肺移植急性排斥反应的诊治(附三例报告)

Diagnosis and treatment of acute rejection of lung transplantation: report of three cases

目的 观察和探讨肺移植急性排斥反应的临床表现、诊断方法、经支气管活检排斥反应的病理分类和治疗。方法 2 0 0 2年 9月至 2 0 0 3年 6月 ,分别为 3例肺气肿、肺功能重度减损的患者进行了单肺移植。其中后 2例为同一供者的左、右肺 ,第 2例受者HLA无 1个位点匹配。结果 第 1例左肺移植术后第 9d发生 1次急性排斥 (A2b级 ) ,经大剂量甲泼尼龙冲击治疗后症状消退 ;第 2例右肺移植第 7d持续发生急性排斥 (A4c级 ) ,经甲泼尼龙冲击并用OKT3 治疗无效 ,术后第 1 5d死亡 ;第 3例左肺移植第 9d、第 1 5d发生 2次急性排斥 (A3a级 ) ,经甲泼尼龙冲击并用OKT3 治疗 8d后缓解。结论 选择组织相容性好的供、受者进行肺移植 ,是成功的保证。肺组织活检成为诊断急性排斥的金标准 ,对肺移植急性排斥反应的及时诊治是减少术后死亡率的关键。

Objective To discuss the clinical manifestations of acute rejection and its diagnosis and treatment following lung transplantation for end-stage emphysema.Methods From Sep. 2002 to June 2003, 3 patients with end-stage emphysema underwent single-lung transplantation in our hospital. There was non of matches at the HLA-A, HLA-B, HLA-DR locus in second recipient. The surgical technique used was similar to that mentioned in the literature. Immunosuppressants included cyclosporine, mycophenolate mofetil and corticosteroid.Results Acute rejection (A2b) occurred on the 9th day after operation in the first case and the patient was cured by bolus methylprednisolone given intravenously. The second patient was died on the 15th day after operation because of acute rejection (A4c). Acute rejection (A3a) occurred on the 9th and 15th day after operation in the third patient who was cured by bolus methylprednisolone with OKT3 given intravenously. The first patient was survived for one and half year and his lung function was improved significantly. The third patient was survived for 6 months. Conclusions Mismatches between donors and recipients at the HLA are important risk factors for early high-grade rejections after lung transplantation. Transbronchial biopsies were the gold standard for diagnosing acute rejection. The diagnosis and treatment of acute rejection as soon as possible is the key to reduce mortality rate of lung transplants.