肾移植术后淋巴组织增生性疾病一例报告暨文献复习

Post- transplant lymphoproliferative disorder of kidney： a case report and literature review

目的报道1例少见的肾移植术后淋巴组织增生性疾病[post—transplant lvmphopmlifemtive disorder，PTLD），并结合文献复习，探讨本病的临床病理特点以及诊疗思路，以提高临床医生对该病的认识。方法分析患者的临床资料并对切除的移植肾标本进行光镜、免疫荧光、免疫组化及原位杂交检测。结果本例为肾移植术后患者，定期复查肾功能正常，术后1年半超声和CT检查提示移植肾占位性病变（5．6cm×5．4cm），考虑为原发于肾脏的恶性肿瘤并行移植物切除。大体肾脏切面见一个直径约7cm的鱼肉状、质嫩肿物。镜下可见多种炎症细胞浸润，以淋巴细胞浸润为主，破坏肾实质，并可见Reed—Sternberg样细胞。免疫组化提示大部分淋巴样细胞CD20及CD79a阳性，原位杂交Epstein—Barr病毒编码RNAs（EBERs）弥漫（＋），病变符合PTLD，多形性B细胞增生（多形性PTLD）合并Epstein—Barr病毒感染。结论移植物内淋巴细胞增生可见于多种情况，如T细胞性排斥反应、病毒感染、肾盂肾炎或者PTLD等，这几种疾病容易相互混淆，及时确诊、早期干预有利于改善预后。

Objective To improve clinicians＂ understanding of post - transplant lymphoproliferative disorder （PTLD） after renal transplantation, a rare case of this disease was reported and literature was reviewed. Method The clinical data and pathological changes of the allograft, immunohistochenmistry （IHC） and in situ hybridization （ISH） were analyzed. In addition, the relevant literature was reviewed. The clinicopathological features and differential diagnoses of FFLD were discussed. Result A renal mass （5.6 cm x 5.4 cm）, which was suggestive of primary renal malignancy, had been detected on the patient after received renal transplantation for a year and a half. Grossly, the mass was 7cm in diameter, with fleshy texture. Microscopically, the renal parenehyma was destructed and infiltrated with massive inflammatory cells, mostly lymphoid cells and occasionally Reed- Sternberg-fike cells. IHC showed CD20 and CD79a were predominantly expressed in lymphoid cells. ISH showed diffused Epstein- Barr virus encoded RNAs （EBERs） positivity. The above findings were consistent with PTLD, polymorphic B cell hyperplasia （polymorphic PTLD）, with concurrent Epstein- Barr virus infection. Conclusion Lymphoid infiltration in a renal allograft needs to be differentiated fiom T- cell rejection, viral infection, nephropyelitis, as well as PTLD. Early detection and proper management of PTLD may help improve the graft survival rate.