淋巴细胞去除加血浆置换对高敏患者肾移植后排斥反应的影响

目的探讨淋巴细胞去除+血浆置换(PE)减少高敏患者肾移植后排斥反应的疗效。方法32例肾移植前群体反应性抗体(PRA)阳性≥30%(30%~90%)患者,先作血淋巴细胞去除加PE治疗(LAPE)1~3次后,当PRA<30%后才作尸体肾移植作治疗组。32例PRA阳性,强度≥30%(30%~70%)患者进行尸体肾移植作对照组。比较两组患者术后6个月内排斥反应情况。结果对照组术后排斥反应率为68.8%(22/32)。治疗组移植后排斥反应发生率为9.4%(3/32),P<0.001。结论淋巴细胞去除加PE治疗能明显减少有预先形成抗体的高敏患者的肾移植后排斥反应,疗效满意。     

血浆置换预防和治疗肾移植后加速及超急性排斥反应的观察

目的　探讨血浆置换疗法（PE）对预防和治疗肾移植后排斥反应的疗效。方法　选择30例肾移植前群体反应抗体（PRA）增高≥30%及10例肾移植后出现加速性排斥反应的患者,在用免疫抑制剂的同时作膜分离法血浆置换。结果　PE能清除各种免疫球蛋白及循环抗体,PE前后对比差异有显著性（P＜0.01）,PE治疗后全部患者（30例）PRA≤10%,肾移植后经过6～9个月的观察,27例（占90%）未出现超急、加速或严重的急性排斥反应;10例肾移植后出现加速性排斥反应者,8例（占80%）逆转。结论　PE配合免疫抑制剂治疗,对预防和减轻肾移植后排斥反应疗效确切。     

血浆置换预防和治疗肾移植后加速急性排斥反应的观察

目的：探讨血浆置换疗法（PE）对预防和治疗肾移植后排斥反应的疗效。方法：选择30例肾移植前群体反抗体（PRA）增高≥30％及10例肾移植后出现加速性排斥反应的患者，在用免疫抑制剂的同时作膜分离法血浆置换。结果：PE能清除各种免疫球蛋白及循环抗体，PE前后对比差异有显著性（P＜0．01），PE治疗后全部患者（30例）PRA≤10％，肾移植后经过6－9个月的观察，27例（占90％）未出现超急，加速或严重的急性排斥反应；10例肾移植的出现加速性提斥反应者，8例（占80％）逆转。结论PE配合免疫抑制剂治疗，对预防和减轻肾移植后排斥反应疗效确切。     

肾移植受者群体反应性抗体监测的临床意义

目的 分析群体反应性抗体（PRA）监测对预测肾移植受者排斥反应发生的意义及探讨对高水平PRA受者的临床处理.方法 应用酶联免疫吸附分析法（ELISA法）动态监测肾移植受者的PRA水平,以PRA≥10%为阳性,10%≤PRA＜50%为低致敏、PRA≥50%为高致敏,并对37例术前高致敏患者行血浆置换.结果 1527例肾移植受者中,PRA阳性350例（22.9% ）,其中高致敏 94例（26.8% ）;PRA阳性组排斥反应发生率（21.1% ）高于PRA阴性组（3.8% , P〈0.01）, 术后PRA转为阳性组排斥反应发生率高于PRA无变化组（P〈0.01）,行血浆置换受者与未行血浆置换受者排斥反应发生率无差异（P〉0.05）,接受过移植、多次妊娠、多次输血受者易致敏,HLA-A、B、DR配型错配抗原〉3个受者急性排斥的发生率（16.9% ）明显高于错配抗原≤3个受者（1.7% , P〈0.01）.结论 动态监测PRA水平有助于预测排斥反应的发生.     

