WPŁYW AKTYWNOŚCI PROCESÓW PROTEOLITYCZNYCH NA STAN ODŻYWIENIA PACJENTÓW Z CHOROBĄ ZWYRODNIENIOWĄ STAWÓW I NIEWYDOLNOŚCIĄ ZEWNĄTRZWYDZIELNICZĄ TRZUSTKI

Liliya S. Babinets, Iryna M. Halabitska, Yuliia Ya. Kotsaba, Iryna O. Borovyk, Bogdan O. Migenko,
Svitlana S. Ryabokon, Lydmila S. Tsybulska

SHEI “I. Ya. Horbachevsky Ternopil State Medical University of the Ministry of the Public Health of Ukraine”, Ternopil, Ukraine

ABSTRACT

Introduction: The excretory insufficiency of pancreas in patients with primary osteoarthrosis is formed at the comorbid pathologies and as a result of long-term treatment of osteoarthrosis using the non-steroidal anti-inflammatory drugs, steroids, chondroprotectors and chondrostimulators etc.

The aim: to study the state of the proteolysis system and immune status, the presence and depth of the dysbiosis of colon in patients with primary osteoarthrosis against a violation of their excretory insufficiency of pancreas.

Materials and methods: There were 64 outpatients with primary OA (group 1) and 74 patients with primary OA in combination with diseases associated with EIP (group 2). The control group consisted of 30 healthy people. The age of the patients ranged from 29 to 74 years. The diagnosis of primary OA was established on the basis of unified diagnostic criteria, the X-ray stage of the primary OA, according to J. H. Kellgren and J. S. Lawrence.

Results: It was proved that there is a deeper excitation of the excretory function of the pancreas in patient with osteoarthrosis and comorbid pathologies of the gastrointestinal tract with the excretory insufficiency of pancreas, as well as the presence of the excretory insufficiency of pancreas in patients with primary osteoarthrosis without the clinically available the excretory insufficiency of pancreas. In patients with primary osteoarthrosis that went through the isolation or in combination with the diseases accompanied by the excretory insufficiency of pancreas, a statistically significant activation of the total proteolysis by the level of the proteolytic activity of the plasma was established. In group 2, dysbiotic changes were significantly deeper than in group 1. The obtained results indicate the presence of secondary immune deficiency in patients and non-specific activation of the humoral part of the immune system and the inflammatory process.

Conclusion: Statistically more significant changes were observed in group 2, indicating the progression of the detected changes in comorbidity conditions.

 

Wiad Lek 2018, 71, 2 cz. I, -276

 

INTRODUCTION

Primary osteoarthrosis (OA) is a chronic progressive degenerative-dystrophic joint disease. It is characterized by degeneration of articular cartilage with subsequent changes in subchondral bone and the development of marginal osteophytes and is often accompanied by reactive synovitis. Studies also found a high incidence of the gastrointestinal tract (GI) diseases in patients with OA, especially those that are accompanied by a violation of the excretory insufficiency of pancreas (EIP), which also contributes to the activation of proteolysis. The EIP in patients with OA is formed at the comorbid pathologies (chronic pancreatitis (CP) with EIP and incretory insufficiency in the form of diabetes mellitus (DM), functional biliary disorders, diseases of the liver and bile-excreting system, diseases of the gastroduodenal zones, enterocolitis and dysbiosis of colon (DC)); as a result of long-term treatment of OA using the non-steroidal anti-inflammatory drugs, steroids, chondroprotectors and chondrostimulators etc [1, 2, 3].

Inflammation plays significant part in the pathogenesis of OA. The main mechanism of cartilage degradation are production of proinflammatory cytokines (IL-1β, IL-6, FNP-α, etc.). They release enzymes that damage collagen (collagenase, elastase, peptidase) and proteoglycans (metalloproteinases, stromelysin, cathepsins) and activate proteolytic activity. This leads to increased destruction of hyaluronic fibers and a decrease cartilage regeneration [4].

