Yang et al. Journal of Physiological Anthropology
https://doi.org/10.1186/s40101-019-0194-1(2019) 38:4

ORIGINAL ARTICLE

Open Access

NR3C1 gene polymorphisms are associatedwith high-altitude pulmonary edema in
Han Chinese
Yingzhong Yang1,2,3*, Hui Du1, Yuhong Li4, Wei Guan4, Feng Tang1,2,3, Qin Ga1,2,3 and Ri-Li Ge1,2,3

Abstract
Background: High-altitude pulmonary edema (HAPE) is a life-threatening form of non-cardiogenic edema which
occurs in unacclimatized individuals after rapid ascent to high altitude. NR3C1 gene encodes for glucocorticoid
receptor (GR) which plays an important role in stress and inflammation. This study aimed to investigate theassociation of NR3C1 polymorphisms with the susceptibility to HAPE in Han Chinese.
Methods: The 30 SNPs in the NR3C1 gene were genotyped by the Sequenom MassARRAY SNP assay in 133 HAPE
patients (HAPE-p) and 135 matched Han Chinese resistant to HAPE (HAPE-r). The genotypic and allele frequencies,
odds ratios (ORs), and 95% confidence intervals (95% CIs) were calculated, respectively.
Results: The 12 SNPs showed a significant difference between the HAPE-p and HAPE-r groups. In allelic model
analysis, we found that the allele “A” of rs17287745, rs17209237, rs17209251, rs6877893, and rs1866388; the allele “C”
of rs6191, rs6188, and rs2918417; the allele “T” of rs33388 and rs4634384; and the allele “G” of rs41423247 andrs10052957 were associated with increased the risk of HAPE. In the genetic model analysis, we found that rs17287745,
rs6191, rs6188, rs33388, rs2918417, rs6877893, rs1866388, rs41423247, rs4634384, and rs10052957 were relevant to theincreased HAPE risk under the dominant model.
In addition, the haplotype AACACTCAAGTG of the 12 SNPs was detected to be significantly associated with HAPE risk
(OR = 2.044, 95%CI = 1.339~3.120, P = 0.0008), while the haplotype GGAGCACGACCG was associated with thedecreased risk of HAPE (OR = 0.573, 95% CI = 0.333~0.985, P = 0.0422).
Conclusions: Our findings provide new evidence for the association between SNPs in NR3C1 and an increased risk of
HAPE in the Chinese population. NR3C1 polymorphisms are associated with the susceptibility to HAPE in Han Chinese.
Keywords: HAPE, NR3C1, Polymorphism, Susceptibility

Background
High-altitude pulmonary edema (HAPE) is non-cardiogenic pulmonary edema that usually occurs at altitudes
above 2500 m in rapidly ascending non-acclimatized individuals within the first week after arrival [1, 2]. HAPE is
characterized by high pressure in pulmonary arteries, withedema in pulmonary interstitial tissue and alveoli, leading
to pulmonary capillary stress failure and a high* Correspondence: yingzhong-yang@hotmail.com
1
Research Center for High Altitude Medical Sciences, School of Medicine,
Qinghai University, 16 Kunlun Rd, Xining 810001, Qinghai, People’s Republicof China2
Basic and Applied Key Laboratory for High Altitude Medical Science andTechnology of Qinghai, Xining 810001, Qinghai, China
Full list of author information is available at the end of the article

permeability type of edema. HAPE was defined as a
non-inflammatory hemorrhagic pulmonary edema, which
may evolve with the features of secondary inflammation[3]. Circulating inflammatory markers of IL-6, IL-1ra, and
CRP are upregulated in response to high altitude, andhypoxia-induced inflammation at high altitude may contribute to the development of HAPE [4, 5].
The incidence of HAPE could be reduced by dexamethasone [6]. Glucocorticoids (GCs) have various effects,
which are exclusively mediated by the intracellular glucocorticoid receptor (GR). After the binding to GCs, GR istranslocated to the nucleus where it interacts withglucocorticoid-responsive elements of different genes todrive gene transcription [7]. In inflammatory reactions,© The Author(s). 2019, corrected publication 2022 Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Yang et al. Journal of Physiological Anthropology(2019) 38:4

GC inhibits the production of pro-inflammatory cytokines
and stimulates the production of anti-inflammatory cytokines [8]. NR3C1 (nuclear receptor subfamily 3, group C,
member 1) gene is located on chromosome 5q31-q32 andencodes for the human GR [9]. Variants in the NR3C1
gene may contribute to the spectrum of GC responses indifferent diseases [7, 10–12]. Previously, we screened thevariants in exons of the NR3C1 gene and reported that
rs6194 polymorphism was correlated with HAPE susceptibility [12]. In this study, we aimed to investigate theassociation of the polymorphisms in non-coding regionsof the NR3C1 gene with the susceptibility to HAPE in
Han Chinese.

