Clinicopathological features analysis of focal segmental glomerulosclerosis after kidney transplantation
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摘要:
目的 探讨肾移植术后复发及新发局灶节段性肾小球硬化(FSGS)的临床和病理特征。 方法 选取经移植肾穿刺活组织检查(活检)病理确诊为FSGS的受者34例,根据自体肾原发病及循环渗透因子检测,将34例受者分为复发FSGS组(12例)和新发FSGS组(22例)。比较复发与新发两组间受者在临床指标及移植肾病理损伤程度的差异。 结果 两组受者系膜增生评分、肾小球球性硬化率、肾小管萎缩评分、间质纤维化评分和足细胞增生发生率之间的差异均无统计学意义(均为P > 0.05); 复发FSGS组受者的节段性肾小球硬化率为0.10(0.08,0.27),低于新发FSGS组受者的0.19(0.13,0.33)(P < 0.05)。两组受者抗体介导的排斥反应、药物性肾小管损伤、BK病毒感染发生率之间的差异均无统计学意义(均为P > 0.05); 复发FSGS组受者T细胞介导的排斥反应发生率为17%,低于新发FSGS组受者的55%(P < 0.05)。免疫组织化学结果显示移植肾组织内浸润炎症细胞主要为T细胞; 复发FSGS组和新发FSGS组管周毛细血管C4d沉积阳性率分别为33%(4/12)和32%(7/22),差异无统计学意义(P > 0.05); 免疫荧光结果显示多数病例移植肾肾小球节段性硬化区IgM团块状沉积,电子显微镜显示移植肾肾小球均存在足突广泛融合或节段性分布。 结论 复发FSGS组肾损伤程度和T细胞介导的排斥反应发生率低于新发FSGS组。综合分析肾移植受者术前和术后的临床表现、实验室检测和病理学检查等有助于复发和新发FSGS的早期诊断和治疗。 Abstract:Objective To investigate the clinicopathological features of recurrent and de novo focal segmental glomerulosclerosis (FSGS) after kidney transplantation. Methods Thirty-four recipients pathologically diagnosed with FSGS by renal allograft biopsy were enrolled in this clinical trial. According to the detection of primary diseases of renal allografts and circulating permeability factors, 34 recipients were divided into the recurrent FSGS group (n=12) and de novo FSGS group (n=22). The differences of clinical indexes and the degree of pathological injury of renal allografts were compared between two groups. Results There was no significant difference in the mesangial hyperplasia score, glomerulosclerosis rate, renal tubular atrophy score, interstitial fibrosis score and podocyte proliferation rate between two groups (all P > 0.05). In the recurrent FSGS group, segmental glomerulosclerosis rate of the recipients was 0.10 (0.08, 0.27), lower than 0.19 (0.13, 0.33) in the de novo FSGS group (P < 0.05). No significant difference was found in the incidence of antibody-mediated rejection, drug-induced renal tubular injury and BK virus infection between two groups (all P > 0.05). The incidence of T cell-mediated rejection in the recurrent FSGS group was 17%, lower than 55% in the de novo FSGS group (P < 0.05). Immunohistochemical staining showed that the infiltrating inflammatory cells in the renal allografts were mainly T lymphocytes. The positive rates of C4d deposition in peripheral capillaries between the recurrent and de novo FSGS groups were 33% (4/12) and 32% (7/22), with no significant difference (P > 0.05). Immunofluorescence results revealed IgM deposition in the segmental glomerulosclerosis area of renal allografts in most cases. Electron microscopy showed extensive fusion or segmental distribution of podocytes in the glomerulus of renal allografts. Conclusions The degree of renal functional injury and the incidence of T cell-mediated rejection in the recurrent FSGS group are lower than those in the de novo FSGS group. Comprehensive analysis of preoperative and postoperative clinical manifestations, laboratory testing and pathological examination of kidney transplant recipients contribute to early diagnosis and treatment of recurrent and de novo FSGS. -
图 1 移植肾免疫组织化学、免疫荧光和电镜图片
注:A图为复发FSGS,图示肾小球节段性硬化(苏木素-伊红,×200); B图为新发FSGS,图示肾小球节段性硬化(过碘酸-雪夫,×200); C图为复发FSGS,图示足细胞增生(过碘酸-六胺银,×400); D图为急性TCMR,图示肾小管炎(过碘酸-雪夫,×200); E图为慢性活动性AMR,图示肾小球毛细血管基底膜增厚、双轨形成(过碘酸-雪夫,×200); F图为新发FSGS伴药物性肾损伤(苏木素-伊红,×200); G图为新发FSGS受者BKV感染的肾小管上皮细胞核SV40(+)(免疫组化,×100); H图为肾小球节段性硬化区IgM团块状沉积(免疫荧光,×200); I图为电镜示足突广泛融合或节段性分布(磷钨酸,×4 300)。
Figure 1. Immunohistochemistry, immunofluorescence and electron microscopy images of renal allograft
表 1 两组受者病理学参数的比较
Table 1. Comparison of pathological parameters of recipients between the two groups
病理学参数 复发FSGS组(n=12) 新发FSGS组(n=22) 统计值 P值 系膜增生评分[M(P25, P75),分] 1.25(1.00,1.25) 1.00(1.00,1.00) -1.888 0.136 肾小球球性硬化率[M(P25, P75)] 0.07(0,0.33) 0.20(0.07,0.38) -1.305 0.204 节段性肾小球硬化率[M(P25, P75)] 0.10(0.08,0.27) 0.19(0.13,0.33) -2.244 0.025 肾小管萎缩评分[M(P25, P75),分] 1.0(1.0,1.0) 1.0(1.0,1.0) -0.974 0.488 间质纤维化评分[M(P25, P75),分] 1.0(0,1.0) 1.0(1.0,1.0) -0.735 0.534 足细胞增生发生率[n(%)] 4(33) 7(32) 0.031 0.583 表 2 两组受者并发症发生率比较
Table 2. Comparison of complication rates of recipients between the two groups[n(%)]
并发症 复发FSGS组(n=12) 新发FSGS组(n=22) 统计值 P值 AMR 0 4(18) 2.473 0.158 TCMR 2(17) 12(55) 4.600 0.035 药物性肾小管损伤 0 5(23) 3.197 0.095 BKV感染 0 1(5) 0.562 0.647 -
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