高度致敏肾移植受者的脱敏治疗

目的:探讨高敏肾移植受者脱敏治疗的可行性.方法:群体反应性抗体(PRA)＞80%的高敏受者15例,采用血浆置换(PE)联合应用大剂量静脉注射免疫球蛋白(IVIG)行脱敏治疗,并连续监测抗体特异性,寻找HLA相容的供肾.结果:15例患者在(19.7±6.8)d内接受PE(5.4±1.9)次和IVIG(2.1±0.5)g/kg治疗后,Ⅰ类PRA下降(51.1±10.1)%,Ⅱ类PRA下降(29.2±13.1)%.采用脱敏治疗前血清作交叉配型均为阳性,治疗后血清交叉配型均为阴性.15例受者均接受肾移植术,术后未发生超急性排斥,2例患者发生急性排斥反应.随访(23.8±11.0)月,移植肾功能均良好,Scr为(122.6±28.2)μmol/L.结论:采用PE/IVIG方法能有效地对高敏受者进行脱敏治疗.     

静脉丙种球蛋白联合血浆置换预防肾移植术后排斥反应

目的探讨静脉丙种球蛋白联合血浆置换(PE)预防肾移植术后排斥反应的疗效。方法选择9例肾移植术前群体反应性抗体(PRA)及淋巴毒(CDC)增高的患者进行静脉丙种球蛋白联合PE治疗。结果9例患者经静脉丙种球蛋白联合PE治疗后PRA及CDC与治疗前相比差异有统计学意义(P<0.01)。其中7例成功地进行了肾移植。结论对肾移植术前PRA及CDC增高的患者予以静脉丙种球蛋白联合PE治疗可以有效降低PRA及CDC。     

高度致敏肾移植患者的围术期处理

目的 探讨高度致敏肾移植患者的围手术期处理.方法 对22例高度致敏肾移植患者术前组织配型及预处理,术后抗排异方案以及肾功恢复情况进行研究.结果 17例患者术前经血浆置换3～8次后群体反应性抗体(PRA)降至30%以下,5例患者术前PRA仍大于50%.术后发生超急性排斥反应(HAR)1例(9.9%),抗排异反应未能逆转,予以切除移植肾;急性排斥反应(AR)8例(36.3%),经甲强龙+ATG(ALG)冲击治疗后6例肾功恢复正常,2例转为肾功能延迟恢复(DGF);术后DGF5例(22.7%),予以血液透析+低剂量抗排异药物维持,肾功均恢复正常.结论 避开相应抗体进行良好的组织配型,是高度致敏患者肾移植成功的关键;术前行血浆置换降低高度致敏患者PRA,使用ATG或ALG可降低手术风险,提高排斥反应逆转率.     

抗CD25单抗联合血浆分离在高敏肾移植受体应用的临床研究

目的 探讨抗CD25单抗联合血浆分离在群体反应性抗体(PRA)阳性的高敏肾移植受体中的应用价值。方法 在41例PRA平均为52．2％的高敏肾移植受体中，24例仅用双滤过法血浆分离(DFPP)预处理(对照组)，17例在DFPP处理的基础上加用两个剂量的抗CD25单抗诱导治疗(治疗组)，比较两组急性排斥反应的发生率、严重程度和逆转情况、1年人／肾存活率以及并发症的发生。结果 治疗组仅2例(11．8％)发生急排，分别为IA和ⅡJ3级，对照组1例(4．2％)发生超排，10例(41．7％)发生急排，ⅡA级以上有6例，2组差异有显著性意义(P=0．039)。一年人／肾存活率治疗组为100％／94．1％，对照组为100％／91．7％，两组并发症无明显差异。结论PRA阳性的高敏肾移植受体在DFPP基础上应用抗CD25单抗能显著降低急性排斥的发生，减轻排斥反应的严重程度，获得满意的1年人／肾存活率。     

预存DSA强阳性患者二次肾移植诊治经验

预存供体特异性抗体(DSA)阳性是肾移植的禁忌证。预存DSA增加排斥反应发生率,使致敏患者存活率降低,直接影响肾移植结果。本文总结1例预存DSA强阳性患者,在二次肾移植前采用血浆置换、利妥昔单抗输注、持续抗胸腺细胞球蛋白滴注,并大剂量静脉注射免疫球蛋白等联合用药方案,抗HLAⅡ类抗体滴度显著降低。术后动态监测该受者群体反应性抗体(PRA)和DSA水平,早期发现排斥反应,及时采用地塞米松冲击、抗胸腺细胞球蛋白、大剂量静脉注射免疫球蛋白治疗排斥反应,取得良好效果,患者DSA消失。术后随访5个月,移植肾功能良好。     

