交叉反应组配型在高致敏患者肾移植中的应用

目的 探讨交叉反应组(CBEG)配型在高致敏患者肾移植中的临床意义。方法 动态监测肾移植受者体内群体反应性抗体(PRA)的水平及其特异性，按照CREG配型原则选择最匹配的供者。结果 60例受者术前PRA超过11％，均有单纯性或混合性升高；按照CREG配型，0～1个抗原错配、2个抗原错配、3～4个抗原错配者术后肌酐恢复正常的时间平均为6．5d、7．0d、12．7d，发生肾功能恢复延迟的例数分别为0、7例、3例，各组间的差异具有显著性(P＜0．05)。结论 高致敏受者在肾移植时采用CREG配型，可避开受者预存的HLA抗体特异性所对应的抗原，对于提高肾移植人／肾存活率具有重要意义。     

Influence of mismatching of HLA cross-reactive groups on cadaveric kidney transplantation

Finding fully HLA-matched recipients for a given donor is not practical due to the allelic diversity of the loci. Cross-reactive group (CREG) matching has been considered a feasible alternative to HLA matching. However, the true efficacy of CREG matching in cadaveric kidney transplantation is controversial. Using conventional HLA and CREG classifications proposed by Rodey and McKenna, we counted the number of mismatches for 319 patients who received cadaver kidney transplants between 1992 and 2003 at Asan Medical Center in Korea. When we compared transplants with four or fewer HLA-A, -B, and -DR antigen mismatches with those with five or more, we observed a significant difference in 5-year survival rate (88.5% versus 78.6%; P = .0189). Transplants with no or one HLA-DR mismatch had a significantly better 5-year survival rate than those with two HLA-DR mismatches (87.9% versus 80.0%; P = .0469). Among transplants with one or two HLA-DR mismatches, transplants with zero or one CREG mismatch showed better 5-year graft survival rate than those with two or more CREG mismatches (89.4% versus 79.8%; P = .0415) only in McKenna's CREG classification. These results suggest that the impact of CREG mismatches on graft survival may depend on CREG classification and on the distribution of HLA-DR mismatches.     

Renal retransplantation in patients with HLA-antibodies

The results of 92 consecutive renal retransplantations, performed during a 5-year period in recipients with HLA-antibodies, were retrospectively analysed. The actuarial 1-year graft survival (1-y GS) was 65% for all retransplantations, as compared with 63% for first grafts in sensitized recipients. For the second (n = 56), third (n = 24) and fourth-fifth (n = 12) grafts 1-y GS was 64%, 71% and 58%, respectively. Acute rejection was the major cause of graft loss (45%). Recipients with > 3 years GS of the preceding transplant had significantly better GS at retransplantation. Also, grafts with no HLA mismatches had significantly prolonged GS. One-y GS was 78% when PRA (panel reacting antibody) was less than 50%, and 60% when PRA was more than 50%. A benefit of repeated mismatches was demonstrated in the subgroup with PRA < 50%, in contrast to recipients with PRA > 50%, suggesting that, in some patients, an absence of antibody response against certain antigens might be used as a basis for future deliberate mismatching.     

Success rate and impact of HLA matching on kidney graft survival in highly immunized recipients

From 1985 to 1990, 225 highly immunized recipients were transplanted based on a program of serum exchange and priority allocation of kidneys to crossmatch negative recipients. The 1-year graft survival rate in first transplant recipients was 73% and in second transplant recipients, 71 %. Recipients of third or fourth transplants had a 25 % lower success rate. HLA matching exerted a significant influence on graft outcome. Twenty-five first or second grafts with zero mismatches for HLA-B,-DR had a 91 % 1-year survival rate, in contrast to a 58% survival rate of 38 grafts with of three or four HLA-B,-DR mismatches (log rank P < 0.001).     