Due to the processes of maldigestion and malabsorption in patients with EIP often develops DC. The presence and depth of the DC determines the severity of the diseasescourse accompanied by EIP and primary OA, the severity of trophic disorders: multivitamin and polymineral deficiency, secondary immunodeficiency, osteoporosis, anemia etc [5].

THE AIM

The goal of the work: to study the state of the proteolysis system and immune status (IS), the presence and depth of the DC in patients with primary OA against a violation of their EIP.

MATERIALS AND METHODS

There were 64 outpatients with primary OA (group 1) and 74 patients with primary OA in combination with diseases associated with EIP (group 2). The control group consisted of 30 healthy people.

The exclusion criteria were cancer diseases, acute and exacerbation of chronic pathologies of vital organs, severe diabetesmellitus type 2, diabetesmellitus type 1, active stomach and duodenum ulcers, viral hepatitis and liver cirrhosis, Crohn’s disease, non-specific ulcerative colitis, cystic fibrosis.

The age of the patients ranged from 29 to 74 years. The diagnosis of primary OA was established on the basis of unified diagnostic criteria, the X-ray stage of the primary OA, according to J. H. Kellgren and J. S. Lawrence [6].

The level of EIP was determined by the level of faecal α-elastase-1, using ELISA of the company Bioserv Elastase-1-ELISA. The proteolytic activity of the plasma (PAP) was determined by hydrolysis of protamine sulfate. The activity of the kallikrein (KK) was investigated using a method based on the determination of the amount of paranothiananiline. Prekalikrein (PKK) was determined by the Veremeenka’ method. The activity of the α1-proteinase inhibitor (α1-PI) and α2-macroglobulin (α2-MG) was determined by the unified spectrophotometric method. Determination of kininase-II activity was performed by spectrophotometric Folk’ method. Colon dysbiosys was determinated using method of R.V. Epstein-Litvak and F.L. Wilson. To assess the immune status, the cell and humoral components of CD3, CD22, CD4, CD8, CD16 were using ELISA with monoclonal antibodies; concentration of the main classes Ig (M, G, A) in the serum – by the G. Mancini method of radial immunodiffusion of globulins; activity of complement system – by hemolytic test.

RESULTS AND DISCUSSION

The analysis of the obtained parameters of fecal elastase-1 levels in the study groups showed the presence of EIP in both groups of study – correspondingly (153.83±5.34) μg/g and (58.65±4.73) μg/g – in comparison with the group control ((213±6.29) μg/g), as well as a statistically significantly lower level of faecal α-elastase in group 2 compared to that in group 1 (p <0.05). This indicated the presence of a deeper violation of the excretory function of pancreas in patients with OA and comorbidities of the gastrointestinal tract disorders from the EIP, as well as the presence of a low-grade EIP in group 1 of patients with OA. This confirms the opinion on the need to investigate this problem in order to take into account the availability of the EIP for the formation of an effective rehabilitation complex for patients with OA with comorbidities of the gastrointestinal tract disorders.

A statistically significant activation of total proteolysis by the level of PAP in both studied groups was revealed, however, in the group of patients with primary OA against the background of EIP, activation of PKK was more significant. Also, the analysis showed the presence of an increase in specific proteolysis, or kininogenesis, by the level of the proteolytic enzyme of the KK, which plays the most important role in the formation of kinins in the group with comorbid pathology. The decrease in the inactive precursor of KK-PKK in both studied groups was established, however, the decrease in group 2 was more significant. There was an elevated α1-PI level statistically significantly higher in group 2 than in group 1 and control group. A statistically significant decrease in α2-MG levels in groups 1 and 2 was found, but in group 2, the decrease in the level of this indicator was statistically significant. Also, the decrease of kininase-II activity was statistically significant in the comorbidity of the primary OA with diseases of the gastrointestinal tract with EIP (p <0.05) (Tab. I).

In the examination of patients, dysbiotic changes of varying degrees were detected in both groups of the study: group 1 in 25 (39.06%) patients was grade 1 of DC, in 18 (28.13%) persons was grade 2 of DC.

In group 2 grade 1 of DC was in 35 (47.30%) patients, in 24 (32.43%) person was grade 2 of DC.