高度致敏肾移植受者的脱敏治疗

对于高度致敏肾移植受者是否应该做HLA抗体清除治疗是一个有争议的问题。部分学者认为群体反应性抗体 (PRA) >80 %的高敏受者不宜接受肾移植术。我们采用血浆置换 (PE)和大剂量静脉注射免疫球蛋白 (IVIG)相结合的方法 ,对 8例PRA >80 %高敏受者进行了脱敏治疗 ,效果良好。报告如下。1　资料与方法1 .1　临床资料HLA Ⅰ类抗体PRA >80 %高敏受者 8例 ,男 2例 ,女 6例 ;年龄 35～ 79岁。首次移植受者 6例 ,二次移植受者 2例。术前 2个月内HLA Ⅰ类抗体峰值PRA 82 %～ 93% ,平均 87% ;HLA Ⅱ类抗体峰值PRA 67%～ 1 0 0 % ,平均 84…     

肾移植受者致敏状态的预测及其临床意义

群体反应性抗体（ＰＲＡ）的测定对了解受者体内抗ＨＬＡ抗体的水平及致敏状态，预防超急和加速排斥反应的发生具有重要意义，其敏感性明显高于供受者交叉配型试验（ＣＤＣ），高ＰＲＡ（阳性率≥５０％）与严重排斥反应及移植物存活率下降密切相关。血浆置换（ＰＥ）能有效清除ＰＲＡ阳性受者血清中的抗体，避免超急和加速排斥反应的发生，但良好的ＨＬＡ配型对提高ＰＲＡ阳性患者的手术成功率和移植物存活率更重要。通过随机多次淋     

Terminal complement inhibition decreases antibody-mediated rejection in sensitized renal transplant recipients

Sensitized renal transplant recipients with high levels of donor-specific alloantibody (DSA) commonly develop antibody-mediated rejection (AMR), which may cause acute graft loss or shorten allograft survival. We examined the efficacy of terminal complement inhibition with the humanized anti-C5 antibody, eculizumab, in the prevention AMR in renal transplant recipients with a positive crossmatch against their living donor. The incidence of biopsy-proven AMR in the first 3 months posttransplant in 26 highly sensitized recipients of living donor renal transplants who received eculizumab posttransplant was compared to a historical control group of 51 sensitized patients treated with a similar plasma exchange (PE)-based protocol without eculizumab. The incidence of AMR was 7.7% (2/26) in the eculizumab group compared to 41.2% (21/51) in the control group (p = 0.0031). Eculizumab also decreased AMR in patients who developed high levels of DSA early after transplantation that caused proximal complement activation. With eculizumab, AMR episodes were easily treated with PE reducing the need for splenectomy. On 1-year protocol biopsy, transplant glomerulopathy was found to be present in 6.7% (1/15) eculizumab-treated recipients and in 35.7% (15/42) of control patients (p = 0.044). Inhibition of terminal complement activation with eculizumab decreases the incidence of early AMR in sensitized renal transplant recipients (ClincalTrials.gov number NCT006707).     

群体反应性抗体在肾移植中的意义

目的 研究群体反应性抗体（ＰＲＡ０在肾移植中的意义。方法 对１７８例肾移植患者进行了术前、术后ＰＲＡ检测。结果 肾移植术前ＰＲＡ阳性患者有２３例,肾移植术后发生急性排斥反应的为２０例。术后ＰＲＡ阳性受者５８例,发生排斥反应的有３４例。移植前后ＰＲＡ阴性患者有１０８例,有８例发生排斥。在肾移植患者中所产生的抗ＨＬＡ抗体的频率和ＨＬＡ抗原的分布不同。结论 ＰＲＡ检测对预测移植肾排斥有重要意义。     

