Zhao Xiaomu, Huang Gang, Randhawa Simrath, Zeng Gang, Lunz John, Randhawa Parmjeet
1 Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China. 2 Department of Organ Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China. 3 Department of Pathology, The Thomas E Starzl Transplantation Institute, University of Pittsburgh, School Of Medicine, Pittsburgh, PA.
Transplantation. 2017 Feb;101(2):395-401. doi: 10.1097/TP.0000000000001118.
Recent literature has stressed the prominent role of antibodies in graft loss. This study was designed to assess a growing perception that T cell-mediated rejection (TCMR) is no longer clinically relevant.
Five hundred forty-five renal allograft recipients over a 3-year period were screened for biopsies with: (a) TCMR including borderline change (BL), (b) negative complement protein C4 degradation fragment, and (c) absence of donor-specific antibody at time of transplant, within 30 days of the biopsy, and up to 4 measurements at later time points.
These stringent requirements identified 28 "pure" cases of late TCMR/BL. Low-grade glomerulitis, peritubular capillaritis, or chronic transplant glomerulopathy were found in 9/28 (32%) biopsies. Serum creatinine showed complete short-term remission in 7/10 (70%) BL and 9/18 (50%) TCMR patients 1 month postbiopsy. Yet, both treated and untreated patients demonstrated further decline in graft function as assessed by serum creatinine and estimated glomerular filtration rate.
Late TCMR seen in 7.9% of biopsies can contribute to significant deterioration of graft function in patients in whom the dominant contribution of antibody-mediated injury has been reasonably excluded. Our data also reinforce existing literature showing that microvascular lesions do not have absolute specificity for a diagnosis of antibody-mediated rejection.
近期文献强调了抗体在移植物丢失中的突出作用。本研究旨在评估一种日益增强的观念，即T细胞介导的排斥反应（TCMR）在临床上已不再具有相关性。
对545例在3年期间接受肾移植的受者进行活检筛查，条件包括：（a）TCMR，包括临界变化（BL）；（b）补体蛋白C4降解片段阴性；（c）移植时、活检后30天内以及后续多达4个时间点均无供体特异性抗体。
这些严格标准确定了28例晚期TCMR/BL“纯”病例。在28份活检标本中有9份（32%）发现轻度肾小球炎、肾小管周围毛细血管炎或慢性移植肾小球病。活检后1个月时，7/10（70%）的BL患者和9/18（50%）的TCMR患者血清肌酐显示完全短期缓解。然而，无论是接受治疗还是未接受治疗的患者，通过血清肌酐和估计肾小球滤过率评估，移植肾功能均进一步下降。
在7.9%的活检标本中发现的晚期TCMR可导致在已合理排除抗体介导损伤主要作用的患者中移植肾功能显著恶化。我们的数据也强化了现有文献表明微血管病变对抗体介导排斥反应的诊断不具有绝对特异性。
