异体手移植急性排斥反应的成功预防

Successful prevention from acute rejection in human hand allograft

目的:探讨异体手移植急性排斥反应的防治措施。方法:1999-09-21南方医科大学南方医院为2例男性患者同时进行了右手异体移植,其一患者2年前炸鱼时将右手炸毁,初期手术作残端修整;其二患者2年前右腕部被钢丝勒断,在当地医院行再植术失败后作残端修整。2000-09-26又为一双前臂缺失患者进行了异体手移植,患者的双前臂炸伤缺失1年,缺失平面为右前臂中下1/3,左前臂中上1/3。3例患者心理及免疫状态均正常,无全身性疾病,残肢局部情况好,强烈要求手移植。以与受者ABO、Rh血型相同,HLA配型良好的脑死亡患者为供体;所有供肢尺桡骨骨髓刮除,其中2例供肢于移植前行8Gy的X射线照射;全部患者显微镜下吻合动脉、静脉及神经,联合应用免疫抑制剂;动态检测外周血T细胞亚群和细胞因子。结果:①患者手移植一般情况及移植手皮肤、组织病理检查结果:3例患者手移植后,生命体征平稳,移植术后手血运均良好,无合并细菌、病毒和真菌感染,皮肤愈合同断肢再植,移植手全部成活,临床症状、体征及皮肤病理检查均提示没有发生急性排斥反应。②外周血细胞因子动态检测提示:移植术后诱导期血清中白细胞介素2、肿瘤坏死因子α、干扰素-γ水平迅速下降,1周后恢复至手术前水平,随后逐渐降低并维持在低水平。结论:异体手移植急性排斥反应的预防与供受者间的组织配型、供肢的适当处理、免疫抑制剂应用的个体化、微创外科技术、周密的预防感染措施等因素密切相关。术后监测血清中白细胞介素2、肿瘤坏死因子α、干扰素-γ的水平可以早期判断排斥反应的发生。

AIM： To explore the prevention of acute rejection in human hand allograft. METHODS： Two male patients underwent right hand allograft in the Nanfang Hospital of Southern Medical University on 21^st September 1999. In the two patients, the right hand of one was exploded when exploding the fish and underwent initially fitting; the right wrist of the other was carved by steel-wire and underwent fitting after the failure replantation two years ago. On 26^th September 2000, another patient with traumatic both forearms amputation underwent the hand allograft, whose both forearms were injured in explosion one year ago, with deletion in 1/3 middle and lower of the right forearm and 1/3 middle and upper of the left forearm. The 3 patients had normal psychological and immune state without systemic disease, and their disabled limb condition was better, which requested urgently hand allograft. Three brain-dead donors were matched respectively to ABO- and Rh-compatible, HLA-half compatible. After removed the marrow of ulnar and radial bone by scraping, two of the donor＇s arms was irrigated with 8 Gy X-ray; The artery, vein and nerve of the patients were anastomosed under microscope combined with immunosuppressants. T-lymphocyte subsets and cytokine were dynamically detected. RESULTS： ①General condition, transplanted hand skin and histopathologic examination of the patients： After transplantation, the vital signs were stable, and the circulation of the transplanted hands was satisfactory： No bacteria, virus or fungal infection were found. The skin healing was fused with the replanted limb, all the grafted hands survived. No acute rejection reaction was found in the clinical symptoms, physical signs and skin pathologic examination.②Dynamic detection of cytokine in peripheral blood： The level of serum interleukin 2 （IL-2）, tumor necrosis factor α（TNF-α） and interferon γ（IFN-γ） were descent quickly within the first post-transplantation week and returned at induction period of immunosuppressive agent, but remained at low level. CONCLUSION： Tissue matching with donor, reasonable handle of donor limbs, individualized immunosupressants, refined and exact microsurgical technology, and effective infection prevention can prevent acute rejection. Monitoring of serum IL-2, TNF-α and IFN-γ in the peripheral blood of patients is helpful to judge the occurrence of acute rejection.