免疫吸附预防高致敏肾移植受者超急性排斥反应

目的探讨免疫吸附对高致敏‘肾移植受者超急性排斥反应的预防作用。方法对10例群体反应抗体（PRA）〉40％的‘肾移植受者术前行免疫吸附治疗，观察其超急性排斥反应发生情况及不良反应。结果10例高致敏肾移植受者均未发生超急性排斥反应，仅有2例发生急性排斥反应，并通过免疫吸附及调整免疫抑制剂得到逆转。所有受者随访至今移植‘肾功能良好，未发生排斥反应。结论免疫吸附可以安全、有效地预防高致敏人群‘肾移植术后超急性排斥反应。     

Flow cytometry crossmatching as a predictor of acute rejection in sensitized recipients of cadaveric renal transplants

Flow cytometry crossmatching (FCXM) was developed as a more sensitive assay than the standard complement-dependent cytotoxicity crossmatch (CDCXM) for the detection of anti-donor antibodies, that mediate hyperacute rejection and graft loss in the early post-transplant period in renal transplant recipients. The role of FCXM in predicting long-term clinical outcome in renal allograft recipients is unclear. This study examines the role of FCXM in predicting long-term clinical outcome in highly sensitized recipients of cadaveric renal transplants. All patients (n = 100) with peak panel reactive antibody (PRA) levels > 30%, who received cadaveric renal transplants between 1/1/'90 and 12/31/'95 at our institution, were divided into FCXM + and FCXM - groups. The incidence of acute rejection was determined for each group during the first yr after transplant. Graft survival rates at 1, 2, and 3 yr, and creatinine levels were also compared between groups. FCXM + patients experienced a higher incidence of acute rejection during the first yr after transplant (69 vs. 45%), and a higher percentage of FCXM + patients had more than one episode of acute rejection during the first yr after transplant (34 vs. 8%) when compared to FCXM - patients. There was no statistically significant difference in 1-, 2-, or 3-yr graft survival between FCXM + and FCXM - patients (76 vs. 83, 62 vs. 80, 62 vs. 72%, respectively). These results suggest that sensitized FCXM + cadaveric renal transplant recipients have a higher incidence of acute rejection episodes in the first yr after transplant. Given the association of multiple rejection episodes with poor long-term allograft survival, FCXM may be a useful predictor of long-term clinical outcome in this sub-group of renal transplant recipients.     

Plasmapheresis during cardiopulmonary bypass: a proposed treatment for presensitized cardiac transplantation patients

Potential thoracic organ transplantation recipients who have positive cytotoxic antibody screens as quantified panel reactive antibodies (PRA) are at risk for immediate or long-term immunologic events that may affect the donor organ. The patient population at risk includes those who are supported with cardiac assist devices, multiparous women, and individuals receiving numerous homologous blood products. We treated three highly positive PRA patients with intraoperative plasmapheresis coupled to the cardiopulmonary bypass system to remove sufficient cytotoxic antibody. Upon the availability of donor hearts of an unknown HLA type, intraoperative plasmapheresis was performed using a Cobe Spectra Plasmapheresis system coupled to a Terumo CXSX18 oxygenator system. Three plasma volume exchanges of fresh frozen plasma (FFP) were performed while the patients were on cardiopulmonary bypass. One to one and one-half plasma volume exchange plasmaphereses were performed with a declining schedule for the next 30 days post-transplantation in combination with aggressive B-cell specific immunosuppressive therapy. The three patients are NYHA functional class I and free of rejection at 6 months post-transplantation. In conclusion, intraoperative plasmapheresis is effective and safe for the patient who would not be otherwise transplanted because of markedly elevated PRAs.     

高度致敏受者的肾移植术

目的 探讨高度致敏肾移植受者的组织配型和抗排斥治疗方案。方法 回顾性分析45例高度致敏肾移植受者的HLA抗体、HLA配型和肾移植后抗排斥反应治疗效果。结果 肾移植术后发生超急性排斥反应2例(4．4％)，急性排斥反应9例(20.9％)，经激素、抗胸腺细胞球蛋白、血浆置换等治疗后均逆转。人／肾1年存活率分别为95．6%／91．1％。结论 避开相应抗体的良好HLA配型，是高度致敏受者肾移植成功的关键。术后采用抗胸腺细胞球蛋白短程诱导、并用他克莫司、霉酚酸酯治疗，能减少急性排斥的发生率，提高移植物的存活率。