活体肾移植前对致敏患者的处理经验及疗效分析

Management experience and effect analysis of highly sensitized recipients before living kidneytransplantation

目的总结活体肾移植前对致敏患者的处理经验，并对移植效果进行分析。方法回顾性分析609例活体肾移植受者的临床资料。根据移植前群体反应性抗体（PRA）水平将受者分为高致敏组（41例，PRAY30％），低致敏组（102例，PRA为0～30％）和非致敏组（466例，PRA为0）。所有受者经HLA抗体检测和淋巴细胞毒交叉配合试验（CDC）确认没有针对供者的HLA抗体后进行肾移植。高致敏组给予抗胸腺细胞球蛋白诱导治疗，低致敏组给予抗白细胞介素2受体单抗诱导治疗。随访1年以上，观察各组术后移植‘肾功能、急性排斥反应发生率、受者和移植肾存活率及并发症发生率。结果高致敏组、低致敏组和非致敏组受者术后移植肾恢复正常的时间和1年时肾小球滤过率均无明显差异；3组均未发生超急性排斥反应，急性排斥反应发生率分别为9．76％（4／41）、8．82％（9／102）和8．15％（38／466），术后1年移植肾存活率分别为97．6％（40／41）、97．1％（99／102）和98．1％（457／466），受者存活率分别为97．6％0（40，／41）、98．0％0（100／102）和98．9％o（461／466），3组间上述指标的差异均无统计学意义（P〉O．05）。高致敏组的感染发生率为31．7％（13／41），明显高于低致敏组的26．5％（27／102）和非致敏组的21．6％0（101／466）（P〈O．05）。结论致敏受者肾移植前经HLA抗体检测和CDC配型，避开受者体内供者特异性抗体针对的供肾，并给予免疫诱导治疗，可以获得与非致敏受者相似的良好效果。

Objective To summarize the management experience of sensitized recipients before living kidney transplantation and to analyze the effect. Method A retrospective analysis was done on the clinical data of 609 cases of living kidney transplant recipients. According to the pretransplant panel reactive antibody （PRA）, we allocated them into highly sensitized group （41 cases, PRA 30%）, low sensitized group （102 cases, PRA 0-30%） and non-sensitized group （466 cases, PRA = 0）. All cases were confirmed with no anti-donor HLA antibodies by HLA antibody detection and complement-dependent cytotoxicity （CDC） before transplantation. The recipients in＇highly sensitized group were treated with anti＇-thymoglobulin （ATO） as induction therapy, while those in low sensitized group were given IL-2R antibody （IL-2Ra）. Renal function, incidence of acute rejection （AR）, patient and graft survival rate, and complications were observed upon 1-year follow-up. Result There was no significant difference in renal function recovery time and eGFR at 1 year among highly sensitized, low sensitized and nonsensitized groups. In highly sensitized, low sensitized and nonsensitized groups, the incidence of AR was 9. 76% （4/41）, 8.82% （9/＇102） and 8. 15% （38/466）, 1-year graft survival rate was 97. 6% （40/41）, 97. 1% （99/102） and 98. 1% （457/466）, and 1-year patient survival rate was 97. 6% （40/41）, 98. 0% （100/102） and 98. 9% （461/466）, respectively, with the difference being not statistically significant among these three groups （P〉0. 05）. Infection rate in highly sensitizedgroup was 31.7% （13/41）, which was significantly higher than in low sensitized group （26. 5%, 27/102） and non-sensitized group （21.6%, 101/466） （P〈0. 05）. Conclusion Avoiding donors with donor special antigen （DSA） by HLA antibody detection and CI）C before kidney transplantation, and sensitized recipients with induction therapy can share similar well effect to non-sensitized recipients.