Kon S P, Templar J, Dodd S M, Rudge C J, Raftery M J
Department of Renal Medicine & Transplantation, Royal London Hospital, England.
Transplantation. 1997 Feb 27;63(4):547-50. doi: 10.1097/00007890-199702270-00011.
Renal allograft biopsy is the accepted gold standard for investigating episodes of graft dysfunction in the early posttransplant period. The situation is less clear in late transplant biopsies. Later renal biopsies performed for graft dysfunction or as part of a routine investigative protocol have not been subjected to detailed critical evaluation. Two hundred sixty-three consecutive renal allograft biopsies in a single center were evaluated. They were arbitrarily divided into three groups based on interval after transplantation: group 1, up to 3 months (n=117); group 2, 4-12 months (n=60); and group 3, greater than 12 months after transplantation (n=86). There were no significant differences in demographic factors among the groups. The mean interval after transplantation was 0.8+/-0.1 months in group 1, 6.1+/-0.3 months in group 2, and 40.1+/-3.4 months in group 3. There were six principal diagnostic categories: acute rejection (AR), chronic rejection (CR), cyclosporine (CsA) nephrotoxicity, acute tubular necrosis (ATN), normal, and others. A statistically significant decrease in the frequency of AR (P<0.001) was seen in group 3 (3%) compared with groups 1 (43%) and 2 (37%). In contrast, the frequency of CR was significantly higher (P<0.001) in group 3 (71%) compared with groups 1 (0) and 2 (10%). ATN was seen almost exclusively in group 1. All but one of the 37 patients with ATN were in this group. CsA nephrotoxicity remained an important cause of graft dysfunction in all three groups, with no significant difference in incidence among the three groups. The differences between groups with other histological types were not significant. Patient management was changed based on the biopsy report in 84 patients in group 1 (72%), 45 patients in group 2 (75%), and only 16 patients in group 3 (19%) (P<0.001). In only seven patients in group 3 did the change in management result in a significant change in serum creatinine. All of these seven patients had CsA nephrotoxicity on biopsy and also had a significantly higher level of CsA compared with those with AR or CR. Thus, the diagnosis might have been possible without the need for biopsy. We conclude that late renal allograft biopsies are only rarely helpful in patient management and as such should be an investigation of last resort.
肾移植活检是移植术后早期评估移植肾功能异常的公认金标准。对于晚期移植活检，情况则不太明确。因移植肾功能异常或作为常规检查方案的一部分而进行的晚期肾活检尚未得到详细的批判性评估。对一个中心连续进行的263例肾移植活检进行了评估。根据移植后的时间间隔将它们随机分为三组：第1组，移植后3个月内（n = 117）；第2组，4至12个月（n = 60）；第3组，移植后超过12个月（n = 86）。各组间人口统计学因素无显著差异。第1组移植后的平均时间间隔为0.8±0.1个月，第2组为6.1±0.3个月，第3组为40.1±3.4个月。有六个主要诊断类别：急性排斥反应（AR）、慢性排斥反应（CR）、环孢素（CsA）肾毒性、急性肾小管坏死（ATN）、正常及其他。与第1组（43%）和第2组（37%）相比，第3组（3%）的AR发生率有统计学意义的下降（P < 0.001）。相比之下，第3组（71%）的CR发生率显著高于第1组（0）和第2组（10%）（P < 0.001）。ATN几乎仅见于第1组。37例ATN患者中除1例之外均在该组。CsA肾毒性仍是所有三组移植肾功能异常的重要原因，三组间发生率无显著差异。其他组织学类型组间差异不显著。第1组84例患者（72%）、第2组45例患者（75%）以及第3组仅16例患者（19%）根据活检报告改变了患者管理（P < 0.001）。第3组中仅7例患者管理的改变导致血清肌酐有显著变化。这7例患者活检均显示CsA肾毒性，且与AR或CR患者相比，其CsA水平显著更高。因此，可能无需活检即可做出诊断。我们得出结论，晚期肾移植活检对患者管理帮助甚少，因此应作为最后的检查手段。
