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摘要: 为了进一步规范器官移植病理学临床技术操作，中华医学会器官移植学分会组织器官移植专家和移植病理学专家，从移植病理学诊断的基本内容、基本原则、基本方法等方面，制定器官移植病理学临床技术操作规范（2019版）之移植病理学诊断的基本规范；从尸体供肾病理学评估、移植肾活组织检查（活检）病理学临床技术操作规范、移植肾活检病理学诊断临床技术操作规范、移植肾活检电镜诊断临床技术操作规范等方面，制定器官移植病理学临床技术操作规范（2019版）之移植肾脏病理学临床技术操作规范。
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图 1 尸体捐献供肾移植前活检病理学特征（苏木素-伊红，×200）
图示供肾多数肾小管呈显著的急性肾小管坏死，多数坏死的肾小管上皮细胞崩解脱落于管腔内，肾小管基膜裸露
Figure 1. Pathological characteristics of pre-implantation biopsy in deceased donor kidney
图 2 供肾肿瘤占位病变的临床处理策略示意图
Figure 2. Schematic diagram of clinical management strategy on space-occupying lesions of donor kidney
图 3 移植肾穿刺活检组织标本分切方式
LM为光镜标本，IF为免疫荧光显微镜标本，EM为电镜标本；A图示自皮质端取2 mm作电镜标本，4 mm作免疫病理标本，其余部分用作光镜标本；B图示自皮质端依次割为1、2、4 mm的数段，然后依次隔段分作三堆以分别进行电镜、免疫病理及光镜检查，这种分割法可以保证各种检查的标本中均可能包含肾小球；C图示若取得的标本细而且短，则应及时考虑重穿，各条标本分作光镜、免疫病理及电镜的检查，或可将第2针的活检组织分为荧光和电镜标本
Figure 3. The method of dividing the biopsy tissue of transplanted kidney
图 4 移植肾急性T细胞介导的排斥反应的病理学特征
A图示移植肾活检组织间质内弥漫性单个核炎症细胞浸润（HE，×100）；B图示肾小管上皮炎（HE，×400）；C图示动脉血管内膜炎，动脉内膜淋巴细胞浸润及内膜水肿增厚，局部管腔轻度狭窄（HE，×100）；D图示移植肾动脉分支管壁纤维素样坏死（HE，×200）
Figure 4. Pathological characteristics of acute T cell-mediated rejection in renal allograft
图 5 移植肾慢性活动性T细胞介导的排斥反应的病理学特征
A图示移植肾慢性排斥反应中的慢性移植物动脉血管病，动脉内膜增生增厚及增厚的内膜内仍可见淋巴细胞浸润（HE，×200）；B图示移植肾组织间质轻度纤维化和肾小管萎缩，但在萎缩肾小管内仍可见肾小管炎（HE，×400）
Figure 5. Pathological characteristics of chronic active T cell-mediated rejection in renal allograft
图 6 移植肾活动性抗体介导性排斥反应的病理学特征
A图示肾小球炎，肾小球毛细血管腔内淋巴细胞浸润（HE，×400）；B图示肾小管周毛细血管炎（Masson，×1 000）；C图示肾小管周毛细血管内皮C4d阳性，同时可见管腔内淋巴细胞淤积（箭头所示）（免疫组化，×1 000）
Figure 6. Pathological characteristics of active antibody-mediated rejection in renal allograft
图 7 移植肾CNI类免疫抑制剂毒性损伤的病理学特征
A图示急性CNI类免疫抑制剂毒性损伤，肾小管上皮细胞内细小等大空泡变（HE，×400）；B图示移植肾入球微动脉管壁平滑肌细胞空泡变（PAS，×400）；C图示轻微慢性CNI类免疫抑制剂毒性损伤，肾小球入球微动脉管壁结节样透明样变（HE，×400）；D图示慢性CNI类免疫抑制剂毒性损伤的肾组织间质条带状纤维化（Masson，×100）
Figure 7. Pathological characteristics of nephrotoxicity of CNI immunosuppressants in renal allograft
图 8 移植肾细菌感染性急性间质性肾炎的病理学特征（HE，×400）
A、B图示移植肾间质可见大量中性粒细胞浸润和肾小管内中性粒细胞管型
Figure 8. Pathological characteristics of bacterial infectious acute interstitial nephritis in renal allograft
图 9 移植肾BK病毒相关肾病的病理学特征
A图示肾小管上皮细胞内病毒包涵体及肾间质内大量以中性粒细胞为主的炎症浸润，少数小管明显的中性粒细胞管型（HE，×100）；B图示BK病毒包涵体（HE，×1 000）；C图示肾小管上皮细胞SV40-T抗原（免疫组化，×200）；D图示电镜下BK病毒感染的肾小管上皮细胞细胞核内可见直径为35~50 nm的病毒颗粒及典型的病毒颗粒排列呈整齐的晶格状样（×30 000）
Figure 9. Pathological characteristics of BK virus associated nephropathy in renal allograft
图 10 移植肾活检组织内巨细胞病毒感染的病理学特征
A图示肾小管上皮细胞核内“枭眼样”病毒包涵体（HE，×400）；B图示肾小管上皮细胞核CMV阳性（免疫组化，×400）；C图示电镜中CMV病毒颗粒，中央为致密的病毒核心被外周较厚的被膜包绕（×45 000）
Figure 10. Pathological characteristics of cytomegalovirus infection in transplanted kidney biopsy tissues
图 11 移植肾复发性草酸盐肾病和Fabry病的病理学特征
A、B图为移植肾复发性草酸盐肾病的病理学表现，A图示肾移植术后2个月的移植肾穿刺活检组织多数肾小管腔内均可见透明样、碎玻璃草酸盐结晶堵塞（HE，×400），B图示在偏振光显微镜下，草酸盐结晶呈明显的折光（×200）；C图为移植肾复发性Fabry病的病理学表现，图示移植肾活检组织电镜检查中可见大部分足细胞内有特征性的“髓样小体或斑马小体”沉积（×6 000）
Figure 11. Pathological characteristics of recurrent oxalate nephropathy and Fabry disease of renal allograft
图 12 电镜下常见的移植肾病理学特征