Materials and methods
Subjects

HAPE patients (HAPE-p) had been hospitalized in Yushu
People’s Hospital from 2010 to 2017 owing to the onset of
HAPE after arriving 1 to 7 days at Yushu (3760 m) of
Qinghai province. The patients were diagnosed with HAPE
based on the diagnostic criteria [13]. The blood samples
and data were collected. Healthy lowlanders resistant to
HAPE (HAPE-r) were enrolled from the same area, withmatched age, gender, workplace, and type of work. These
subjects had not suffered from HAPE or any other mountain sickness after staying at high altitude for at least 3
months. One hundred thirty-three HAPE and 135 matched
HAPE-r were enrolled. This study was approved by the
Ethics Committee of the Medical College of Qinghai
University, and every subject signed written consent. All
subjects were of lowlander Han Chinese ethnicity and had
no blood relationship with any other enrolled subject.
Clinical characteristics

Hemoglobin concentration, hematocrit, and percent oxygen saturation were determined from venous blood samples using the Mindray Hematology Analyzer (BC-2300,
Shenzhen, People’s Republic of China) and the Pulse Oximeter (Ohmeda 3700 Pulse Oximeter, DatexOhmeda,
Boulder, Colorado, USA). Sample collection and DNA extraction were the same with the previous one [12].

Page 2 of 8

non-coding regions. SNPs were genotyped by thesingle-base extension detecting technology (iPLEX)(Capital Bio Corporation, Beijing, China). The primers for
PCR and single-base extension were designed by using theSequenom MassARRAY Assay Design Genotyping
Software and Tools (Sequenom, San Diego, CA, USA).
PCR was performed under the following thermal cycling
conditions: 94 °C for 4 min, then 94 °C for 20 s, 56 °C for
30 s, and 72 °C for 1 min for 45 cycles, and 72 °C for 4 min.
PCR products were treated with shrimp alkaline phosphatase to remove free deoxyribonucleoside triphosphates, andsingle-base extension reaction was performed in a system
consisted of 2.0 mL of EXTEND MIX, 0.619 mL of ddH2O,
0.94 mL of Extend primer mix, 0.2 mL of iPLEX buffer
plus, 0.2 mL of iPLEX terminator, and 0.041 mL of iPLEX
enzyme (Sequenom, San Diego, CA, USA). The thermal
cycling conditions were as follows: 94 °C for 30 s, then
94 °C for 5 s, 52 °C for 5 s, and 80 °C for 5 s for 40 cycles,
and 72 °C for 3 min. The purified extension products weredispensed onto a 384-element SpectroCHIP bioarray(Sequenom, San Diego, CA, USA), and mass spectrometric analysis was performed using the MALDI-TOF(matrix-assisted laser desorption/ionization—time offlight) (Sequenom, San Diego, CA, USA). The results wereanalyzed using TYPER 4.0 software (Sequenom, San
Diego, CA, USA).
Statistical analysis

SPSS software (version 17.0, SPSS, Inc., Chicago, USA)was used for statistical analysis. Haplotype frequencies
and the expected number of haplotypes for each individual were performed using SHEsis online software(http://analysis.bio-x.cn). Allele frequencies were calculated based on genotype frequencies in HAPE patientsand control subjects, and inter-group differences were
estimated by the chi-square test. Deviations from Hardy-Weinberg equilibrium (HWE) were assessed by thechi-square test. The criterion for significance was P <0.05 for all comparisons.

