽基肽酶4抑制剂
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作者
陈志会
杨艳
凃玲
徐西振

CHEN Zhihui
YANG Yan
TU Ling
XU Xizhen