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器官移植病理学临床技术操作规范(2019版)—心脏移植

中华医学会器官移植学分会

中华医学会器官移植学分会. 器官移植病理学临床技术操作规范(2019版)—心脏移植[J]. 器官移植, 2019, 10(4): 393-401. doi: 10.3969/j.issn.1674-7445.2019.04.008
引用本文: 中华医学会器官移植学分会. 器官移植病理学临床技术操作规范(2019版)—心脏移植[J]. 器官移植, 2019, 10(4): 393-401. doi: 10.3969/j.issn.1674-7445.2019.04.008
Branch of Organ Transplantation of Chinese Medical Association. Clinical technical operation specification for pathology of organ transplantation (2019 edition): heart transplantation[J]. ORGAN TRANSPLANTATION, 2019, 10(4): 393-401. doi: 10.3969/j.issn.1674-7445.2019.04.008
Citation: Branch of Organ Transplantation of Chinese Medical Association. Clinical technical operation specification for pathology of organ transplantation (2019 edition): heart transplantation[J]. ORGAN TRANSPLANTATION, 2019, 10(4): 393-401. doi: 10.3969/j.issn.1674-7445.2019.04.008

器官移植病理学临床技术操作规范(2019版)—心脏移植

doi: 10.3969/j.issn.1674-7445.2019.04.008
基金项目: 

国家高技术研究发展计划(“国家863计划”) 2012AA021009

国家卫生和计划生育委员会行业科研专项基金 201302009

中国医学科学院医学与健康科技创新工程 2016-12M-01-015

中国医学科学院中央级公益性科研院所基本科研业务费专项基金 2018PT32018

华中科技大学自主创新基金 01-08-540149

详细信息
    通讯作者:

    郭晖,研究方向为移植病理学基础及临床应用研究,Email:zcguo@tjh.tjmu.edu.cn

  • 中图分类号: R617, R36

Clinical technical operation specification for pathology of organ transplantation (2019 edition): heart transplantation

  • 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,从移植心脏心内膜心肌活组织检查的临床操作规范、移植心脏排斥反应的病理学诊断临床技术操作规范、移植心脏的心肌缺血损伤的病理学诊断临床技术操作规范、移植心脏血管病的病理学诊断临床技术操作规范、移植后淋巴组织增生性疾病的病理学诊断临床技术操作规范、移植心脏心内膜心肌活组织检查病理报告的基本内容规范、移植心脏心内膜心肌活组织检查病理学诊断的难点与局限性、移植心脏病理学相关的其它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)之移植心脏病理学临床技术操作规范。

     

  • 图  1  组织块充足的活检和前次活检部位的病理学特征

    A图示EMB最大切面,组织块数量、大小、心肌组织比例均符合要求(标尺2.0 mm);B图示EMB活检组织内可见前次活检后在心内膜下形成的局灶性纤维疤痕组织,其中无单个核细胞浸润(HE,×100)

    Figure  1.  Pathological characteristics of biopsy with sufficient tissue mass and previous biopsy site

    图  2  不同病理分级移植心脏急性细胞性排斥反应的病理学特征

    A图为ACR 1R级,心肌间质局灶性少量单个核细胞浸润,但无明确心肌损伤(HE,×200);B图为ACR 1R级,心肌间质内单个局灶性的、较密集的单个核细胞浸润伴心肌细胞损伤(HE,×200);C图为ACR 2R级,心肌活检组织内两处局灶性的、密集的单个核细胞浸润,伴心肌细胞损伤并被炎性浸润替代,两处炎症灶接近融合(HE,×200);D图为ACR 3R级,心肌组织间质内弥漫性的、大量的单个核细胞浸润伴多灶心肌细胞损伤,心肌正常组织结构破坏(HE,×400)

    Figure  2.  Pathological characteristics of acute cellular rejection of cardiac allograft with different pathological grades

    图  3  移植心脏抗体介导的排斥反应的组织病理学特征

    A图示心肌间质水肿,毛细血管扩张,伴血管内细胞数量增多(HE,×200);B图示心肌间毛细血管内皮肿胀伴腔内巨噬细胞淋巴细胞聚集(活化的单个核细胞),呈组织病理学阳性(HE,×400)

    Figure  3.  Histopathological characteristics of antibody-mediated rejection in cardiac allograft

    图  4  移植心脏抗体介导的排斥反应的免疫病理学特征(免疫组化,×200)

    A图示多数心肌间毛细血管内皮可见C4d阳性的线样沉积,呈免疫病理学阳性;B图示较多心肌间毛细血管内可见CD68阳性巨噬细胞聚集,呈免疫病理学阳性

    Figure  4.  Immunopathological characteristics of antibody-mediated rejection in cardiac allograft

    图  5  移植心脏Quilty病变的组织病理学特征(HE,×200)

    A图示EMB活检组织内心内膜下部位局灶性、结节性单个核细胞浸润(↑);B图示心内膜淋巴细胞向深部扩展、浸润破坏浅层心肌;C图为B图邻近切面,可见ACR样改变

    Figure  5.  Histopathological characteristics of Quilty effect in cardiac allograft

