肾移植超急性排斥反应的病理学机制及其临床对策

Study on clinical pathologic mechanism and treatment of hyperacute rejection in 64 cases of renal grafts

目的：探讨移植肾超急性排斥（ＨＡＲ）的病理学机制及其临床对策。方法：回顾性分析６４例ＨＡＲ患者。将切除的移植肾标本行形态学及荧光抗体染色观察；并对ＨＡＲ的临床表现、治疗结果及再次手术情况等进行了总结。结果：（１）ＨＡＲ的病理学改变：早期肾间质小血管及肾小球毛细血管内大量红细胞淤滞为主要改变，可发现淤滞的红细胞呈串珠状贴附在血管壁上；（２）临床治疗结果：２１ 例术中立即切除移植肾，４２例分别于术后第１～２０ 天切肾，仅１ 例经对症处理后，移植肾逐渐萎缩未予摘除。１５ 例ＨＡＲ患者经严格配型、血浆置换及抗淋巴细胞免疫球蛋白（ＡＴＧ）治疗，在短期内行再次移植，１０ 例获得成功。１１例ＨＡＲ患者，６ 个月～２ 年后再行二次移植，仅４ 例获得成功。结论：（１）据病理学机制推测：红细胞可能参加超急性排斥反应；（２）ＨＡＲ发生的影响因素：反复输血，多次妊娠，再次移植，服用过人参、西洋参、中药及各种营养剂；（３）ＨＡＲ的临床分型：可分为Ⅰ型（即刻ＨＡＲ），Ⅱ型（延迟ＨＡＲ），Ⅲ型（亚ＨＡＲ）；（４）发生ＨＡＲ后以近期内（１～１７ ｄ）再次移植的效果优于传统的６个月～２ 年后；（５）对策：强调对高敏人群做ＰＲＡ配型或随机淋巴细胞毒性试?

Objective: To further study the pathological mechanism and the clinical treatment of hyperacute rejection (HAR). Methods: From August 1978 to February 1998,1 524/1 604 cases of renal transplantation were done in our hospital. Sixty four cases developed HAR. Sixty three cases of the renal graft were studied by light microscopy, histochemistry and immunohistochemistry. Results: (1) A large number of the red blood cells lied and stagnated instead of circulation in the little blood vessels of renal interstitial and the blood capillary of glomerulics during the early stage of HAR. As the rejection progressed,the neutrophil cells were aggregated in the capillary bed of glomerulus. (2) Twenty one renal graft were removed during the transplant surgery.Fourty two cases' renal graft were resected 1 to 20 days later. One cases' renal graft was gradually atrophy and not be removed.Twenty six cases who were defeated because of HAR received recurrent transplantation.Fifteen cases were done in short range(1 to 17 days later),ten cases were successful.Another eleven cases were done 6 months to 2 years later the first operation,four cases were successful. Conclusion: (1) The red blood cells might take part in HAR and the red blood cells and the neutrophil cells might have a twofold function in HAR, that might accelerate the renal graft damages.(2) To carry danger of HAR: recurrent blood transfusion;multiple pregnant;recurrent transplantation;to get panax,Westerner,Chinese drugs and nutriment. (3) The clinical classification of HAR: a three grade standard of HAR was proposed,including Ⅰtype(immediately HAR), Ⅱtype(delayed HAR) and Ⅲtype(subhyperacute rejection). (4) The cases who were defeated because of HAR received recurrent transplantation in short range(1 to 17 days) was better than that of 6 months to 2 years later the first operation. (5) It was important to emphasize that PRA and CDC should be done in the high sensitive people.