刘君昌 高小林 刘兴凯 姜泰茂

【摘要】急性排斥反应是目前肾移植术后的主要并发症，也是导致慢性排斥反应和移植肾失功的重要原因。临床出现不典型急性排斥反应，可能影响临床医师的判断，从而造成病情延误，对移植肾造成极大的损害。该例肾移植患者在术后早期出现血清肌酐反弹升高，临床各项指标（尿量、他克莫司药物浓度、移植肾检查）均在正常范围，给予患者调整抗排斥药物、应用IgG治疗，血清肌酐仍进行性升高，复查供体特异性抗体、群体反应抗体检测结果均正常，最后通过移植肾穿刺活组织检查（活检）确定为细胞介导的急性排斥反应，给予大剂量糖皮质激素冲击治疗，临床血清肌酐水平下降，其后每周随访复查结果良好。该例的诊治过程提示，移植肾穿刺活检的病理学观察可以及时、准确地诊断肾移植术后的合并症，对于降低移植肾风险、提高移植人/肾存活率至关重要。

【关键词】肾移植;细胞介导急性排斥反应;移植肾穿刺活组织检查

【Abstract】Acute rejection is the main complication after renal transplantation， and a major cause of chronic rejection and graft failure. The incidence of atypical acute rejection in clinical practice may affect the judgment of clinicians， thereby leading to treatment delay and severe damage to renal graft. In this study， the patient experienced an increase in the creatinine level in the early stage after renal transplantation， whereas all clinical parameters （urine volume， tacrolimus concentration， and renal graft examination） were all within the normal range. The patient was given with anti-rejection drugs and treated with human immunoglobulin. The serum creatinine level remained progressively elevated. Re-examination results of donor-specific antibody （DSA） and panel reactive antibody （PRA） were normal. Finally， the diagnosis of acute rejection mediated by cell was confirmed by renal graft biopsy. High-dose corticosteroids shock therapy was delivered. Clinical serum creatinine levels were declined. Normal results were obtained during the follow-up every week. The diagnosis and treatment of this case prompted that pathological observation during renal graft biopsy can timely and accurately diagnose the complications after renal transplantation， which plays a pivotal role in lowering the risk of renal graft and enhancing the survival of recipients and renal graft.

【Key words】Kidney transplantation;Acute rejection mediated by cell;Renal graft biopsy

隨着新型免疫抑制药物的广泛应用，移植肾排斥发生率明显降低，移植人/肾存活率大大提高，目前同种异体肾移植已成为终末期肾病的有效治疗手段。但急性排斥反应（AR）是目前肾移植术后的主要并发症，也是导致慢性排斥反应和移植肾失功的最重要原因[1]。临床出现不典型AR，可能影响临床医师的判断，从而造成病情延误，对移植肾造成极大的损害。因此，对于AR要尽可能快地作出早期诊断，及时治疗，防患于未然，减少对移植物的损害，进一步提高肾移植术后人/肾的长期存活有重要意义。……