血管钙化发病研究进展

北京大学医学部

唐朝枢

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血管钙化 钙磷在血管、心肌和心瓣膜的异常沉积婴儿期血管钙化、尿毒症性小动脉钙化

和 钙化的瓣膜病可以危及生命钙化 可发生于血管中膜和内膜

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血管钙化的类型

A: Atherosclerotic calcification. B: Medial calcification.C: Valvular calcification. D: Calciphylaxis. Johnson RC et al.

Circ Res. 2006;99:1044-1059.

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Demer LL, et al. Circulation,2008; 117:2938-2948.)

血管钙化的类型和特征

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80% 血管损伤和 90% 冠状动脉疾病发生血管钙化

血管钙化 - 众多心血管疾病的共同病理学基础

血管钙化

高血压

糖尿病

高脂血征

慢性肾功能衰竭老化

中膜钙化

内膜钙化

动脉粥样硬化

血管钙化可作为心血管疾病危险增加的标示分子

概念转变既往 : 血管钙化是机体钙磷代谢失衡所

致的钙盐被动沉积于组织间的过程。 1990 年代以来 : 血管钙化是一个与骨

发育相似的主动的、高度可调控的细胞介导的过程。

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• 血管钙化认识的重大变革 : 血管钙化是与骨发育和骨代谢相似的过程 血管钙化时内皮细胞、间充质细胞 和造血干细胞

相互作用且对机械刺激、炎症、代谢发生反应，激活骨形态发生信号。

这些因素相互作用在骨导致骨矿化，在动脉壁则导致血管钙化 ( 一元论 ) 。

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血管钙化发病的多机制

J Am Soc Nephrol 2004; 15: 2959–2964

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(a) Elastic membranes of the T. media become disrupted in developing lesions. (b) Smooth muscle cells of the T. media change their orientation. (c) Infiltrating cells similar in appearance to chondrocytes are seen in lacunae in the T. media. (d–f) The chondrocyte-like cells appear active in secreting intercellular fibrous matrix, which becomes calcified and the vessel wall becomes hardened and inflexible. Resin sections stained with alkaline toluidine blue. Scale bars: a =25 um; b–e =10 um; f =50um.

Acta histochemica 2006 ;108 : 415—424

B

C D

E F

血管钙化的发病A B

23/4/21 10Heart. 2001;85:13–17

动脉钙化发病的共同通路假说

23/4/21 11Hofbauer L. C.,et al. Osteoporos Int . 2007;18:251–259

骨形态发生蛋白 -2 (BMP-2)

23/4/21 12Hruska KA, et al. Circ Res. 2005;97:105-114

近十年的新进展— 1: 成骨细胞和破骨细胞的标示分子参与血管钙化的发病

骨保护素 (OPG) 参与血管钙化

23/4/21 13Ketteler , et al. Hypertension. 2006;47:1027-1034

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Comparative morphology of advanced lesions in the innominate artery of OPG/.apoE/ and OPG/.apoE/ mice. Light micrographs of representative lesions stained with the Movat’s stain These micrographs show examples of the increases in plaque size and alterations in cellularity and calcification. Arrows denote areas highlighted in insets. Insets show the von Kossa staining for hydroxyapatite of the same areas in adjacent slides. Magnification 100 for the Movat’s stained sections and 400 for the von Kossa stained sections.

Bennett BJ., et al; Arterioscler Thromb Vasc Biol. 2006;26:2117-2124.)

A-C:OPG-/- .ApoE-/- mice

D-F: OPG+/+.apoE-/- mice

20-W 40-W 60-W

60-W40-W20-W

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血管钙化

骨桥蛋白骨保护素基质 Gla 蛋白骨形态发生蛋白 -7骨连素

骨形态发生蛋白 2,4骨钙素1 型胶原蛋白碱性磷酸酶

+_

成骨细胞和破骨细胞的标示分子参与血管钙化的发病

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ADM decreased calcium content and ALP activity