Successful cadaveric renal transplantation of patients highly sensitized to HLA Class I antigens

The purpose of our investigation was to evaluate long-term graft survival and the role of histocompatibility in patients who were highly sensitized to human leukocyte antigen (HLA) Class I antigens and received a cadaveric renal transplant. Our multi-institutional study evaluated 7-yr graft outcomes and the histocompatibility requirements of 61 (6.1%) highly sensitized (anti-human globulin panel reactive antibody [AHG PRA], > or = 80%) cadaveric renal transplantation patients, transplanted between 1988 and 1997, among 999 consecutive cadaveric renal transplants. One- and 7-yr graft survival in the high PRA group (n = 61) was 76 and 59%, and was not significantly different from that in the low PRA group (n = 938), 86 and 59% (Wilcoxon = 0.11; log-rank = 0.45) (died with a functioning graft [DWFG] not censored). When those data were divided into primary and regrafts, 1- and 7-yr graft outcomes for high and low PRA groups were not significantly different [(primary, 1- and 7-yr survival: high PRA = 83 and 74%, n = 30, and low PRA = 87 and 61%, n = 825; log-rank = 0.37 for DWFG not censored) (regrafts, 1- and 7-yr survival: high PRA = 70 and 42%, n = 31, and low PRA = 80 and 43%, n = 113; log-rank = 0.36 for DWFG not censored)]. We did observe a subgroup of the high PRA patient group that had inferior graft outcomes. Graft outcome at 1 and 6 yr in the high PRA group for patients who had one to two DR mismatches (65 and 50%, n = 41) was significantly worse than for high PRA patients who had zero DR mismatches with their donors (100 and 78%, n = 20) (log-rank = 0.01 for DWFG not censored). Furthermore, the mean number of HLA-A and -B mismatches was significantly greater in the high PRA/DR-mismatched group (1.7 +/- 1.2, n = 41) compared with the high PRA/zero DR-mismatched group (0.5 +/- 1.1, n = 19) (p < 0.001). Overall, these data suggest that the patient who is highly sensitized to HLA Class I antigens has a long-term graft outcome that is equivalent to less sensitized patients, but that HLA-DR mismatching and a higher degree of Class I mismatching may be poor prognostic indicators in such patients.     

The impact of HLA frequency differences in races on the access to optimally HLA-matched cadaver renal transplants. The Medical Advisory Committee.

We examined the donor/recipient HLA match of 448 consecutive cadaver renal transplants to determine if donor race had an impact on the quality of HLA match that was achieved. Eighty (17.9%) kidneys from black donors and 368 (82.1%) from nonblack donors (87.8% caucasians) were distributed to the blood type compatible and crossmatch negative recipients on the basis of a local variance of the United Network for Organ Sharing (UNOS) point system. There were 278 (62%) nonblack and 170 (38%) black recipients, numbers close to those of nonblacks and blacks on the waiting list (59% and 41%, respectively). Kidneys from nonblack donors represented 86% (240/278) of transplants for nonblack and 75% (128/170) of transplants for black recipients. The best matches, i.e., zero-A,B,DR, zero-A,B, zero-B,DR, and 1-A,B,DR mismatches, for nonblack recipients were solely derived from the nonblack donors, and the few well-matched kidneys from black donors were distributed to black recipients. Black recipients with zero mismatches were few (3, 2%) compared with nonblacks (21, 8%). Kidneys received by black recipients were more likely to be poorly matched (5-6 mismatches) if coming from nonblack donors (57/128, 44%) than black donors (11/42, 26%), P = 0.035. It was also observed from HLA frequency comparisons that well-matched kidneys from nonblack donors were rarely distributed to black patients with HLA phenotypes unique to or more common in blacks who represented a sizeable portion of blacks on the waiting list. We conclude that better donor/recipient HLA matches are achieved when both donors and recipients are of the same race. Thus a larger number of black donors are needed to improve the quality of HLA matching for potential black kidney transplant recipients.     

