Matas A J, Sibley R, Mauer M, Sutherland D E, Simmons R L, Najarian J S
Ann Surg. 1983 Feb;197(2):226-37. doi: 10.1097/00000658-198302000-00017.
Following renal transplantation, immunosuppression is usually increased to treat presumed rejection episodes. However, a) many conditions mimic rejection in the post-transplant period, and b) many rejection episodes are irreversible. As increased immunosuppressive therapy is associated with an increased risk of infection, it would be ideal to limit antirejection therapy to only the rejection episodes that are reversible. The role of percutaneous allograft biopsy was studied as an aid to decide which patients to treat for rejection, to limit unnecessary immunosuppression and to predict allograft survival. One hundred thirty-five patients with suspected rejection underwent 206 allograft biopsies without complication. Two hundred four biopsies were available for study. Biopsies were coded on a 1-4 scale (minimal, mild, moderate, severe) for acute and chronic tubulointerstitial infiltrate and vascular rejection, as well as no rejection (e.g., recurrence of original disease). Treatment decisions were made on the basis of the biopsy combined with clinical data. All patients have been followed two years and outcome correlated with biopsy findings (death, nephrectomy, and return to dialysis defined as kidney loss). The results were the following: 1) biopsies represented changes within the kidney. Of 16 kidneys removed within one month of biopsy, no nephrectomy specimen showed less rejection than that seen on biopsy. 2) Eighty-one biopsies (39.7%) led to tapering or not increasing immunosuppression (either no rejection, minimal rejection, or irreversible changes). 3) Kidneys having either severe acute or chronic vascular rejection (less than 30% function at three months) had significantly (p less than 0.05) decreased survival three to 24 months postbiopsy than those with minimal or mild vascular rejection or tubulointerstitial infiltrate (83% function at three months). 4) Kidneys with moderate chronic vascular rejection and those with severe acute tubulointerstitial infiltrate had significantly (p less than 0.05) decreased survival at six to 24 months. 5) Kidneys with moderate chronic vascular rejection (MCV) without an acute infiltrate (ATI) had significantly better survival than those having both MCV and ATI. 6) Similarly, kidneys having severe ATI alone had better survival than those with ATI plus vascular rejection. It was concluded that a) percutaneous allograft biopsy can be done without graft loss or infection; b) biopsy represents changes throughout the kidney; c) biopsy aids in deciding when to treat for rejection and in deciding when to withhold increased immunosuppression, and d) allograft biopsy predicts the outcome of treatment of a rejection episode.
肾移植后，通常会增加免疫抑制治疗以处理推测的排斥反应。然而，a）许多情况在移植后阶段会模仿排斥反应，且b）许多排斥反应是不可逆的。由于增加免疫抑制治疗与感染风险增加相关，因此理想的做法是仅对可逆的排斥反应进行抗排斥治疗。研究了经皮同种异体肾活检在帮助决定哪些患者应接受排斥反应治疗、限制不必要的免疫抑制以及预测同种异体肾存活方面的作用。135例疑似排斥反应的患者接受了206次同种异体肾活检，无并发症发生。204次活检可供研究。活检根据急性和慢性肾小管间质浸润及血管排斥反应以及无排斥反应（如原发病复发）的程度分为1 - 4级（轻微、轻度、中度、重度）。根据活检结果结合临床数据做出治疗决策。所有患者均随访了两年，结果与活检结果相关（死亡、肾切除以及恢复透析定义为肾丢失）。结果如下：1）活检代表肾脏内的变化。在活检后一个月内切除的16个肾脏中，没有一个肾切除标本显示的排斥反应比活检时轻。2）81次活检（39.7%）导致免疫抑制逐渐减少或不再增加（无排斥反应）、轻微排斥反应或不可逆变化）。3）发生严重急性或慢性血管排斥反应（三个月时肾功能低于30%）的肾脏在活检后三至24个月的存活率显著（p < 0.05）低于那些有轻微或轻度血管排斥反应或肾小管间质浸润（三个月时肾功能83%）的肾脏。4）中度慢性血管排斥反应的肾脏以及严重急性肾小管间质浸润的肾脏在六至24个月时存活率显著（p < 0.05）降低。5）无急性浸润（ATI）的中度慢性血管排斥反应（MCV）的肾脏比同时有MCV和ATI的肾脏存活率显著更高。6）同样，单独有严重ATI的肾脏比有ATI加血管排斥反应的肾脏存活率更高。得出的结论是：a）经皮同种异体肾活检可在不导致移植物丢失或感染的情况下进行；b）活检代表整个肾脏的变化；c）活检有助于决定何时治疗排斥反应以及何时不增加免疫抑制；d）同种异体肾活检可预测排斥反应治疗的结果。
