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We report our experience of 36 renal transplanted patients against a current T negative allo-cross-match, but historical T and/or B positive allo-cross-matches, whatever the result of the current B cross-match. Additionally, we have determined the immunoglobulin class of the antibody directed against B and T lymphocytes. The graft survival rate did not differ between the 36 patients forming the study group, and the 229 patients transplanted within the same period with negative T and B, on current and historical sera, cross-matches. Within this study group there was no changes in graft survival rate for the following three subgroups, which were retrospectively defined: historical positive (14 patients) versus negative (22 patients) T cross-match, current positive (15 patients) versus negative (21 patients) B cross-match, and IgM (16 patients) versus IgG (20 patients) against B lymphocytes. In terms of transplant outcome, our policy was thus safe.  相似文献   

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目的:探讨影响致敏受者肾移植术后人/肾存活的相关因素。方法:对82例致敏受者尸体肾移植患者可能影响移植肾存活相关的20个因素47个水平,进行Logrank单因素分析和Cox模型多因素回归分析。结果:82例的1、2和3年的人存活率分别为98%、96%和94%;移植肾存活率分别为90%、87%和83%。总的移植肾半生存期为4.7年。单因素分析,群体反应抗体水平和动态变化、供体特异性抗体、急性排斥、慢性排斥、冷缺血时间、早期肾功能、血肌酐水平和免疫诱导剂等9个因素;多因素分析,急性排斥、供体特异性抗体和群体反应抗体类型等3个因素;单因素和多因素同时分析,急性排斥和供体特异性抗体2个因素,对致敏受者移植肾短期和长期的存活率有重要的影响(P<0.05)。结论:高质量的供肾、群体反应抗体动态监测、尽力避免和有效处理术前和术后相关危险因素,对提高致敏受者肾移植的人/肾存活率有重要的作用。  相似文献   

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The effect of B cell cross-match (XM) was investigated in 680 first deceased-donor kidney transplants in a single centre from 1990 to 1999: 74 transplants presented a B-positive XM (Group 1) 606 had a B-negative XM (Group 2). The absence in Group 1 of weak/low-titre anti-HLA Class I antibodies was assured blocking anti-Class I reactivity by treating B cells with non-cytotoxic anti-beta2 microglobulin (alphabeta2 M) serum before XM. Graft survivals up to 5 years were not significantly different; some differences were nevertheless observed: HLA-A,B,DR mismatches influenced graft outcome in Group 1: patients with 0-2 mismatches had better survival than patients with 3-4. When analysed according DR mismatch, patients with 1 mismatch had worse graft survival than well matched patients (p<0.05). No significant difference depending on HLA match was observed in Group 2. Early acute rejection rate was similar in the Groups except the rejection episodes after one year: Group 1 had significantly more. 61/74 patients of Group 1 were retrospectively analysed for anti-HLA-DR,DQ reactivity: only 11/61 had anti-HLA-DR or DQ antibodies (3/11 were donor specific); graft survival and rejections were not significantly different in the patients with and without anti-HLA Class II antibodies. Anti-donor B cell reactivity, at XM, once excluded the presence of weak/low-titre anti-HLA Class I antibodies, did not influence first kidney graft survival.  相似文献   

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Calcineurin inhibitors (CNI) are an important component of most immunosuppressive protocols utilized in renal transplantation. Both CNI available (cyclosporine and tacrolimus) have been used for many years. Studies comparing the efficacy of these two agents in terms of long-term graft or patient survival have thus far failed to show an advantage for either agent. This failure to show a difference could possibly be due to underpowering of clinical trials. The authors used the SRTR database to analyze 5-yr graft survival of the microemulsion formulation of cyclosporine (Neoral) as compared with tacrolimus. To minimize the donor variability and bias, a paired kidney analysis was used. Deceased donors from the years 1995-2002 were analyzed from the SRTR database. All paired kidneys during this period, where one kidney was allocated to a patient receiving initial Neoral therapy and its mate allocated to a patient receiving initial tacrolimus therapy were evaluated. Multivariate and univariate analysis were performed. Univariate analysis demonstrated equivalent graft survival for Neoral compared with tacrolimus (66.9% versus 65.9%, respectively). Multivariate analysis could not demonstrate a difference in risk for 5-yr patient survival or graft loss. Renal function was superior for tacrolimus at all time points, whereas the slope of 1/Cr over time did not differ for the two agents. In this paired kidney analysis, no difference in 5-yr renal allograft survival could be found between the two agents. Renal function was superior in the patients receiving initial tacrolimus therapy; however, slope of 1/Cr did not differ between the agents.  相似文献   