Blood transfusions and HLA matching--an either/or situation in cadaveric renal transplantation

Cyclosporine-treated recipients of primary cadaver donor renal transplants had a one-year graft survival rate of 79% if they received pretransplant blood transfusions (n = 5308). The one-year survival rate for nontransfused recipients (n = 709) was significantly lower at 69% (P less than 0.001). The transfusion effect was larger in black recipients (a 17% difference) than in white recipients (5%). The effect was also larger in recipients of grafts poorly matched for HLA-A, B, -B, DR, or -DR antigens than in recipients of well-matched grafts. Transfusions did not significantly improve graft survival in recipients with zero or one HLA-A, B or -B, DR, or zero -DR-mismatched grafts. However, transfusions accounted for increases of 10%, 14%, and 17% in patients receiving grafts mismatched at 2, 3, or 4 HLA-B, DR antigens, respectively. Several factors including cyclosporine and HLA matching have contributed to improving graft survival rates in nontransfused recipients. Sensitization was noted in 20% of transfused patients awaiting primary renal transplants in Southern California, as compared with 10% in transplanted patients, suggesting a tendency to transplant nonsensitized patients. Of the sensitized patients, 75% were female. Based on these data, we suggest that high survival of primary kidney allografts in the cyclosporine era can best be maintained by the continued use of pretransplant transfusions for the majority of recipients--or, alternatively, by HLA matching for patients who are at higher risk of becoming sensitized.     

The influence of histocompatibility on graft rejection and graft survival within a single center population of heart transplant recipients.

BACKGROUND: We report a consecutive single center series of 261 patients who received first orthotopic heart transplants from 1986 to 1997. The 1- and 5-year graft survivals were 78 and 68%. The influence of histocompatibility was investigated by comparing graft survival and numbers of treated rejection episodes with HLA-A, -B, and -DR mismatches over different time periods. FINDINGS: Recipients with six mismatches for HLA-A+-B+-DR combined (13.4%) had reduced survival at 7 years (47%) when compared with other recipients (64%). In the first year of transplant, recipients with four HLA-A+-B mismatches had significantly reduced actuarial graft survival (P=0.03) with the greatest influence apparent at 6 months [0-3 mismatches (n=193) 85% versus 4 mismatches (n=68) 69%; P=0.005, OR=2.1]. For 182 recipients with functioning hearts at 1 year, the number of rejection episodes treated within this time was strongly influenced by HLA-DR mismatch [0 DR mismatch (n=15) mean 1.2 rejection episodes versus 1 DR mismatch (n=76) mean 2.7 rejection episodes versus 2 DR mismatches (n=91) mean 3.8 rejection episodes: P=0.0002]. Of these 182 transplants, recipients who had more than four treated rejection episodes during the first year had a significantly reduced 7- year survival [<5 rejection episodes (n=133) 85% versus more than four rejection episodes (n=49) 66%; P=0.02, OR=3.4], as did those with two HLA-DR mismatches [0+1 mismatch (n=91) 87% versus 2 mismatches (n=91) 70%; P<0.05, OR=2.4]. INTERPRETATION: We show that graft loss in the first 6 months of transplant is significantly influenced by four HLA-A+-B mismatches. HLA-DR mismatch significantly increases the number of rejection episodes within the first year, without influencing graft survival. After 12 months both >4 rejection episodes in the first year and two HLA-DR mismatches are markers for late graft loss. We postulate that immunological graft loss in the first 6 months is dominated by the direct allorecognition pathway driven by HLA-DR mismatch. This mechanism is later lost or suppressed. Our data highlight HLA-DR mismatch as a marker for late graft loss and we show an advantage to avoiding transplanting hearts with six HLA-A+-B+-DR mismatches and to minimizing HLA-DR mismatches whenever possible.     

Cross-reactive group matching does not lead to a better allocation and survival of donor kidneys

BACKGROUND: In cadaveric renal transplantation HLA-A, -B, -DR matching of donor and recipient is beneficial for graft survival. However, allocation based on HLA matching seems to favor recipients with more frequently occurring HLA antigens. In this study we investigated whether matching on the basis of cross-reactive groups (CREGs), defined according to the United Network for Organ Sharing (UNOS), would be a good alternative for the allocation of kidneys without negatively influencing graft survival. Theoretically, this approach would provide more recipients with an immunologically well-matched donor organ. METHODS: The influence of CREG matching on graft survival was studied in univariate analyses using the Eurotransplant database. RESULTS: No beneficial effect of CREG matching was observed, whereas a significant HLA matching effect was observed in the 0 CREG mismatched donor/ recipient combinations. Only in the small subgroup with 1 MM for HLA-A, -B and 0 MM for HLA-DR, a significantly better survival was observed, when this mismatch belonged to the 0 or 1 MM CREG group versus two or more MM CREG group. However, this subgroup concerns only 8% of the transplants performed. CONCLUSIONS: In contrast to other reports, our study showed that HLA matching is by far more beneficial than CREG matching. In the homogenous Eurotransplant population, adjusting the matching criteria toward CREG matching would not lead to an improved graft survival.     

