慢性移植肾肾病不同病理类型的预后及其相关因素的研究
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摘要
目的：慢性移植肾肾病(chronic allograft nephropathy, CAN)是晚期移植肾失功的首要原因,其病因复杂。Banff2005在病理诊断上删除了CAN这一概念,代之以间质纤维化和肾小管萎缩(interstitial fibrosis and tubular atrophy, IF/TA),同时引入了两个新的病理类型：慢性抗体介导的排斥(chronic antibody-mediated rejection, CAMR),慢性T-细胞介导的排斥(chronic T-cell mediated rejection, CTMR)。目前关于CAMR和CTMR的临床指标和预后的资料报道有限。本研究着眼于分析比较IF/TA、CAMR、CTMR和其他类型的慢性移植肾肾病的预后及其相关因素。
方法：本研究回顾性分析2004年1月至2012年6月期间我院肾脏病中心经活检诊断的CAN病例130例(其中35例为切除肾活检标本),应用banff05标准对当时诊断“CAN”的病理进行病因细化诊断,并提取以下临床和病理指标：肾移植至临床诊断CAN的时间、肾移植至活检的时间、移植肾存活时间、基础eGFR(应用MDRD公式,肾移植后1年内最低血肌酐所对应的GFR)、活检时的eGFR、每年的△eGFR (较基础eGFR下降的百分比)、HLA错配数、急性排异发生率、病理C4d评分、是否为切除肾活检标本等。从肾移植手术到2012年6月,从临床诊断CAN(超过6个月,3次检测显示SCr上升30%)到2012年6月,分别采用Kaplan-Meier法分析不同病理类型的预后。采用COX回归模型,分别对受体性别、手术年龄、供肾重量、冷缺血时间、基础血肌酐、基础eGFR、HLA错配数、急性排异发生率、病理C4d评分、是否为切除肾活检标本10项研究因素进行单因素及多因素分析。
结果：130例CAN病例中,IF/TA组62例(47.69%),CAMR组27例(20.77%),CTMR组30例(23.08%),慢性钙调磷酸酶抑制剂(calcineurin inhibitor, CNI)中毒性肾病组10例(7.692%),多瘤病毒性肾病1例(0.769%)。前四组肾移植至临床诊断CAN的中位时间分别为55.5(5-209)个月,86.0(9-200)个月,25.5(3-126)个月和116(49-172)个月。肾移植至活检的中位时间分别为56.5(2-209)个月,92.0(44-200)个月,121.5(7-241)个月和116(49-172)个月。活检时的eGFR分别为42±16ml/min·1.73m2,36±23ml/min·1.73m2,8±4ml/min·1.73m2,和46±10ml/min·1.73m2。从肾移植手术到2012年6月的生存分析显示,移植肾各个病理分类预后不同(P=0.000)。CTMR与其他组相比,具有较差的预后：CTMR vs IF/TA (P=0.002); CTMR vs CAMR (P=0.027); CTMR vs CNI (P=0.000)。CNI与CAMR相比,预后较好(P=0.008)。CNI与IF/TA相比,预后较好(P=0.021)。从肾移植到2012年6月的单因素分析显示,HLA错配数(P=0.001,RR=1.311)和急性排异(P=0.012,RR=1.974)这2项因素与移植肾预后差相关。多因素分析后,HLA错配数(P=0.003,RR=1.283)和急性排异(P=0.033,RR=1.855)对于移植肾存活率都有显著影响。分组后的多因素分析显示,非免疫因素参与组(IF/TA62例+CNI10例)HLA错配数(P=0.287,RR=1.140)和急性排异(P=0.909,RR=0.948)对移植肾预后影响不明显；免疫因素参与组(CAMR27例+CTMR30例)HLA错配数(P=0.002,RR=1.419)和急性排异(P=0.007,RR=2.768)显著增加预后不良风险。从临床诊断CAN到2012年6月的单因素分析显示,HLA错配数(P=0.069,RR=1.170)和急性排异(P=0.063,RR=1.651)这2项因素对预后影响不明显。分组后的多因素分析显示,非免疫因素参与组(IF/TA62例+CNI10例)HLA错配数(P=0.825,RR=0.972)和急性排异(P=0.554,RR=0.759)对移植肾预后影响不明显；免疫因素参与组(CAMR27例+CTMR30例)HLA错配数(P=0.011,RR=1.320)和急性排异(P=0.014,RR=2.422)显著增加预后不良风险。
结论：CAN的病理诊断类型中,CTMR和CAMR的预后可能较差,CNI的预后较好。在CTMR和CAMR的患者中,HLA错配数和急性排异显著增加预后不良风险。而在IF/TA和CNI的患者中,HLA错配数和急性排异对预后影响不明显。
Objective:Chronic antibody-mediated rejection (CAMR) and chronic T-cell mediated rejection (CTMR) were two new categories introduced in the Banff2005. Current knowledge about the natural history, prognosis-related factors of CAMR and CTMR is limited. This study compared the survival and prognosis-related factors of CAMR, CTMR and other types of chronic allograft nephropathy (OT-CAN).
