术前单次大剂量ATG诱导治疗在PRA阳性肾移植受者中的应用

Application of preoperative single bolus high-dose antithymocyte globulin induction therapy in renal graft recipients with positive PRA

目的评价术前单次大剂量兔抗胸腺细胞球蛋白(ATG)诱导治疗用于群体反应性抗体(PRA)阳性肾移植受者时的有效性及安全性。方法26例PRA阳性肾移植受者组成PRA阳性组(PRA≥10%),该组患者于肾移植手术之前2h开始接受单次大剂量ATG诱导治疗(Fresenius,9mg/kg)。另外选取同时期接受肾移植手术的PRA阴性受者组成阴性对照组(PRA<10%,n=30),该组患者仅于术前6h口服骁悉1g作为诱导治疗。两组患者的维持免疫抑制剂方案均采用标准的三联方案(钙调蛋白抑制剂+骁悉+强的松)。两组患者术后均接受12个月的随访,对排异反应事件、感染事件和肾功能变化进行记录。结果在术后12个月中,PRA阳性组有4例患者(15.4%)出现急性排异发应(AR),阴性对照组内有6例患者(20.0%)出现AR(P=0.737)。PRA阳性组内6例患者(23.1%)共发生10次感染事件(1.7次/例),阴性对照组内有8例患者(26.7%)共发生11次感染事件(1.4次/例)(P=0.757和P=0.890)。PRA阳性组内的患者接受术前单次大剂量ATG诱导治疗后未出现严重的副作用,与对照组比较差异无统计学意义。PRA阳性组和对照组患者的平均住院时间分别为(16.2±3.1)d和(16.7±3.3)d(P=0.563)。两组患者均未发生移植物功能延迟恢复(DGF)。两组患者的1年人肾存活率均为100%。结论术前单次大剂量ATG诱导治疗安全有效,可以明显降低PRA阳性患者的AR和DGF的发生率,改善移植肾的预后。

Objective To evaluate the efficacy and safety of preoperative single bolus highdose antithymocyte globulin （ATG） induction therapy in renal graft recipients with positive PRA. Methods 26 renal graft recipients with positive PRA （ PRA ≥ 10% ） received a single preoperative bolus ATG induction therapy （ Fresenius, i.v. 9 mg/kg） two hours before operation, who were categorized as PRA ＋ Group. Another 30 renal graft recipients with negative PRA （PRA 〈 10% ） were enrolled into this study as negative contrel group （Group N）, who were treated with mycophenolate mofetil （MMF） （1g） as induction therapy 6 hours before operation. All patients were given standard triple therapy regimen as maintenance immuno - suppression, which consisted of tacrolimus （ FK - 506） or cyclosporine A, MMF, and prednisolone. All patients had been followed up for 12 months. Acute rejection （AR） and infection episodes were recorded and renal function was monitored during follow - up. Results During the follow - up, 4 patients （ 15.4% ） suffered AR episodes in PRA ＋ Group and 6 （20.0%） in Group N （ p = 0. 737 ） ; 6 patients （23.1%） experienced 10 infection episodes （average, 1.7 episodes per infected patient） in PRA ＋ Group, and 8 （26.7%）experienced 11 infection episodes （average, 1.4episodes per infected patient）in Group N （ p = 0.757, 0.890）. No severe ATG - related side effects were observed in PRA ＋ Group. The hospital stay was 14 -29 days （mean, 16.2 ±3.1）in PRA ＋ Group and 13 -25 days （mean, 16.7 ±3.3）in Group N, respectively （ P =0.563）. No delayed graft function （DGF） was observed in all the patients. Both the 12 -month actuarial patient and graft survival rates were 100% in the two groups. Conclusion Preoperative single - bolus high - dose ATG is an effective and safe induction therapy yielding acceptable acute rejection rate in renal graft recipients with positive PRA.