A图为肾移植术后移植肾复发性IgA肾病，图示肾小球系膜区高密度块状电子致密物沉积（★，×5 000）；B图为肾移植术后移植肾复发性FSGS，图示肾小球足细胞足突广泛融合（↑，×8 000）；C图为移植肾急性TMA，图示肾小球毛细血管内皮细胞肿胀，内皮下间隙增宽（★，×8 000），间隙内填充有低电子密度的无定形物质；D图为移植肾肾小球炎，图示肾小球毛细血管腔内可见多个淋巴细胞（↑，×5 000）；E、F图为移植肾慢性活动性AMR所致移植肾肾小球病和肾小管管周毛细血管基膜多层化，E图示肾小球毛细血管袢增厚、基底膜双层化（↑，×5 000）；F图示肾小管周毛细血管基膜增厚及增生为多层（↑，×6 000）
Figure 12. Common pathological characteristics of renal allograft under electron microscopy
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[1] 陈实, 郭晖.移植病理学[M].北京:人民卫生出版社, 2009. [2] 朱有华, 曾力.肾移植[M].北京:人民卫生出版社, 2017. [3] 中华医学会器官移植学分会, 中华医学会外科学分会移植学组, 中国医师协会器官移植医师分会.中国心脏死亡捐献器官评估与应用专家共识[J/CD].中华移植杂志(电子版), 2014, 8(3): 117-122. DOI: 10.3877/cma.j.issn.1647-3903.2014.03.001.Branch of Organ Transplantation of Chinese Medical Association, Division of Transplantation of Branch of Surgery of Chinese Medical Association, Branch of Organ Transplant Physician of Chinese Medical Doctor Association. Expert consensus on evaluation and application of organ donated after cardiac death in China[J/CD]. Chin J Transplant(Electr Vers), 2014, 8(3): 117-122. DOI: 10.3877/cma.j.issn.1647-3903.2014.03.001. [4] 中华医学会器官移植学分会.中国心脏死亡器官捐献工作指南(第2版)[J].中华器官移植杂志, 2011, 32(12):756-758.DOI: 10.3760/cma.j.issn.0254-1785.2011.12.014.Branch of Organ Transplantation of Chinese Medical Association. Work guideline of donation after cardiac death in China(2nd edition)[J]. Chin J Organ Transplant, 2011, 32(12):756-758.DOI:10.3760/cma.j.issn.0254-1785.2011. 12.014. [5] 中华医学会器官移植学分会, 中国医师协会器官移植医师分会.中国公民逝世后器官捐献供肾体外低温机械灌注保存专家共识(2016版)[J/CD].中华移植杂志(电子版), 2016, 10(4): 154-158.DOI: 10.3877/cma.j.issn.1674-3903.2016.04.002.Branch of Organ Transplantation of Chinese Medical Association, Branch of Organ Transplant Physician of Chinese Medical Doctor Association. Expert consensus on donor kidney in external hypothermic machine perfusion preservation of Chinese donation after citizen' s death(2016 edition)[J/CD].Chin J Transplant(Electr Vers), 2016, 10(4): 154-158.DOI: 10.3877/cma.j.issn.1674-3903.2016.04.002. [6] 郭晖, 陈知水, 陈实.公民逝世后器官捐献供肾的病理学评估[J].器官移植, 2018, 9(1):1-8. DOI: 10.3969/j.issn.1674-7445.2018.01.001.GUO H, CHEN ZS, CHEN S. Pathological evaluation of donor kidney in donation after citizen' s death[J]. Organ Transplant, 2018, 9(1):1-8.DOI: 10.3969/j.issn.1674-7445.2018.01.001. [7] 郭晖.对DCD供肾病理学评估研究的思考[J/CD].实用器官移植电子杂志, 2017, 5(6): 417-424. DOI: 10.3969/j.issn.2095-5332.2017.06.004.GUO H. Reflections on the pathology evaluation study of donor kidney nephrology of DCD[J/CD]. Pract J Organ Transplant (Electr Vers), 2017, 5(6): 417-424. DOI: 10.3969/j.issn.2095-5332.2017.06.004. [8] HAAS M. Donor kidney biopsies: pathology matters, and so does the pathologist[J]. Kidney Int, 2014, 85(5):1016-1019. DOI: 10.1038/ki.2013.439. [9] GOUMENOS DS, KALLIAKMANI P, TSAMANDAS AC, et al. The prognostic value of frozen section preimplantation graft biopsy in the outcome of renal transplantation[J]. Ren Fail, 2010, 32(4):434-439. DOI: 10.3109/08860221003658241. [10] RANDHAWA P. Role of donor kidney biopsies in renal transplantation[J].Transplantation, 2001, 71(10):1361-1365. doi: 10.1097/00007890-200105270-00001 [11] RANDHAWA PS, MINERVINI MI, LOMBARDERO