Method:This study enrolled130transplant recipients with biopsy-proven CAN in Kidney Disease Center,1st Affiliated Hospital of College of Medicine, Zhejang University, China, between January,2004and July2012. They were classified into four groups:IF/TA, CAMR, CTMR and CNI. Their survival data was obtained via medical records and telephone follow up. All statistical analyses were carried out using SPSS20software package.
Result:We diagnosed62IF/TA,27CAMR,30CTMR and10CNI. The median time from kidney transplantation to biopsies was56(2-209) months in IF/TA,92(44-200) months in CAMR,122(7-241) months in CTMR, and116(49-172) months in CNI. The eGFR (MDRD) at the time of biopsies was42±16ml/min·1.73m2,36±23ml/min·1.73m2,8±4ml/min·1.73m2, and46±10ml/min·1.73m2, separately. The median time from kidney transplantation to clinical diagnosis of CAN was55.5(5-209) months,86.0(9-200) months,25.5(3-126) months and116(49-172) months. Death-censored graft survival from transplantation was worse in CTMR compared with IF/TA (P=0.002), CAMR (P=0.027) and CNI (P=0.002). HLA mismatches and acute rejection were negatively correlated with the long-term survival of patients with CTMR and CAMR.
Conclusion:Graft survival from transplantation may be worse in patients with CTMR and CAMR, and may be better in patients with CNI. HLA mismatches and acute rejection were risk factors for patients with CTMR and CAMR.
方法：本研究回顾性分析2004年1月至2012年6月期间我院肾脏病中心经活检诊断的CAN病例130例(其中35例为切除肾活检标本),应用banff05标准对当时诊断“CAN”的病理进行病因细化诊断,并提取以下临床和病理指标：肾移植至临床诊断CAN的时间、肾移植至活检的时间、移植肾存活时间、基础eGFR(应用MDRD公式,肾移植后1年内最低血肌酐所对应的GFR)、活检时的eGFR、每年的△eGFR (较基础eGFR下降的百分比)、HLA错配数、急性排异发生率、病理C4d评分、是否为切除肾活检标本等。从肾移植手术到2012年6月,从临床诊断CAN(超过6个月,3次检测显示SCr上升30%)到2012年6月,分别采用Kaplan-Meier法分析不同病理类型的预后。采用COX回归模型,分别对受体性别、手术年龄、供肾重量、冷缺血时间、基础血肌酐、基础eGFR、HLA错配数、急性排异发生率、病理C4d评分、是否为切除肾活检标本10项研究因素进行单因素及多因素分析。
结果：130例CAN病例中,IF/TA组62例(47.69%),CAMR组27例(20.77%),CTMR组30例(23.08%),慢性钙调磷酸酶抑制剂(calcineurin inhibitor, CNI)中毒性肾病组10例(7.692%),多瘤病毒性肾病1例(0.769%)。前四组肾移植至临床诊断CAN的中位时间分别为55.5(5-209)个月,86.0(9-200)个月,25.5(3-126)个月和116(49-172)个月。肾移植至活检的中位时间分别为56.5(2-209)个月,92.0(44-200)个月,121.5(7-241)个月和116(49-172)个月。活检时的eGFR分别为42±16ml/min·1.73m2,36±23ml/min·1.73m2,8±4ml/min·1.73m2,和46±10ml/min·1.73m2。从肾移植手术到2012年6月的生存分析显示,移植肾各个病理分类预后不同(P=0.000)。CTMR与其他组相比,具有较差的预后：CTMR vs IF/TA (P=0.002); CTMR vs CAMR (P=0.027); CTMR vs CNI (P=0.000)。CNI与CAMR相比,预后较好(P=0.008)。CNI与IF/TA相比,预后较好(P=0.021)。从肾移植到2012年6月的单因素分析显示,HLA错配数(P=0.001,RR=1.311)和急性排异(P=0.012,RR=1.974)这2项因素与移植肾预后差相关。多因素分析后,HLA错配数(P=0.003,RR=1.283)和急性排异(P=0.033,RR=1.855)对于移植肾存活率都有显著影响。