Transcript 投影片 1

Journal Reading
2006-10-13
Present by Dr.陳志榮
The Banff 97 Working
Classification of Renal
Allograft Pathology
Racusen LC, Solez K, Colvin RB, Bonsib SM, Castro MC, Cavallo T,
Croker BP, Demetris AJ, Drachenberg CB, Fogo AB, Furness P, Gaber LW,
Gibson IW, Glotz D, Goldberg JC, Grande J, Halloran PF, Hansen HE,
Hartley B, Hayry PJ, Hill CM, Hoffman EO, Hunsicker LG, Lindblad AS,
Yamaguchi Y, et al.
Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
[email protected]
~ kidney International,55(2),1999, 713-23
Introduction
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Standard interpretation to guide
therapy and clinical trials.
Banff schema and Collaborative
Clinical Trials in Transplantation
(CCTT)
Method and Materials
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Analysis of data using Banff
classification.
Publication of and experience of
the CCTT modification.
International conferences.
Data from recent studies of impact
of vasculitis on transplant outcome.
Result
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Specimen adequacy.
Semiquantitative method.
Actue/active lesion scoring.
 Tubulitis, intimal arteritis, interstitial
inflammation, glomerulitis.
Chronic/sclerosing lesion scoring.
 Interstitial fibrosis, tubular atrophy,
allograft glomerulopathy, mesangial
matrix increase.
Actue/active lesion
scoring
Actue/active lesion
scoring
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Intimal artertitis:
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Lymphocytic infiltration beneath
the endothelium.
Arteritis:
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Inflammation in the media and/or
with fibrinoid necrosis of vessel
wall.
Actue/active lesion
scoring
Actue/active lesion
scoring
Actue/active lesion
scoring
Actue/active lesion
scoring
Chronic/sclerosing lesion
scoring
Chronic/sclerosing lesion
scoring
Chronic/sclerosing lesion
scoring
Chronic/sclerosing lesion
scoring
Chronic/sclerosing lesion
scoring
Chronic/sclerosing lesion
scoring
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Arteriolar hyaline change (nodular) :
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Cyclosporine or FK506 toxicity.
Separate from chronic vascular change.
Arteriolar hyalinosis (ah) score
Discussion
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Historical review
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Finkelstein et al.,1976 (precyclosporine era).
Banfi et al.
Matas et al., 1983
Banff classification,1991 (Banff 93)
Discussion
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Vasculitis in renal allograft:
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Poorer response to therapy and/or
outcome.
Intimal arteritis ± fibrinoid necrosis.
Roche mycophenolate mofetil
study: 87 biopsies=> allograft loss
rate.
Nickeleit et al: less responsive to
steroid.
Discussion
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Interstitial inflammation
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I2t2 for diagnosis of rejection is likely
appropriate.
Rush et al.: 1/3 asmptomatic patient
(subclinical rejection) had i2t2 lesions
with a less than 10% change in serum
creatinine but had good treatable
response.
borderline rejection i1t1
i1t2=>? Significance for rejection.
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Correlate with clinical finding.
With decreased function=>therapay.
With stable function=> no therapy.
Discussion
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Antibody-mediated component
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Widespread endothelial injury.
Fibrinoid changes of vessel wall.
Glomerular and small vessel
thromboses.
Infarctions.
Glomerulitis.
Polymorphonuclear leukocytes in
peritubular capillaries.
Discussion
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Other disease processes
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Polymorphonuclear leukocyte
(PMNL) in interstitium and tubular
lumina.
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PMNL in peritubular and
glomerular capillaries.
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Aucte bacterial infection.
Severe acute endothelial injury and
possible antibody-mediated
rejection.
Eosinphils.
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Hypersensitivity reaction.
Discussion
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Viral infection
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Megalic cells, nuclear smudging,
intranuclear or cytoplasmic
inclusions.
Cytomegalovirus, polyoma virus,
adenovirus etc.
Colvin: relatively severe tubular
cell injury and mild inflammation
raises the possibility.
Discussion
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Post-transplant lymphoproliferative
disorder (PTLD)
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Immunoblasts, plasma cell, large
cleaved/noncleaved cells and
small round lymphocyte.
Nuclear atypia, EBV association, B
cell preponderant.
D/D: rejection.
Discussion
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Cyclosporine
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Tubular vacuolization.
Microvascular toxicity: glomerular
and arterioles.
Discussion
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Diagnosis==>prediction of allograft
function and outcome.
Early intervention.
Molecular study.
How to handle the renal
transplant biopsy
D’Agati, Jennette,Silva edn.Non-neoplastic
kidney diseases, Atlas of non-tumor
pathology, first series, fascicle 4, 2005,p668
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Materials:
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Two cores of tissue.
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focal in early stages
Glomeruli:≧10
Arteries≧2
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Processing:
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Majority of specimen.
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Small portion.
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Light microscopic examination. (as
renal biopsy routine)
immunofluorescence study.
EM examination.
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not general reserved.
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Light microscopic examination
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Three H&E slides.
Three PAS or silver stained slides.
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One Masson trichrome stained
slide.
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Glomerulitis or tubulitis, arteriolar
hyaline, double contours of
glomerular capillaries.
Interstitial fibrosis.
Each section:3-4 microns.
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Immunofluorescence study:
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C4d: routine use to exclude acute
humoral rejection.
? Full panel in early transplant
perioid.
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IgM, IgG, IgA, C3,C1q,fibrinogen,
kappa and lambda light chain.
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Rapid processing:
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Same day.
Formalin-fixed.
Frozen section is less reliable.
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Allograft renal transplant routine
protocol in WanFang Hospital.
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Thank you for your attention!