Increased late hepatic artery thrombosis rate anddecreased graft survival after liver transplants with zero cross-reactive group mismatches

The use of broad-specificity cross-reactive groups (CREGs)at the A and B HLA loci has been proposed as a means to improve both access and outcome for renal transplantation but has not yet been studied for liver transplantation. We retrospectively analyzed our results for all adult liver transplantations performed at our center between 1989 and 1996 for which HLA typing and complete 3-year follow-up data were available. Two hundred eight transplantations were studied, with a mean follow-up of 66 ± 2 months (range, 36 to 110 months); A and B loci were converted to CREGs by the method of Rodey. Thirteen percent of the patients with 0 CREG mismatches had hepatic artery thrombosis versus 2% for those with 1 or more mismatches (odds ratio, 6.7; 95% confidence interval, 2.6 to 17.3 by univariate analysis; odds ratio, 3.5; 95% confidence interval, 1.1 to 11.7 by logistic regression analysis). These events occurred significantly later in the 0-CREG mismatch group (21 ± 7 v 4 ± 2 months post-transplantation; P = .04 by Student's t-test). Graft survival rates were significantly lower for patients with 0 CREG mismatches (56% v 68% at end of study; P = .05 by Cox-Mantel test). The number of CREG mismatches had no effect on the frequency of rejection, steroid-resistant rejection, or infectious complications, including cytomegalovirus. Neither total nor individual A, B, or DR HLA matching had an effect on outcome. There appears to be little evidence that intentional CREG matching would improve outcomes for liver transplantation and, under some circumstances, could be deleterious.     

Sensitized patients require sharing of highly matched kidneys

BACKGROUND: Improved HLA matching can allow for renal transplantation in sensitized patients. United Network for Organ Sharing (UNOS) is currently considering removing the points awarded for HLA matching. METHOD: Twenty-six transplant centers shared kidneys, according to the algorithm: A, UNOS mandatory 0-mismatch (MM) share; B, UNOS mandatory 0-mm payback; C, 0 - B,Dr-MM; PRA> or = 40%; ROP tray negative; D, 0-B,Dr-MM; panel reactive antibodies (PRA) <40%; E, 0-B,Dr payback; F, local use. RESULTS: A total of 354 patients received transplants through the program and were compared with 6492 control patients. There was a significantly greater primary nonfunction rate in sensitized patients in spite of similar length cold ischemia time. Blacks were not significantly disadvantaged by the HLA matching requirements of the program. White recipients were favored by the matching program to the detriment of race group "other." Women were more frequently found in the sensitized groups but were not favored by sharing. Retransplant patients and patients with current PRA > or = 40% were favored by the sharing program. Sharing for HLA match does not improve graft survival at 1, 2, 3 years. CONCLUSIONS: (1). Elimination of suboptimal HLA matching by UNOS will probably not adversely affect 1-, 2-, and 3-year graft survival; (2). Removing the consideration for HLA matching will result in fewer transplant opportunities for highly sensitized patients such as retransplants and currently sensitized patients.     

Correlation of HLA matching with kidney graft survival in patients with or without cyclosporine treatment

In a series of more than 8000 first cadaver transplants performed during a two-year period, 2198 recipients treated with cyclosporine had a higher graft survival rate (76 +/- 1% at 1 year) than 6392 recipients without cyclosporine (64 +/- 1%, P less than 0.0001). Matching for HLA-B plus HLA-DR resulted in a significant correlation with graft outcome, in patients with or without cyclosporine treatment (P less than 0.0001). Regardless of whether cyclosporine was used or not, grafts with 0 HLA-B,-DR incompatibilities had approximately 20% higher success rates at one year than grafts with 4 mismatches. A high (86 +/- 3%) graft survival rate was obtained in 161 cyclosporine-treated recipients with 0 HLA-B,-DR mismatches. Matching for the HLA-B and HLA-DR loci is shown to have an additive effect in cadaver kidney transplantation.     

