移植肾后期急性排斥反应的临床研究

Late episodes of acute rejection in renal transplantation:Experience with 83 cadavaric renal allograft recipients

目的 :探讨肾移植一年后急性排斥反应 (晚期急性排斥 )的临床、病理、抗排斥治疗效果及其预后。 方法 :将肾移植一年后发生急性排斥反应 (AR)的 83例患者列入本研究对象 ,应用甲基强的松龙 (MP) 0 5g/d冲击治疗 ,连续 3天。然后以环孢素A(CsA)切换成普乐可复 (FK5 0 6 )或霉酚酸酯 (MMF)替代硫唑嘌呤 (Aza)。根据抗排斥治疗效果 ,判断疗效和预后。 结果 :平均随访时间 4 3 6 (13～ 6 4 )个月 ,晚期AR发生率为 18 9%。移植后一年 1、2、3次发生AR者分别占 6 5 1%、2 5 3%和 9 6 %。其中有症状性排斥和无症状性排斥反应各占 5 6 6 %和4 3 4 %。有症状性AR患者中以高血压最为常见 (6 1 7% )。 7 6 %的患者于移植后一年擅自减用或停用免疫抑制药物 ,导致免疫抑制不足发生排斥反应。 83例晚期AR经抗排斥治疗 ,87 9%获得缓解 (2 7 7%完全缓解 ,6 0 2 %部分缓解 ,12 1%治疗无反应 )。首次发生AR者经冲击治疗 ,35 2 %完全缓解 ,6 4 8%部分缓解 ;2次排斥反应治疗缓解率为 81 0 % (完全缓解 19 1% ,部分缓解 6 1 9% ) ;3次AR抗排斥治疗效果极差 (无反应者高达 75 % )。晚期急性细胞性排斥反应 (ACR)组抗排斥治疗后 ,5 4 8%完全逆转 ,4 5 2 %部分缓解 ;ACR +慢性排斥反应 (CR)组 14 2 %抗排斥逆转 (

Objective:To investigate the clinical and pathological features of acute rejection(AR) beyond one year after renal transplantation,we retrospectively analyzed the clinical and pathologic data in 83 cadavaric renal allograft recipients in one transplantation center. Methodology:Between Jan 1994 and Dec 1999 in Jinling Hospital,83 patients in 494 cadaveric renal allograft recipients developed late episodes of acute renal allograft rejection beyond one year after the transplantation.All the episodes occurred when the allografts were functioning,and may clinically presented with acute deterioration of renal filtration,enlargement and pain of the allograft,uncontrolled hypertension,oliguria and weight gain.A percutaneous allograft biopsy was timely performed in each patient with each episodes of acute rejection.The pathological diagnosis were made by a panel of renal pathologists and nephrologist,according to the Banff criteria for acute renal allograft rejection. Results:Within a mean period of follow up for 43 6(13～64 months),54 pratients developed a first episode of AR after one years of transplantation,21 developed the second episode of AR,and 8 developed the third episode of AR.Among them,6 episodes of AR occurred because of improper reduction of the dosage of immunosuppressants.Clinically 56 4% recipients with late AR presented with uncontrolled hypertension(61 7%),oliguria(44 7%),or weight gain(38 8%),while 43 4% were asymptomatic.And pathologically,31 recipients with clinical AR showed the features of acute cellular rejection,and 42 showed the features of chronic rejection (CR) besides those of AR.87 9% of the recipients with late AR responded to a high dose steroid treatment,with 100% for those with the first AR,81 0% for those with the second AR,and partial or no response for those with the third AR.After the salvage anti rejection treatment,17(54 8%) recipients with acute cellular rejection were reversed completely,and 14(45 2%) were partially reversed.For those 42 patients with pathologic AR features and CR features,6 were completely reversed,34 partially reversed and 2 not reversed.During the follow up of these patients with late AR,it was found that better graft survival was significantly associated with the response to the salvage therapy. Conclusion:Monitoring of AR in later stages is essential for cadaveric renal allograft recipients.The diagnosis of late AR is made with the combination and the clinical features and the pathologic data revealed by the timely allograft biopsy.Responsiveness to antirejection therapy is assoiated with the times of AR and the long term prognosis.