In group 2, dysbiotic changes were significantly deeper than in group 1. This indicates a statistically weaker course in patients with the comorbidity conditions of the primary OA and gastrointestinal tract disorders and with EIP.

The obtained results indicate the presence of secondary immune deficiency in the patients under study (T-lymphocytopenia was detected in І-ІІ grade with a decrease in all subpopulations of T-lymphocytes) and non-specific activation of the humoral part of the immune system and the inflammatory process (depletion of the total hemolytic activity of the complement, statistically significant increase of Blymphocytes level with growth of level of all classes Ig (more IgA and Ig M), circulating immune complexes). However, statistically more significant changes were observed in group 2, indicating the progression of the detected changes in comorbidity conditions (p <0.05) (Tab. II).

CONCLUSION

1. It was proved that there is a deeper excitation of the excretory function of the pancreas (severe) in patient with osteoarthrosis and comorbid pathologies of the gastrointestinal tract with the excretory insufficiency of pancreas, as well as the presence of the excretory insufficiency of pancreas in patients with primary osteoarthrosis without the clinically available the excretory insufficiency of pancreas.

2. In patients with primary osteoarthrosis that went through the isolation or in combination with the diseases accompanied by the excretory insufficiency of pancreas, a statistically significant activation of the total proteolysis by the level of the proteolytic activity of the plasma was established. Also, the analysis showed the presence of an increase in specific proteolysis, or kininogenesis, by the level of proteolytic enzyme kallikrein. Reduced inactive precursor kallikrein – prekalikrein is established. There was an increased level of α1-proteinase inhibitor, which controls the activity of proteolysis, binding trypsin and proteolytic enzymes of internal and external origin. A decrease in the level of α2-macroglobulin was found, which indicates the depletion of the inhibitory protection of the organism, because this indicator blocks the kinogenase action of the kallikrein and displays active porteinases of endo- and exogenous origin. Also, decreased activity of kininase-II was revealed, which indicates weakening of the protective reactions of the organism through hyperproduction of kinins (p <0.05).

3. In the examination of patients, dysbiotic changes of varying degrees were detected in both groups of the study: group 1 in 25 (39.06%) patients was grade 1 of the dysbiosis of colon, in 18 (28.13%) persons was grade 2 of the dysbiosis of colon.

In group 2 grade 1 of the dysbiosis of colon was in 35 (47.30%) patients, in 24 (32.43%) person was grade 2 of the dysbiosis of colon.

In group 2, dysbiotic changes were significantly deeper than in group 1. This indicates a statistically weaker course in patients with the comorbidityconditions of the primary osteoarthrosis and gastrointestinal tract diseases and with the excretory insufficiency of pancreas.

4. The obtained results indicate the presence of secondary immune deficiency in the patients under study (T-lymphocytopenia was detected in І-ІІ grade with a decrease in all subpopulations of T-lymphocytes) and non-specific activation of the humoral part of the immune system and the inflammatory process (depletion of the total hemolytic activity of the complement, statistically significant increase of B-lymphocytes level with growth of level of all classes Ig (more Ig A and Ig M), circulating immune complexes). However, statistically more significant changes were observed in group 2, indicating the progression of the detected changes in comorbidity conditions.

References

1. Babinets, L.S., Kytsai, K.Yu., Kotsaba, Yu.Ya., Halabitska, I.M., Melnyk, N.A. et al. (2017). Improvement of the complex medical treatment for the patients wіth chronic biliary pancreatitis. Wiadomosci lekarskie, 2, 213-216.

2. Babinets, L.S., Galabitskaya, I.M., Maevska, T.G. (2017). Zovnishn’osekretorna nedostatnist’ pidshlunkovoyi zalozy ta dysbalans systemy prooksydanty-antyoksydanty pry pervynnomu osteoartrozi z komorbidnymy stanamy [External-secretion pancreatic insufficiency and an anti-oxidant antioxidant system imbalance in primary osteoarthritis with comorbid conditions]. Zdobutka klinichnoyi ta eksperymental’noyi medytsyny – Achievement of clinical and experimental medicine, 3, 22-25 [in Ukrainian].

