1例小肠移植术后抗体介导的血管性排斥反应诊断与治疗  

Antibody-mediated vascular rejection after intestine transplantation:A case report

作　　者：李元新[1] 石炳毅[1] 刘磊[1] 王雅文[1] 陈莉萍[1] 梁玉梅[2] 曹兵生[3] 

机构地区：[1]解放军第309医院全军器官移植中心"器官移植与免疫调节北京市重点实验室",北京100091 [2]解放军第309医院病理科,北京100091 [3]解放军第309医院超声诊断科,北京100091

出　　处：《军医进修学院学报》2012年第1期12-15,共4页Academic Journal of Pla Postgraduate Medical School

基　　金：军队"十一五"科技攻关项目(08G133)~~

摘　　要：目的报道1例临床资料,结合文献回顾对小肠移植术后急性血管性排斥反应(AVR)诊断和治疗进行总结。方法小肠移植术前进行组织交叉配型、群体反应抗体(PRA)检测。免疫抑制方案采用阿来佐单体诱导,术后单用他克莫司维持方案。移植肠末端腹壁造口黏膜色泽暗紫是AVR典型表现,但需排除外科技术并发症。AVR病理诊断为小血管内炎症细胞边集、血管内纤维素和血小板样沉积,管腔内有不同程度血栓形成,动脉壁纤维蛋白样坏死,C4d染色阳性。根据血管损伤严重程度,小肠移植AVR可分为0级和1-3级。结果淋巴细胞毒试验及PRA均阴性,术后40h发现移植造口发暗,B超显示移植肠血管通畅,术后44h造口液转为血性,行剖腹探查术发现移植肠已失去生机,遂切除移植肠。病理诊断重度血管性排斥反应(3级),C4d染色阳性。结论黏膜色泽暗紫是AVR典型临床表现,但需排除外科技术并发症。对于轻度的AVR,早期、及时的诊断和积极治疗可挽救移植肠,但重度AVR移植肠的切除率非常高。Objective To report a case of acute vascular rejection（AVR） after intestine transplantation and summarize its diagnosis and treatment by reviewing its related literature. Methods Panel reactive antibody（PRA） was cross-matched and detected before intestine transplantation. Immune suppression was induced by Alemtuzumab and t0crolimus was used in maintenance treatment after operation. Dark purple stoma mucous membrane of abdominal wail was a typical indication of AVR and the complication of surgery should be excluded before it was diagnosed. Pathological diagnostic criteria for AVR included inflammatory cells, sedimentation of fibrin and platelets, and thrombi in blood vessels, fibrinoid necrosis of artery wall, and positive staining of C4. AVR after intestine transplantation could be classified as grades 0-3 according to the severity of blood vessel injury. Results Lymphocytotoxicity test （LCT） and PRA were negative. The stoma for transplantation became dark 40h after operation. B type ultrasonic examination showed that the transplanted intestine was patent. Bloody fluid was found at the stoma 44h after operation. Exploratory laporatomy revealed that the viability of transplanted intestine was lost, thus severe AVR（grade 3） was diagnosed with C4d positively stained. Conclusion Dark purple stoma mucous membrane is a typical clinical manifestation of AVR. Complication of surgery should be excluded before it is diagnosed. Early diagnosis and active treatment can avoid intestine transplantation for mild AVR. However, the resection rate of transplanted intestine for severe AVR is extremely high.

关 键 词：小肠移植 急性血管性排斥反应 补体C4d 

分 类 号：R617[医药卫生—外科学]