Increased response of calcified vessel to ADM

control calcified calcified+ADM0

25

50

75

100 *

#

aotr

ic c

alci

um

co

nte

nt

(u

mo

l/g d

w)

control calcified ADM+calcified0

100

200

300

*

#ao

rtic

AL

P a

ctiv

ity

(U

/mg

pro

)

(-)ADM (+)ADM 10-7M0.0

0.9

1.8

2.7 ConCalcified

*

#

35%(P<0.01)

82.5%(P<0.01)

cA

MP

pro

du

cti

on

(p

mo

l/m

g p

ro)

control CaCa+ADM

肾上腺髓质素 (ADM) 抑制血管钙化

von Kossa staining

近十年的新进展— 2:

维持血管稳态的旁 / 自分泌因子参与血管钙化发病

Peptides. 2004; 25:601-608. Regul peptides 2004;120:77-83.

血管紧张素 II

J Geriatric Cardiology. 2004; 1(2):108-113.

von Kossa staining

23/4/21 18Acta Pharmacol Sin 2006; 27: 299–306

(original magnification ×40).

Control

VDN group

VDN+LowNaHS group

VDN+High NaHS group

硫化氢 (H2S) 抑制血管钙化

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内皮素 -1 促进血管钙化

Peptides. 2003;24(8):1149-1156.

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血管钙化

肾上腺髓质素GhrelinC- 型钠尿肽 (CNP)一氧化碳一氧化氮硫化氢皮质抑素

血管紧张素 II内皮素尾加压素 II

维持血管稳态的血管旁 / 自分泌因子功能紊乱

细胞表型转换

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近十年的新进展— 3 ：基质囊泡形成介导血管平滑肌细胞钙化

Shanahan CM. Curr Opin Nephrol Hypertens 2005; 14:361–367

23/4/21 22Johnson RC et al. Circ Res. 2006;99:1044-1059.

近十年的新进展— 4: 血管钙化时成骨细胞来源的多元学说

需要新的治疗策略

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Potential therapies for medial vascular calcification

O’Neill, WC . Kidney Int.2008; 74: 1376–1378.

1) The first step is the formation of CaHPO4, which can be reduced by lowering phosphate concentrations2) Thiosulfate may inhibit this reaction by forming ion pairs with calcium ions3) Hydroxyapatite formation is normally inhibited by pyrophosphate (PPi) that is produced by VSMCs from ATP; Large doses of Ppi inhibit vascular calcification in vitamin D-toxic rats.4) PPi is hydrolyzed by tissuenonspecific alkaline phosphatase (TNAP) on the smooth muscle membrane, and

this could be targeted by newly developed TNAP inhibitors.5) Bisphosphonates are non-hydrolyzable analogues of PPi that also inhibit hydroxyapatite formation in vitro.

Because of their stability, they inhibit vascular calcification in rats at far lower doses than PPi.6) Magnesium ions also inhibit hydroxyapatite in vitro at clinically relevant concentrations.

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• 老年人血管钙化与骨质疏松并存—治疗学的两难问题 • 血管钙化治疗的趋势—逆转血管钙化 ( 逆转细胞表型转变 ) 是可能的

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谢 谢谢 谢

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P11

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MSX2: a transcription factor promoting osteogenic gene expression including alkaline phosphatase, osteopontin and many others.Msx-2 is required for intramembranous bone formation, and Cbfal is critical in osteoblast differentiation, endochondral bone formation, and neovascularization.7,84 Recent studies demonstrate that Msx-2–dependent transcriptional programming may drive osteoblastic lineage development.Sox9: chondrocyte transcription factorsRunx2/Cbfa1, Osterix, and MSX22: the osteoblast transcription factors

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Osteoprotegerin (OPG) is a key regulator of osteoclast activation by acting as a soluble decoy receptor scavenging the osteoclast activator receptor activator of nuclear factor B ligand ([RANKL] Figure 3). Increased OPG availability prevents binding of RANKL to its receptor, receptor activator of nuclear factor B. In genetic knockout animal models, OPG deficiency not only leads to pronounced osteoporosis but is associated with calcifications of the aorta and of renal arteries.

