Meehan S M, Siegel C T, Aronson A J, Bartosh S M, Thistlethwaite J R, Woodle E S, Haas M
Department of Pathology, University of Chicago, Illinois 60637, USA.
J Am Soc Nephrol. 1999 Aug;10(8):1806-14. doi: 10.1681/ASN.V1081806.
The relationship of borderline infiltrates to acute rejection by Banff criteria in renal allografts of patients receiving only maintenance immunosuppression is not clear. Renal allograft biopsies with borderline lesions that were not treated with additional anti-rejection therapy were retrospectively studied. Sixty-five such biopsies were identified from 50 patients, and their outcome was determined by serum creatinine and/or histologic findings in subsequent biopsies, up to 40 d after the initial biopsy. In addition to the borderline infiltrates, there was evidence of acute cyclosporine or tacrolimus toxicity (58%), acute tubular necrosis (12%), and urinary obstruction (12%). Forty-day follow-up after 30 (46%) biopsies revealed serum creatinine < 110% of baseline, and repeat biopsies were not indicated. In 17 (26%), the serum creatinine initially decreased, then increased, and follow-up biopsies showed acute rejection in nine. In 18 (28%), the creatinine remained elevated and follow-up biopsies revealed acute rejection in nine. The untreated borderline infiltrates were thus nonprogressive after 47 biopsies (72%) and progressed to histologic acute rejection after 18 (28%). When there was increasing or persistently elevated creatinine after the initial biopsy, 51% of cases (18 of 35) progressed to acute rejection. Infiltrates that progressed to rejection had more frequent glomerulitis (7 of 18 versus 3 of 47, P = 0.003) and Banff acute score indices (i+t+v+g) >2 (16 of 18 versus 29 of 47, P = 0.03). A majority (72%) of borderline infiltrates not given additional anti-rejection therapy did not progress to acute rejection over 40 d of follow-up, suggesting that conservative management of these lesions, at least in the short term, may be more appropriate than routine treatment as acute rejection.
仅接受维持性免疫抑制治疗的患者肾移植中，按照班夫标准，边缘浸润与急性排斥反应之间的关系尚不清楚。我们对未接受额外抗排斥治疗的伴有边缘性病变的肾移植活检组织进行了回顾性研究。从50例患者中识别出65份此类活检组织，并通过血清肌酐和/或后续活检（初始活检后长达40天）的组织学结果来确定其转归。除边缘浸润外，还有急性环孢素或他克莫司毒性（58%）、急性肾小管坏死（12%）和尿路梗阻（12%）的证据。30份（46%）活检组织40天的随访显示血清肌酐<基线值的110%，无需进行重复活检。17份（26%）中，血清肌酐最初下降，随后升高，随访活检显示9份存在急性排斥反应。18份（28%）中，肌酐持续升高，随访活检显示9份存在急性排斥反应。因此，47份活检组织（72%）中未经治疗的边缘浸润未进展，18份（28%）进展为组织学急性排斥反应。初始活检后肌酐升高或持续升高时，51%的病例（35份中的18份）进展为急性排斥反应。进展为排斥反应的浸润更常出现肾小球炎（18份中的7份对47份中的3份，P = 0.003）且班夫急性评分指数（i+t+v+g）>2（18份中的16份对47份中的29份，P = 0.03）。在40天的随访中，大多数（72%）未接受额外抗排斥治疗的边缘浸润未进展为急性排斥反应，这表明至少在短期内，对这些病变进行保守处理可能比作为急性排斥反应进行常规治疗更为合适。
