肾-骨髓联合移植诱导免疫耐受:能够促进移植后嵌合体的形成吗?

Induction of immune tolerance using kidney-bone marrow transplantation:Does it promote chimerism formation?

背景:特异性的供者骨髓造血干细胞输注促进了嵌合体的形成,可以诱导器官移植免疫耐受。然而为达到细胞嵌合进行骨髓移植的预处理毒性大,发生移植物抗宿主反应的风险较高,人们开始寻找一些毒性更小的方案,其中包括免疫抑制剂联合骨髓输注等,尽管动物实验中已有诱导成功的耐受模型,但临床实用的诱导耐受方法则难以突破。目的:以嵌合体理论为基础,分析肾-骨髓联合移植诱导嵌合体形成与免疫耐受的相关性及安全性。设计、时间及地点:对比观察,于1998-01/2005-12在郑州市第三人民医院泌尿外科完成。对象:根据ABO/Rh血型相同及HLA配型原则,将同期等待肾移植的96例女性慢性肾功能衰竭患者分为2组,每组48例。联合移植组患者接受尸体肾、骨髓联合移植;同期接受上述同一供者另一肾脏的尿毒症患者作为对照组。供者为48例健康男性。方法:供者在取肾的同时,采集骨髓加入细胞冷冻保养液,经细胞程序降温至-198℃液氮罐保存。移植后应用大剂量抗人T淋巴细胞免疫球蛋白诱导治疗2周,于肾脏移植后2周实施骨髓细胞回输,输注的单个核细胞数为(0.9～2.5)×108/kg。采用聚合酶链反应方法检测人性别决定基因SRY。抽血检测CD3,CD4,CD8,CD25,以酶联免疫吸附法测定血白细胞介素10、肿瘤坏死因子α、肿瘤坏死因子β等血细胞因子质量浓度。主要观察指标:移植后于不同时间点对受体进行嵌合体、淋巴细胞亚群及细胞因子检测。随访观察两组受者的临床移植效果及并发症发生情况。结果:联合移植组嵌合体阳性率显著高于对照组(P<0.05)。随访3年,嵌合体阳性受者和嵌合体阴性受者排斥发生率差异具有显著性意义(13%,35%,P<0.05)。联合移植组呈现免疫抑制状态,未见移植物抗宿主病发生。结论:肾-骨髓联合移植能促进移植后嵌合体的形成,显著降低排斥反应发生率,是一种安全有效的诱导免疫耐受的方法。

BACKGROUND：Infusion of hemopoietic stem cell from donors can promote the chimeric formation and induce specific immunologic tolerance in the allograft recipients.However,the pretreatment for cell transplantation has great toxicity to recipients.So immunosuppressant combined bone marrow infusion is introduced to anti graft versus host reaction.OBJECTIVE：Based on microchimerism,to study the security and associativity of chimera formation induced by kidney-bone marrow transplantation and immunologic tolerance.DESIGN,TIME AND SETTING：The contrast observation was performed at the department of urinary surgery,The Third People＇s Hospital of Zhengzhou City from January 1998 to December 2005.PARTICIPANTS：According to ABO/Rh blood type and HLA matching,96 female patients with chronic renal failure and waiting for kidney transplantation were divided into 2 groups,In the combination group,patients received kidney combined bone marrow transplantation;the other uremia patients received the other kidney of cadavers were served as control group.The donors were 48 healthy males.METHODS：Bone marrow of donors was collected simultaneously with kidney obtain and preserved with cryoprotectant at-198 ℃ in nitrogen canister.After kidney transplantation,large dose of anti-human lymphocyte immune globulin were used for 2 weeks,then （0.9-2.5）×10^8/kg mononuclearcell was reinfused.PCR-SRY was used to identify donor derived cell-chimerism.Lymphocyte subgroup of recipients was determined by blood test;and interleukin 10 was measured by enzyme linked immunosorbent assay;in addition,the mass concentration of tumor necrosis factor α and tumor necrosis factor β was detected.MAIN OUTCOME MEASURES：Chimerism,lymphocyte subsets and cytokines were detected at various time points following transplantation.Simultaneously,the transplantation results and complication status of recipients were observed.RESULTS：The positive rate of chimera in the combination group was greater than that of the control group （P〈0.05）.The 3-year follow-up showed that incidence differences of acute rejection between recipients with positive chimera and recipients with negative chimera had significance （13%,35%,P〈0.05）.There was no graft versus host disease occurred in the combination group.CONCLUSION：Kidney-bone marrow transplantation can augment chimerism in early postoperative period,and significantly reduce the rate of acute rejection,which is safe and beneficia1to induce specific immunologic tolerance in the renal allograft recipients.