    图  6  移植心脏后期心肌缺血损伤的病理学特征(HE,×200)

    图示因慢性排斥反应所致的移植心脏血管病,引起心肌局灶凝固性坏死伴较广泛空泡变性

    Figure  6.  Pathological characteristics of late myocardial ischemia injury in cardiac allograft

    图  7  移植心脏血管病与冠状动脉粥样硬化的病理学特征

    A图示CAV壁内小动脉内膜同心性纤维肌性增生伴内膜炎和动脉周围炎(HE,×100);B图示移植心脏心表冠状动脉偏心性粥样硬化斑块内脂质沉积、纤维化、钙化(HE,×20)

    Figure  7.  Pathological characteristics of cardiac allograft vasculopathy and coronary artery atherosclerosis

    图  8  心脏移植术前选择性EMB的病理学发现(HE,×400)

    A图示巨细胞性心肌炎,可见心肌局灶坏死,大量单核淋巴细胞和较多嗜酸性粒细胞浸润,多核巨细胞易见,但无明显的肉芽肿结节形成;B图示心肌淀粉样变性,心肌细胞间隙加宽,可见粉染、均质的淀粉样物质沉积

    Figure  8.  Pathological findings of selective EMB in the patients before cardiac transplantation

    表  1  移植心脏急性细胞性排斥反应的病理分级(ISHLT 2004年)[7]

    Table  1.   Pathological classification of acute cellular rejection in cardiac allograft (ISHLT 2004)

    级别 组织病理学改变
    0R 无排斥反应
    1R,轻度 间质或(和)血管周的炎性浸润,伴最多一灶心肌损伤
    2R,中度 两灶或多灶炎性浸润伴相关的心肌损伤
    3R,重度 弥漫的炎性浸润伴多灶心肌损伤±水肿±出血±血管炎
    R为ISHLT 2004年修订的级别,以区别于ISHLT 1990年的分级
    下载: 导出CSV

    表  2  移植心脏抗体介导性排斥反应的组织病理学诊断标准(ISHLT 2013年)[8]

    Table  2.   Histopathological diagnostic criteria of antibody-mediated rejection in cardiac allograft (ISHLT 2013)

    形态学标准 病理所见
    血管内活化的单个核细胞 心肌间毛细血管和小静脉内巨噬细胞聚集、扩张和充填血管腔
    内皮细胞胞核增大、胞浆肿胀,血管腔狭窄或梗阻
    重度AMR 心肌间质水肿、出血,心肌细胞坏死,毛细血管碎裂,混合的炎性细胞浸润,内皮细胞核固缩和(或)核碎裂
    下载: 导出CSV

    表  3  移植心脏抗体介导性排斥反应的病理学诊断分级方案(ISHLT 2013年)[6]

    Table  3.   Pathological grading diagnosis of antibody-mediated rejection in cardiac allograft

    分级 定义 病理基质
    pAMR 0 病理学的AMR阴性 组织学和免疫病理学实验双阴性
    pAMR 1(H+) 单一组织病理学的AMR 组织学阳性,而免疫病理学阴性
    pAMR 1(I+) 单一免疫病理学的AMR 组织学阴性,而免疫病理学阳性[CD68阳性和(或)C4d阳性]
    pAMR 2 病理学的AMR 组织学和免疫病理学双阳性
    pAMR 3 重度病理学的AMR 间质出血,毛细血管破裂,混合的炎性细胞浸润,内皮细胞核固缩和(或)核碎裂,明显的水肿并有免疫病理学阳性。与重度的血流动力学异常和不良预后相关
    下载: 导出CSV

    表  4  移植心脏抗体介导性排斥反应的临床分期[10]

    Table  4.   Clinical stages of antibody-mediated rejection in cardiac allograft

    顺序 AMR分期 主要特征
    1 亚临床期 DSA阳性,无移植心功能损伤或衰竭的病理学证据
    2 临床前期 有移植心功能损伤的病理学证据,但无心功能衰竭,无临床症状
    3 急性临床期 有移植心功能损伤的病理学证据,有心功能衰竭,有或无临床症状
    4 慢性期 移植心脏血管病,或慢性移植物功能衰竭,或限制性心脏生理学改变
    限制性心脏生理学改变指心脏射血分数保留的心功能受损状态
    下载: 导出CSV

    表  5  移植心脏血管病与冠状动脉粥样硬化的血管病理学特征比较

    Table  5.   Comparison of vascular pathological features between cardiac allograft vasculopathy and coronary artery atherosclerosis

    病理学特征 移植心脏血管病 冠状动脉粥样硬化
    受累血管 所有血管类型,主要累及壁内血管 近端冠状动脉
    斑块类型 弥漫,同心性 局灶,偏心性
    血管炎症 罕见
    内弹力板 完整 破坏
    钙盐沉积
    下载: 导出CSV
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  • 收稿日期:  2019-03-21
  • 网络出版日期:  2021-01-19
  • 刊出日期:  2019-07-15

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