移植肾膜性肾病的临床病理及预后

Clinicopathologic features and prognosis of membranous nephropathy after renal allografting

目的:探究移植肾膜性肾病(MN)受者的临床病理特征及其预后。方法:回顾性分析19例肾移植受者术后移植肾活检确诊为MN的临床病理资料,将受者分为原发病不明组(A组,12例)和复发组(B组,7例),比较两组临床病理及预后之间的差异。结果:两组亲属活体肾移植的比例和术后基线肾功能情况的差异均无统计学意义( P>0.05)。B组受者术后平均16.4个月后出现复发,明显早于A组。两组移植肾损害主要表现为蛋白尿、肾病综合征和(或)肾功能不全。B组血抗磷脂酶A2受体(PLA2R)抗体和肾组织PLA2R抗原染色的阳性率明显高于A组。B组肾组织IgG4亚型染色强度强于A组。A组受者术后5年移植肾存活率为77.8 %,而复发受者为66.7 %,两者比较,差异无统计学意义( P>0.05)。 结论:抗PLA2R抗体在移植肾MN复发过程中发挥了重要作用,移植肾组织PLA2R染色有助于对原发病的判断,其敏感性高于血清抗PLA2R受体。利妥昔单抗是治疗移植肾膜性肾病的有效方案,值得进一步研究。

Objective To explore the clinicopathologic features and renal prognosis of patients with post-transplant membranous nephropathy(MN).Methods Patients with allograft biopsy-proven MN were reviewed retrospectively and divided into unknown etiology group(A,n=12)and recurrent membranous nephropathy(rMN)group(B,n=7).Their clinicopathological data and renal prognosis were assessed and compared.Results No differences existed in the proportion of living-related donor or post-transplant allograft function.Group B had recurrence at 16.4 months after transplantation and it was significantly shorter than group A.Allograft impairment manifested as proteinuria,nephrotic syndrome and/or renal insufficiency in both groups.The positive rate of serum anti-PLA2R antibody and renal PLA2R staining was significantly higher in group B than that in group A.Similarly,the intensity of IgG4 subtype staining was also stronger in group B than that in group A.The 5-year cumulative renal survival rates from end-stage renal disease(ESRD)were 77.8%and 66.7%in groups A and B respectively.No significant inter-group difference existed in renal prognosis.Conclusions Anti-PLA2R antibody plays an important role in the recurrence of rMN after renal allografting.PLA2R staining is useful for detecting primary disease and its sensitivity is higher than that of serum anti-PLA2R antibody.Rituximab is an effective treatment for post-transplant MN.Follow-up studies with a larger sample size are required for further verification.