CRRT联合免疫吸附和血浆置换治疗肾移植术后AMR合并多器官功能衰竭

CRRT combined with immunoabsorption and plasma exchange in treatment of AMR complicated with multiple organ failure after renal transplantation

目的探讨应用连续性肾脏替代治疗(CRRT)联合免疫吸附和血浆置换治疗肾移植术后抗体介导的排斥反应(AMR)合并多器官功能衰竭的效果。方法将28例肾移植术后诊断为AMR合并多器官功能衰竭的患者随机分为2组,对照组(12例)和治疗组(16例)。两组患者均给予甲泼尼龙0.8 g/d冲击治疗5 d,口服环孢素1.5 mg/(kg·d),CRRT以及强心、利尿等对症治疗;治疗组在治疗后第7、10日给予免疫吸附和血浆置换治疗。比较两组患者治疗后的总体情况;比较两组患者治疗前后肾功能[血尿素氮(BUN)、血清肌酐(Scr)]和血电解质的变化;分析两组患者治疗前后肾组织病理学检查和免疫组织化学(免疫组化)染色结果。结果 28例患者中,临床治愈24例,其中治疗组14例,对照组10例;3例恶化,其中治疗组2例,对照组1例;对照组1例死于脑出血。治疗7、12 d后,治疗组和对照组患者的BUN和Scr水平比较,差异均有统计学意义(P<0.05~0.01)。治疗组和对照组的血钠和血钾治疗前后比较,差异均有统计学意义(P<0.05~0.01)。肾组织病理学检查显示,治疗12 d后,治疗组和对照组患者的移植肾组织浸润的淋巴细胞减少,血管炎减轻;与对照组比较,治疗组的肾小球、小管间质及血管的病理评分均较低,差异均有统计学意义(均为P<0.01)。免疫组化染色结果显示,治疗12 d后,两组患者的移植肾组织ED1阳性的单核细胞减少,且治疗组ED1阳性的单核细胞减少更为明显;治疗12 d后,治疗组患者肾小管间质的CD4^+/CD8^+细胞比值比对照组更低,差异有统计学意义(P<0.01)。结论 CRRT联合免疫吸附和血浆置换组合治疗是治疗肾移植术后AMR合并多器官功能衰竭的有效方法。

Objective To investigate the clinical efficacy of continuous renal replacement therapy(CRRT)combined with immunoabsorption and plasma exchange in the treatment of antibody-mediated rejection(AMR)complicated with multiple organ failure after renal transplantation.Methods Twenty-eight patients diagnosed with AMR complicated with multiple organ failure after renal transplantation were randomly divided into the control group(n=12)and treatment group(n=16).All patients were given with methylprednisolone 0.8 g/d shock therapy for 5 d,oral intake of ciclosporin 1.5 mg/(kg·d),CRRT,cardiotonics,diuretics and other symptomatic treatments.In the treatment group,immunoabsorption and plasma exchange were delivered on the 7th and 10th d after treatment.The overall conditions were statistically compared between two groups.The changes of renal function[blood urea nitrogen(BUN),serum creatinine(Scr)]and blood electrolyte before and after treatment were compared between two groups.The results of histopathological examination and immunohistochemical staining of the renal tissues before and after treatment were analyzed in two groups.Results Among 28 patients,24 cases were clinically cured,including 14 in the treatment group and 10 in the control group.The symptoms of 3 patients were deteriorated,including 2 in the treatment group and 1 in the control group.One patient in the control group died of cerebral hemorrhage.After 7 d and 12 d treatment,the levels of BUN and Scr significantly differed between the treatment group and control group(P<0.05-0.01).The levels of blood sodium and potassium significantly differed between two groups before and after treatment(P<0.05-0.01).Pathological examination of renal tissue demonstrated that after 12 d treatment,the number of lymphocytes infiltrated in the transplanted kidney tissues was reduced and the degree of vasculitis was alleviated in two groups.Compared with the control group,the pathological scores of glomerulus,tubulointerstitial and blood vessels were significantly lower in the treatment group(all P<0.01).Immunohistochemical staining revealed that after 12 d treatment,the number of ED1-positive monocytes in the transplanted kidney tissues was declined in both groups,especially in the treatment group.Following 12 d treatment,the ratio of CD4+/CD8+cells in renal tubulointerstitial in the treatment group was significantly lower than that in the control group(P<0.01).Conclusions CRRT combined with immunoabsorption and plasma exchange is an effective method to treat AMR complicated with multiple organ failure following renal transplantation.