小肠移植中应用Campath 1H诱导和低剂量他克莫司维持抗排斥治疗

目的 报告Campath 1H诱导和单用低剂量他克莫司维持的免疫抑制方案在2例小肠移植应用的经验.方法 小肠移植术中给予Campath 1H 30 mg及甲泼尼龙2 g.移植肠血管开放后给予他克莫司,术后早期从静脉途径给药,逐渐过渡至通过移植肠给予他克莫司.术后前3个月他克莫司血药浓度维持在10～15μg/L,术后第4个月开始,他克莫司血药浓度减低至5μg/L左右.结果 2例患者生存期均已超过1年,其中1例患者于术后第13个月时行移植肠末端造口关闭、还纳手术.2例患者各发生一次病理学检查证实的不确定(IND级)至轻度(1级)排斥反应,给予小剂量甲泼尼龙治疗后排斥反应消失;1例患者于术后8个月发生一次轻至中度排斥,给予大剂量激素冲击治疗后病理证实排斥反应消失.Campath 1H应用后淋巴细胞和单核细胞计数明显下降,其后缓慢回升.无明显感染及移植物抗宿主反应(GVHD)征象发生.移植肠功能良好,分别于术后第21天和第14天摆脱静脉营养,依赖口服饮食维持营养状态.结论 小肠移植中应用Campath 1H诱导,单用低剂量他克莫司、无激素维持方案,能有效地控制排斥反应,不增加感染发生的机会,未发生GVHD.患者移植肠功能良好,能尽早摆脱静脉营养.

Preliminary experience with Campath IH induction combinated with low-dose monotherapy of tacrolimus in small bowel transplantation

Objective To report preliminary experience of the protocol of combining Campath 1H induction with low-dose monotherapy of tacrolimus and no steroid in two cases of small bowel transplantation. Methods Campath 1H 30 mg was infused during the small bowel transplantation, and the patients were given 1 gram of methylpredniselone followed by the Campath 1H and another gram of methylpredniselone before reperfusion. Tacrolimus was infused just after the reperfusion. The tacrolimus was administered from vein first and then from gut tract, the blood tacrolimus level was controlled at 10 to 15 μg/L within the first 3 months after the operation, and reduced to 5 μg/L thereafter. Results The two recipients have survived more than 1 year, one received surgical closure of intestinal graft terminal stoma 13 months after the transplantation. One episode of indeterminate to mild acute rejection was verified by pathology through routine ileoscopical biopsy in each cases, and one episode of mild to moderate acute rejection occurred 8 months after the trausplantation, and the patients recovered after low dose or bolus steroid therapy. The peripheral lymphocyte counts and monocyte counts decreased greatly after Carnpath 1 H was given, and recovered very slowly thereafter. No sign of infection and graft versus host disease (GVHD) was found, and the grafted intestine achieved excellent function. The total parenteral nutrition was ceased on the day 21 and 14 after the operation, respectively, and the patients lived on oral intake to maintain nutrition status. Conclusions It's showed that the protocol combining Campath 1H induction with low-dose monotherapy of tacrolimus without steroid in small bowel transplantation can control graft rejection effectively without increasing the opportunity of infection, no sign of GVHD is found, and the grafted intestine could achieve excellent function.