UCLA Liver Transplantation: Analysis of Immunological Factors Affecting Outcome

Abstract: From 1988 to 1993, UCLA completed 938 first and 1,146 total orthotopic liver transplants (OLT). Race analysis demonstrated a 1-year patient survival of 89% in Blacks (n = 45) versus 80% in Whites (n = 492, p < 0.02), with no significant difference shown between His-panics (n = 278) and Whites. The 1-year patient survival in Asians was 50% (n = 58, p < 0.02 vs. Whites) even when hepatitis B was excluded (59%, n = 43). The 1-year patient survival of hepatitis B surface antigen positive Asians (n = 15) was only 21% (p < 0.02 vs. all others). OLT patients whose panel reactive antibody (PRA) was < 10% (n = 339) demonstrated no graft or patient survival advantage versus recipients whose PRA was >10% (n = 71). A positive antidonor flow cytometry crossmatch (>30 mean channel shifts, n = 76) was associated with a decreased 1-year graft survival (56% vs. 73%, p < 0.05) when compared to flow negative recipients (n = 185). Graft survival for 0 DR mismatches was 74% at 1 year compared with 57% for 1 DR mismatche (p < 0.02) and 59% for 2 DR mismatches (p < 0.02).     

The effect of mismatching for HLA-DR in recipients of renal allografts sharing one HLA-ABC haplotype with related donors

The effects of mismatching for DR antigens on renal allograft survival rates have largely been restricted to analyses of cadaver transplant results. Analyses of HLA matching in recipients of transplants from related donors have focused on the number of haplotypes shared between the recipients without regard to DR, or on the total number of HLA antigens mismatched, or on the degree of MLC responsiveness of the recipient to the donor. Most related donor-recipient pairs sharing only one HLA haplotype will be mismatched for DR at the other haplotype, but because there are a limited number of DR alleles, sharing of DR antigens on the mismatched haplotypes occurs relatively frequently. To determine the influence of mismatching for DR on the fate of renal allografts from related donors, we analyzed the results of 172 kidney transplants from related donors who shared one HLA-ABC haplotype with the recipient. There were 156 primary grafts and 16 retransplants; 147 donor-recipient pairs were satisfactory typed for DR antigens. Because genotyping was not usually done, we performed two analyses under two different assumptions. The first assumption was that individuals expressing less than or equal to 1 DR antigen had null antigens, or were homozygous for DR; the alternative assumption was that blanks were true antigens and individuals with blanks were heterozygous. The first assumption is more likely to be correct, and is the assumption used in most analyses of the effect of DR antigen mismatches on the results of cadaveric transplantation. Under the first assumption, of the 147 related donor-recipient pairs in whom DR typing was satisfactory, 33% were mismatched for 0, 64% for 1, and 3% for 2 DR antigens. The one-year absolute graft survival rates in recipients of kidneys from donors with 0 mismatches for DR was 92% (n = 49); in those with one mismatch for DR it was 82% (n = 94); and from those with two mismatches it was 50% (n = 4). The one-year graft survival rate in 25 donor-recipient pairs in which one or both members could not be satisfactorily DR typed was 76%. Differences in graft survival rates between the 0 and 1 and the 1 and 2 DR-mismatched groups were not statistically significant.(ABSTRACT TRUNCATED AT 400 WORDS)     