Results
Basic characteristics of populations

SNP selection and genotyping

In this study, a total of 30 SNPs (minor allele frequencies(MAFs) > 5%) in the NR3C1 gene have been identified in
the HapMap Han Chinese population and are located in

The demographic and clinical characteristics of HAPE-pand HAPE-r are presented in Table 1. We found that percent oxygen saturation was significantly lower whereas
heart rate was significantly higher in the HAPE-p group

Table 1 High-altitude exposures and physiological phenotypes for the study populations
GroupsSubjects (n)Gender

Altitude (m)Average age (year)

HGB (g/dL)

Hct (%)HR (b/m)SPO2 (%)

HAPE-p

133

Male

3760

40.20 ± 9.91

157.24 ± 15.24*

47.79 ± 4.97*

109.73 ± 14.85*

62.46 ± 11.89*

HAPE-r

135

Male

3760

40.92 ± 5.15

172.80 ± 14.54

50.74 ± 8.15

80.84 ± 12.03

88.85 ± 4.17

Values are means ± SD. P < 0.05 vs HAPE-r
HAPE-p high-altitude pulmonary edema patients, HAPE-r high-altitude pulmonary edema resistant (control), HGB hemoglobin, Hct hematocrit, HR heart rate, SPO2
oxyhemoglobin saturation

Yang et al. Journal of Physiological Anthropology(2019) 38:4

compared to that in the HAPE-r group. As expected,
HGB and Hct were higher in the HAPE-r group comparedto that in the HAPE-p group. There was no significant difference in age between HAPE-p and HAPE-r groups.
Genotype and allele distribution

We examined the genotypic distributions, allelic frequencies, and associations of 30 SNPs in all subjects. The SNP
rs4244032 showed deviations from HWE, while other
SNPs were in HWE in both groups (Table 2). The allele
and genotype distributions of the 30 SNPs in the HAPE-pand HAPE-r groups are presented in Table 3(Additional file 1). Twelve SNPs (rs17287745, rs17209237,

Page 3 of 8

rs6191, rs17209251, rs6188, rs33388, rs2918417,
rs6877893, rs1866388, rs41423247, rs4634384, rs10052957)
were significantly associated with HAPE (P < 0.05). In allelic model analysis, we found that the allele “A” ofrs17287745, rs17209237, rs17209251, rs6877893, andrs1866388; the allele “C” of rs6191, rs6188, and rs2918417;
the allele “T” of rs33388 and rs4634384; and the allele “G”
of rs41423247 and rs10052957 were associated with increased the risk of HAPE. In the genetic model analysis,
we found that rs17287745, rs6191, rs6188, rs33388,
rs2918417, rs6877893, rs1866388, rs41423247, rs4634384,
and rs10052957 were relevant to increased HAPE risk
under the dominant model.

Table 2 SNPs information of the NR3C1 gene and the Hardy–Weinberg Equilibrium (HWE) in the current population
SNP ID

