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慢性移植肾功能不全诊疗技术规范(2019版)

中华医学会器官移植学分会

中华医学会器官移植学分会. 慢性移植肾功能不全诊疗技术规范(2019版)[J]. 器官移植, 2019, 10(5): 526-532, 539. doi: 10.3969/j.issn.1674-7445.2019.05.011
引用本文: 中华医学会器官移植学分会. 慢性移植肾功能不全诊疗技术规范(2019版)[J]. 器官移植, 2019, 10(5): 526-532, 539. doi: 10.3969/j.issn.1674-7445.2019.05.011
Branch of Organ Transplantation of Chinese Medical Association. Technical specification for diagnosis and treatment of chronic renal allograft dysfunction (2019 edition)[J]. ORGAN TRANSPLANTATION, 2019, 10(5): 526-532, 539. doi: 10.3969/j.issn.1674-7445.2019.05.011
Citation: Branch of Organ Transplantation of Chinese Medical Association. Technical specification for diagnosis and treatment of chronic renal allograft dysfunction (2019 edition)[J]. ORGAN TRANSPLANTATION, 2019, 10(5): 526-532, 539. doi: 10.3969/j.issn.1674-7445.2019.05.011

慢性移植肾功能不全诊疗技术规范(2019版)

doi: 10.3969/j.issn.1674-7445.2019.05.011
基金项目: 

国家自然科学基金 81570681

国家自然科学基金 81570681

国家自然科学基金 81570680、81571555

详细信息
    通讯作者:

    文吉秋,1975年生,博士,副主任医师,硕士研究生导师,研究方向为移植肾排斥反应、移植肾病复发及移植肾MRI,Email:wjqdoctor@163.com

  • 中图分类号: R617, R619

Technical specification for diagnosis and treatment of chronic renal allograft dysfunction (2019 edition)

  • 摘要: 为了进一步规范慢性移植肾功能不全的诊断和治疗,中华医学会器官移植学分会组织器官移植学专家从慢性移植肾功能不全的诊断思路和治疗原则、移植肾复发肾小球疾病、钙神经蛋白抑制剂(CNI)肾损伤等方面,制订本规范。

     

  • 图  1  IgA肾病复发的移植肾活检病理学表现

    A图示肾小球系膜增生,壁层上皮细胞增生(PAS,×200);B图示新月体形成,临近毛细血管袢受压,余毛细血管袢开放良好,肾小管和间质血管未见明确病变(PAS,×200);C图示系膜区IgA沉积,对应区域系膜增生(免疫荧光,×400);D图示电镜下可见肾小球系膜增生,系膜区可见电子致密物

    Figure  1.  Pathological findings of renal allograft biopsy in recurrence of IgA nephropathy

    图  2  局灶性节段性肾小球硬化复发的移植肾活检病理学表现

    A图示光镜下可见局灶节段硬化伴有足细胞增生(PAS,×400);B图示局灶节段硬化(PAS,×400);C图中箭头所示为局灶节段硬化病变(PASM,×400);D图示电镜下可见足突融合,足细胞胞浆内空泡,基膜内和内皮下未见明显电子致密沉积

    Figure  2.  Pathological findings of renal allograft biopsy in recurrence of focal segmental glomerulosclerosis

    图  3  膜性肾病复发的移植肾活检病理学表现

    A、B图示肾小球毛细血管袢僵硬,走行不规则(PAS,×400);C图示肾小球基底膜外侧可见钉突形成(PASM,×400);D图示肾小球血管袢IgG颗粒状沉积(免疫荧光,×400);E图示电镜下可见肾小球上皮侧电子致密物沉积;F图示肾组织内PLA2R阳性(免疫荧光,×400)

    Figure  3.  Pathological findings of renal allograft biopsy in recurrence of membranous nephropathy

    图  4  C3肾小球病复发的移植肾活检病理学表现

    A图示肾小球内系膜区重度增生,袢内可见细胞浸润(箭头)(PAS,×200);B图示部分系膜插入基底膜内,形成双轨样改变,部分表现为毛细血管内皮细胞增生(箭头)(PAS,×400);C图示肾小球系膜区和血管袢均可见C3沉积,部分患者沉积在血管袢(免疫荧光,×400);D图示电镜下肾小球系膜区和血管袢均可见电子致密物沉积

    Figure  4.  Pathological findings of renal allograft biopsy in recurrence of C3 glomerulopathy

    图  5  PGNMID复发的移植肾活检病理学表现

    A图示轻度系膜增生(PAS,×400);B图示重度系膜增生(PAS,×400);C图示毛细血管内增生(PAS,×400);D图示膜增生性病变(PAS,×400)

