肝移植665例穿刺活检病理诊断总结

Pathologic diagnosis of 1123 post-transplant liver biopsies from 665 liver transplant patients

目的总结我国目前肝移植(OLTx)病理诊断的基本情况和经验。方法回顾性分析4家医院的665例、1123例次OLTx肝穿刺活检的病理诊断结果,肝组织常规HE染色,部分病例做巨细胞病毒(CMV)、HBsAg、细胞角蛋白(CK)19、CD4和CD8免疫组织化学染色。结果各单位间病理诊断并发症类型在4～12种。本组每例肝穿刺次数为1～9次,平均2.2次/例,肝穿刺时间为OLTx术后2～2877d。OLTx术后并发症发生率居前5位的是:急性排异(237例,35.6%)、缺血/再灌注损伤(89例,13.4%)、胆管狭窄(37例,5.6%)、药物性损伤(33例,5.0%)、慢性排异(31例4.7%);平均诊断时间最早的5种并发症依次是原发性无功能(4.7d±2.1d)、缺血/再灌注损伤(14.0d±4.0d)、急性排异(32.1d±62.9d)、肝动脉栓塞/狭窄(62.9d±74.2d)、CMV感染(107.7d±93.0d)。结论本结果为了解OLTx术后主要并发症的病理类型、发生频率与时机等提供了参考依据。排异与非排异性并发症之间的鉴别始终是移植病理诊断的难点,特别应注意熟悉各主要并发症的变异型组织学表现。Banff排异活动指数(RAI)对于临床评估排异程度有较大参考价值,建议诊断时常规应用。

Objective To summarize the Chinese experience in pathologic diagnosis of liver biopsies after orthotopie liver transplantation （OLTx）. Methods 1123 post-transplant liver biopsies from 665 OLTx patients from the Shanghai Eastern Hepatobiliary Surgery Hospital, Tianjin First Central Hospital, Guangzhou Sun Yat-sen University and Chongqing Southwest Hospital were retrospectively analyzed. All liver biopsies were stained with hematoxylin and eosin. Immunohistochemical studies for cytomegalovirus, HBsAg, CK19, CD4 and CD8 were also performed in selected examples. Results In the involved hospitals, 4 to 12 types of complications were encountered after OLTx. The number of liver biopsies performed for each patient ranged from 1 to 9 （mean = 2. 2）. The timing of these biopsies varied from the second to the 2877 th post-transplant day. The 5 most common complications were acute cellular rejection （35.6%） , ischemic-reperfusion injury （ 13.4% ） , biliary stricture （5.6%） , drug complication （5.0%） and chronic rejection （4. 7% ）. The 5 earliest complications after OLTx were primary non-function （ occurring at day 4. 7 ± 2. 1 ） , ischemic-reperfusion injury （ occurring at day 14. 0 ± 4.0 ）, acute cellular rejection （ occurring at day 32. 1 ± 62. 9 ）, hepatic artery thrombosis / stricture （ occurring at day 62. 9 ± 74. 2） and cytomegalovirus infection （occurring at day 107.7 ± 93.0）. Conclusions This study has evaluated the types, incidence and timing of major complications occurring after OLTx. The most important issue is the distinction between rejection and non-rejection pathology. Thorough understanding of atypical pathologic features of these complications is necessary. The Banff Schema （ rejection activity index ） for grading liver allograft rejection is useful for monitoring anti-rejection therapy and should be used routinely.