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Advances in pathogenesisof vascular calcification

Chao Shu Tang

Peking University Health Science Center

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Vascular calcification : The abnormal deposition of calcium phosphate

salts in blood vessels, myocardium, and cardiac valves.

Lifethreatening, as in the case of generalized infantile arterial calcification, calcific uremic arteriolopathy, and calcific valve disease.

Occur either in the intima or in the media.

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Types of Vascular Calcification

A: Atherosclerotic calcification. B: Medial calcification.C: Valvular calcification. D: Calciphylaxis. Johnson RC et al.

Circ Res. 2006;99:1044-1059.23/4/21 33

Demer LL, et al. Circulation,2008; 117:2938-2948.)23/4/21 34

Vascular calcification was found in 80% damaged vessels and 90% coronary artery diseases

Vascular calcification-commeon clinical pathologic basis of cardiovascular diseases

Vascular calcification

Hypertension

Diabetes

Hyperlipidemia

Chronic renal failureAging

Media calcification

Intima calcification

Atherosclerosis

Vascular calcifications as a marker of increased cardiovascular risk 23/4/21 35

Previously Vascular calcification was thought to be a passive process which involved the deposition of calcium and phosphate into the vessel wall.

However, since late 1990’s growing evidence has shown that vascular calcification is a highly regulated, cell-mediated process similar to bone formation.

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A breakthrough in recognition of vascular calcification

The recognition of vascular calcification similarity to bone development and metabolism

Endothelial, mesenchymal, and hematopoietic cells interact and respond to mechanical, inflammatory, metabolic, and morphogenetic signals governing skeletal mineralization

Their counterparts in the artery wall govern arterial mineralization.

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Multiple mechanisms of vascular calcification pathogenesis

J Am Soc Nephrol 2004; 15: 2959–2964 23/4/21 38

(a) Elastic membranes of the T. media become disrupted in developing lesions. (b) Smooth muscle cells of the T. media change their orientation. (c) Infiltrating cells similar in appearance to chondrocytes are seen in lacunae in the T. media. (d–f) The chondrocyte-like cells appear active in secreting intercellular fibrous matrix, which becomes calcified and the vessel wall becomes hardened and inflexible. Resin sections stained with alkaline toluidine blue. Scale bars: a =25 um; b–e =10 um; f =50um.

Acta histochemica 2006 ;108 : 415—424

A

B

C D

E F

B

Pathogenesis of vascular calcification

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A B

Heart. 2001;85:13–1723/4/21 40

Common pathway hypothesis of arterial calcification pathogenesis

Hofbauer L. C.,et al. Osteoporos Int . 2007;18:251–25923/4/21 41

Bone morphogenetic protein-2 (BMP-2)

Hruska KA, et al. Circ Res. 2005;97:105-11423/4/21 42

New advances in the recent decade-1:

Markers of osteoblast and osteoclast are involved in vascular calcification

Osteoprotegerin (OPG) is involved in vascular calcification

Ketteler , et al. Hypertension. 2006;47:1027-103423/4/21 43

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Comparative morphology of advanced lesions in the innominate artery of OPG/.apoE/ and OPG/.apoE/ mice. Light micrographs of representative lesions stained with the Movat’s stain These micrographs show examples of the increases in plaque size and alterations in cellularity and calcification. Arrows denote areas highlighted in insets. Insets show the von Kossa staining for hydroxyapatite of the same areas in adjacent slides. Magnification 100 for the Movat’s stained sections and 400 for the von Kossa stained sections.

Bennett BJ., et al; Arterioscler Thromb Vasc Biol. 2006;26:2117-2124.)