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Between July 2001 and November 2003, 16 patients with a positive flow-cytometry crossmatch to their potential living donor for kidney transplant were treated with desensitization protocol based on plasmapheresis and low-dose IVIg starting 1 week before the scheduled transplant. Twelve patients (75%) converted to negative crossmatch and were successfully transplanted. Immunosuppression consisted of induction with thymoglobulin, tacrolimus, mycophenolate mofetil, and steroids. Plasmapheresis and IVIg were continued on alternate days for the first postoperative week. The 1-year patient and graft survival was 100%. The rate of acute rejection was 41% (16% cellular and 25% humoral). All of the rejection episodes resolved with treatment. Combination of plasmapheresis and IVIg allows successful conversion from positive to negative flow-cytometry crossmatch in 75% of cases; after conversion, kidney transplant can be carried out with a high rate of success.  相似文献   

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We retrospectively studied all 1149 transplants performed at our center between 1993 and 2003 to determine the incidence and clinical effect of pretransplant B-positive cross-match on kidney graft survival. The patients were divided in two groups: B-negative (n = 1102) and B-positive in current sera (n = 47; 4.1%). AB-positive test was more frequent among regrafted patients (14% vs 3%; P = .00). Demographic data were not different between the groups. The overall rate of graft loss was similar (26% vs 24%, respectively; P = .86). However, early nonsurgical graft losses were more frequent among B-positive patients (46% vs 20%, respectively; P = .04). IgM was the most frequent immunoglobulin in the B-positive group (76% IgM and 24% IgG). There was no significant difference between B-negative and B-positive groups in the 1-, 5-, and 10-year graft survival rates (87% vs 83%, 73% vs 78%, 64% vs 66%, respectively; P = .87). The graft survival was significantly reduced comparing an IgG anti-B cell to the B-negative group (P = .03) as well as IgG compared to IgM (P = .004). In conclusion, only B-positive cross-match due to IgG decreased graft survival. Even though it is an uncommon situation (0.9%), this study stressed the clinical value of the B-cell cross-match as a tool to identify patients with a higher immunological risk.  相似文献   

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A positive T-cell cross-match is a well-established contraindication to deceased donor renal transplantation (DDRT); however, the significance of a positive B-cell cross-match (BCXM) remains debatable. Thus, given the high demand and scarce supply for deceased donor (DD) kidneys, only T- and B-cell cytotoxic cross-match-negative recipients were considered for DDRT in the past at our institution. Since September 2007, we have started performing DDRT across a historical positive cytotoxic BCXM. When a matched DD kidney became available, patients who were BCXM-positive (BCXM+) on historical sera would undergo repeat cross-match with current sera, using enhanced techniques. BCXM+ and current T-cell immunoglobulin (Ig)G cross-match-negative patients underwent transplantation with enhanced immunosuppression. Donor-specific anti-HLA antibodies (DSA) were tested for only in BCXM+ patients. The present study was designed to review outcomes of historical BCXM+ versus BCXM-negative (BCXM−) DDRT. Between September 2007 and October 2009, 11 BCXM+ and 50 BCXM− DDRT were performed. All patients were followed-up till October 31, 2010. Demographics and sensitization history of both groups were comparable. DSA were present in 6 (54.5%) BCXM+ patients, irrespective of their current cross-match status. All BCXM+ patients received induction immunosuppression with anti-thymocyte globulin, whereas only 60% of BCXM− patients had induction therapy. All BCXM+ patients and the majority of BCXM− patients received a calcineurin inhibitor-based maintenance regimen. DSA-positive patients received several sessions of plasmapheresis, followed by cytomegalovirus (CMV) hyperimmune globulin after every session. Graft and patient survivals were similar at 12 and 24 months in both groups. Their incidence of BK viremia, CMV antigenemia, and early acute rejection was also similar. The presence of DSA did not increase the risk for acute rejection. Performing DDRT across a positive BCXM with enhanced immunosuppression has enabled highly sensitized patients to receive a transplant with noninferior short-term outcomes compared with low-immunologic risk patients.  相似文献   