The transfusion effect in cadaver kidney transplants--yes or no

The transfusion effect in first cadaver kidney transplants was re-examined at the UCLA Transplant Registry. One-year graft survival rates were 71% for non-transfused patients, which improved to 75% (P less than 0.05) with a single transfusion, 77% (P less than 0.01) with 2, and 78% (P less than 0.01) with 3 and 4 transfusions. One-year graft survival rates did not improve further with additional transfusions but remained at the same level. Thus, the transfusion effect clearly does exist, and 2 to 4 transfusions are sufficient to obtain the maximum beneficial transfusion effect. Patients with zero HLA-DR mismatched transplants had no blood transfusion effect. Transfusions improved the 1-year graft survival rate by 8% for transplant recipients with 1 DR-mismatched grafts (P less than 0.01) and by 10% with 2 DR-mismatched grafts (P less than 0.01). The transfusion effect was greater in Black than White recipients; however, the 77% 1-year graft survival rate for transfused Black recipients of zero DR-mismatched kidneys did not differ from that of transfused comparably matched Whites. We conclude that transfusion protocols should not be abandoned unless patients receive zero DR-mismatched kidneys.     

Allocation of Deceased Donor Kidneys in São Paulo, Brazil: Effect of Human Leukocyte Antigen Compatibility on Graft Survival

In Brazil, organ transplantation has been regulated by a federal law since 1997. This law was created to guarantee equal access to treatment on a national scale. Deceased donor organ procurement and sharing are centralized and controlled by the Health Department of each state of the nation, following a regional allocation policy. In São Paulo, time on the waiting list was the main criterion adopted to allocate deceased donor kidneys up to January 1, 2002. After that, HLA mismatches (MM) were the main criterion. The aim of this study was to investigate the impact of HLA compatibility on graft survival among 3312 consecutive kidney recipients. The 2-year kidney graft survival rates were compared among recipients transplanted based on the waiting time policy and based on HLA MM. Better results were observed in the HLA MM group (78.1% vs 64.9%; P < .0001). Regarding kidney allocation based on HLA MM, recipients transplanted with 0 HLA-A, -B, or -DR MM showed significantly better 5-year survival rates than those with 1-2 or 3-4 or 5-6 HLA-A, -B, or -DR MM (70.36% vs 64.71% vs 58.07% vs 55.64%; P < .050). We concluded that HLA compatibility is a feasible criterion to allocate deceased donor kidneys in Brazil.     

The interaction between the Lewis blood group system and HLA-matching in renal transplantation

A retrospective study was initiated to investigate the influence of recipients' Lewis subtype and HLA-matching on cadaveric kidney graft outcome. A total of 1111 patients receiving a first cadaveric kidney graft were analyzed. No difference in one-year graft survival was found between Lewis-negative (73%, n = 133) and Lewis-positive (73%, n = 978) recipients. Further subdivision of the study group into HLA-A,-B well-matched (0 or 1 mismatches [MM]) and poorly matched (2, 3, or 4 MM) revealed a strong deleterious effect of HLA-A,-B mismatching in the Lewis-negative group only. One year graft survival in Lewis-negative HLA-A,-B poorly matched (2, 3, or 4 A,B MM) patients was 60% (n = 67) versus 86% (n = 66) in the Lewis-negative HLA-A,-B well-matched (0 or 1 A,B MM) group (P = 0.004). For the Lewis-positive group the one-year graft survival rates were 72% (2, 3, or 4 A,B MM; n = 498) and 74% (0 or 1 A,B MM; n = 480), respectively (P = n.s.). The additional beneficial effect of HLA-DR matching again turned out to be strongest in the Lewis-negative group. In Lewis-negative, HLA-DR (0 MM) and -A,-B well-matched recipients (n = 36) graft survival was 94% versus only 64% in the Lewis-negative, DR matched, A,-B mismatched (2, 3, or 4 A,B MM) group (n = 25; P = 0.09). In the Lewis-positive, HLA-DR 0 mismatched group the one-year survival rates were 78% (0 or 1 A,B MM; n = 240) and 73% (2, 3, or 4 A,B MM; n = 253), respectively (P = 0.05). Our data suggest that donor recipient selection should not be based on Lewis matching per se. However, since Lewis-negative patients are at high risk of graft failure when receiving HLA mismatched kidneys, they should preferentially receive optimally HLA matched grafts.     