Gene

Band

Position

Alleles
A/B

Global MAF

HAPE-p

HAPE-rrs174048

NR3C1

5q31-q32

143270839

C/T

C = 0.1014/508

0.491

0.216

rs17287745

NR3C1

5q31-q32

143275450

G/A

G = 0.2528/1266

0.678

0.427

rs17209237

NR3C1

5q31-q32

143277647

G/A

G = 0.1542/772

0.543

0.394

rs6198

NR3C1

5q31-q32

143278056

C/T

C = 0.0839/420

0.965

0.826

rs6191

NR3C1

5q31-q32

143278591

A/C

A = 0.4016/2011

0.473

0.855

rs10482704

NR3C1

5q31-q32

143282198

A/C

A = 0.0080/40

1

0.966

rs258751

NR3C1

5q31-q32

143282715

A/G

A = 0.0547/274

0.491

0.216

rs17209251

NR3C1

5q31-q32

143289658

G/A

G = 0.1472/737

0.585

0.380

rs258813

NR3C1

5q31-q32

143295125

A/G

A = 0.2312/1158

0.323

0.082

rs6188

NR3C1

5q31-q32

143300779

A/C

A = 0.2306/1155

0.323

0.072

rs33388

NR3C1

5q31-q32

143317730

A/T

A = 0.3934/1970

0.473

0.759

rs33389

NR3C1

5q31-q32

143320934

T/C

T = 0.1064/533

0.491

0.236

rs2918417

NR3C1

5q31-q32

143346605

T/C

T = 0.2236/1120

0.321

0.072

rs6877893

NR3C1

5q31-q32

143347628

G/A

G = 0.4030/2018

0.320

0.952

rs10482642

NR3C1

5q31-q32

143348466

C/T

C = 0.0988/495

0.965

0.826

rs17399352

NR3C1

5q31-q32

143375125

C/T

C = 0.1394/698

0.798

0.272

rs2963155

NR3C1

5q31-q32

143376439

G/A

G = 0.2228/1116

0.553

0.075

rs2963156

NR3C1

5q31-q32

143378931

T/C

T = 0.1615/809

0.717

0.256

rs1866388

NR3C1

5q31-q32

143380220

G/A

G = 0.2139/1071

0.459

0.160

rs41423247

NR3C1

5q31-q32

143399010

C/G

C = 0.2546/1275

0.821

0.592

rs6189NR3C1

5q31-q32

143400774

T/C

T = 0.0106/53

0.965

0.966

rs4634384

NR3C1

5q31-q32

143401132

C/T

C = 0.3972/1989

0.671

0.513

rs10052957

NR3C1

5q31-q32

143407136

A/G

A = 0.2212/1108

0.323

0.074

rs9324924

NR3C1

5q31-q32

143412919

T/G

T = 0.4808/2408

0.574

0.042

rs7701443

NR3C1

5q31-q32

143413085

A/G

G = 0.4605/2306

0.906

0.420

rs4244032

NR3C1

5q31-q32

143415160

G/A

G = 0.1326/664

0.000

0.002

rs4607376

NR3C1

5q31-q32

143416967

A/G

G = 0.3966/1986

0.782

0.724

rs12656106

NR3C1

5q31-q32

143429382

C/G

C = 0.3413/1709

0.840

0.429

rs12655166

NR3C1

5q31-q32

143429707

C/T

0.287

0.780

rs12521436

NR3C1

5q31-q32

143438042

A/G

0.581

0.291

Alleles A/B = minor/major alleles, Global MAF = global minor allele frequency
HAPE-p high-altitude pulmonary edema patients, HAPE-r high-altitude pulmonary edema resistant (control)

A = 0.2776/1390

P valueYang et al. Journal of Physiological Anthropology(2019) 38:4

Page 4 of 8

Table 3 Comparison of genotype distributions and allele frequencies for SNPs associated with HAPE risk under the dominant andrecessive model in both groups, respectively
SNP

OR (95% CI)

χ2P

45 (33.3)

1.650 (0.964–2.823)

3.365

0.067

9 (6.7)5.444 (1.144–25.915)

5.558

0.018

1.884 (1.204–2.946)

7.841

0.005

1.867 (1.113–3.131)

5.656

0.017

42 (31.6)

1.373 (0.803–2.349)

1.348

0.246

8 (6.0)4.578 (0.946–22.166)

4.222

0.040

1.609 (1.028–2.517)

4.382

0.036

1.547 (0.922–2.594)

2.748

0.097

Genotype/allele

HAPE-p (n%)

HAPE-r (n%)

AA

98 (73.7)

81 (60.0)AG

33 (24.8)

GG

2 (1.5)A

229 (86.1)

207 (76.7)

G

37 (13.9)

63 (23.3)

AA

98 (73.7)

81 (60.0)

AG + GG

35 (26.3)

54 (40.0)

AA

95 (72)83 (62.4)

AG

35 (26.5)

GG

2 (1.5)rs17287745
Genotype

AlleleDominant model

rs17209237
Genotype

AlleleDominant modelA

225 (85.2)

208 (78.2)

G

39 (14.8)

58 (21.8)

AA

95 (72.0)

83 (62.4)

AG + GG

37 (28.0)

50 (37.6)

CC

88 (66.7)

69 (51.9)

rs6191
Genotype

AlleleDominant modelCA

38 (28.8)

53 (39.8)

1.779 (1.055–2.999)

4.709

0.03

AA

6 (4.5)

11 (8.3)

2.338 (0.824–6.638)

2.661

0.103

C

214 (81.1)

191 (71.8)

A

50 (18.9)75 (28.2)

1.681 (1.118–2.526)

6.299

0.012

CC

88 (66.7)

69 (51.9)

CA + AA44 (33.3)

64 (48.1)

1.855 (1.129–3.048)

5.999

0.014

AA

94 (72.3)