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Abstract The study of a two-locus association between HLA-B and -DRB1 revealed a significant 43 linkage disequilibrium. Donorrecipient HLA-DRB1 was determined by these 43 linkages. Zeromismatch for HLA-DRB 1 had a significant effect on the graft survival rate in living related and cadaver transplants. The 5-year graft survival rate was 94% in the zero-mismatch group for HLA-DRB 1, 96% for related transplants, 92% for cadaver cases, and 94% in HLA identical siblings. A statistically significant difference was found between the zeromismatch group for HLA-DRB 1 and mismatch groups for HLA-DRB 1 or HLA-DR (P<0.01). The zero-mismatch group for HLADRB 1 had mismatches for HLA-A and/or HLA-B in 46 of 70 cases (66%). No significant differences in the rejection rate was observed between zero-mismatch and mismatch cases for HLA-A and/or -B in the zero-mismatch group for HLA-DRB l. In the second step, genotyping was conducted in 118 cases. The 5-year graft survival rate was 93% in the zero-mismatch group for HLA-DRB 1 and 86% in mismatch group (not a significant difference). We concluded that zero-mismatch transplant for HLA-DRB l had a better long-term graft survival rate regardless of HLA class I.  相似文献   

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影响致敏患者移植肾存活的危险因素分析   总被引:2,自引:0,他引:2  
目的探讨影响致敏患者移植肾存活的危险因素,以提高致敏患者移植肾长期存活率。方法对102例接受肾移植的致敏患者的资料进行回顾性分析,用KaplanMeier计算移植肾1、3、5年存活率,用LogRank进行单因素分析、Cox模型多因素回归分析,计算相对危险度。结果术后随访(30±2)个月,未出现超急性排斥反应,发生急性排斥反应33例,经激素及抗淋巴细胞抗体治疗后,25例逆转;16例移植肾功能丧失,其中7例死亡,死亡原因为肺部感染5例,心血管疾病2例;人/肾1、3、5年存活率分别为95%/90%、93%/85%、93%/75%;单因素及多因素分析表明,受者年龄、移植次数、HLA相配程度、PRA水平、移植后PRA升高、移植肾功能恢复正常的时间、血肌酐水平、移植肾功能恢复延迟、急性排斥反应及感染等10个因素对移植肾的存活有重要或非常重要影响。结论良好控制影响移植肾存活的危险因素,致敏患者肾移植同样能取得满意的效果。  相似文献   

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Abstract Altogether 57 patients were included in the related kidney transplantation program. Forty-four recipients were mixed lymphocyte culture (MLC) negative or slightly positive (SI < 7) against their mother/father donor, and most of them showed Fey RII [erythrocyte antibody inhibition (EAI)] blocking antibody in their sera as the consequence of previous random transfusion. Thirteen patients showed significantly high MLC reactivity against their prospective parent donor (SI < 7) and had no EAI blocking antibody in their sera. The latter group was immunized either by buffy coat or purified platelets obtained from their donor in general two or three times at biweekly intervals. The indication for transplantation of donor-specific transfusion (DST)-treated patients was based on the appearance of EAI antibody and a significant reduction in the MLC reactivity (9 patients). DST patients had 100% kidney graft survival for 5 years and the DST untreated ones 75 %. Suggested responsible factors for this observation are the haploidentity in HLA and the induction of suppressive immune regulation by DST.  相似文献   

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BACKGROUND: Tolerance to organ allografts in primates including man has been elusive, although in rodents and pigs tolerance can be achieved to organ allografts with relatively short courses of immunosuppressive treatment. In all varieties of graft acceptance that do not require full-dose maintenance immunosuppression, immunological engagement of donor and recipient and an early unstable period have been observed. On the basis of the hypothesis that elimination of aggressive T cell function should tip the balance in favor of an operationally tolerant state, experiments have been performed in monkeys allowing recipient-donor interaction before T-cell ablation and a short course of immunosuppression. METHODS: Rhesus monkeys received an allogeneic kidney graft from a MHC-mismatched donor. The animals either received anti-CD3 immunotoxin (FN18-CRM9) alone, started 2 days after transplantation, or in combination with a short course of cyclosporine (CsA) and/or rapamycin (RAPA), started at 5 days after transplantation. Kidney function was followed by monitoring serum creatinine levels and regular biopsies. Humoral and cellular antidonor immunity was tested in vitro before and at several time points after transplantation. RESULTS: Graft survival of monkeys that received CsA alone (mean survival time (MST)=29.3) was significantly prolonged compared with the controls (MST=6). FN18-CRM9 treatment alone also resulted in prolonged graft survival (MST=29.4). The combined treatment of FN18-CRM9 and CsA and/or RAPA resulted in prolonged graft survival after all immunosuppression was stopped (MST=207.8). CONCLUSIONS: It seems feasible to postpone immunosuppression posttransplantation and yet prevent allograft rejection without the need of permanent immunosuppression.  相似文献   

