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目的探讨慢性移植肾肾病(CAN)的病理学特点与临床应对策略。方法对20例临床诊断为慢性移植肾功能减退、病理诊断为CAN者的病理资料进行系统分析,依据Banff97标准对肾小球硬化、间质纤维化、肾小管萎缩及小动脉内膜炎等CAN特征性表现进行综合评分后,做出病理诊断和分层分析。20例肾移植后采用以环孢素A(CsA)为基础的免疫抑制方案,诊断为CAN后,3例转换为他克莫司(FK506)与霉酚酸酯(MMF)联用,17例转换为西罗莫司(Sir)与MMF联用,比较转换治疗前后肾功能的变化。结果9例(45%,9/20)合并发生亚临床排斥反应,激素冲击治疗有效;20例均存在间质纤维化、肾小管萎缩与肾小球硬化。慢性移植肾功能减退对转换治疗的反应与间质纤维化和肾小管萎缩的程度无明显相关性,但与肾小球硬化率密切相关,肾小球硬化率低于30%者预后良好,超过50%者移植肾功能丧失。结论肾小球硬化率有可能成为判断CAN病变程度和预后的指标;治疗慢性移植肾功能减退时应重视合并发生的亚临床排斥反应,撤除CsA、采用Sir与MMF联用方案值得推荐。
Objective To investigate the pathological features and clinical strategies of chronic allograft nephropathy (CAN). Methods Twenty cases of pathologically diagnosed chronic renal allograft were enrolled in this study. The pathological data of patients diagnosed as CAN were systematically analyzed. According to the standard of Banff97, glomerulosclerosis, interstitial fibrosis, tubular atrophy and arterial intima of small artery After the characteristic score was comprehensively evaluated, pathological diagnosis and stratified analysis were made. After 20 cases of renal transplantation, cyclosporine A (CsA) -based immunosuppressive regimen was used. After diagnosis of CAN, 3 cases were switched to FK506 with mycophenolate mofetil (MMF) and 17 cases Converted to sirolimus (Sir) combined with MMF, compared changes in renal function before and after conversion therapy. Results Nine patients (45%, 9/20) had subclinical rejection and hormone therapy was effective. All 20 patients had interstitial fibrosis, tubular atrophy and glomerulosclerosis. There was no significant correlation between the response of chronic allograft to renal transplantation and the degree of interstitial fibrosis and tubular atrophy. However, it was closely related to the rate of glomerulosclerosis. The rate of glomerulosclerosis less than 30% had a good prognosis, 50% of transplant renal dysfunction. Conclusions The rate of glomerulosclerosis may be an index to judge the degree and prognosis of CAN. Treatment of chronic renal allograft should pay attention to subclinical reocclusion and remove CsA. It is recommended to combine Sir and MMF.