vtioВестник трансплантологии и искусственных органовRussian Journal of Transplantology and Artificial Organs1995-1191Academician V.I.Shumakov National Medical Research Center of Transplantology and Artificial Organs", Ministry of Health of the Russian Federation10.15825/1995-1191-2018-1-45-54vtio-854Research ArticleКлиническая трансплантологияClinical TransplantologyМОРФОЛОГИЧЕСКАЯ СТРУКТУРА ПАТОЛОГИИ ПОЧЕЧНОГО АЛЛОТРАНСПЛАНТАТА И ЕЕ ВЛИЯНИЕ НА ОТДАЛЕННЫЙ ПРОГНОЗMORPHOLOGICAL STRUCTURE OF LATE RENAL GRAFT DYSFUNCTION AND ITS EFFECT FOR LONG-TERM RESULTSСтоляревичЕ. С.StolyarevichE. S.

Столяревич Екатерина Сергеевна, кафедра нефрологии ФПДО

123182, г. Москва, ул. Пехотная, д. 3

Stolyarevich Ekaterina Sergeevna, Nephrology Chair

123182, Pekhotnaya str., 3, Moscow

Stolyarevich@yandex.ruЖилинскаяТ. Р.ZhilinskayaT. R.АртюхинаЛ. Ю.ArtyukhinaL. Yu.КимИ. Г.KimI. G.ЗайденовВ. А.ZaydenovV. A.ТомилинаН. А.TomilinaN. A.

Кафедра нефрологии ФПДО

Москва

Nephrology Chair

Moscow

ФГБУ «Национальный медицинский исследовательский центр трансплантологии и искусственных органов имени академика В.И. Шумакова» ; ГБУЗ «Городская клиническая больница № 52 Департамента здравоохранения г. Москвы», Московский городской нефрологический центр; ФГБОУ ВО «Московский государственный медико-стоматологический университет им. А.И. Евдокимова»РоссияV.I. Shumakov National Medical Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian Federation; City Clinical Hospital No. 52 of the Moscow City Health Department; A.I. Yevdokimov Moscow State University of Medicine and DentistryRussian FederationГБУЗ «Городская клиническая больница № 52 Департамента здравоохранения г. Москвы», Московский городской нефрологический центрРоссияCity Clinical Hospital No. 52 of the Moscow City Health DepartmentRussian FederationФГБУ «Национальный медицинский исследовательский центр трансплантологии и искусственных органов имени академика В.И. Шумакова»РоссияV.I. Shumakov National Medical Research Center of Transplantology and Artifi cial Organs of the Ministry of Healthcare of the Russian FederationRussian Federation2018240420182014554Copyright © Столяревич Е.С., Жилинская Т.Р., Артюхина Л.Ю., Ким И.Г., Зайденов В.А., Томилина Н.А., 20182018Столяревич Е.С., Жилинская Т.Р., Артюхина Л.Ю., Ким И.Г., Зайденов В.А., Томилина Н.А.Stolyarevich E.S., Zhilinskaya T.R., Artyukhina L.Y., Kim I.G., Zaydenov V.A., Tomilina N.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.transpl.ru/vtio/article/view/854

Цель настоящего исследования – проанализировать частоту встречаемости и отдаленный прогноз различных морфологических вариантов дисфункции трансплантата, а также определение особенностей, влияющих на течение нефропатии.

Материалы и методы

Материалы и методы. Проанализированы клинико-лабораторные и морфологические данные 1470 пациентов с дисфункцией трансплантата, развившейся в среднем через 48,6 ± 46,1 мес. после АТП и проявлявшейся повышением уровня креатинина крови до 0,23 ± 0,14 ммоль/л. Морфологическая диагностика причины дисфункции проводилась в соответствии с Banffклассификацией.

