高致敏受者接受ABO血型不相容供者供肾移植一例及文献复习

ABO-incompatible kidney transplantation in highly presensitized recipients using deceased donors: a case report and literature review

目的探讨高致敏受者接受ABO血型不相容(ABOi)供者供肾移植的可行性和安全性,并总结文献经验。方法2018年5月,1例O型血高致敏受者成功接受了1例HLA 7/8相配的B型血死亡后器官捐献(DD)供者供肾的二次肾移植,回顾性分析该病例的临床资料。受者术前抗B-IgM水平为1∶16,无针对HLA的预存供者特异性抗体(DSA),术前行单次血浆置换+静脉注射免疫球蛋白(IVIg)联合抗CD20单抗处理。结果手术顺利完成,术后2 d移植肾功能恢复至正常水平。但在术后9 d,血肌酐由最低97 μmol/L反弹至131 μmol/L,抗B-IgM由术后第7天的1∶2升高至1∶16。移植肾穿刺活检显示,轻微肾小管周毛细血管炎和少许轻度肾小管上皮炎。无新生DSA。给予血浆置换联合IVIg治疗2次,并序贯单独IVIg治疗2 d(20 g/d),血肌酐稳定在120~140 μmol/L,术后第3周抗B-IgM在降至1∶4并保持在低水平。随访7个月,最近1次检测血肌酐为114 μmol/L,无蛋白尿和感染等并发症。结论对HLA高致敏受者采用ABOi但HLA高度匹配的DD供肾移植可以有效避免早期HLA抗体介导的排斥反应,可能为高致敏受者获得移植机会提供一个潜在临床策略。

Objective To explore the feasibility and safety of kidney transplantation in highly sensitized recipients by using ABO incompatible (ABOi) and yet human leucocyte antigen (HLA) supremely matched deceased donor kidneys and summarize the literatures as well. Methods A kidney graft from a deceased donor of blood type B was transplanted to a highly presensitized recipient of blood type O to achieve a HLA matching number of 7/8 in May 2018. Donor specific antibody (DSA) against HLA was negative and baseline anti-B IgM 1∶16. Plasmapheresis (PP) plus intravenous immunoglobulin (IVIG) plus anti-CD20 antibodies were offered on operation day. Clinical data was retrospectively analyzed. Results Renal graft functioned immediately and achieved a normal level of serum creatinine (SCr) at d2 after transplantation. However, the value of SCr increased to 131 μmol/l at d9 with a simultaneously elevated level of anti-B IgM from 1∶2 at d7 to 1∶16. A renal graft biopsy at d11 showed mild inflammation in peritubular capillaries and focal tubulitis with minimal interstitial infiltration. No de novo DSA was detected. Then PP plus IVIG were then given twice, followed by an administration of IVIG alone for another 2 days (20 g/d). After treatments, SCr had a range of 120-140 μmol/l and anti-B IgM level decreased to 1∶4 at d21 post-transplantation. During a follow-up of 6 months, there was no onset of proteinuria or infection and the last value of SCr was 114 μmol/L. Conclusions In HLA highly sensitized recipients awaiting for transplant opportunities, successful prevention of HLA antibodies-mediated rejection may be achieved by using ABO incompatible and yet HLA compatible deceased donors.