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目的探讨肾小管周围毛细血管补体裂解片断(C4d)沉积在移植肾急性排斥反应中的临床意义。方法对肾移植后发生急性排斥反应的78例受者进行移植肾活体穿刺检查,共获取移植肾活检穿刺标本86份。根据Banff97病理分型将86份活检标本分为BanffⅠ型32份,Ⅱ型51份,Ⅲ型3份。应用免疫组织化学法检测出86份标本中有30份出现肾小管周围毛细血管C4d沉积,阳性率为34.9%。分析C4d阳性其与Banff97分型、术前一般情况、抗排斥治疗、移植肾功能及移植肾预后的关系。结果BanffⅠ和Ⅱ型受者移植肾中C4d阳性率分别为21.9%和39.2%,两者相比差异无统计学意义(P=0.101)。有妊娠史、术前群体反应性抗体(PRA)>30%和再次移植的受者C4d阳性率较高。C4d阳性的受者发生排斥反应时血肌酐较阴性受者高,分别为(312.56±196.26)μmol/L和(210.97±136.59)μmol/L,两组差异有统计学意义(P=0.0115)。C4d阳性受者对激素和ATG冲击治疗与阴性受者比较,敏感率明显降低。C4d阳性的受者移植肾1年生存率较阴性受者低,分别为64.3%和90.0%,两组间差异有统计学意义(P=0.006)。结论移植肾C4d阳性的受者发生排斥反应时,对常规的激素冲击和ATG抗排斥治疗不敏感,血肌酐明显升高,移植肾1年存活率下降,受者预后较差。
Objective To investigate the clinical significance of the deposition of peritubular capillary peritumoral lytic fragment (C4d) in the acute rejection of renal allograft. Methods 78 recipients of acute rejection after renal transplantation were examined by biopsy of transplanted kidneys. Totally 86 transplanted renal biopsy specimens were obtained. According to the pathological classification of Banff97, 86 biopsy specimens were divided into 32 specimens of Banff Ⅰ type, 51 specimens of type Ⅱ and 3 specimens of type Ⅲ. Immunohistochemical detection of 86 specimens of 30 cases of tubular capillaries around the deposition of C4d, the positive rate was 34.9%. To analyze the relationship between C4d positive and Banff97 classification, preoperative general condition, anti-rejection therapy, renal graft function and renal allograft prognosis. Results The positive rate of C4d in the grafts of Banff Ⅰ and Ⅱ recipients was 21.9% and 39.2%, respectively. There was no significant difference between the two groups (P = 0.101). Patients with a history of pregnancy, preoperative group reactive antibody (PRA)> 30% and re-transplant recipient C4d positive rate. The level of serum creatinine in patients with C4d-positive rejection was significantly higher than that in patients with negative rejection (312.56 ± 196.26 μmol / L vs 210.97 ± 136.59 μmol / L, respectively), with significant difference between the two groups (P = 0.0115). C4d-positive recipients of hormone and ATG shock treatment compared with negative recipients, the sensitivity was significantly reduced. The one-year survival rate of recipients with C4d-positive recipients was 64.3% and 90.0% lower than that of the negative ones, respectively. There was a significant difference between the two groups (P = 0.006). Conclusion The rejection of C4d-positive recipients is not sensitive to the conventional hormone shock and ATG anti-rejection therapy. The serum creatinine is significantly increased, and the one-year survival rate of transplant recipients is decreased. The prognosis of recipients is poor.