联合脱敏治疗在高度致敏受者肾移植中的应用分析

Application of desensitization therapy in renal transplantation of highly sensitized recipients

目的探讨脱敏治疗在高度致敏受者肾移植中的应用疗效。方法回顾性分析25 例群体反应性抗体峰值≥ 30%的高致敏患者行同种异体肾移植术的临床资料。男性8 例,女性17 例,平均年龄( 45±12)岁。首次接受移植者8例,二次移植者 15例,三次移植者 2例,输血史 17例,妊娠史 12例。3 例为亲属供体肾移植,其余均为尸体供体肾移植。术前行血浆置换或蛋白A 免疫吸附+利妥昔单抗+静脉注射丙种球蛋白脱敏治疗。术前交叉淋巴毒试验阴性。采用兔抗人胸腺细胞免疫球蛋白和甲泼尼龙免疫诱导,术后他克莫司+吗替麦考酚酯+皮质激素三联维持治疗。结果其中20(20/25)例患者移植后1 周内血肌酐降至正常。1 例出现超急性排斥反应,于手术当天切除移植肾,1 例于术后第3 天出现加速性排斥反应,血浆置换3 次治疗无效,于术后第7 天切除移植肾,4 例出现移植肾功能延迟恢复,术后第18 ~ 25 天肾功能恢复正常。发生急性排斥反应5 例(20%),其中2 例诊断为抗体介导急性排斥反应,经血浆置换治疗3 次和兔抗人胸腺细胞免疫球蛋白冲击治疗1 周后逆转,其余3 例为细胞性排斥反应经激素冲击治疗后逆转,1 年移植肾存活率92%(23 / 25)。结论高致敏受者肾移植在良好人类白细胞抗原(humanleukocyte antigen,HLA)配型,尽量避开受者预存的抗HLA 抗体位点的前提下,术前采用血浆置换或免疫吸附联合利妥昔单抗、静脉注射丙种球蛋白进行脱敏治疗,能有效预防和治疗急性排斥反应。

Objective To summarize the clinical experience of renal transplantation in highly sensitized recipients. Methods Allogeneic kidney transplantation was performed in 25 hypersensitized patients with panel reactive antibody peak ≥ 30%. There were 8 males and 17 females. The average age was( 45±12). There were 8 patients who underwent transplantation for the first time,15 patients with secondary transplantation, 2 patients with three transplants, 17 patients with a history of blood transfusion,and 12 patients with a history of pregnancy. There were 3 patients with living donor kidney transplantation,and the rest were cadaveric donor kidney transplants. Preoperatively, plasma exchange or protein A immunosorbent + rituximab + intravenous gamma globulin desensitization were performed. Preoperative cross lymphatic toxicity test was negative. Rabbit anti-human thymocyte immunoglobulin and methylprednisolone were induced, and tacrolimus +mycophenolate mofetil + corticosteroid triple maintenance therapy was used. Results The serum creatinine was decreased to normal in 20( 20/25) patients within 1 week after transplantation. The hyperrejection occurred in 1 patient, and the transplanted kidney was removed on the day of surgery. The accelerated rejection occurred in 1 patient on the 3 d after surgery,plasma exchange therapy was ineffective for 3 times,the transplanted kidney was removed on the 7 d after surgery. The delayed recovery of graft function occured in 4 patients, and renal function was returned to normal between 18 and 25 d after surgery. Acute rejection occurred in 5 patients( 20%), of which 2 patients were diagnosed with the reversal of antibody mediated acute rejection after 3 times of plasma exchange therapy and 1 week of fiverine shock therapy, and the remaining 3 patients were the reversal of cellular rejection after steroid bolus therapy. The 1 year survival rate of transplanted kidney was 92%( 23/25). Conclusion Renal transplantation of highly sensitized recipients could effectively prevent and treat acute rejection by preoperative desensitization with plasma exchange or immunosorption combined with rituximab and intravenous gamma globulin under the premise of good human leukocyte antigen (HLA) matching and avoiding the preexisting anti-HLA antibody sites.