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摘要: T细胞介导的排斥反应(TCMR)是器官移植排斥反应的主要效应机制之一, 也是最常见的急性排斥反应类型。2019年Banff移植病理学诊断标准(Banff标准)根据免疫损伤病变的特征将TCMR分为急性TCMR (aTCMR)和慢性活动性TCMR (caTCMR)。本文对TCMR的基本定义、移植肾Banff标准中TCMR病理学的研究历程和TCMR的基本病变及其诊断分级进行综述, 旨在为早期识别、诊断和治疗TCMR提供依据, 以预防其进展为caTCMR, 进而保障移植肾和受者的长期存活。
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关键词:
- Banff移植病理学诊断标准(Banff标准) /
- T细胞介导的排斥反应(TCMR) /
- 抗体介导的排斥反应(AMR) /
- 慢性移植物血管病(CAV) /
- 慢性移植物损伤指数(CADI) /
- 肾小管萎缩 /
- 间质纤维化 /
- 动脉内膜炎
Abstract: T cell-mediated rejection (TCMR) is one of the main mechanisms of rejection in organ transplantation, which is also the most common type of acute rejection.Based on Banff classification on allograft pathology (Banff classification) in 2019, TCMR can be divided into acute TCMR (aTCMR) and chronic active TCMR (caTCMR) according to the characteristics of immune lesions.In this article, the basic definition of TCMR, the research progress on TCMR pathology according to Banff classification for renal allograft, and the basic pathological changes and diagnostic grading of TCMR were reviewed, aiming to provide evidence for early identification, diagnosis and treatment of TCMR and prevent the progression of TCMR into caTCMR, thereby guarantying the long-term survival of both the renal allograft and recipient. -
图 4 移植肾caTCMR的CAV病理学表现
注: A图示动脉内膜轻度增生, 管腔狭窄程度<25%, 为轻度CAV (cv1)(HE, × 400);B图示动脉内膜中度增生, 管腔狭窄程度在26%~50%, 为中度CAV (cv2)(HE, × 200);C图示动脉内膜重度增生, 管腔狭窄程度>50%, 增生的动脉内膜内可见炎症细胞浸润, 提示急性排斥反应仍在进展, 为重度CAV (cv3)(HE, × 200);D图示小动脉内膜重度增生>50%, 管腔接近闭塞, 为重度CAV (cv3)(HE, × 200)。
Figure 4. Pathological findings of CAV of caTCMR in renal allograft
表 1 移植肾急性病理学改变及其半定量计分
Table 1. Acute pathological changes of renal allograft and its semi-quantitative scoring
计分
(分)间质炎症细胞浸润①(i) 肾小管炎(t) 肾小球炎(g) 动脉内膜炎②(v) 0 无或仅有轻微的间质炎症细胞浸润(< 10%的肾间质被累及) 肾小管上皮层内无单个核炎症细胞浸润 无肾小球炎 无动脉内膜炎 1 10°%~25°%的肾间质被炎症细胞浸润累及 个别肾小管管腔有1~4个炎症细胞浸润或10个肾小管上皮细胞内有1~4个炎症细胞浸润 < 25%的肾小球出现肾小球炎 至少在1支动脉血管分支横截面内可见轻度至中度动脉内膜炎 2 26°%~50°%的肾间质被炎症细胞浸润累及 个别肾小管管腔有5~10个炎症细胞浸润或10个肾小管上皮细胞内有5~10个炎症细胞浸润 25%~75°%的肾小球出现肾小球炎 至少在1支动脉血管分支横截面内存在严重的动脉内膜炎, 因内膜水肿增厚导致至少25°%的动脉管腔丧失 3 > 50°%的肾间质被炎症细胞浸润累及 个别肾小管管腔有 > 10个炎症细胞浸润, 或出现至少2个部位的肾小管基膜损伤并伴有i2或i3和t2 > 75°%的肾小球出现肾小球炎 透壁性动脉炎、动脉中膜平滑肌层坏死或动脉管壁纤维素样坏死 注:①对于浸润的炎症细胞中出现嗜酸性粒细胞、中性粒细胞或浆细胞并且这些细胞数量超过浸润细胞总数的10%者,应予以注明。
②注明活检组织内可见多少动脉血管分支,多少动脉被累及以及肾组织是否出现梗死、出血。表 2 移植肾慢性病理学改变及其半定量计分
Table 2. Chronic pathological changes of renal allograft and its semi-quantitative scoring
计分
(分)肾小球病(cg) 间质纤维化(ci) 肾小管萎缩(ct) 动脉内膜增生(cv) 肾小球毛细血管系
膜基质增生(mm)0 无肾小球病, 在多数病变的肾小球内, 肾小球血管襻外周毛细血管基底膜呈双轨状变化的肾小球 < 10°% 间质纤维化累及肾皮质组织的5% 无肾小管萎缩 动脉血管无慢性血管病变 肾小球内无系膜基质增生 1 在多数非硬化肾小球内, 肾小球血管襻外周毛细血管基底膜呈双轨状变化的肾小球接近25% 间质纤维化累及肾皮质组织的6%~25% 肾皮质组织内 < 25°%的肾小管萎缩 动脉内膜增生形成管腔狭窄导致管腔闭塞 < 25%, 伴或不伴动脉内弹力膜的损伤或内膜泡沫细胞形成以及炎症细胞浸润 < 25%的非硬化肾小球内出现系膜基质增生(至少为中度增生) 2 在多数非硬化肾小球内, 肾小球血管襻外周毛细血管基底膜呈双轨状变化的肾小球达到26%~50% 间质纤维化累及肾皮质组织的26%~50% 肾皮质组织内26%~50%的肾小管萎缩 cv1的病变进一步进展, 动脉内膜增生导致管腔狭窄使管腔闭塞26%~50% 26%~50%的非硬化肾小球内出现系膜基质增生(至少为中度增生) 3 在多数非硬化肾小球内, 肾小球血管襻外周毛细血管基底膜呈双轨状变化的肾小球 > 50% 间质纤维化累及 > 50%的肾皮质组织 肾皮质组织内 > 50°%的肾小管萎缩 严重的慢性动脉血管病变, 动脉内膜增生致管腔狭窄使管腔闭塞 > 50% > 50%的非硬化肾小球内出现系膜基质增生(至少为中度增生) -
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