小肠移植后亚临床排斥反应的临床病理研究一例

目的 探讨小肠移植后亚临床型细胞性排斥反应(SCR)的临床表现、肠镜下改变和病理特点.方法 小肠移植1例,受者为女性,34岁,供者为男性.应用抗CD52单克隆抗体行诱导治疗,术后单用他克莫司(Tac)、无皮质激素的维持治疗方案.怀疑发生可疑排斥反应(IND)级至I级排斥反应时,提高血Tac浓度,行短程小剂量皮质激素治疗,排斥反应控制不佳时,则行甲泼尼龙冲击治疗;发生中度排斥反应时提高血Tac浓度,给予甲泼尼龙2 g,随后应用皮质激素递减方案.术后头2个月内,每周行2次肠镜和病理学检查,之后频次减为1次/周.结果 至随访结束患者已存活19个月(611 d),期间共发生有临床症状的急性排斥反应6次,亚临床排斥反应3次.3次亚临床排斥反应时,2次肠镜下未见明显改变,1次表现为斑点状的充血、水肿,放大肠镜下绒毛数量轻度减少.3次亚临床排斥反应的病理检查中,1次以黏膜上皮剥脱为主,隐窝上皮损伤较轻,组织学改变符合轻度急性排斥反应;而另2次以隐窝上皮的损伤为主,为可疑急性排斥反应.结论 SCR可能是临床排斥反应的早期阶段,无明显临床症状,肠镜下改变不明显,诊断主要依靠病理学检查,但必须排除移植肠血管病变、肠梗阻、各类炎症等术后并发症.

Clinicopathological study of subclinical cellular rejection after isolated small bowel transplantation

Objective To investigate the clinical presentation, endoscopy and pathological features of subclinical cellular rejection (SCR) of small bowel allotransplantation. Methods Three times of SCR in a patient after isolated small bowel transplantation were studied by endoscopy and microscopy, and the clinical data and literature were reviewed. Results SCR was an unusual type of acute rejection after small bowel transplantation. SCR showed low-grade morphological changes of acute rejection, and may be relived after low-dose steroid or bolus steroid was given. Conclusion The causes of SCR are not clear now. SCR may be the early stage of clinical acute rejections, and may be correlated with unexpected high grade acute rejection, and chronic loss function of graft. The biopsy through ileoscopy is a "golden standard" of diagnosis of SCR in small bowel transplantation.However, the vessel lesions of graft, ileus, and inflammation should be excluded before diagnosis.