84 (62.7)

GA

34 (26.2)

42 (31.3)

1.382 (0.806–2.371)

1.388

0.239

GG

2 (1.5)8 (6.0)4.476 (0.925–21.671)

4.079

0.043

1.614 (1.028–2.532)

4.380

0.036

1.554 (0.924–2.614)

2.781

0.095

1.959 (1.072–3.579)

4.877

0.027

1.810 (1.027–3.193)

4.294

0.038

1.959 (1.072–3.579)

4.877

0.027

1.812 (1.076–3.052)

5.047

0.025

rs17209251
Genotype

AlleleDominant modelA

222 (85.4)

210 (78.4)

G

38 (14.6)

58 (21.6)

AA

94 (72.3)

84 (62.7)

GA + GG

36 (27.7)

50 (37.3)

CC

112 (84.2)

98 (73.1)

rs6188
Genotype

AlleleDominant modelCA

21 (15.8)

36 (26.9)

AA

0 (0.0)0 (0.0)C

245 (92.1)

232 (86.6)

A

21 (7.9)36 (13.4)

CC

112 (84.2)

98 (73.1)

CA + AA21 (15.8)

36 (26.9)

TT

88 (66.7)

69 (51.1)

AT

38 (28.8)

54 (40)rs33388
Genotype

Yang et al. Journal of Physiological Anthropology(2019) 38:4

Page 5 of 8

Table 3 Comparison of genotype distributions and allele frequencies for SNPs associated with HAPE risk under the dominant andrecessive model in both groups, respectively (Continued)
SNP

Genotype/allele

HAPE-p (n%)

HAPE-r (n%)

OR (95% CI)χ2P

2.551 (0.911–7.141)

3.352

0.067

1.739 (1.160–2.607)

7.251

0.007

1.913 (1.166–3.138)

6.666

0.010

1.942 (1.063–3.548)

4.741

0.029

1.796 (1.018–3.167)

4.172

0.041

1.942 (1.063–3.548)

4.741

0.029

AA

6 (4.5)12 (8.9)

AlleleT

214 (81.1)

192 (71.1)

A

50 (18.9)78 (28.9)

Dominant modelTT

88 (66.7)

69 (51.1)

AT+AA

44 (33.3)

66 (48.9)

rs2918417
GenotypeCC

111 (84.1)

98 (73.1)

CT

21 (15.9)

36 (26.9)

TT

0 (0.0)0 (0.0)AlleleC

243 (92.0)

232 (86.6)

T

21 (8.0)36 (13.4)

Dominant modelCC

111 (84.1)

98 (73.1)

CT + TT

21 (15.9)

36 (26.9)

AA

87 (68)68 (51.1)

AG

35 (27.3)

54 (40.6)

1.974 (1.161–3.356)

6.385

0.012

2.346 (0.826–6.663)

2.678

0.102

1.779 (1.176–2.689)

7.553

0.006

2.028 (1.226–3.356)

7.670

0.006

2.002 (1.030–3.894)

4.288

0.038

1.881 (0.996–3.552)

3.892

0.049

2.002 (1.030–3.894)

4.288

0.038

rs6877893
Genotype

GG

6 (4.7)

11 (8.3)

AlleleA

209 (81.6)

190 (71.4)

G

47 (18.4)

76 (28.6)

Dominant modelAA

87 (68.0)

68 (51.1)

AG + GG

41 (32.0)

65 (48.9)

rs1866388
GenotypeAA

116 (87.9)

105 (78.4)

GA

16 (12.1)

29 (21.6)

GG

0 (0.0)0 (0.0)AlleleA

248 (93.9)

239 (89.2)

G

16 (6.1)

29 (10.8)

Dominant modelAA

116 (87.9)

105 (78.4)

AG + GG

16 (12.1)

29 (21.6)

GG

93 (69.9)76 (56.3)

CG

36 (27.1)

49 (36.3)

1.666 (0.984–2.819)

3.636

0.057

3.059 (0.923–10.142)

3.633

0.057

1.732(1.134–2.645)

6.544

0.011

1.805 (1.091–2.985)

5.342

0.021

rs41423247
GenotypeCC

4 (3.0)10 (7.4)

AlleleG

222 (83.5)

201 (74.4)

C

44 (16.5)

