肾移植引起的急性排斥反应的治疗

Management of acute rejection of kidney allograft

目的评价肾移植引起的急性排斥反应的治疗措施及影响愈后的相关因素。方法回顾性研究326例首次移植中86例发生急性排斥反应(AR)的治疗措施、结果及愈后的相关因素。结果86例AR经治疗后5例失败,81例成功,其中68例采用甲基强地松龙(MP)冲击治愈者为48例,11例一线用抗胸腺淋巴细胞球蛋白(ATG)治愈10例,7例一线用OKT3 治愈6例;20例MP冲击无效者全部续用ATG或OKT3治疗,14例逆转成功;对上述治疗无效的8例中6例应用环孢素(CSA)的患者改换为普乐可复(FK506)后治愈3例;共5例因AR不能控制,并发感染、移植肾破裂或血管栓塞而切除移植肾。结论MP冲击为治疗AR的常用有效手段,冲击后第2、3天血肌酐(SCr)上升>10%者多疗效较差。发生AR时SCr较高者治愈率低。ATG和OKT3作为一线或二线治疗措施均有良好效果。对于难治性AR,ATG和OKT3亦无效者,改换基础免疫抑制治疗,即CSA 转化为FK506,有一定的治疗效果。

Objective To evaluate the management of acute rejection (AR) after kidney transplantation and investigate the factors influencing the clinical outcome of the patients. Methods A retrospective study was conducted in 86 cases of AR developed after primary kidney transplantation in the light of therapeutic measures, clinical outcome and prognosis. Results Among these patients, 81 survived AR after treatment. In patients with pulse treatment with methylprednisolone (MP), 48 out of 68 managed to survive the crises, while in those who received ATG as the first line drug therapy 10 out of 11 patients survived and in other cases, 6 out of 7 did due to first-line OKT3 administration. All the 20 patients who did not respond to MP received ATG or OKT3 instead, with14 recovered. Of the 8 patients who failed to be cured by the management above, 6 with previous CSA treatment took FK506 and 3 were consequently cured. Five patients lost the allografts because of uncontrollable infection, allograft rupture or thrombosis. Conclusions MP therapy is still the most commonly used primary treatment for acute rejection episodes. Increase of SCr by more than 10% on days 2 and 3 of MP therapy indicates poor prognosis. ATG or OKT3 can be effective against acute rejection not only as first-line but also as second-line drug. In condition of steroid-resistant rejection when ATG and OKT3 fail to manage, a change to baseline immunosuppression may be considered as the replacement of CSA with FK506.