3. Babinets, L.S., Maevska, T.G. (2017). Kliniko-patohenetychni aspekty osteodefitsytu pry osteoartrozi u poyednanni z khronichnym pankreatytom [Clinical and pathogenetic aspects of osteodyphritis in osteoarthritis in combination with chronic pancreatitis]. Zdobutka klinichnoyi ta eksperymental’noyi medytsyny – Achievement of clinical and experimental medicine, 2, 31-37 [in Ukrainian].

4. Hochberg, M. (2012). Osteoarthritis year 2012 in review: clinical. Osteoarthritis Cartilage, 20, 1465-1469.

5. Babinets, L.S., Kotsaba, Yu.Ya., Denefil, O.V. (2013). Enteropankreatychnyy syndrom i yoho vplyvy na trofolohichni porushennya pry khronichnomu pankreatyti [Enteropankreatic syndrome and its effects on trophological disturbances in patients with chronic pancreatitis]. Mizhvidomchyy zbirnyk «Hastroenterolohiya». – Interdepartmental collection «Gastroenterology», 4 (50), 61-64 [in Ukrainian].

6. Unifikovanyy klinichnyy protokol pervynnoyi, vtorynnoyi (spetsializovanoyi) medychnoyi dopomohy ta medychnoyi reabilitatsiyi [Unified clinical protocol of primary, secondary (specialized) medical aid and medical rehabilitation]. (2014). Ministry of Health of Ukraine, 638 [in Ukrainian].

 

Scientific research work 0113U001244 “Comorbid conditions in the clinic of internal diseases and the practice of family doctor: predictors of development, early diagnosis, prevention and treatment”.

ADDRESS FOR CORRESPONDENCE

Liliya Babinets

tel.: +380-67-352-07-43

e-mail: irynkagal@gmail.com

Received: 20.02.2018

Accepted: 10.04.2018

Table І. The level of proteolysis indexes in patients with OA and EIP

Index of proteolysis

Research group

Control group

(n=30)

Control group

(n=64)

Control group

(n=74)

PAP, ml of arginine/(hl)

30,41±0,71

43,36±2,54*

48,42±2,28**

KK, μmol/(min)

54,12±1,43

139,78±5,67*

151,65±7,44**

PKK μmol/(min)

74,79±1,89

51,26±2,47*

45,18±4,34**

α1-PI, g/l

1,43±0,02

1,68±0,03*

1,74±0,04**

α2-MG, g/l

1,45±0,02

0,95±0,03*

0,85±0,06**

Kininase-II activity,

μmol GC/(min)

271,38±1,45

185,32±3,31*

172,45±7,86**

Note:

* – significant difference in the data related to the control group (p <0.05)

** – significant difference in the data related the 2-nd group to the 1-th group (p<0.05)

Table ІІ. The level of IS indexes in patients with OA and EIP

Index of IS

Research group

Control group

(n=30)

1-th group

(n=64)

2-nd group

(n=74)

CD3, %

67,50±0,59

47,95±0,56*

41,58±0,44**

CD22, %

15,20±0,43

19,95±0,27*

22,33±0,29**

CD16, %

13,30±0,23

10,49±0,17*

8,48±0,09**

CD4, %

40,85±1,33

32,18±0,52*

30,52±0,53**

CD8, %

25,55±1,65

13,92±0,24*

13,36±0,26**

Ig G, g/l

8,72±0,27

12,16±0,15*

12,48±0,16**

Ig A, g/l

1,74±0,05

2,75±0,07*

3,32±0,08**

Ig M, g/l

1,45±0,05

2,61±0,05*

2,64±0,09**

CIC, mind. units

64,25±1,55

215,72±5,42*

243,91±6,92**

Complement (СН50), 

hem. unit

289,30±4,91

163,03±2,29*

152,64±2,81**

ІRІ (CD4/CD8)

1,67±0,06

2,33±0,05*

2,30±0,04**

Note:

* – significant difference in the data related to the control group (p <0.05)

** – significant difference in the data related the 2-nd group to the 1-th group (p <0.05).