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摘要: 近年来,随着肺移植外科技术和术后管理经验的积累,我国肺移植例数逐步增长。肺移植术后移植肺可出现多种并发症,主要包括由移植肺缺血-再灌注损伤(IRI)等所致的原发性移植肺无功能(PGD)、急性与慢性排斥反应以及移植术后应用免疫抑制剂所致机体免疫力下降出现的机会性感染或淋巴组织异常增生等。移植肺并发症的确诊主要依据移植肺活组织检查(活检)。本文对移植肺病理学研究的简史、移植肺活检的主要方法及其病理学处理技术、肺移植术后主要并发症及其活检病理学诊断标准进行阐述,旨在为指导临床对上述并发症采取针对性的治疗方案提供参考。
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关键词:
- 慢性阻塞性肺疾病 /
- 囊性纤维化 /
- 急性细胞性排斥反应(ACR) /
- 抗体介导的排斥反应(AMR) /
- T细胞介导的排斥反应(TCMR) /
- 经支气管肺活检(TBLB) /
- 经支气管冷冻肺活检(TBCB) /
- 支气管肺泡灌洗 /
- 闭塞性细支气管炎(OB) /
- 移植相关血管病(TAV)
Abstract: In recent years, the quantity of lung transplantation has been gradually increased in China along with the accumulation of surgical techniques and postoperative management experience of lung transplantation. Multiple lung allograft complications may occur after lung transplantation, mainly including primary graft dysfunction (PGD) caused by ischemia-reperfusion injury (IRI) of the lung allograft, acute and chronic rejection, opportunistic infection or lymphoproliferative disorder of lymphoid tissues induced by the decrease of host immunity due to postoperative use of immunosuppressants, etc. The diagnosis of complications after lung transplantation mainly relies on biopsy of the lung allograft. In this article, the brief history of lung allograft pathology, main approaches and pathological processing techniques of lung allograft biopsy, major complications after lung transplantation and pathological diagnostic criteria were elucidated, aiming to provide reference for targeted management of these complications in clinical practice.-
Key words:
- Chronic obstructive pulmonary disease /
- Cystic fibrosis /
- Acute cellular rejection (ACR) /
- Antibody-mediated rejection (AMR) /
- T cell-mediated rejection (TCMR) /
- Transbronchial lung biopsy (TBLB) /
- Transbronchial cryobiopsy (TBCB) /
- Bronchoalveolar lavage /
- Obliterative bronchiolitis (OB) /
- Transplant-associated vasculopathy (TAV)
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表 1 肺移植术后主要并发症
Table 1. Major complications after lung transplantation
术后时间 并发症类型 围手术期及术后近期
(术后1个月内)血管与气管吻合口并发症、超急性排斥反应、植入反应、IRI或PGD、急性T细胞介导的排斥反应或AMR、感染 术后中期
(术后1个月至1年)急性T细胞介导的排斥反应或AMR、感染、移植后淋巴组织异常增生、药物毒性反应、通气相关病变 术后远期
(术后1年以上)急性细胞性排斥反应、急性AMR、感染、慢性支气管性排斥反应或闭塞性细支气管炎、慢性血管性排斥反应或移植相关血管病、限制性移植肺综合征、中性粒细胞性可逆性移植肺功能障碍、移植后淋巴组织异常增生、原发病复发 表 2 移植肺排斥反应诊断标准及其分级(2007年ISHLT标准)
Table 2. Diagnostic criteria and classification of rejection of lung allograft (2007 ISHLT working formulation)
分级 诊断标准 急性细胞性排斥反应(A级) A0级,无急性排斥反应;A1级,轻微急性排斥反应;A2级,轻度急性排斥反应;A3级,中度急性排斥反应;A4级,重度急性排斥反应 淋巴细胞性支气管炎(B级) BX级,活检标本偏少或标本挤压等无法满足诊断;B0级,无淋巴细胞性支气管炎;B1R级,低级别的淋巴细胞性支气管炎;B2R级,高级别的淋巴细胞性支气管炎 慢性支气管性排斥反应(OB)(C级) C0级,无OB改变;C1级,有OB改变 慢性血管性排斥反应(TAV)(D级) D0级,无TAV病变;D1级,有TAV病变 -
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