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摘要: 移植肝活组织检查(活检)病理学不仅在供肝病理学评估,而且在移植术后并发症的诊断和鉴别诊断中是不可缺少的。移植肝并发症的病理学诊断相关研究随着临床肝移植的扩展而日益深入,国际上逐渐制订了Banff移植肝活检病理学诊断标准,我国移植肝活检的病理学研究也逐步开展,并逐渐形成了适合我国肝移植临床实际的移植肝活检病理学诊断标准。本文对Banff移植肝活检病理学研究的历史和移植肝并发症的主要病变进行综述,旨在为我国更好地开展移植肝活检病理学诊断,协助临床进行肝移植术后并发症的明确诊断和针对性治疗,进一步提高移植肝和受者的良好存活提供参考依据。
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关键词:
- 移植病理学 /
- 肝移植 /
- 活组织检查 /
- 病理学诊断标准 /
- 抗体介导的排斥反应(AMR) /
- T细胞介导的排斥反应(TCMR) /
- 慢性移植物血管病 /
- 药物性肝损伤
Abstract: The pathology of liver allograft biopsy is not only essential for the evaluation of liver donor, but also for the diagnosis and differential diagnosis of posttransplantation complications. With the development of liver transplantation in clinical practice, relevant studies of the pathological diagnosis of liver allograft complications have been deepened. Banff classification on liver allograft pathology have been gradually established within the international community. In China, pathological studies related to liver allograft pathology have been steadily carried out, and the pathological diagnostic basis of liver allograft pathology suitable for the clinical practice of liver transplantation in China has been gradually formed. This article reviews the history of Banff liver allograft pathology and major pathological lesions of liver allograft complications, aiming to provide reference for implementing pathological diagnosis of liver allograft pathology in China, assisting clinical diagnosis and targeted treatment of complications after liver transplantation, and further improving the survival of liver allograft and recipients. -
表 1 Banff标准中移植肝排斥反应的RAI评分
Table 1. RAI scoring of rejection of liver allograft in Banff classification
计分(分) 门管区炎症 胆管炎症 血管炎症 1 仅少数的门管区内可见淋巴细胞等炎症细胞浸润,门管区范围无明显扩大 少数小叶间胆管上皮内炎症细胞浸润和胆管上皮轻度损伤改变(包括细胞核增大、核/浆比增加) 少数小叶间血管(小叶间动脉或小叶间静脉)和(或)中央静脉的血管炎表现 2 多数或全部门管区内均出现混合性炎症细胞浸润(包括淋巴细胞、浆细胞、少数中性粒细胞和嗜酸性粒细胞等),门管区扩大。如果出现多量嗜酸性粒细胞浸润伴门管区水肿和微血管内皮细胞肿大改变,应注意急性AMR因素 多数胆管上皮内炎症细胞浸润,较多胆管出现损伤改变包括胞核多形性、极像紊乱和胞浆空泡变 多数或全部小叶间血管和(或)中央静脉的血管炎表现,少数中央静脉周围肝细胞脱失 3 多数或全部门管区出现混合性炎症细胞浸润,门管区因水肿和大量炎症细胞浸润范围扩大,部分门管区内炎症细胞扩展进入周围肝组织内 在2的基础上出现多数或全部胆管退化或灶性胆管腔破坏崩解 在2的基础上,出现中重度中央静脉炎及其周围炎并延伸至周围肝实质和中央静脉周围多数肝细胞坏死 表 2 移植肝慢性排斥反应的病理学诊断标准
Table 2. Pathological diagnostic criteria for chronic rejection of liver allograft
主要病变部位 早期的慢性排斥反应
(至少符合两条)晚期的慢性排斥反应
(至少符合两条)小胆管(< 60 μm) 多数门管区内小叶间胆管出现损伤, < 50%门管区出现小叶间胆管消失 ≥50%门管区出现小叶间胆管消失,其余门管区内小叶间胆管出现损伤退化 小叶间动脉 < 25%门管区出现小叶间动脉消失 ≥25%门管区出现小叶间动脉消失 终末肝静脉和Ⅲ区肝细胞 终末肝静脉周围单个核细胞浸润,腺泡Ⅲ区肝细胞坏死和炎症细胞浸润,轻度纤维化 终末肝静脉程度不等的炎症细胞浸润,局灶性静脉闭塞,中到重度(桥样)纤维化 肝动脉主干分支 动脉内膜炎、局灶性泡沫细胞沉积,无管腔狭窄或闭塞 内膜泡沫细胞沉积及纤维组织增生导致管腔狭窄甚至闭塞 胆管主干分支 炎症损伤和灶性泡沫细胞沉积 管壁纤维化 其他 “过渡性”肝炎和多灶性肝细胞坏死 肝窦泡沫细胞沉积、胆汁淤积 -
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