肾移植术后耐激素急性排斥反应的诊治体会

Steroid-resistant kidney transplant acute rejection:diagnosis and treatment

目的总结肾移植术后耐激素的急性排斥反应(steroid-resistant acute rejection,SRAR)的诊治体会。方法对32例SRAR患者的临床资料进行回顾性分析。所有患者经临床表现、移植肾彩色多普勒超声(彩超)检查、移植肾穿刺病理活组织检查(活检)诊断为SRAR并分型。确诊后采用抗胸腺细胞球蛋白(ATG)+麦考酚吗乙酯(MMF)+他克莫司(FK506)+肾上腺皮质激素(激素)的强化免疫抑制方案,并予对症和支持治疗。结果 32例患者中细胞性AR占23例,体液性AR占6例,混合型占3例。经治疗后,逆转27例(84%),肾功能恢复正常,随访1～5年,肾功能维持正常;好转4例,随访1～3年,血清肌酐140～270μmol/L;无效1例,恢复血液透析。治疗过程并发呼吸道感染3例、伤口感染2例,均经对症治疗后治愈。结论根据临床表现、术后大剂量甲泼尼龙冲击治疗无效,结合移植肾彩超、病理检查结果等确诊SRAR。及时采用ATG+MMF+FK506+激素的强化免疫抑制方案治疗SRAR,效果良好。

Objective To sum up the experience on the diagnosis and treatment of steroid-resistant acute rejection （SRAR） after renal transplantation. Methods Clinical data of 32 patients with SRAR were analyzed retrospectively. SRAR was diagnosed and classified by clinical manifestations, color Dopple uhrasonography and pathological biopsy of transplanted kidney. Strengthened immunosuppression regimen containing antithymocyte globulin （ATG）, mycophenolate mofetil （MMF）, tacrolimus （FK506） as well as adrenocortical hormone was used after the diagnosis. Symptomatic and supporting treatments were also applied. Results Among the 32 cases, 23 cases developed cellular acute rejection, 6 cases developed humoral acute rejection and another 3 cases developed mixed cellular and humoral acute rejection. SRAR was reversed and the recovery of renal function was observed in 27 cases （ 84 % ） after treatment. During a 1-5 y follow-up period, the renal function of the 27 cases remained normal. The renal function was improved in 4 cases and the serum creatinine fluctuated from 140 tLmol/L to 270 txmol/L during the follow-up period for 1-3 y. One cases developed renal function failure and underwent hemodialysis again. During the therapeutic process, three cases developed re- spiratory tract infection and two cases developed wound infection. All were cured after symptomatic treatment. Conclusion SRAR can be diagnosed by clinical manifestations, ineffectiveness of large doses of methylpred-nisolone after transplantation, color Dopple ultrasonography and pathological biopsy of transplanted kidney. It is helpful that strengthened immunosuppression regimen containing ATG, MMF, FK506 and adrenocortical hormone is used for SRAR.