Kara M, Demir F, Ata P, Ozel L, Gumrukcu G, Unal E, Canbakan M, Gucun M, Esadoglu V, Ozdemir E, Cemel H, Titiz M I
First General Surgery, Transplantation and Genetics Units, Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey.
Transplant Proc. 2012 Jul-Aug;44(6):1694-6. doi: 10.1016/j.transproceed.2012.05.029.
Acute and chronic humoral injuries in renal transplant recipients are the main reasons for graft rejection and failure. Histological and clinical characteristics of humoral rejection and symptoms are variable and not always helpful for differential diagnosis. Clinical monitoring of the allograft, an elevated serum panel-reactive antibody (PRA), and the presence of donor-specific antibody (DSA) during immune monitoring as well as C4d staining of biopsy material can establish the differential diagnosis. Even without a cellular component, humoral rejection reaction is serious because the target tissue is the graft endothelium. Because the kidney graft has a rich vascular structure this attack causes permanent injury to the kidney in the long term. Graft dysfunction in this setting is usually more severe, requiring dialysis therapy, compared with acute cellular reactions. Positive C4d staining of peritubular capillaries in biopsy material represent a hallmark of complement-dependent cytotoxicity, supporting the diagnosis of humoral rejection. We analyzed C4d staining as a hallmark of humoral rejection.
From 2009 to 2011, we analyzed the relationship between pathological findings of C4d immunohistochemistry staining and the clinical outcomes of 45 kidney transplant recipients who underwent a kidney biopsy because of graft dysfunction due to possible humoral rejection.
Biopsy specimens of 15 patients stained C4d positive; the remaining 30 showed negative results. Intravenous steroids, PP + IVIG with or without antithymocyte globulin (ATG), was administered for treatment. Sixty six percent (n = 10) of patients were C4d positive with 16% (n = 5) of those showing C4d-negative biopsy results, losing their grafts, and returning to hemodialysis.
C4d staining refractory humoral rejection injury was related to poor graft outcomes.
肾移植受者的急性和慢性体液损伤是移植物排斥和失败的主要原因。体液排斥的组织学和临床特征以及症状各不相同，对鉴别诊断并不总是有帮助。对同种异体移植物进行临床监测、免疫监测期间血清群体反应性抗体（PRA）升高以及供体特异性抗体（DSA）的存在以及活检材料的C4d染色可以进行鉴别诊断。即使没有细胞成分，体液排斥反应也很严重，因为靶组织是移植物内皮。由于肾移植物具有丰富的血管结构，这种攻击长期会对肾脏造成永久性损伤。与急性细胞反应相比，这种情况下的移植物功能障碍通常更严重，需要透析治疗。活检材料中肾小管周围毛细血管的C4d染色阳性代表补体依赖性细胞毒性的标志，支持体液排斥的诊断。我们分析了C4d染色作为体液排斥的标志。
2009年至2011年，我们分析了45例因可能的体液排斥导致移植物功能障碍而接受肾活检的肾移植受者的C4d免疫组化染色病理结果与临床结局之间的关系。
15例患者的活检标本C4d染色呈阳性；其余30例呈阴性结果。给予静脉注射类固醇、PP + IVIG，加或不加抗胸腺细胞球蛋白（ATG）进行治疗。66%（n = 10）的患者C4d呈阳性，其中16%（n = 5）活检结果为C4d阴性的患者失去了移植物，重新开始血液透析。
C4d染色难治性体液排斥损伤与移植物不良结局相关。