分组后的多因素分析显示,非免疫因素参与组(IF/TA62例+CNI10例)HLA错配数(P=0.287,RR=1.140)和急性排异(P=0.909,RR=0.948)对移植肾预后影响不明显；免疫因素参与组(CAMR27例+CTMR30例)HLA错配数(P=0.002,RR=1.419)和急性排异(P=0.007,RR=2.768)显著增加预后不良风险。从临床诊断CAN到2012年6月的单因素分析显示,HLA错配数(P=0.069,RR=1.170)和急性排异(P=0.063,RR=1.651)这2项因素对预后影响不明显。分组后的多因素分析显示,非免疫因素参与组(IF/TA62例+CNI10例)HLA错配数(P=0.825,RR=0.972)和急性排异(P=0.554,RR=0.759)对移植肾预后影响不明显；免疫因素参与组(CAMR27例+CTMR30例)HLA错配数(P=0.011,RR=1.320)和急性排异(P=0.014,RR=2.422)显著增加预后不良风险。
结论：CAN的病理诊断类型中,CTMR和CAMR的预后可能较差,CNI的预后较好。在CTMR和CAMR的患者中,HLA错配数和急性排异显著增加预后不良风险。而在IF/TA和CNI的患者中,HLA错配数和急性排异对预后影响不明显。
Objective:Chronic antibody-mediated rejection (CAMR) and chronic T-cell mediated rejection (CTMR) were two new categories introduced in the Banff2005. Current knowledge about the natural history, prognosis-related factors of CAMR and CTMR is limited. This study compared the survival and prognosis-related factors of CAMR, CTMR and other types of chronic allograft nephropathy (OT-CAN).
Method:This study enrolled130transplant recipients with biopsy-proven CAN in Kidney Disease Center,1st Affiliated Hospital of College of Medicine, Zhejang University, China, between January,2004and July2012. They were classified into four groups:IF/TA, CAMR, CTMR and CNI. Their survival data was obtained via medical records and telephone follow up. All statistical analyses were carried out using SPSS20software package.
Result:We diagnosed62IF/TA,27CAMR,30CTMR and10CNI. The median time from kidney transplantation to biopsies was56(2-209) months in IF/TA,92(44-200) months in CAMR,122(7-241) months in CTMR, and116(49-172) months in CNI. The eGFR (MDRD) at the time of biopsies was42±16ml/min·1.73m2,36±23ml/min·1.73m2,8±4ml/min·1.73m2, and46±10ml/min·1.73m2, separately. The median time from kidney transplantation to clinical diagnosis of CAN was55.5(5-209) months,86.0(9-200) months,25.5(3-126) months and116(49-172) months. Death-censored graft survival from transplantation was worse in CTMR compared with IF/TA (P=0.002), CAMR (P=0.027) and CNI (P=0.002). HLA mismatches and acute rejection were negatively correlated with the long-term survival of patients with CTMR and CAMR.
Conclusion:Graft survival from transplantation may be worse in patients with CTMR and CAMR, and may be better in patients with CNI. HLA mismatches and acute rejection were risk factors for patients with CTMR and CAMR.
引文
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[4]Halloran PF. Call for revolution:a new approach to describing allograft deterioration. Am J Transplant.2002 Mar;2(3):195-200.
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