69 (25.6)

Dominant model

GG

93 (69.9)76 (56.3)

CG + CC

40 (30.1)

59 (43.7)

rs4634384
Genotype

AlleleTT87 (67.4)

68 (51.1)

CT

37 (28.7)

52 (39.1)

1.798 (1.061–3.047)

4.793

0.029

CC

5 (3.9)13 (9.8)

3.326 (1.131–9.786)

5.206

0.023

T

211 (81.8)

188 (70.7)

C

47 (18.2)

78 (29.3)

1.863 (1.234–2.812)

8.894

0.003

Yang et al. Journal of Physiological Anthropology(2019) 38:4

Page 6 of 8

Table 3 Comparison of genotype distributions and allele frequencies for SNPs associated with HAPE risk under the dominant andrecessive model in both groups, respectively (Continued)
SNP
Dominant model

Genotype/allele

HAPE-p (n%)

HAPE-r (n%)

TT87 (67.4)

68 (51.1)

CT + CC

42 (32.6)

65 (48.9)

GG

112 (84.2)

99 (73.3)

OR (95% CI)

χ2

P

1.980 (1.200–3.269)

7.214

0.007

1.939 (1.062–3.542)

4.734

0.030

1.795 (1.018–3.165)

4.170

0.041

1.939 (1.062–3.542)

4.734

0.030

rs10052957
Genotype

AlleleDominant modelGA

21 (15.8)

36 (26.7)

AA

0 (0.0)0 (0.0)G

245 (92.1)

234 (86.7)

A

21 (7.9)36 (13.3)

GG

112 (84.2)

99 (73.3)

GA + AA21 (15.8)

36 (26.7)

Data are shown as odds ratio (OR), 95% confidence interval (CI), and P values comparing HAPE patients and control group
P value in italics indicates statistical significance after comparisons
HAPE-p high-altitude pulmonary edema patients, HAPE-r high-altitude pulmonary edema resistant (control)

Linkage disequilibrium and haplotype analysis of the 12
SNPs

The locations of these SNPs are shown in Table 2, andthe linkage disequilibrium of the SNPs is shown in Fig. 1.
In the HAPE-p group, the SNPs were in strong linkage
disequilibrium with each other (Fig. 1a). In comparison,few SNPs were found in linkage disequilibrium witheach other in the control group (Fig. 1b). The degree ofgenetic linkage between these SNPs is estimated as Dvalues. Red panels indicate that there exists a strong
pairwise linkage disequilibrium between adjacent SNPs;
the higher D value is represented with the darker red
block, the higher degree of genetic linkage between the
SNPs, whereas the white panels indicate that the linkage
disequilibrium is weak or non-existent. The haplotype

analysis of the 12 SNPs showed a significant difference between the two groups in Table 3, and the haplotype
AACACTCAAGTG was detected to be significantly associated with HAPE risk (OR = 2.044, 95%CI = 1.339~3.120,
P = 0.0008), while the haplotype GGAGCACGACCG was
associated with decreased the risk of HAPE (OR = 0.573,
95% CI = 0.333~0.985, P = 0.0422) (Table 4).

Discussion
It is known that hypoxia can induce inflammation [14].
The levels of circulating proinflammatory markers wereincreased in healthy volunteers who spent three nights
at an elevation higher than 3400 m [4]. In addition,
HAPE patients at early stage showed increased counts ofalveolar macrophages, neutrophils, and lymphocytes andFig. 1 Linkage disequilibrium among the 12 SNPs of the NR3C1 gene in the HAPE-p group (a) and HAPE-r group (b). The degree of genetic
linkage between these SNPs is estimated as D values. Red panels indicate that there exists a strong pairwise linkage disequilibrium between
adjacent SNPs whereas white panels indicate that the linkage disequilibrium is weak or non-existentYang et al. Journal of Physiological Anthropology(2019) 38:4

Page 7 of 8

Table 4 Haplotype analysis for 12 SNPs of the NR3C1 gene in HAPE and control groups
Haplotype

HAPE-p (freq)

HAPE-r (freq)

χ2

P value

Odds ratio [95%CI]

AAAAAATGGCCA

11.47 (0.043)

21.87 (0.081)

3.502

0.06130.500 [0.239~1.046]

AACACTCAAGTG

206.53 (0.776)

