腎上腺醣皮質激素 (Glucocorticoid, GC) 一直以來都是治療慢性
發炎病症或自體免疫疾病 (如系統性紅斑性狼瘡, SLE) 的主要藥物。
腎上腺醣皮質激素的生物活性和藥理作用，主要藉由與位於細胞質內
之腎上腺醣皮質激素接受體 (Glucocorticoid receptor, GR) 結合後進入
細胞核內，作用於標的基因上。藉著影響標的基因的轉錄作用來調控
相對應的蛋白質轉譯，藉此表現出 GC 抑制發炎的藥理作用。目前治
療各類免疫疾病當中，依據各種病況所需要的劑量，大致上已經標準
化，然而對 GC 的治療反應仍然因人而異。而這對GC 的治療反應不
好的現象， 我們就稱為腎上腺醣皮質激素抗性 (Glucocorticoid
resistance)，嚴重影響疾病預後。由於 GR 決定著病人對GC 藥物的治
療反應良好與否，因此我們可以透過研究GR 的基因來了解病人對這
類藥物的反應。現今知道位於染色體5q31-32 的 GR 基因中九個表現
子 (exon) 具有多個單一核苷酸多型性 (SNP) 位點。目前已知位於插
入子 (intron) 的 BclI C/G 多型性與位於exon 2 的 N363S A/G 多型性
與腎上腺醣皮質激素感受性相關。目前研究也發現到在一些發炎相關
疾病中 (例如結腸潰瘍疾病)，GRβ 的 mRNA 在與對照組比較下有著
上升的現象。在我們的研究結果發現帶有BclI C allele 的 SLE 患者
與 GC 抗藥性有關 (p=0.027)。另外我們發現 SLE 患者其 GRβ 較健康
對照組高。TthIII CT 基因型所表現的GRα 表現量較CC 基因型低
(p=0.028)。最後我們的觀察發現 SLE 病人體內的SUMO-2 自體抗體
與病人是否處於活性發炎期並無直接關係。

For more than fifty years glucocorticoids (GCs) has been used to treat a
wide range of inflammatory diseases, such as allergies, asthma, rheumatoid
arthritis, and autoimmune diseases, due to its potentiality on the antiinflammatory
and immunomodulatory effects. The anti-inflammation actions
of glucocorticoid were mediated by an intracellular receptor, glucocorticoid
receptor (GR), a member of the nuclear receptor family of ligand-dependent
transcription factor. Upon activation by their ligand, GRs translocated to the
nuclear and then bound to glucocorticoid responsive element (GRE) or
negative glucocorticoid responsive elemen (nGRE). The administration of
GCs depended on the acuity of disease and on the responses of patient
clinically. Although some Systemic Lupus Erythematosus (SLE) patients
given the maximal steroid doses, the response to the therapy remained
poorly, and thus called “glucocorticoid resistance”. Despite the fact that the
side effects and complications in SLE patients may result from the
restrictions of physic; it has been documented that there were some
relationships between the glucocorticoid resistance with the polymorphisms
of GR, and the levels of glucocorticoid receptor beta. However, no
significant differences in the GR polymorphisns (TthIII, ER22/23EK, N363S,
BclI and I559N) between controls and SLE patients were found and there
were no significant differences found on the levels of SUMO-2 antibody
between patients with active and inactive SLE in this study. Neverthless, a
significant association on the the allelic polymorphism of BclI was observed
in patients with glucocorticoid resistance. Additionally, the expression of
GRβ in patients with SLE was higher than that of controls and the TthIII CT
genotype was associated with GRα expression.

