Kemnitz J, Heublein B, Haverich A, Cohnert T R, Hetzer R, Zerkowski H R, Altmannsberger M, Georgii A
Institute of Pathology, Hannover Medical School, F.R.G.
J Heart Transplant. 1990 Nov-Dec;9(6):662-7.
The histopathologic indication for starting antirejection therapy has so far been given by the diagnosis of moderate rejection in endomyocardial biopsies, that is, rejection with necroses of myocytes and predominantly lymphocytic infiltrates (corresponding to the descriptive diagnosis of moderate rejection in the Stanford classification, grade 4 and more in the Texas classification, and A-3 moderate rejection in the Hannover classification). Our present results, however, have shown that the critical limit for the onset of antirejection therapy may be fixed somewhat higher on the scale of severity of acute rejection and that it may be reasonable to define an affection of more than 20% of the total biopsy material by morphologic changes corresponding to the traditional definition of moderate acute rejection as the decisive histopathologic finding that should induce antirejection therapy. This means that the diagnosis of moderate rejection has to be divided into two groups: (1) A-3a moderate acute rejection not yet requiring therapy that, however, does necessitate bioptic control within 7 to 10 days; (2) A-3b moderate acute rejection requiring antirejection therapy. The introduction of this differentiation of histopathologic diagnoses is not just another sophisticated scientific theorem; its practical significance may be seen in a definitive restriction of the application of antirejection therapy, which means a reduction of the risks and side effects imposed on heart-transplanted patients by chemotherapy and particularly by steroid therapy.
迄今为止，启动抗排斥治疗的组织病理学指征是通过心内膜活检诊断为中度排斥反应，即伴有心肌细胞坏死且主要为淋巴细胞浸润的排斥反应（对应于斯坦福分类中的中度排斥反应描述性诊断、德克萨斯分类中的4级及以上以及汉诺威分类中的A-3级中度排斥反应）。然而，我们目前的研究结果表明，抗排斥治疗开始的临界限度在急性排斥反应严重程度分级上可能要定得稍高一些，将活检材料中超过20%出现符合传统中度急性排斥反应定义的形态学改变定义为应启动抗排斥治疗的决定性组织病理学发现可能是合理的。这意味着中度排斥反应的诊断必须分为两组：（1）A-3a级中度急性排斥反应，尚未需要治疗，但需要在7至10天内进行活检监测；（2）A-3b级中度急性排斥反应，需要进行抗排斥治疗。引入这种组织病理学诊断的区分并非只是另一个复杂的科学理论；其实际意义在于明确限制抗排斥治疗的应用，这意味着减少化疗尤其是类固醇治疗给心脏移植患者带来的风险和副作用。