    Figure  5.  Pathological findings of renal allograft biopsy in recurrence of PGNMID

    图  6  PGNMID复发的移植肾活检免疫荧光及电镜表现

    A图示免疫荧光IgG沉积在毛细血管袢(免疫荧光,×400);B图示电镜下肾小球沉积物呈颗粒状,通常无特殊超微结构,通常沉积在内皮下和系膜区,伴或不伴上皮侧沉积;C~F图示免疫荧光IgG亚型仅IgG3阳性(免疫荧光,×400);G、H图示轻链染色仅κ染色阳性(免疫荧光,×400)

    Figure  6.  Immunofluorescence and electron microscopic findings of renal allograft biopsy in recurrence of PGNMID

    图  7  急性CNI肾损伤的移植肾活检病理学表现

    A图示肾小管上皮等立方空泡变性(Masson,×400);B图示急性CNI肾损伤导致的移植肾间质血管内膜黏液样水肿,管腔狭窄,血栓性微血管病样表现(PAS,×400)

    Figure  7.  Pathological findings of renal allograft biopsy in acute CNI renal injury

    图  8  慢性CNI肾损伤的移植肾活检病理学表现

    A、B图示肾小球入球、出球小动脉管壁上有PAS阳性的物质沉积,病理上称为透明样变,A图(PAS,×400),B图(HE,×400);C图示慢性CNI肾损伤导致间质条索样纤维化(Masson,×200)

    Figure  8.  Pathological findings of renal allograft biopsy in chronic CNI renal injury

    表  1  慢性移植肾功能不全的常见病因、临床表现和诊断要点

    Table  1.   Common causes, clinical manifestations and diagnostic points of chronic renal allograft dysfunction

    病因 主要临床表现 诊断要点
    新发或复发肾小球疾病 Scr升高、蛋白尿、血尿 临床缺乏特异性,需行移植肾活检以明确诊断
    慢性细胞性排斥反应 Scr升高 移植肾活检明确诊断
    慢性体液性排斥反应 早期出现单纯蛋白尿,晚期出现Scr升高合并蛋白尿 DSA阳性可辅助诊断,移植肾活检可明确诊断
    CNI移植肾毒性 Scr升高,蛋白尿少见 长期CNI血药浓度高,移植肾活检可明确诊断
    BKVN Scr升高,蛋白尿少见 血、尿BK病毒升高,尿Decoy细胞阳性,移植肾活检可明确诊断
    复发的肾盂肾炎 反复发作的高热、移植肾区疼痛、Scr升高、尿白细胞阳性 中段尿细菌培养阳性
    移植肾动脉狭窄 血压升高,Scr逐渐升高 移植肾动脉超声、MRI或CT血管成像、数字减影血管造影可明确诊断
    尿路梗阻 尿量减少,Scr升高,部分伴有移植肾胀痛 移植肾超声、移植肾MRI尿路成像、肾盂输尿管顺行造影可明确诊断
    CNI为钙神经蛋白抑制剂;BKVN为BK病毒性肾病;Scr为血清肌酐;DSA为供体特异性抗体;活检为活组织检查
    下载: 导出CSV

    表  2  导致慢性移植肾功能不全的常见病治疗原则

    Table  2.   Treatment principles of common diseases leading to chronic renal allograft dysfunction

    病因 治疗原则
    新发或复发肾小球疾病 针对不同复发疾病采用不同的办法
    慢性细胞性排斥反应 增强免疫抑制强度,加大免疫抑制剂剂量,转换免疫抑制较强的免疫抑制剂方案
    慢性体液性排斥反应 增强免疫抑制强度,加大免疫抑制剂剂量,转换免疫抑制较强的免疫抑制剂方案去除抗体治疗:免疫吸附、血浆置换;大剂量丙种球蛋白;利妥昔单抗、硼替佐米、卡非佐米等
    CNI肾损伤 减少CNI药物剂量,调低血药浓度将CNI换为西罗莫司(或依维莫司)、贝拉西普等药物
    BKVN 降低免疫抑制强度,调整免疫抑制剂方案抗病毒治疗
    复发的肾盂肾炎 明确病原体,药物试验敏感的抗生素足疗程治疗排除梗阻因素,调整免疫抑制剂方案
    移植肾动脉狭窄 介入治疗:球囊扩张,血管支架植入移植肾动脉狭窄段再次成型术
    尿路梗阻 移植肾输尿管支架置入;输尿管狭窄段扩张;输尿管狭窄段切除再次成型术
    下载: 导出CSV
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出版历程
  • 收稿日期:  2019-06-20
  • 网络出版日期:  2021-01-19
  • 刊出日期:  2019-09-15

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