中文摘要.................................................................. i
英文摘要.................................................................. ii
縮寫表...................................................................... iii
壹、緒論....................................................................1
一、系統性紅斑性狼瘡 (Systemic Lupus Erythematosus, SLE).............................................1
1-1 系統性紅斑性狼瘡病徵介................................. 1
1-2 狼瘡腎炎 (Lupus nephritis,LN)..........................4
1-3 系統性紅斑性狼瘡之治療.........................................5
二、腎上腺醣皮質激素 (Glucocorticoid, GC) 與腎上腺醣皮質激素接受
體(Glucocorticoid receptor, GR)…………………………..…………..
10
2-1 腎上腺醣皮質激素 (Glucocorticoid, GC)……………………..…. 10
2-2 腎上腺醣皮質激素接受體 (Glucocorticoid receptor, GR) 之
DNA、蛋白質結構……………..…………..….……………...…
13
2-3 GR 之作用機轉…………………………………….……..........… 14
2-4 GRβ 之抑制作用機轉…………………..………...……….……… 16
三、腎上腺醣皮質激素抗性 (Glucocorticoid Resistance) ......................… 16
3-1 GR 單一核苷酸多型性 (Single Nucleotide Polymorphism) 對於
GC resistance 的影響……...……………………..…………..…...
17
3-2 醣皮質激素 beta 變異型 (GRβ) 的相關研究………………..… 18
四、系統性紅斑性狼瘡 SUMO自體抗體之研究…………………….…… 19
4-1 SLE 病人自體抗體種類…………………………………….….… 19
4-2 SUMO (Small Ubiquitin-Related Modifier)……………….…......... 22
貳、研究目的…………………………………………..………………..…. 25
參、材料與方法……..…………………………………………………..…. 26
一、腎上腺醣皮質激素的單一核苷酸多型性的相關研究…………….… 26
二、腎上腺醣皮質激素beta-變異型的相關研究…………………………. 33
三、SLE 病人血清內 SUMO-2 自體抗體偵測………………..………… 36
四、統計方法………………………………………………………………. 42
肆、實驗結果……………………………………………………….……… 43
一、系統性紅斑性狼瘡病人之醣皮質激素接受體的基因多型性分佈情
形……………………………………………………………….………
43
1-1 醣皮質激素接受體基因多型性與系統性紅斑性狼瘡病人之關
係………………………………………………………………..…
43
1-2 GC 治療敏感性以及GC 治療有抗性的系統性紅斑性狼瘡病人
之臨床特性…………………………………………………….….
43
1-3 GC 治療敏感性以及GC 治療有抗性的系統性紅斑性狼瘡病人
其 TthIII 以及 BclI 基因多型性之分佈……………………......
44
1-4 併有腎炎現象之 GC 治療敏感性以及 GC 治療有抗性的系統
性紅斑性狼瘡病人其 TthIII 以及 BclI 基因多型性之分佈…..
45
1-5 系統性紅斑性狼瘡病人之 TthIII 及 BclI 基因半套體頻率之比
較………………………………………………………..………
46
二、 系統性紅斑性狼瘡病人之醣皮質激素接受體的mRNA 表現情
形……………………………………………………….…………..... 46
2-1 SLE 病人及健康對照組的GR mRNA 表現…………………... 46
2-2 TthIII、BclI 基因型對GRα/GRβ mRNA 表現量的影響…….….. 47
三、 系統性紅斑性狼瘡病人與健康對照組之SUMO-2 自體抗體偵
測……………………………………………………………….…….
48
3-1 活性期以及非活性期紅斑性狼瘡病人之臨床特性………….…. 48
3-2 紅斑性狼瘡病人與對照組的SUMO-2 自體抗體偵測…………. 48
3-3 紅斑性狼瘡病人SUMO-2 自體抗體與各項臨床數據關係……. 49
伍、討論………………………………………………………………….… 50
陸、參考文獻…………………………………………………………….… 56
柒、實驗圖表…………………………………………………………….… 60
Table 1 Polymorphisms of Glucocorticoid Receptor in patients with SLE
and healthy control……………………………………………………….…
60
Table 2 Clinical characteristics of patients with GC-responsive and
GC-resistant SLE………………………………………………………..…..
61
Table 3-1 Polymorphisms TthIII and BclI in patients with GC-responsive
and GC-resistant SLE……………………….……………………………....
62
Table 3-2 Polymorphisms of TthIII and BclI in patients with nephritic
SLE………………………………………………………….………….…...
63
Table 3-3 Polymorphisms TthIII and BclI in nephritis with
GC-resistant……………………………………………………………….....
64
Table 4-1 Haplotype frequence of TthIII、BclI in patients with SLE and
healthy controls……………………………………..……………….………
65
Table 4-2 Haplotype frequence of TthIII、BclI in SLE nephritis or GC
resistance……………………………………………….…………….…….. 66
Table 4-3 Haplotype frequence of TthIII、BclI in lupus nephritis patients
with GC resistance………….……………………………………………….
67
Figure 1 The GRα mRNA levels between patients with SLE and healthy
controls…………………………………………………………..……….…
68
Figure 2 The GRβ mRNA levels between patients with SLE and healthy
controls……………………………………………………………..……….
69
Table 5-1 The effect of TthIII、BclI genotype to the patients with the higher
GRα and GRβ mRNA……………………………………………....……...
70
Table 5-2 The effect of TthIII、BclI genotype to the qRT-PCR cycle
numbers of GRα and GRβ..............................................................................
71
Table 6-1 Clinical characteristics and disease activity of patients with
SLE……………………………………………………………….…………
72
Figure 3 The SUMO-2 antibody levels in patients with active/inactive
SLE and normals…………………………………………………..…….…..
73
Table 6-2.1 The SUMO-2 antibody in healthy controls…………….….…… 74
Table 6-2.2 The SUMO-2 antibody in active patients fellowed up for
months…………………………………………………………….……….....
75
Table 6-2.3 The SUMO-2 antibody in inactive patients fellowed up for
months……………………………………………………………….…….....
76
Figure 4-1 The association between SUMO-2 antibody and Clinical
characteristics (SLEDAI, ds-DNA antibody and complement 3/4) in
acvtive/inactive patients…………………………………..……………….…
77
捌、附錄……………………………………………….………………..…… 70
附錄一 100 位健康對照組的 GR 基因多型性資料…………..……….… 70
附錄二 109 位SLE 病患的 GR 基因多型性資料…………………. 82
附錄三 GR α/β mRNA 之表現量資料………………………………..... 85
附錄四 數月追蹤非活性期/活性期病人抗 SUMO-2 自體抗體以及臨床特徵資料………………..84
附錄五 ER22/23EK (G/A) 定序圖………………………………………... 91

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