174.13 (0.645)

11.2060.00082.044 [1.339~3.120]

GGAGCACGACCG

24.00 (0.090)

39.00 (0.144)

4.127

0.04220.573 [0.333~0.985]

GGCGCTCAAGTG

8.47 (0.032)

14.87 (0.055)

1.857

0.17290.553 [0.233~1.311]

P value in italics indicates statistical significance after comparisons, data are shown as odds ratio (OR), 95% confidence interval (CI)
HAPE-p high-altitude pulmonary edema patients, HAPE-r high-altitude pulmonary edema resistant (control), χ2 chi square

markedly elevated concentrations of lactate dehydrogenase, IL-1beta, IL-6, IL-8, and TNF-alpha in the bronchoalveolar lavage fluid [15–17]. Moreover, vascular leakage,accumulations of inflammatory cells in multiple organs,and elevated serum levels of cytokines were observed inmice exposed to low oxygen concentration [18–20]. It has
been speculated that hypoxia-induced inflammatory cytokines at high altitude may contribute to the developmentof HAPE by causing capillary leakage in the lung [4].
Oral administration of dexamethasone is effective inpreventing acute mountain sickness (AMS) [6, 18].
Glucocorticoids are regarded as endogenous “dexamethasone” that regulate a broad spectrum of physiologic functions essential to the maintenance of basal andstress-related homeostasis, including inflammatory reactions. The effects of GCs are mediated by GRs, which aresteroid/thyroid/retinoic acid nuclear receptor superfamilyof transcription factors and function as a liganddependent transcription factor that regulates the expression of glucocorticoid-responsive genes. Approximately
20% of the genes expressed in human leukocytes are regulated by GCs [7]. Genetic mutations in NR3C1 have beenfound to substantially diminish GR function [10]. Therefore, the genetic variations in the NR3C1 gene are important to explain the pathogenesis of diseases.
In this study, we genotyped 30 SNPs of the NR3C1 genein Han Chinese with and without HAPE. For the first time,
we reported significant differences between the two groupsin 12 SNPs. Moreover, these polymorphisms were significantly associated with the risk of HAPE. The haplotype[AACACTCAAGTG] may increase the risk of HAPE. This
new clue may better explain the genetic variations in the
NR3C1 gene contributing to the pathogenesis of HAPE.

Acknowledgements
We thanks those physicians for sample collection, Dr Jiangxi from the Yushu
People’s Hospital, Dr Nima from the Yushu Bayi Hospital.
Funding
This work were supported by Natural Science Foundation of China (No.
81760335), Qinghai Thousand Talents Program, The 2nd round of “Qinghai
135 high-level talents training project”, Basic Applied Study Foundation of
Qinghai (2019-ZJ-7006).
Availability of data and materials
All data and material are freely available.
Authors’ contributions
YY conceived of the study and drafted the manuscript. HD carried out themolecular genetic studies and performed the statistical analysis. YL, WG, FT,
QG, and RLG collected the samples. All authors read and approved the final
manuscript.
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the Medical College of
Qinghai University, and every subject signed written consent.
Consent for publication
Not applicableCompeting interests
The authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.
Author details
1
Research Center for High Altitude Medical Sciences, School of Medicine,
Qinghai University, 16 Kunlun Rd, Xining 810001, Qinghai, People’s Republicof China. 2Basic and Applied Key Laboratory for High Altitude Medical
Science and Technology of Qinghai, Xining 810001, Qinghai, China.
3
Qinghai-Utah United Key Laboratory for High Altitude Medical Science,
Xining 810001, Qinghai, China. 4Department of Respiration, AffiliatedHospital, Qinghai University, Xining 810001, Qinghai, China.
Received: 17 October 2018 Accepted: 28 March 2019Conclusions
Our study suggests that the polymorphisms of NR3C1
gene are associated with the susceptibility to HAPE in
Han Chinese.
Additional file
Additional file 1: Table S1. Comparison of genotype distributions andallele frequencies for SNPs associated with HAPE risk under the dominant
and recessive model in both groups, respectively. (DOC 306 kb)

