预致敏婴儿再次肾移植一例并文献复习

Renal re-transplantation in a pre-sensitized small infant and literature review

目的探讨预致敏婴儿接受婴儿供者供肾移植的可行性和安全性,并总结文献经验。方法回顾性分析2017年7月1例预致敏婴儿成功接受二次肾移植的临床资料。受者首次肾移植时年龄6个月,二次移植时年龄8个月,由于初次肾移植后的急性排斥反应(AR)而致敏,在二次肾移植术前预存有低水平的抗HLA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+抗CD20单抗处理。结果移植肾功能立即恢复,术后1周复查预存DSA仍为低水平阳性,无新生DSA。移植后1年复查预存DSA转阴。随访2年,无新生DSA,未发生AR,蛋白尿阴性,最近一次复查血肌酐为31 μmol/L,估算肾小球滤过率为110 ml·min^-1·1.73 m^-2。受者体格发育亦呈追赶性生长,2岁8个月时身高93 cm,体重13.5 kg,符合同龄儿童正常的生长曲线。结论预致敏患儿对脱敏处理耐受性良好,效果满意。在精密手术和精细化管理下,婴儿接受婴儿供肾肾移植可获得良好效果。

Objective To explore the feasibility and safety of kidney transplantation for pre-sensitized infants using deceased donors and summarize the relevant literature reports. Methods A second kidney transplantation was successfully performed for an 8-month-old pre-sensitized girl in July 2017. She had a low level of donor specific antibody (DSA) against human leucocyte antigen (HLA) B62 due to severe acute rejection (AR) after her first kidney transplantation. For desensitization, plasmapheresis and intravenous immunoglobulin plus anti-CD20 antibodies were offered on operative day. Clinical data and outcomes were retrospectively analyzed. Results Renal graft regained immediate function after transplantation. Preformed DSA could be detected at 1 week. However, there was no de novo DSA. At 1 year post-transplantation, preformed DSA turned negative. During a follow-up period of 2 years, renal graft showed an excellent function with a serum creatinine of 31 μmol/l and eGFR of 110 ml/min/1.73m^2. No AR episode or proteinuria occurred. DSA stayed negative. Simultaneously physical development also caught up. Her height of 93 cm tall and weight of 13.5 kg at month 24 & 8 months corresponded to normal growth curve of her age. Conclusions Pre-sensitized infant could tolerate desensitization therapy well and achieve satisfactory outcomes. With surgical precisions and optimized managements, kidney transplantation provides excellent renal functions and survivals for infants with organs from deceased donors.