柴芩承气汤攻伐三焦热毒防治重症胰腺炎多器官功能衰竭的“肠-淋巴-组蛋白”新机制

“San Jiao toxic heat” is considered key in Traditional Chinese Medicine (TCM) to the pathogenesis of multiple organ failure (MOF) following severe acute pancreatitis (SAP). Our recent work has revealed that circulating histones (damage-associated molecular pattern molecules) are important meditators of SAP-MOF. The “gut-lymph” concept, whereby toxic gut products bypass the liver to enter directly into the circulation to mediate systemic inflammation and MOF, offers a compelling basis for the hypothesis that histones and San Jiao toxic heat act through this mechanism. Further it is considered that San Jiao toxic heat is countered by enteral administration of Chai-Qin-Cheng-Qi Decoction (CQCQD) that has been shown to mitigate SAP-MOF through purgation and inhibition of circulating histone toxicity. This programme seeks to: (1) investigate the putative novel mechanism of gut-lymph-induced lymphocyte cell death and histone release to gain an in-depth understanding of histone-induced lymphocyte cell death; (2) verify the effects of TLR4 and CQCQD on gut-lymph-histone release during SAP-MOF in experimental SAP; (3) investigate strategies to neutralise circulating histones to reduce the severity of SAP-MOF. Successful completion of this study will provide an example of the systematic evaluation of TCM in the context of recent advances in the understanding of the pathogenesis of SAP-MOF. This research will enable a better understanding of the complex pathogenesis of SAP-MOF to identify core molecular therapeutic targets by which TCM acts and provide further novel strategies for its treatment.

三焦热毒弥漫是重症急性胰腺炎（SAP）导致多器官功能衰竭（MOF）的核心病机。我们在发现作为损伤相关模式分子-循环组蛋白是SAP-MOF关键介质的扎实工作基础上，结合“肠-淋巴”途径导致SAP-MOF的发病机制，提出“肠-淋巴-组蛋白/三焦热毒”科学假说，即循环组蛋白作为热毒介质来源并循行“肠-淋巴”途径进入血循环导致MOF；临床验方柴芩承气汤（CQCQD）通过攻下、抑制循环组蛋白毒性即攻伐三焦热毒而防治SAP-MOF。通过①首次探讨肠淋巴毒性成分引起组蛋白释放进而导致淋巴细胞死亡的机制；②验证TLR4受体和CQCQD在SAP-MOF中对“肠-淋巴-组蛋白”释放的影响；③阻断循环组蛋白对SAP-MOF的疗效等研究验证该假说。从而以有形解剖结构和物质基础诠释中医模糊理论，对阐明SAP-MOF复杂的发病机制、探索确有疗效中药方剂治疗靶点提供创新研究思路和策略，也为其转化研究打下坚实基础。

多器官功能衰竭（MOF）是重症急性胰腺炎（SAP）死亡最主要原因，SAP-MOF发生发展机制尚不清楚，目前仅以支持和对症治疗为主，无特效药物。本团队前瞻性数据分析表明中西医治疗的病人死亡峰已由原来的“双峰”变为第一周的“单峰”，死亡率为19.6%，低于国际的30%。本团队验方柴芩承气汤（CQCQD）在前期研究中发现对SAP多个动物模型有显著的保护作用。阐明CQCQD防治SAP-MOF，降低其死亡率的机制具有重要的理论意义和临床价值。本项目系统揭示了CQCQD通过结合肠淋巴液中的组蛋白，攻伐三焦热毒，治疗SAP-MOF的机制。主要结果如下：（1）3-羟基犬尿氨酸（3-hydroxykynurenine, 3-HK）和组蛋白时间浓度性引起淋巴细胞凋亡，组蛋白引起淋巴细胞凋亡的机制外源性，TLR4敲除对高剂量组蛋白有保护作用。（2）SAP-MOF大鼠肠淋巴液中组蛋白升高，与胰腺淀粉酶成正相关；中和组蛋白或抑制TLR4可以降低其对大鼠微血管内皮细胞毒性。（3）CQCQD保护胰腺损伤，减少MOF；黄芩苷等中药有效成分可进入大鼠肠淋巴液，CQCQD灌喂大鼠肠淋巴组蛋白浓度和细胞毒性降低；黄芩苷和大黄酸可以通过结合组蛋白降低肠淋巴液毒性。