肾移植前群体反应性抗体阳性致敏受者的处理措施及预后观察

Preoperative treatment and prognosis observation in sensitized recipients of kidney transplantation

目的研究肾移植前群体反应性抗体（PRA）阳性致敏受者的处理措施及预后观察。方法2007年1月至2012年7月为41例术前PRA阳性受者施行了肾移植，术前预先服用免疫抑制剂或采用抗CD25单克隆抗体行免疫诱导，行血浆置换、免疫吸附、静注大剂量免疫球蛋白，并要求供者HLA抗原避开受者所有预存的抗HLA抗体，淋巴毒交叉试验（CDC）阴性。术后采用抗人淋巴细胞球蛋白（ATG）强化免疫诱导，采用他克莫司＋吗替麦考酚酯（MMF）＋皮质激素的三联免疫抑制方案；移植肾功能正常后静脉使用米卡芬净，口服更昔洛韦及复方磺胺甲啄唑预防性抗感染治疗。结果41例PRA阳性致敏受者中，术前HLAI类抗体阳性者13例，HLAⅡ类抗体阳性者15例，13例同时存在HLAI类和Ⅱ类抗体阳性，且PRA≥50％。15例术后1周内血肌酐降至正常。术后均未发生超急性排斥反应及加速性排斥反应，有14例发生急性排斥反应（AR），发生率为34．1％（14／41）。其中12例经皮质激素冲击治疗后移植肾功能恢复正常，2例经环磷酰胺或ATG治疗3～5d后排斥反应逆转。1例术后4个月因发生肺部真菌感染经治疗无效死亡。术后1年人、肾存活率为97．6％（40／41）。结论PRA阳性致敏受者肾移植时必须要求供者HLA抗原避开受者所有预存的抗HLA抗体，且CDC配型阴性，结合脱敏治疗、免疫诱导治疗及术后应用强效免疫抑制剂等能有效预防急性排斥反应，提高术后人、肾存活率。

Objective To study the preoperative treatment and prognosis observation？ in sensitized recipients of kidney transplantation. Method Forty-one recipients positive for preoperative PRA accepted renal allograft transplantation from January 2007 to July 2012. All recipients were given immunosuppressant or immune induction by anti-CD25mAb in advance, and plasma exchange, immunoadsorption and intravenous high-dose immune globulin were administered. Meanwhile, donor HLA antigens had to avoid all stored HLA antibodies of the recipient, and lymphocyte cytotoxicity cross test （CDC） had to be negative. Anti-human lymphocyte globulin （ATG） was used to strengthen the immune induction, and tacrolimus ＋ mycophenolate mofetil （MMF） ＋ corticosteroids triple immunosuppressive regimen was adopted after transplantation. Then intravenous micafungin would be given after transplanted kidney function was normal, and ganciclovir and sulfamethoxazole were taken orally to prevent infection. Result In 41 recipients positive for preoperative PRA, 13 cases were positive for only HLA class I antibodies, 15 cases for only HLA class II antibodies, and there existed 13 cases of both HLA class I and class II antibodies also with PRA≥50%. Fifteen patients achieved normal serum creatinine in one week, and no hyperacute rejection and accelerated rejection occurred. Fourteen recipients experienced an episode of acute rejection （34. 15%, 14/41）： 12 recovered by steroids bolus therapy, and the other two reversed in 3-5 days by cyclophosphamide or ATG treatment. One case died of mycotic pneumonia in 4 months later. One-year recipient/kidney survival rate was 97. 6% （40/41）. Conclusion The recipients positive for preoperative PRA only can accept renal allograft transplant while the donor＇s HLA antigens had to avoid all stored HLA antibodies of recipients themselves and CDC test was negative. After that the combination of desensitization therapy, immune induction therapy and postoperative potent immunosuppressant can prevent acute rejection effectively and increase postoperative recipient/kidney survival rate.