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Introduction

The number of overweight and obese patients undergoing renal transplantation has increased dramatically over the past two decades. Studies on graft survival and posttransplantation complications have often yielded conflicting results. Some authors have reported similar results for graft and patient survivals between obese and normal weight patients, but with a marginally increased rate of postoperative complications. In contrast, other reports note higher percentage of graft losses as well as increased mortality. In our study, we analyzed early- and long-term outcomes among obese versus nonobese kidney transplant recipients.

Patients and Methods

Between January 2000 and December 2008, we performed 563 cadaveric kidney transplantations. Recipients were classified in 1 of 5 groups based on their body mass index (BMI) at the time of transplantation: group A (n = 68; BMI < 18.5); group B (n = 310; 18.6 < BMI < 24.9); group C (n = 143; 25 < BMI < 29.9); group D (n = 32; 30 < BMI < 34.9); and group E (n = 10; BMI ≥ 35). The comparative analysis included patient and graft survivals, postoperative complications, onset of delayed graft function (DGF), acute rejection episodes, hospital stay, and serum creatinine values in the first 3 years posttransplantation.

Results

At a mean follow-up of 53 months (range, 3-112 months), DGF was observed in 20 patients in group A (29.4%), 82 in group B (26.4%), 43 in group C (30%), 16 in group D (50%), and 4 in group E (40%). Nevertheless, obese patients (groups D and E) showed higher mean serum creatinine values and worse renal function at 6 months (P = .001), 1 year (P < .001), and 3 years (P = .001). Moreover, they were at increased risk of an acute rejection episode (P = .01) and more susceptible to cardiovascular and metabolic complications (P = .01). Morbidly obese patients displayed a higher incidence of postsurgical complications (P = .002). There were no differences in the incidences of chronic allograft nephropathy (CAN) or infectious complications. Despite the differences in morbidity among the 5 groups, we failed to observe significant differences in patient or graft survivals at 6, 12, 36, or 60 months.

Conclusion

Our findings suggested that obese patients should not be discriminated against simply based on the BMI. At our center, obese (BMI >35) transplantation candidates undergo a thorough cardiac evaluation, as well as pulmonary, endocrine, and nutritional counseling seeking to minimize medical and surgical complications and improve survival and quality of life.  相似文献   

16.
Cyclosporine and long-term kidney graft survival   总被引:5,自引:0,他引:5  
Opelz G  Döhler B 《Transplantation》2001,72(7):1267-1273
BACKGROUND: Previous analysis of kidney transplant data from the Collaborative Transplant Study database showed that patients receiving cyclosporine 3-6 mg/kg/day 1 year posttransplantation had the best graft survival rate 7 years posttransplantation. Longer-term and additional analyses have now been performed. METHODS: Data from cadaver kidney transplants performed between 1985 and 1998 were analyzed retrospectively. Patients were included if they had a functioning graft 1 year posttransplantation, and the daily cyclosporine dose administered 1 year posttransplantation was reported. Data on cyclosporine dose, serum creatinine concentration, and systolic blood pressure were recorded 1 and 5 years after transplantation; information on graft survival was documented at yearly intervals. RESULTS: Patients receiving cyclosporine 3-6 mg/kg/day 1 year posttransplantation had the best graft survival rate 10 years posttransplantation. Cyclosporine <2 mg/kg/day was least beneficial overall and in subanalyses based on age, risk level, and 1-year serum creatinine concentration. The microemulsion cyclosporine formulation (Neoral) was associated with a significantly higher 4-year graft survival rate than the conventional formulation (Sandimmune; P=0.0001). Median systolic blood pressure 5 years posttransplantation was similar in each 1-year cyclosporine dose category (range of medians 139.0-140.0 mmHg). The percentages of patients with serum creatinine concentrations of <130, 130-260, 260-400, or >400 micromol/L 1 and 5 years posttransplantation were similar across 1-year cyclosporine dose categories, with the exception of >6 mg/kg/day, where there was a shift toward a less favorable serum creatinine concentration over time. CONCLUSIONS: The 1-year cyclosporine dose was significantly associated with long-term graft survival, with evidence of underimmunosuppression at doses <3 mg/kg/day and overimmunosuppression at doses >6 mg/kg/day, but had little influence on systolic blood pressure or serum creatinine concentration at doses up to 6 mg/kg/day.  相似文献   