A-C:OPG-/- .ApoE-/- mice

D-F: OPG+/+.apoE-/- mice

20-W 40-W 60-W

60-W40-W20-W

Markers of osteoblast and osteoclast are involved in vascular calcification

Vascular calcification

OPNOPGMGPBMP7Osteonectin

BMP2,4OsteocalcinCollagen Type IALP

+_

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ADM decreased calcium content and ALP activity

Increased response of calcified vessel to ADM

control calcified calcified+ADM0

25

50

75

100 *

#

aotr

ic c

alci

um

co

nte

nt

(u

mo

l/g d

w)

control calcified ADM+calcified0

100

200

300

*

#ao

rtic

AL

P a

ctiv

ity

(U

/mg

pro

)

(-)ADM (+)ADM 10-7M0.0

0.9

1.8

2.7 ConCalcified

*

#

35%(P<0.01)

82.5%(P<0.01)

cA

MP

pro

du

cti

on

(p

mo

l/m

g p

ro)

control CaCa+ADM

Adrenomedullin (ADM) inhibits vascular calcification

von Kossa staining

New advances in the recent decade-2:

The paracrine/autocrine dysfunction of vessels might play an important role in vascular calcification

Peptides. 2004; 25:601-608. Regul peptides 2004;120:77-83.

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Angiotensin II

J Geriatric Cardiology. 2004; 1(2):108-113.

Acta Pharmacol Sin 2006; 27: 299–306

von Kossa staining(original magnification ×40).

Control

VDN group

VDN+LowNaHS group

VDN+High NaHS group

Hydrogen sulfide (H2S) inhibits vascular calcification

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Endothelin-1 promotes vascular calcification

Peptides. 2003;24(8):1149-1156.23/4/21 49

Vascular calcification

AdrenomedullinGhrelinC-type natriuretic peptide(CNP)Carbone monoxideNitric oxideHydrogen sulfideCortistatin

Angiotensin IIEndothelinUrotensin II

The paracrine/autocrine dysfunction of vessels might play an important role in vascular calcification

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Cell phenotype transformation

New advances in the recent decade-3: Matrix vesicle formation-mediated vascular calcification in VSMCs

Shanahan CM. Curr Opin Nephrol Hypertens 2005; 14:361–36723/4/21 51

Johnson RC et al. Circ Res. 2006;99:1044-1059.

New advances in the recent decade-4: Multiple hypothesis of origin of osteoblast in vascular calcification

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Novel therapeutics re needed

Potential therapies for medial vascular calcification

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O’Neill, WC . Kidney Int.2008; 74: 1376–1378.

1) The formation of CaHPO4 lowered phosphate concentrations2) Thiosulfate combined calcium ions to form ion pairs3) Hydroxyapatite formation is normally inhibited by pyrophosphate (PPi) that is produced by VSMCs from ATP; Large doses of Ppi inhibit vascular calcification in vitamin D-toxic rats.4) PPi is hydrolyzed by tissuenonspecific alkaline phosphatase (TNAP) on the smooth muscle membrane, and

this could be targeted by newly developed TNAP inhibitors.5) Bisphosphonates are non-hydrolyzable analogues of PPi that also inhibit hydroxyapatite formation in vitro.

Because of their stability, they inhibit vascular calcification in rats at far lower doses than PPi.6) Magnesium ions also inhibit hydroxyapatite in vitro at clinically relevant concentrations.

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• Vascular calcification and osteoporosis

coexist in older people

-- A dilemma of therapeutics problem• New trends in treatment of vascular

calcification

--Reversal of calcified nodules(Reversal of

transformed cellular phenotyes)

Thank you for your Thank you for your attentionattention

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MSX2: a transcription factor promoting osteogenic gene expression including alkaline phosphatase, osteopontin and many others.Msx-2 is required for intramembranous bone formation, and Cbfal is critical in osteoblast differentiation, endochondral bone formation, and neovascularization.7,84 Recent studies demonstrate that Msx-2–dependent transcriptional programming may drive osteoblastic lineage development.Sox9: chondrocyte transcription factorsRunx2/Cbfa1, Osterix, and MSX22: the osteoblast transcription factors

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P13

Osteoprotegerin (OPG) is a key regulator of osteoclast activation by acting as a soluble decoy receptor scavenging the osteoclast activator receptor activator of nuclear factor B ligand ([RANKL] Figure 3). Increased OPG availability prevents binding of RANKL to its receptor, receptor activator of nuclear factor B. In genetic knockout animal models, OPG deficiency not only leads to pronounced osteoporosis but is associated with calcifications of the aorta and of renal arteries.

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P21

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P22

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P23