The effect of HLA mismatch on highly sensitized renal allograft recipients

Paramesh AS, Zhang R, Baber J, Yau CL, Slakey DP, Killackey MT, Ren Q, Sullivan K, Heneghan J, Florman SS. The effect of HLA mismatch on highly sensitized renal allograft recipients.
Clin Transplant 2010: 24: E247–E252. © 2010 John Wiley & Sons A/S. Abstract: Introduction: We examined the effects of increasing human leukocyte antigen (HLA) mismatches (MM) on long‐term graft outcomes in patients transplanted with a panel reactive antibody (PRA) >80% over a 10‐yr period. Methods: A total of 142 recipients were divided into three groups based on the number of HLA MM with their allograft (0–2, 3–4 and 5–6 MM; Groups I, II and III). All patients received the same immunosuppression protocol. Results: The higher MM groups had a higher incidence of rejection (4.4% vs. 11.4% vs. 31.3%, p < 0.01). A multivariate analysis showed that rejection was the only significant variable affecting graft loss (OR = 7.45, p = 0.01). There was a trend toward more CMV infection and worse graft function with higher MM. Kaplan–Meier five‐yr graft survival estimates were 100% vs. 81% vs. 74% for Groups I, II and III, respectively (p = 0.14). Conclusions: In patients with PRA levels >80%, a higher HLA MM is associated with higher incidence of acute rejection. Acute rejection was the only significant variable affecting graft loss. We found a trend toward more CMV infections and worse graft outcomes with higher MM. Closer HLA matching and immunologic monitoring needs to be considered to improve graft outcomes among sensitized recipients.     

预防预致敏受者尸体肾移植术后急性排斥反应的临床研究

目的 探讨HLA配型及新型免疫抑制剂治疗方案对预防致敏患者肾移植术后急性排斥反应的影响.方法 实验组选择46例术前致敏患者(术前PRA>10%),对照组选择同期705例未致敏患者(术前PRA<10%),实验组患者均采用诱导治疗(ATG 100 mg/d,5～7 d)+三联免疫抑制剂维持治疗方案(FK506+MMF+激素),比较两组间患者术后急性排斥反应发病率、移植肾功能延迟恢复比例、移植肾/患者一年存活率,同时分析HLA配型对移植肾急性排斥反应的影响.结果 实验组与对照组急性排斥反应的发病率分别为30.43%和19.57%(P<0.05);移植肾功能延迟恢复发病率分别为60.86%和11.87%(P<0.01).患者一年存活率分别为95.65%和98.44%,一年移植肾存活率分别为93.48%和96.88%;一年时平均血肌肝分别为130 mmol/dL和125 mmol/dL,差异无统计学意义.实验组患者HLA相配率(4.2)明显高于对照组患者(2.8)(P<0.05).实验组中HLA配型2-4错配的患者与0-2错配患者的急性排斥反应发病率有显著性差异,高度致敏患者(移植术前PRA>50%)急性排斥反应发病率较低度致敏患者(PRA 10%～20%)发病率高,移植术后PRA水平持续升高者更容易出现急性排斥反应.结论供、受者之间良好的HLA配型及采用新型免疫抑制药物治疗方案,对预防及减轻致敏患者移植术后急性排斥反应疗效确切.     

Evaluation of flowcytometric crossmatching in renal allograft recipients.

Forty-four cadaver renal allograft recipients who had flowcytometric cross-match (FCXM) testing and sequential quadruple immunosuppression were studied with respect to the number of rejection episodes and the functional viability of the graft in the first year after transplantation. Fourteen of these patients had antibodies to donor T cells by FCXM. All were negative by conventional crossmatch. Multiple-regression analysis with HLA mismatches, panel-reactive antibody (PRA) percentage, flowcytometric channel shifts and transplant number as independent variables revealed that transplant number and high PRA (> 50%) impacted (p < 0.05) on serum creatinine at 1 month and 1 year, and graft survival at 1 year. In first transplants, a positive FCXM had no impact on 1-year graft survival rates; however, in retransplants, a positive FCXM and/or high PRA had a significant negative impact on 1-year graft survival. This study indicates that the FCXM should be utilized for retransplant patients, and in patients with a high PRA, in an attempt to improve graft survival for these high-risk recipients.