Результаты

Результаты. В морфологической структуре дисфункции преобладали случаи острого (26,8%) и хронического (12,4%) отторжения, в 35,1% случаев выявлялся нефросклероз с признаками нефротоксичности СNI (19,3%) или без таковых (15,8%). В 10,6% причиной дисфункции был возвратный либо de novo гломерулонефрит трансплантата. Структура дисфункции менялась в зависимости от срока выполнения биопсии: в первый год после АТП преобладали случаи функциональных нарушений (21%) и острое отторжение трансплантата (40,5%). По мере увеличения срока частота острого отторжения снижалась, при этом доля гуморального отторжения возрастала от 28 до 52% всех случаев острого отторжения. Частота хронического отторжения, нефросклероза, не связанного с иммунным ответом, и возвратной патологии, напротив, возрастала с 13, 26 и 5,5% в первый год до 26,4, 35,3 и 22,8% в поздние сроки после АТП. Выживаемость трансплантатов к 8 годам составляла у пациентов с функциональными изменениями 76%, при нефросклерозе, с признаками или без признаков нефротоксичности СNI – 62%, при возвратной / de novo патологии – 42%, при остром отторжении – 38%, а при ХОТ – лишь 5%. Ухудшение прогноза при C4d-позитивном отторжении отмечалось лишь в случаях острого, но не хронического отторжения. Наличие признаков CNI-нефротоксичности значимого влияния на прогноз не оказывало.

Заключение

Заключение. Патология почечного трансплантата гетерогенна по своей морфологической структуре и меняется в зависимости от срока после АТП. Наиболее частыми причинами дисфункции являются острое и хроническое отторжение трансплантата, неспецифический нефросклероз, в том числе с признаками CNIнефротоксичности, а также возвратная патология. Наихудший прогноз отмечался при ХОТ, несколько более высокая выживаемость трансплантатов отмечалась при остром отторжении и возвратной патологии. Нефросклероз, не связанный с активацией иммунного ответа, как с признаками CNI-нефротоксичности, так и без таковых, в наименьшей степени сказывался на отдаленном прогнозе АТП.

Aim

Aim: to analyze the frequency of different histological diagnoses and it simpact on graft survival in a cohort of patients with renal allograft dysfunction, and to determine pathology features, infl uencing prognosis.

Materials and methods

Materials and methods. The data obtained from 1470 biopsies, performed by indication at different time after kidney transplantation (48.8 ± 46.1 months) were analyzed retrospectively according to the Banff 2013 classifi cation.

 Results

 Results. The majority of graft dysfunction episodes were attributed to fi ve causes: acute (26,8%) and chronic (12,4%) rejection; chronic nephrotoxicity of СNI (19,3%), interstitial fi brosis/tubular atrophy (15,8%) and recurrent or de novo glomerulonephritis (10,6%). T-cell-mediated acute rejection and functional disorders were the most often cause of dysfunction during the fi rst year after transplantation (40,5% and 21% respectively) but decreased over time. On the other hand, the frequency of chronic rejection, interstitial fi brosis/tubular atrophy with or without СNI nephrotoxicity and recurrent or de novo glomerulonephritis increased from 13%, 26% and 5,5% at the fi rst year to 26,4%, 35,3% and 22,8% respectively at 8 year after transplantation. Chronic rejection represented a major risk for graft loss – 8-year graft survival did not exceed 5%. The prognosis of acute rejection as well as de novo or recurrent glomerular pathologies was more favorable (38% and 42% respectively). In cases of interstitial fi brosis/tubular atrophy with or without СNI nephrotoxicity 8-year graft survival was slightly lower than in the functional disorders (62% and 76%). In acute rejection prognosis for C4d-positive forms was worse compared to C4d-negative, while in chronic rejection there was no difference between C4d-positive and C4d-negative forms. The features of СNI nephrotoxicity did not infl uence the prognosis of non-specifi c interstitial fi brosis and tubular atrophy.

Conclusion

Conclusion. Transplant pathology in patients with allograft dysfunction is heterogeneous and changes over time. Acute and chronic rejection; interstitial fi brosis/tubular atrophy with or without СNI nephrotoxicity and recurrent/de novo glomerular pathology are the most often causes of graft dysfunction, but only rejection (mostly chronic) and glomerular pathology are associated with unfavorable prognosis.

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The authors declare that there are no conflicts of interest present.