M, et al. Biopsy of marginal donor kidneys: correlation of histologic findings with graft dysfunction[J]. Transplantation, 2000, 69(7):1352-1357. doi: 10.1097/00007890-200004150-00024 [12] REMUZZI G, GRINYÒ J, RUGGENENTI P, et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. Double Kidney Transplant Group (DKG)[J]. J Am Soc Nephrol, 1999, 10(12):2591-2598. [13] ISONIEMI H, TASKINEN E, HÄYRY P. Histological chronic allograft damage index accurately predicts chronic renal allograft rejection[J]. Transplantation, 1994, 58(11):1195-1198. doi: 10.1097/00007890-199412150-00010 [14] KARPINSKI J, LAJOIE G, CATTRAN D, et al. Outcome of kidney transplantation from high-risk donors is determined by both structure and function[J]. Transplantation, 1999, 67(8):1162-1167. doi: 10.1097/00007890-199904270-00013 [15] MUNIVENKATAPPA RB, SCHWEITZER EJ, PAPADIMITRIOUJC, et al. The Maryland aggregate pathology index: a deceased donor kidney biopsy scoring system for predicting graft failure[J]. Am J Transplant, 2008, 8(11):2316-2324. DOI: 10.1111/j.1600-6143.2008.02370.x. [16] FLECHNER SM, CAMPBELL SC. The use of kidneys with small renal tumors for transplantation: who is taking the risk?[J]. Am J Transplant, 2012, 12(1):48-54. DOI: 10.1111/j.1600-6143.2011.03794.x. [17] HAAS M, LOUPY A, LEFAUCHEUR C, et al. The Banff 2017 Kidney Meeting report: revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials[J]. Am J Transplant, 2018, 18(2):293-307. DOI: 10.1111/ajt.14625. [18] HUANG G, WU LW, YANG SC, et al. Factors influencing graft outcomes following diagnosis of polyomavirus-associated nephropathy after renal transplantation[J]. PLoS One, 2015, 10(11):e0142460. DOI: 10.1371/journal.pone.0142460. [19] HUANG G, CHEN LZ, QIU J, et al. Prospective study of polyomavirus BK replication and nephropathy in renal transplant recipients in China: a single-center analysis of incidence, reduction in immunosuppression and clinical course[J]. Clin Transplant, 2010, 24(5):599-609. DOI: 10.1111/j.1399-0012.2009.01141.x. [20] KOTTON CN, KUMAR D, CALIENDO AM, et al. The third international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation[J]. Transplantation, 2018, 102(6):900-931. DOI: 10.1097/TP.0000000000002191. [21] TILLOU X, GULERYUZ K, COLLON S, et al. Renal cell carcinoma in functional renal graft: toward ablative treatments[J]. Transplant Rev (Orlando), 2016, 30(1):20-26. DOI: 10.1016/j.trre.2015.07.001. [22] SCOTT MH, SELLS RA. Primary adenocarcinoma in a transplanted cadaveric kidney[J]. Transplantation, 1988, 46(1):157-158. doi: 10.1097/00007890-198807000-00030 [23] TILLOU X, DOERFLER A, COLLON S, et al. De novo kidney graft tumors: results from a multicentric retrospective national study[J]. Am J Transplant, 2012, 12(12):3308-3315. DOI: 10.1111/j.1600-6143.2012.04248.x. [24] NALESNIK MA, WOODLE ES, DIMAIO JM, et al. Donor-transmitted malignancies in organ transplantation: assessment of clinical risk[J]. Am J Transplant, 2011, 11(6):1140-1147. DOI: 10.1111/j.1600-6143.2011.03565.x. -
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