肾移植术后急性体液性排斥反应的治疗

目的 总结肾移植术后急性体液性排斥反应中针对HLA抗体的检测和处理经验.方法 肾移植受者15例,术前行HLA分型、交叉配型和群体反应性抗体(PRA)的检测,术后采用他克莫司(或环孢素A)、霉酚酸酯和糖皮质激素预防排斥反应.15例于肾移植后1～14 d发生抗体介导的急性排斥反应(AMR),采用抗胸腺细胞球蛋白(100 mg/d,使用5 d)治疗,或将环孢素A转换为他克莫司,当PRA明显升高,且血清中出现供者特异性HLA抗体时,即行血浆置换(PP),共行1～5次,每次PP后静脉输注免疫球蛋白(IVIG)100～150 mg/kg,最后1次PP后给予WIG 200～500mg/kg.结果 术后出现抗供者特异性HLA Ⅰ类抗体者9例,抗HLAⅡ类抗体者4例,同时出现抗Ⅰ、Ⅱ类抗体者2例.14例的AMR逆转,1例术后发生移植肾功能恢复延迟,彩色多普勒超声波显示移植肾血流灌注差,于术后第10天切除移植肾.并行二行肾移植.2例AMR后并发急性肾小管坏死,透析后移植肾功能恢复正常.抗排斥反应治疗期间患者均未发生严重感染.随访12～52个月,1例因慢性移植肾肾病恢复血液透析治疗,1例死于心血管疾病,其余患者移植肾功能稳定.结论 将ATG、PP和IVIG联合应用能有效逆转AMR.

HLA-antibodies monitoring and treatment in renal allograft recipients with antibody-mediated acute rejection

Objective To explore HLA-antibodies monitoring and treatment in renal allograft recipients with antibody-mediated acute rejection(AMR).Methods HLA typing,cross-matching and panel reactive antibody(PRA)monitoring were performed preoperatively.Tacrolimus/cyclosporine,mycophenolate mofetil.and steroids were adopted as immunosuppressants after transplantation in renal allograft recipients.Fifteen cases of AMR occurred 1-14 days post-transplant.Treatments included anti-thymocyte globulin(ATG,100 mg/day × 5-7 days),tacrolimus as a substitute for cyclosporine(if used),plasmapheresis(PP,1-5 sessions)when PRA was increased with occurrence of donor specific antibody(DSA)and intravenous immunoglobulin(IVIG,100-150 mg/kg following each PP,200-500 nag/kg after the last PP session).Results Both HLA class-Ⅰ and class-ⅡDSA were found in 2 patients,only class-Ⅰ DsA in 9 patients,and only class-Ⅱ DSA in 4 patients after transplantation.Rejection episodas were reversed in 14 recipients.One recipient received nephrectomy and second renal transplant at the 10th day post-transplant.Two cases of acute tubular necrosis occurred after anti-rejection treatment and recovered after dialysis for 3-6 weeks.No severe infection complications were observed.During a follow-up period of 12-52 months,one recipient became dialysis-dependent due tO chronic allograft nephropathy 16 months post-transplant,and one recipient died of cardiovascular complications 18 months post-transplant.Renal grafts of other 1 2 recipients functioned well with serum creatinine of 112.5±15.8 μmol/L Conclusion Therapy with ATG plus PP-IVIG is effective and safe for the treatment of AMR.