中国三类心死亡遗体器官捐献成人供肾移植术后的临床病理分析

Clinicopathologic Characteristics of Renal Transplant Recipients Whose Transplant Kidneys were from Adult Donors after C-Ⅲ Donation of Cardiac Death

目的 分析中国三类心死亡遗体器官捐献（DCD）成人供肾移植术后的临床病理特征,为临床提供参考。方法 选取2011年9月—2014年5月中国人民解放军第四五八医院、中国人民解放军第三〇三医院收治的因各种原因行移植肾穿刺或移植肾切除后病理检查的DCD供肾受者32例,患者共行移植肾穿刺活检或移植肾切除术后病理检查36例次（DCD供肾组）,由2名副主任医师以上的病理医师参照Banff 2007国际移植肾活检诊断与分级体系对病理结果进行判定。选取同期在两家医院行普通尸体供肾受者40例作为对照组,共进行穿刺活检40例次,比较其与DCD供肾组急性肾小管坏死（ATN）、他克莫司（Tac）中毒、急性排斥反应（AR）、慢性排斥反应（CR）、新发/复发肾病、小管萎缩并间质纤维化发生率。结果 32例DCD供肾受者均采用Tac、霉酚酸酯及醋酸泼尼松三联用药方案。病理检查结果：肉眼观察：穿刺标本均为灰白色细条形组织,长度0.8~1.5 cm,直径约0.1 cm;切除的移植肾标本,肾脏形态和大小未见明显异常,皮、髓质结构清楚,肾盂黏膜光滑未见扩张,肾门血管内未见血栓,输尿管未见狭窄及扩张。光镜下观察：除1例次穿刺组织肾小球数量较少外,其余35例次均合格;19例次肾小球病变轻微病变;14例次肾小球硬化;13例次可见淤血。35例次移植肾小管均存在病变;12例次可见多灶或小灶肾小管坏死;12例次出现肾小管萎缩;14例次出现不同程度的肾间质淋巴细胞浸润;18例次发生动脉内膜肿胀或增厚。DCD供肾受者最终病理诊断（35例次）：Tac中毒21例次（60.0%）,ATN 12例次（34.3%）,新发/复发肾病7例次（20.0%）,AR 6例次（17.1%）,CR 2例次（5.7%）。DCD供肾组Tac中毒、ATN、AR发生率高于对照组（P〈0.05）;DCD供肾组与对照组CR、新发/复发肾病、小管萎缩并间质纤维化发生率比较,差异无统计学意义（P〉0.05）。结论 中国三类DCD成人供肾移植术后病理主要以Tac中毒、ATN、新发/复发肾病为主,受者早期疗效欠理想,应进行相应的预防和治疗,以提高中国三类DCD成人供肾移植术的疗效。

Objective To study the clinicopathologic features of renal transplant recipients whose transplant kidneys were from adult donors after C -Ⅲ donation of cardiac death （ DCD）, to provide a reference for clinical practice. Methods 32 renal transplant recipients who were treated in 458th Hospital of PLA and 303th Hospital of PLA from September 2011 to May 2014, were selected as study subjects, their transplant kidneys were from donors after C -Ⅲ DCD, 36 cases underwent needle biopsy of transplant kidney or received pathological examination after transplant nephrectomy, the pathological results weredetermined by two pathologic doctors with secondary senior positions according to the 2007 Banff system of working classification of renal allograft pathology. 40 renal transplant recipients who were treated in 458th Hospital of PLA and 303th Hospital of PLA during the same period, were selected as control subjects, their kidneys were from cadaver donors, 40 cases underwent needle biopsy of transplant kidney. Incidences of acute tubular necrosis （ ATN）, tacrolimus （Tac） toxicity damage, acute rejection （AR）, chronic rejection （CR）, new/relapse nephropathy, tubular atrophy and interstitial fibrosis were compared between two groups. Results 32 DCD renal transplant recipients were treated with triple drug therapy （ Tac ＋ mycophenolate mofetil ＋ prednisone） . Pathological findings, Visual inspection： The biopsy specimens were gray fine strip organization, the length was between 0. 8 cm and 1.5 era, the diameter was about 0. 1 cm, the transplant kidneys showed normal shape and size, the structure of medulla and cortex was clear, renal pelvic mucosa was smooth and no expansion was observed, no thrombosis was found in renal hilum blood vessels, narrow and expansion of the ureter were not found. Microscopic examination ： 1 case had fewer number of glomerulus, and the other 35 cases were qualified. 19 cases had minor glomerular abnormalities, 14 cases had glomerulosclerosis, 13 cases had extravasated blood. Tubular necrosis of 35 cases had lesions, 12 cases had minimal or multifocal necrosis of tubular necrosis, 12 cases had tubular atrophy, 14 cases had lymphocytes infiltration of renal interstitium, 18 cases had swelling or thickening of endarterium. The final pathological diagnosis of DCD renal transplant recipients （35 cases） ： 18 cases （60. 0% ） had Tac toxicity damage, 12 cases （34. 3% ） had ATN, 7 cases （20. 0% ） had new/relapse nephropathy, 6 cases （ 17.1% ） had AR, and 2 cases （5.7%） had CR. Incidences of Tac toxicity damage, ATN and AR in study subjects were significantly higher than that of control subjects, respectively （P 〈 0. 05 ） . There was no significant difference in incidences of CR, new/relapse nephropathy, tubular atrophy and interstitial fibrosis between study subjects and control subjects （ P 〉 0. 05 ）. Conclusion The main pathological changes of post - transplant kidney from C -Ⅲ DCD donors were Tac toxicity damage, ATN and ornew/relapse nephropathy. The early curative effect for transplant recipients is poor, these diseases should be prevented and treated, thus the curative effect of kidney transplantation from donators after C -Ⅲ DCD can be improved.