References
1. Hackett PH, Roach RC. High-altitude illness. N Engl J Med. 2001;345(2):107.
2. Basnyat B, Murdoch DR. High-altitude illness. Lancet. 2003;361(9373):1967–74.
3. Schoene RB, Hackett PH, Henderson WR, et al. High-altitude pulmonary
edema. Characteristics of lung lavage fluid. JAMA. 1986;256(1):63–9.
4. Hartmann G, Tschöp M, Fischer R, et al. High altitude increases circulatinginterleukin-6, interleukin-1 receptor antagonist and C-reactive protein.
Cytokine. 2000;12(3):246–52.
5. Rosenberger P, Schwab JM, Mirakaj V, et al. Corrigendum: hypoxia-inducible
factor-dependent induction of netrin-1 dampens inflammation caused byhypoxia. Nat Immunol. 2009;10(2):195–202.

Yang et al. Journal of Physiological Anthropology

6.

7.
8.
9.

10.

11.

12.

13.

14.
15.

16.

17.

18.

19.
20.

(2019) 38:4

Maggiorini M, Brunner-La Rocca HP, Peth S, et al. Both tadalafil anddexamethasone may reduce the incidence of high-altitude pulmonary
edema: a randomized trial. Ann Intern Med. 2006;145(7):497–506.
Nicolaides NC, Galata Z, Kino T, et al. The human glucocorticoid receptor:
molecular basis of biologic function. Steroids. 2010;75(1):1–12.
Neeck G, Renkawitz R, Eggert M. Molecular aspects of glucocorticoid hormone
action in rheumatoid arthritis. Cytokines Cell Mol Ther. 2002;7:61–9.
West DV, Eede FVD, Delfavero J, et al. Glucocorticoid receptor gene-based
SNP analysis in patients with recurrent major depression.
Neuropsychopharmacology. 2006;31(3):620–7.
Zalewski G, Wasilewska A, Zoch-Zwierz W, et al. Response to prednisone in
relation to NR3C1 intron B polymorphisms in childhood nephrotic
syndrome. Pediatr Nephrol. 2008;23(7):1073–8.
Niu N, Manickam V, Kalari KR, et al. Human glucocorticoid receptor alphagene (NR3C1) pharmacogenomics: gene resequencing and functional
genomics. J Clin Endocrinol Metab. 2009;94(8):3072–84.
Du H, Zhao J, Su Z, Liu Y, Yang Y. Sequencing the exons of humanglucocorticoid receptor (NR3C1) gene in Han Chinese with high-altitude
pulmonary edema. J Physiol Anthropol. 2018;37(1):7.
Gabry AL, Ledoux X, Mozziconacci M, Martin C. High-altitude pulmonary
edema at moderate altitude (< 2,400 m; 7,870 feet) a series of 52 patients.
Chest. 2003;123(1):49–53.
Eltzschig HK, Carmeliet P. Hypoxia and inflammation. N Engl J Med. 2011;
364(20):1976 author reply 1977.
Grocott M, Martin D, Levett DZ, Mcmorrow R, Windsor J, Montgomery H.
Arterial blood gases and oxygen content in climbers on Mount Everest. N
Engl J Med. 2009;360(2):140–9.
Thompson LF, Eltzschig HK, Ibla JC, et al. Crucial role for ecto-5’nucleotidase (CD73) in vascular leakage during hypoxia. J Exp Med. 2004;
200(11):1395–405.
Kubo K, Hanaoka M, Hayano T, Miyahara T, Hachiya T, Hayasaka M, Koizumi
T, Fujimoto K, Kobayashi T, Honda T. Inflammatory cytokines in BAL fluid
and pulmonary hemodynamics in high-altitude pulmonary edema. Respir
Physiol. 1998;111(3):301–10.
Zhang C, Qiang Q, Jiang Y, et al. Effects of hypoxia inducible factor-1αon
apoptotic inhibition and glucocorticoid receptor downregulation by
dexamethasone in AtT-20 cells. BMC Endocr Disord. 2015;15(1):24.
Tang E, Yu C, Luo Y. Dexamethasone for the prevention of acute mountainsickness: systematic review and meta-analysis. Int J Cardiol. 2014;173(2):133–8.
Eltzschig HK, Abdulla P, Hoffman E, et al. HIF-1-dependent repression ofequilibrative nucleoside transporter (ENT) in hypoxia. J Exp Med. 2005;
202(11):1493.

Page 8 of 8