【作者】 苏茂生；

【导师】 周宁新；

【作者基本信息】 中国人民解放军军医进修学院 ， 肝胆外科， 2004， 硕士

【摘要】 作为治疗终末期肝胆疾病、先天并口代谢性肝病及肝肿瘤等的有效手段，肝移植得到迅猛发展。在手术技术得到解决之后，与围手术期治疗有关的处理尤其是急慢性排斥反应成为制约肝移植近、远期疗效和长期存活的关键。 迄今为止，在临床尚不能诱导特异的免疫耐受的情况下，免疫抑制仍是肝移植术后防治排斥的主要措施。虽然免疫抑制剂更新换代，但至今排斥反应仍有很高的发生率，可达50％～90％。如何早期诊断及鉴别诊断排斥反应，如何更有效的防治排斥反应，成为需要解决的问题。 很多因素影响排斥反应的发生及治疗效果，明确这些影响因素，将对排斥反应的防治做到合理、个体化。 移植肝穿刺病理检查在肝移植术后排斥反应的诊断和鉴别中称为“金标准”，但仍有相当一部分病例不能依靠单纯的病理确诊，探索特异的诊断指标具有重要的意义，颗粒酶B、Fas-L作为排斥反应公认的效应指标，检测其在移植肝中的表达对排斥反应具有指导意义。另外，IL-2是免疫细胞活化并引发排斥反应的重要细胞因子，动态监测sIL-2R含量对肝移植术后早期诊断排斥反应具有重要意义。解放军军医进修学院硕士学位论文【目的】本课题分为两部分，第一部分从临床入手，观察分析61例肝移植围手术期的临床诊治，分析研究影响排斥反应防治的诸多因素。第二部分实验部分，首先通过16例26次移植后肝脏穿刺活检HE染色病理结果的RAI分析评分、Ba nff分级，区分排斥反应类型及程度。然后通过免疫组织化学的方法检测移植肝颗粒酶B、Fas一L的表达及应用ELISA方法动态检测移植后外周血s工L一ZR的含量;最后对二者不同排斥情况下的表达及浓度进行综合评价，寻找其在肝移植中的规律，为肝移植术后排斥反应更合理、个体化的防治提供实验依据。 【方法】1.回顾分析解放军总医院肝胆外科2002年6月至2003年12月收治的61例肝移植患者，就免疫抑制药物的使用、配型、原发病、术前肝功能、性别、年龄等方面进行分析，探讨影响肝移植术后排斥反应发生和疗效的因素.2.收集2002年6月至2004年1月肝穿标本16例26次，HE染色、免疫组化检测颗粒酶B、FaS一L的表达。3.收集16例肝移植术前1天，术后1、3、5、7、10、14、18、21天晨外周血，用ELISA方法检测移植后外周血s工卜ZR的含量;4.用Banff半定量分级方案，对所有HE染色切片进行RA工评分，区分急、慢性及轻、中、重程度;依据排斥反应不同情况，综合分析颗粒酶B/FaS一L的表达情况及5 IL一ZR的含量。数据行统计学处理。 【结果】1.61例肝移植(除7例早期死亡外，计54例)，发生排斥反应情况共38例(70.4%)，其中急性排斥37例(68.5%)，慢性排斥1例 (1.9%)。免疫抑制方案以“FK506+MMF+Pred”三联为主，优于使用CsA组，激素的使用时间较长，出现感染、肿瘤复发及高血糖的机率较高;血型基本相符者2例，均发生急排;原发病中以肝硬化和胆管癌排斥反应高，其次为肝癌;性别中女性5例，排斥3例;年龄中小儿及老龄排斥率高于中间年龄(P<0.05)。2.16例26次肝穿中不明确4例5次(19.23%)，解放军军医进修学院硕士学位论文轻度J急性排斥4例6次(23.08%)，中度急性排斥5例6次(23.08%)，重度急性排斥5例5次(19.23%)，，漫性排斥11级1例1次(3.85%)，111级1例3次(1 1 .54%)，无I级;颗粒酶B阳性16例次，Fas一L阳性14例次，与对照相比P<0.05，排斥反应组与不排斥组及对照组相比P<0.01;3.术后外周血s工L一ZR检测显示其含量随术后时日增高，7一14天为著，随着排斥反应的被控制而逐渐下降，与对照组比较排斥组P<0.以，排斥组术后与术前比较P<0.05，排斥组与不排斥组比较P<0.01。【结论]1.肝移植术后的防治仍以免疫抑制剂为主，免疫抑制剂使用方案、配型、原发病、性别、年龄等影响肝移植术后排斥反应的发生及疗效。2.移植肝穿刺活检病理组织学检查是诊断和鉴别排斥反应的金标准，应依据Ba nff分级标准严格行急排RAI评分及慢排分级，区分排斥反应类型及程度。3.免疫组织化学检测颗粒酶B/Fas一L在发生排斥反应的移植肝活检组织中表达阳性，颗粒酶B阳性率高于Fas一L;外周血s工L一ZR在排斥反应时，其浓度总体升高，随着排斥反应的被控制而逐渐下降。与对照组相比较均有统计学意义。4.考虑到肝移植是一复杂系统的工程，影响因素众多，要寻找排斥反应的早期诊断和鉴别指标尚需大样本的资料总结及进一步更好质控的实验研究;当前仍需提高病理组织学的诊断水平以及对临床影响因素、病理、免疫结果进行综合评价，才能对肝移植术后排斥反应做到相对合理的、实用的、个体化的治疗。更多还原

