肝移植术后耐激素冲击治疗的急性排斥反应的诊治

Steroid-resistant acute rejection after liver transplantation

目的探讨肝移植术后耐激素治疗的急性排斥反应（steroid-resistant acute rejection，SRAR）的诊疗方法。方法中山大学附属第一医院自2004年1月至2007年12月实施596例成人肝移植中，共有96例患者发生113次急性排斥反应（acute rejection，AR），其中11例患者出现SRAR，回顾性分析以上11例患者的临床资料。结果本组患者肝移植术后AR的发生率为16．1％（96／596），发生时间3—410d，中位时间为17d。11例发生SRAR的时间6—72d，中位时间为19d，3例患者接受OKT3治疗，8例患者接受IL-2单克隆抗体联合霉酚酸酯（mycophenolate mofetil，MMF）治疗，7例患者治疗后排斥反应逆转。2例患者接受再次肝移植，与SRAR相关的死亡率为36．4％（4／11），其中1例死于急性肝功能衰竭，1例死于慢性肝功能衰竭，1例再次肝移植术后。肾功能衰竭死亡，1例OKT3治疗后严重感染死亡。结论肝移植术后SRAR虽然发生率低，但预后差，IL-2单克隆抗体和OKT3对部分患者有效。

Objective To explore the outcome and treatment for recipients with steroid-resistant acute rejection （SRAR） after liver transplantation. Methods From Jan 2004 to Dec 2007, 596 adult patients received liver transplantation in the Organ Transplantation Center, the First Affiliated Hospital of Sun Yat-Sen University,96 recipients experienced 113 episodes of acute rejection （AR） after the operation, 11 recipients had no response to conventional steroid bolus treatment, the clinical data of this group of patients was analyzed retrospectively. Results Incidence rate of AR in our single center was 16. 1% （96/596） , among them 9.7% （11/113 ） were steroid-resistant. SRAR occurred averagely on 19 d （6 -72 d）after liver transplantation, 3 were controlled by OKT3 treatment, 4 were reversed by IL-2 receptor inhibitors combined with MMF. Rejection could not be reversed in 4 patients and 2 finally received retransplantation. Mortality rate associated with SRAR was 36. 4 % （4/11） including, one from acute liver failure, 1 from chronic fiver failure, 1 from renal failure after retransplantation and 1 from pulmonary infection after OKT3 treatment. Conclusion SRAR is a severe complication with high mortality after liver transplantation, OKT3 and IL-2 receptor inhibitors are effective in only a portion of these patients.