Fishbein Michael C, Kobashigawa Jon
Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA.
Curr Opin Cardiol. 2004 Mar;19(2):166-9. doi: 10.1097/00001573-200403000-00018.
As the frequency of cellular rejection after heart transplantation is decreasing, biopsy-negative episodes of rejection are being recognized more often. This article reviews the features of humoral rejection, which we believe is responsible for most episodes of biopsy-negative rejection. Hemodynamic compromise, in the absence of acute cellular rejection, called biopsy-negative rejection occurs in 10 to 20% of cardiac allograft recipients. These episodes of rejection are often more severe, and more difficult to treat, than classical acute cellular rejection. Histologic, immunofluorescence, and immunoperoxidase studies of endomyocardial biopsies from such patients often reveal intravascular macrophages, and immunoglobulin and complement deposition in capillaries, in the absence of lymphoid infiltrates, suggesting an antibody-mediated or humoral form of rejection.
Humoral rejection is associated with increased graft loss, accelerated transplant coronary artery disease, and increased mortality. Severely ill patients require intense therapy, which includes high-dose corticosteroids, cytolytic agents, intravenous heparin, intravenous gamma globulin, plasmapheresis, and/or antiproliferative agents.
Currently, our knowledge of the pathogenesis, diagnostic criteria, and optimal therapy for biopsy-negative rejection is incomplete, and evolving.
随着心脏移植后细胞性排斥反应的发生率逐渐降低，活检阴性的排斥反应越来越多地被认识到。本文综述了体液性排斥反应的特征，我们认为其是大多数活检阴性排斥反应的原因。在没有急性细胞性排斥反应的情况下出现血流动力学损害，即活检阴性排斥反应，见于10%至20%的心脏移植受者。这些排斥反应通常比经典的急性细胞性排斥反应更严重，也更难治疗。对此类患者的心内膜活检进行组织学、免疫荧光和免疫过氧化物酶研究，常常显示血管内巨噬细胞以及毛细血管内免疫球蛋白和补体沉积，而无淋巴细胞浸润，提示为抗体介导或体液形式的排斥反应。
体液性排斥反应与移植失败增加、移植后冠状动脉疾病加速以及死亡率增加相关。重症患者需要强化治疗，包括大剂量皮质类固醇、溶细胞药物、静脉注射肝素、静脉注射丙种球蛋白、血浆置换和/或抗增殖药物。
目前，我们对活检阴性排斥反应的发病机制、诊断标准和最佳治疗方法的认识尚不完整，且仍在不断发展。
