CAJ | 학술논문

目的探讨原位肝移植术后慢性排斥反应的病理组织学特点、临床表现以及诊治经验.方法回顾性分析2004年1月至2006年12月收治的516例原位肝移植患者的临床病理资料;对肝移植术后发生慢性排斥反应患者的病理组织学改变、临床表现、诊治方案加以分析.结果 516例肝移植患者中,发生慢性排斥反应12例(2.3%,12/516),其中早期慢性排斥反应7例,晚期慢性排斥反应5例.其主要组织学特征是移植肝组织内的胆管严重减少或缺失和累及中等动脉的闭塞性动脉炎;其中早期慢性排斥反应可表现为小叶间胆管的细胞变性和其数量进行性减少以及形成小叶中央坏死性炎症.12例慢性排斥反应患者中,7例早期慢性排斥反应患者经激素冲击治疗和调整免疫抑制药物后病情得到控制(包括2例接受抗CD3抗体治疗,2例接受抗胸腺细胞球蛋白治疗)且近期疗效满意;5例晚期慢性排斥反应患者肝功能迁延不愈最终至肝功能衰竭而行再次肝移植,其中2例伴术后严重腹腔内感染而死亡,1例死于术后多脏器功能衰竭,另外2例再移植病例获临床治愈.本组慢性排斥反应发生的时间为术后4～26个月;与慢性排斥相关的病死率为25.0%(3/12).结论肝移植术后发生慢性排斥反应的患者缺乏典型的症状和体征,其病理改变可以有重叠和复合存在;移植肝连续穿刺活检和再次移植术后病理仍是目前诊断慢性排斥反应的"金标准".如能及时发现早期慢性排斥反应并积极进行合理的治疗,病情则具有潜在的可逆性;晚期阶段慢性排斥反应所致的移植肝功能衰竭需要再次肝移植治疗.
목적 탐토원위간이식술후만성배척반응적병리조직학특점、림상표현이급진치경험.방법 회고성분석2004년1월지2006년12월수치적516례원위간이식환자적림상병리자료;대간이식술후발생만성배척반응환자적병리조직학개변、림상표현、진치방안가이분석.결과 516례간이식환자중,발생만성배척반응12례(2.3%,12/516),기중조기만성배척반응7례,만기만성배척반응5례.기주요조직학특정시이식간조직내적담관엄중감소혹결실화루급중등동맥적폐새성동맥염;기중조기만성배척반응가표현위소협간담관적세포변성화기수량진행성감소이급형성소협중앙배사성염증.12례만성배척반응환자중,7례조기만성배척반응환자경격소충격치료화조정면역억제약물후병정득도공제(포괄2례접수항CD3항체치료,2례접수항흉선세포구단백치료)차근기료효만의;5례만기만성배척반응환자간공능천연불유최종지간공능쇠갈이행재차간이식,기중2례반술후엄중복강내감염이사망,1례사우술후다장기공능쇠갈,령외2례재이식병례획림상치유.본조만성배척반응발생적시간위술후4～26개월;여만성배척상관적병사솔위25.0%(3/12).결론 간이식술후발생만성배척반응적환자결핍전형적증상화체정,기병리개변가이유중첩화복합존재;이식간련속천자활검화재차이식술후병리잉시목전진단만성배척반응적"금표준".여능급시발현조기만성배척반응병적겁진행합리적치료,병정칙구유잠재적가역성;만기계단만성배척반응소치적이식간공능쇠갈수요재차간이식치료.
Objective To investigate the clinical manifestation and pathological features of chronic rejection(CR) and the management of CR after othotopic liver transplantation (OLT). Methods From January 2004 to December 2006, there were 516 patients who had undergone OLT. All the clinical and pathological data were collected and retrospectively studied. Clinical manifestation, histopathological feature,diagnosis and anti-rejection treatment of CR were summarized and analyzed. Results The incidence of CR was 2.3% (12/516), including 7 cases with early phases of CR and 5 cases with late phases of CR. The main pathological changes of CR were the vanishing bile duct syndrome and obliterative arteriopathy;and the early stage of CR were the damage of inter lobular bile duct, necrotic inflammation in central lobule, and inflammatory cells infiltation in portal area. Among 12 patients with CR,7 cases with early CR were reversed by methylprednisolone(MP) pulse treatment and adjusting immunosuppressant dose, including 2 cases of whom were prescribed OKT3 treatment and 2 cases treated by ATG,and 5 cases with late CR underwent liver retransplantation(re-LT). Two patients died from infection, 1 case died from multiple organ failure in perioperative period after re-LT, another 2 cases were cured by re-LT, and the CR related mortality was 25.0% (3/12). Conclusions Chronic rejection following OLT is lack of typical clinical manifestation and pathological features, and the pathological changes can overlap and coexist. Post-transplant liver biopsy and graft specimen after re-LT is still "gold standard" to CR diagnosis. Some of early CRs can be reversed by early diagnosis and early treatment; for late CR recipient, re-LT should be considered.