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目的:观察C4d在肾移植术后常规活检组织中沉积发生情况及临床意义。方法:294例移植肾功能正常者(男211例,女83例)于术后2~4周内接受常规活检,应用间接免疫荧光检测肾组织C4d的沉积。观察C4d阳性患者病理特点、预后以及移植肾功能情况。结果:“无症状”C4d阳性检出率为6.12%(18/294)。其中弥漫分布2.38%(7/294),局灶分布3.74%(11/294)。该组患者除女性多数术前有妊娠史外(6/8),术前皆无高群体反应性抗体(PRA,panel reactive antibodes)、二次移植、输血等排斥高危因素的存在。随访12月,除1例患者因术后肺部感染救治过程中移植肾受损伤,其余17例患者肾功能稳定。该组患者移植肾组织中除1例出现动脉内膜炎外,并未发现动脉纤维素样坏死、动脉血栓、间质出血、透壁性动脉炎等组织形态学改变。术后起始免疫抑制方案11例为他克莫司(FK506)+霉酚酸酯(MMF)+激素,7例为环孢素A(CsA)+MMF+激素。8例患者行重复移植肾活检,其中6例C4d转阴,1例C4d由弥漫转为局灶阳性。结论:“无症状”C4d阳性患者术前多无发生排斥反应的高危因素,术后移植肾功能稳定,而移植肾组织中无抗体介导体液性排斥反应的特征性组织学改变。在接受免疫抑制治疗后,C4d在肾组织中的沉积可以消失或减弱。
Objective: To observe the deposition and clinical significance of C4d in routine biopsy after renal transplantation. Methods: 294 normal renal transplant recipients (211 males and 83 females) underwent routine biopsy within 2 to 4 weeks after operation, and the deposition of C4d in renal tissues was detected by indirect immunofluorescence. To observe the pathological features of C4d-positive patients, prognosis and renal graft function. Results: The positive rate of “asymptomatic” C4d was 6.12% (18/294). Among them, diffuse distribution was 2.38% (7/294) and focal distribution was 3.74% (11/294). In addition to the preoperative pregnancy history (6/8), most of the patients in this group had no preoperative high PRA (panel reactive antibodes), secondary transplant, transfusion and other rejection risk factors. All the patients were followed up for 12 months. Except one patient suffered from graft injury during the treatment of postoperative pulmonary infection, the remaining 17 patients had stable renal function. The group of patients with renal transplantation in addition to 1 case of endocarditis, did not find arterial fibrosis, arterial thrombosis, interstitial hemorrhage, transmural arteritis and other histological changes. Eleven patients started postoperative immunosuppression with FK506 + mycophenolate mofetil (MMF) + hormone and 7 patients with cyclosporin A (CsA) + MMF + hormone. 8 patients underwent repeated grafting of renal biopsy, of which 6 cases of C4d negative, 1 case of C4d from diffuse to focal positive. Conclusion: There was no risk factors for rejection in patients with “asymptomatic” C4d positive before operation, and the graft function was stable after transplantation. No antibody-mediated characteristic histological changes were observed in the allograft renal tissues. After immunosuppressive therapy, the deposition of C4d in kidney tissue may disappear or diminish.