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《Liver transplantation》2002,8(12):1109-1113
A positive cross-match in cadaveric liver transplantation is relatively acceptable, but its role in living donor liver transplantation (LDLT) is less well known. The aim of this study is to examine the significance of cytotoxic cross-match in adult-to-adult LDLT using small-for-size grafts. Forty-three adult-to-adult LDLTs were performed at Seoul National University Hospital (Seoul, Korea) from January 1999 to July 2001. Subjects consisted of 27 men and 16 women with an average age of 45.4 years. Average liver graft weight was 565.3 ± 145.7 g, and average graft-recipient weight ratio (GRWR) was 0.89% ± 0.20%. HLA cross-match testing by lymphocytotoxicity and flow cytometry was performed routinely preoperatively. Factors that may influence survival, such as age; sex; blood group type A, type B, type O compatibility; cytotoxic cross-match; donor age; surgical time; cold ischemic time; and GRWR, were analyzed. Nine patients (20.9%) died in the hospital. There was a greater in-hospital mortality rate in women than men (37.5% v 11.1%; P = .049). The extra-small–graft group (0.54% ≤ GRWR < 0.8%; n = 14) showed greater in-hospital mortality rates than the small-graft group (0.8% ≤ GRWR ≤ 1.42%; n = 29; 42.9% v 10.3%; P = .022). A positive cross-match was detected in 4 women transplant recipients, and 3 of these patients belonged to the extra-small–graft group. All patients with a positive cross-match died of multiorgan failure after early postoperative acute rejection episodes. Positive cross-match was the only significant factor in multivariate analysis (P = .035). In conclusion, when lymphocytotoxic cross-match and flow cytometry are significantly positive, adult-to-adult LDLT using small-for-size grafts should not be performed. (Liver Transpl 2002;8:1109-1113.)  相似文献   

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Until recently, most transplant units required that a negative crossmatch using all available sera was an essential criterion which would ensure the best use of a donor kidney. This policy was accepted without clinical trial until 1982 when it was suggested that a donor kidney will function successfully in the majority of recipients with a negative crossmatch using current sera and a positive crossmatch with one or more non-current sera, i. e., sera taken 3 or more months prior to the time of the transplant. In the 14 reported series addressing this question, the average 1-year graft survival ranges between 53% and 100% in these highly sensitized patients who receive a primary graft, and between 0% and 100% in those who receive a secondary graft. Controversy does exist as to whether a positive crossmatch in non-current sera is an additional risk factor, i.e., that it decreases graft survival significantly when compared with a similar group of highly sensitized patients who were transplanted with a negative crossmatch on all available pre-transplant sera. Of the published studies on this subject, the majority, but not all, find that there is no difference between controls and positive crossmatch patients who receive a primary graft, but those that receive a secondary graft may be at increased risk. The reasons for the different results from these studies may be related to differences in the many variables which influence graft outcome between various study groups.  相似文献   

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Acute injury and age are characteristics of transplanted tissue that influence many aspects of the course of a renal allograft. The influence of donor tissue characteristics on outcomes can be analyzed by studying pairing, the extent to which two kidneys retrieved from the same cadaver donor manifest similar outcomes. Pairing studies help to define the relative role of donor-related factors (among pairs) versus non-donor factors (within pairs). This study analyzed graft survival for 220 pairs of cadaveric kidneys for the similarity of parameters reflecting function and rejection. It also examined whether the performance of one kidney was predicted by the course of its "mate," the other kidney from that donor. Parameters reflecting function showed sustained pairing posttransplantation, as did graft survival. In contrast, measures of rejection strongly affected survival but showed no pairing. Surprisingly, the survival of a kidney was predicted by the early performance of its mate, an observation we term the "mate effect." Six-month graft survival and renal function were reduced in grafts for which the mate kidney displayed any criteria for functional impairment (dialysis dependency, low urine output [/= 400 micro mol/L), even for kidneys which themselves lacked those criteria. Rejection measures did not demonstrate the mate effect. In conclusion, kidney transplant function is strongly linked to donor-related factors (age, brain death). In contrast, rejection affects survival and function, but it is not primarily determined by the characteristics of the donor tissue. Graft survival reflects both of these influences.  相似文献   

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