2014-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/644429摘要：台灣目前每年登記等待換腎的病患約有 7000 人，但是國內一年捐贈腎臟的器官捐贈者卻只有 200 人左右。如此供需差距極大的情況下，許多等待換腎的病患因為沒有換腎的機會，必須常態性的到醫院進行血液透析治療，無疑對於生活品質或是經濟乃至於健保的消耗都是極大的負擔。因此，對於醫療人員，如何維持換腎病患腎臟功能的健全，術後照顧雖然是困難但也是亟需克服的關鍵。 移植後的病患必須終生服用免疫抑制藥物以對抗排斥反應的發生、避免腎臟功能因排斥現象而急速惡化。但是截至目前為止，所有的免疫抑制藥物對於身體或器官都會產生不同程度的藥物毒性。因此對於醫療人員，該如何拿捏免疫抑制劑的使用和藥物毒性也一直是非常大的挑戰。換句話說，如何維持換腎病患之移植腎不因排斥反應而使喪失功能，是醫療人員長久以來持續努力的方向。 腎臟組織切片染色法是目前診斷移植後排斥現象的準則，但是在診斷上，這種檢測法跟臨床診斷發生互相矛盾的狀況時有所聞，也因此常常錯失及早發現及早治療的情況。排斥現象中，抗體性排斥作用(antibody-mediated rejection)的 診 斷 是 利 用 組 織 切 片 染 色 法 觀 察 腎小管的管周微血管 (peritubular capillaries)C4d 蛋白染色。但是研究發現，有高達 63% C4d 染色陰性的病患仍歸因於抗體性排斥作用導致腎臟失去功能。所以如何發展一套有效、精準又快速的診斷法的確是當務之急。 根 據 病 理 變 化 ， 腎 臟 排 斥 作 用 可 分 成 兩 大 類 ， 抗 體 性 排 斥(antibody-mediated rejection)及細胞性排斥(cellular mediated rejection)。組織切片染色結果的有無是依據專業的病理科醫師主觀判斷下做出的結論，但是如果另一位病理科醫師做出和之前不同的診斷結果，則在兩方彼此意見討論下做出一致的判斷。然而，研究指出僅有 45%細胞性排斥陽性的結果報告是可以同時獲得兩位病理科醫師一致認可的診斷，也就是高達 55%的醫師，互相對於對方細胞性排斥的結果是有疑慮的，這樣的矛盾情況也在抗體性排斥檢體中因為病灶難以觀察而更加嚴重。因此，不管是抗體性或是細胞性排斥，病理診斷的再現性確實對於臨床診斷上是一大問題。 抗體性排斥檢測除了用組織染色也使用螢光染色法，儘管如此，結果判斷上差異還是很大。臨床統計，抗體性排斥診斷確定的結果中，50-63% C4d染色呈陰性，病理科醫師也無法同意單用 C4d 染色就可做為診斷抗體性排斥的依據。如此無法信賴的診斷標準不僅嚴重影響臨床診斷的精確度，更阻斷新式診斷法的發展。有鑒於此，我們有必然的需要發展另一套診斷工具以彌補傳統腎臟組織染色檢測的不足，而分子生物的檢測方式有潛力可以做為臨床診斷的重要參考指標。因此，我們將建立一套利用分子生物檢測診斷的模式，做為腎臟移植後排斥的診斷輔助參考依據，以彌補現行病理診斷不足之處。<br> Abstract: In Taiwan, there are around 7000 patients waiting for renal transplant every year. In this situation, the number of kidney donations could not meet the needs of these patients who require kidney transplant. Therefore, each transplant organ is precious and post-operative care is an important determinant of the outcome after kidney transplant. The immunosuppressant would suppress host immune system and prevent the rejection episodes; however, the drugs also have some sort of toxicities. The major challenge of post-operative care is the balance between the need of immunosuppressant and the drug-related toxicities. The most important determinant of transplant graft survival is the rejection episodes of renal allograft. The gold-standard of diagnosis for allograft rejection is biopsy. Sometimes, the results of biopsy are controversial or not compatible with clinical diagnosis. So far, the diagnosis of antibody-mediated rejection is based on the staining of C4d in peritubular capillaries of renal graft, however, in a report indicated that 63% of renal biopsies were C4d negative but later the deteriorated renal function were attributable to antibody-mediated rejection1. Therefore, it’s urgent to develop new tools to help the diagnosis of rejection besides renal biopsy and pathological diagnosis. Based on pathophysiological changes, clinical kidney rejection has been classified into antibody-mediated rejection and cellular mediated rejection2. Histology examination requires subjective judgment and opinion from experts and has the potential problem of reproducibility of opinions from different pathologists. The pathological diagnosis based on consensus guidelines, which are also opinions. In one report, the renal biopsies diagnosed as T cell-mediated rejection (TCMR) by one pathologist, but only 45% was diagnosed as TCMR by another pathologist independently, with many biopsies called ‘borderline’3. The problem is worse in the situation of antibody-mediated rejection, in which the lesions are more subtle, and all diagnostic features have problems with reproducibility. The standard for pathological diagnosis of antibody-medication rejection is C4d staining, which is performed by two different methods, immunohistochemistry or immunofluorescence, and has considerable variability. About 50-63% antibody-mediated rejection would be C4d negative and pathologists are still unable to agree on the criteria for C4d-negative ABMR. Unreliable gold standards of diagnosis not only affect clinical decisions but also impair development of new diagnostic tools. Therefore, we need to develop another diagnosis tool to compensate the limitation of conventional renal biopsy exam. Molecular diagnosis might provide another reference to help clinical decision making. Therefore, we proposed to establish a method for molecular assessment to renal transplant biopsies. There are three specific aims in this proposal: AIM 1. Establish a reference standard from unselected indication biopsies of renal allograft. AIM 2. Examine the correlation of molecular diagnosis with clinical diagnosis and outcome. AIM 3. Develop non-invasive method to monitor or predict rejection episodes. In this study we will try to establish a reference standard molecular classifier for molecular diagnosis to compensate the limitation of conventional renal biopsy exam. Also, we will try to develop a way for early detection of rejection episodes. Hopefully we could help to prolong the survival of renal allografts and help the patients who suffered from end stage renal disease.