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目的通过对心死亡捐献(donation after cardiac death,DCD)供肾零点穿刺与相应受者程序性活检结果的对照,观察DCD供肾的病理改变及移植后转归,探讨其应用于移植的病理学标准。方法选取2011年7月~2013年1月解放军303医院开展的DCD案例中选取5例缺血再灌注损伤(ischemia-reperfusion injury,IRI)较重的中国Ⅲ型(C-Ⅲ)供肾进行零点穿刺。分别于移植后3、6个月进行程序性活检,观察病理变化并进行分析。结果 5例供肾灌注后呈灰白灰红、暗红色,质韧,质地均匀,无或轻微肿胀,被膜完整。光镜下见肾小球结构大致正常,30%~50%的肾皮质近曲小管上皮细胞不同程度变性、坏死和脱落。10例受者中8例出现移植肾功能延迟恢复,其中6例接受术后3个月活检,另2例接受术后3个月及6个月活检。术后3个月7例活检未见明显肾小管坏死,1例仍有≤20%区域无明显改善。8例近曲小管上皮均不同程度空泡变性,提示钙调磷酸酶抑制剂(calcineurin inhibitor,CNI)中毒。术后6个月非同源供肾活检2例,镜下分别表现为CNI中毒及慢性排斥反应。结论 DCD供肾IRI损伤多导致近曲小管病变且可逆,对其余结构影响小,肾功能可不同程度恢复,C-Ⅲ型供肾的应用较为安全,但损伤重者供肾功能恢复较慢,恢复程度欠佳,远期存活尚需观察。近曲小管坏死50%、其余结构无明显损伤,可作为移植的应用标准供进一步证实和修订。
OBJECTIVE: To observe the pathological changes of DCD donor kidneys and the prognosis of post-transplant donation after cardiac death (DCD) standard. Methods From July 2011 to January 2013, 5 Chinese DCs (C-Ⅲ) with ischemia-reperfusion injury (IRI) puncture. Procedural biopsies were performed 3 and 6 months after transplantation to observe the pathological changes and analyze them. Results After renal perfusion in 5 cases, grayish grayish red, dark red, quality and toughness, uniform texture, no or slight swelling and complete capsule were observed. Light microscope, see the glomerular structure is generally normal, 30% to 50% of renal cortical proximal tubule epithelial cells of varying degrees of degeneration, necrosis and fall off. Eight of 10 recipients had delayed graft function recovery, 6 of whom underwent 3 months postoperative biopsy and the other 2 received 3 and 6 months postoperative biopsy. No obvious tubular necrosis was found in the 7 biopsies 3 months after operation, and no significant improvement was found in the area of ≤20% in 1 patient. 8 cases of proximal tubule epithelium were different degrees of vacuolar degeneration, suggesting that calcineurin inhibitor (calcineurin inhibitor, CNI) poisoning. There were 2 cases of non-homologous donor biopsies 6 months after surgery, and CNI poisoning and chronic rejection were observed under microscope. CONCLUSIONS: Infarction with DCI is more likely to cause proximal convoluted tubule lesion in IRI patients. It has less effect on other structures and renal function can be recovered to different degrees. C-Ⅲ type renal insufficiency is more safe, however, Poor recovery, long-term survival needs to be observed. Near the tubule necrosis 50%, the remaining structure without significant damage, can be used as a transplant standard for further confirmation and revision.