【Abstract】 As the effective method of treating terminal hepatic and biliary disease , chronic metabolism hepatopathy and liver tumor ,liver transplantation has developed quickly. Disposal concerning perioperative treatment especially acute and chronic rejective reaction has become the key of restricting short and long-term effect.Up to now,immunosurppressive agent is still main measurement of preventing and treating rejection when there are not good immunologic tolerance method introduced in clinical practice.Although experienced continuous changes , there are still high rate of 50%-90% rejective incidence as practising immunosurppressive agent in clinical practice.The issue must be solved concerning how to early diagnose and differential diagnose rejection as well as how to prevent and treat rejection.There are lots of factors affecting occurrence and therapeutic efficacy.Grasping these factors will obtain reasonable and individual treatment.Liver biopy is named for "gold standard"in diagonose and differential diagnose rejection of liver transplantation.But for many cases pathological examination cannot work.So seeking specific diadynamic criteria is necessary. Granzyme B and Fas-L expression detecting in transplanted liver rejection posseses important significance as generally accepted effect marker.On the other hand, IL-2 is important cytokine leading to immunologic cell activation and producing rejection. Dynamic monitoring sIL-2R levels poseses important significance for postoperative liver transplantation rejection.[Objective] This topic will be separated 2 parts.The first part will begin with clinical aspect to observe and analyse clinical diagonosis and treatment during perioperation of transplantation. As well as to analyse and investigage affecting factors related to preventing and treating rejection.The second part is experiment.lt is formed by 3 parts.Firstly, rejective type and degree will be differenced by RAI scoring and Banff grading to 16 cases(26 times) HE staining pathological results of liver biopsy.Secondly, granzyme B and Fas-L expression detecting by immuno - histochemistry method and dynamic monitoring sIL-2R levels in postoperative blood by ELISA method will be performed.Finally, both expressions and levels under different rejective circumstance will get comprehensive assessment for the aim to find laws and provide experimental foundation for more reasonably and individually preventing and treating postoperative rejection.[Methods] 1.Through a retrospective analysis of clinical data in 61 liver transplantation cases collecting from Hepabiliary Surgery of General Hospital of PLA from June,2002 to December,2003.and analyse these aspects such as immunosuppression agent program, cross matching -, primary disease -, preoperative liver function sex and age, etc. to try to find affecting factors of occurrence and effect of postoperative rejection of liver transplantation. 2.Sixteen cases(26 times) liver biopsy sample were collected to perform HE staining and detect granzyme B and Fas-L expression by immnohistochemistry method. 3.Blood of liver transplantation patients involving 1 day of preoperation, l,3,5,7, 10, 14, 18,21 day of postoperation were collected to detect sIL-2R content by ELISA method. 4.A11 HE Staining sections were scored by RAI standard and Banff demiquantu grading scheme to difference acute or chronic type and mikU moderate or severe degree; Results of granzyme B and Fas-L expression and sIL-2R levels according to different circumstance of rejection were analysed comprehensivly.Data was disposed by statistical method.[ Results ] 1 .Thirty-eight cases(70.4%) of acute rejection were occurrenced in 61 cases(totaol 54 cases besides 7 cases of earlier period deadth) of liver transplantation. Of which 37 cases(68.5%) was acute rejection and 1 case(1.9%) was chronic rejection.Immunosuppression scheme was dominated by 3 combining of "FK506+MMF+Pred". It was more excellent than CsA group. The usage period of Pred was fairly longer. The probability of infection , tumor relapse and hypergl更多还原