肾移植术后早期耐激素急性排斥反应的临床研究

Clinical study of early steroid-resistant acute rejection after renal transplantation

目的 探讨肾移植术后早期耐激素急性排斥反应 (earlysteroid resistantacuterejectionESRAR)的原因、诊断及治疗方法。方法 回顾分析我科 1999年 10月 -2 0 0 2年 10月肾移植术后 18例诊断为ESRAR患者的临床资料。经临床表现、彩超及移植肾穿刺病理诊断为急性排斥反应。随后采用ATG +FK5 0 6+MMF +Pred免疫抑制方案、早期血液透析及支持等治疗。结果 在术后甲基强的松龙 (methylprednisolone ,MP)冲击治疗过程中 ,15例患者第 2天即无尿 ,3例第 2～ 5d肾功能改善后又出现血尿、少尿。经治疗 14例 ( 77.8%)分别在 15～ 78d逆转 ,肾功能恢复正常 ,随访 1～ 4年 ,肾功能维持正常。 3例好转 ,随访 2～ 3年血肌酐波动在 15 0～ 2 80 μmol L ,1例 ( 5 .6%)无效恢复血液透析。 结论 术后ESRAR极易导致移植肾功能不全 ;早期诊断并采用强有力的免疫抑制方案 ,结合血液透析和支持治疗可以有效逆转ESRAR 。

Objective To investigate the cause, diagnosis, and treatment of early steroid resistant acute rejection (ESRAR) after renal transplantation. Methods Clinical data of 18 patients with ESRAR after renal transplantation from October 1999 to October 2002 were analyzed retrospectively. Acute rejection was confirmed by clinical manifestations, color ultrasonography, and pathological diagnosis of the biopsy of transplanted kidney. Immunosuppressive scheme ATG+FK506+MMF+Pred, hemodialysis, and supporting therapy were employed. Results During the course of treatment with methylprednisolone (MP), anuria occurred in 15 cases on the second day after transplantation, but hematuria and oliguresis in 3 cases from the second to the fifth day after improvement of renal function. ESRAR was reversed and renal functions were recovered in 14 cases during the period from 15 to 78 days after treatment. A follow up time for 1-4 years revealed that the renal functions remained normal. Renal functions were improved in 3 cases. A follow up time for 2-3 years showed fluctuations of the serum creatinine from 150 μmol/L to 280 μmol/L, but failure in 1 case and hemodialysis was performed again. Conclusion ESRAR after renal transplantation can easily result in allograft dysfunction, but ESRAR can be reversed by early diagnosis, efficient immunosuppressive scheme, hemodialysis, and support therapy in time.