ABOi肾移植术后74天并发急性排斥反应致移植肾功能丧失一例并文献复习

One case of ABO-incompatible kidney transplantation failure due to acute rejection at 74 days with a literature review

目的结合文献总结ABO血型不相容(ABO-incompatible,ABOi)肾移植在稳定期发生抗体介导排斥反应并导致移植肾切除的受者诊疗经验。方法2019年11月于山西省第二人民医院行ABOi肾移植术1例,O型受者接受B型母亲右肾捐献,回顾性分析该病例的临床资料。术前采用血浆置换、利妥昔单抗及免疫抑制剂预处理;术后给予抗排异、抗凝及预防感染等治疗。结果手术顺利,术后1周血肌酐降至76μmol/L;术后15 d血红蛋白降至52 g/L,人类细小病毒B19阳性,骨髓穿刺诊断为纯红细胞再生障碍性贫血。予大剂量静脉注射免疫球蛋白(IVIG)并调整他克莫司为环孢素A抗排斥反应治疗。术后发生3次泌尿系感染及人类细小病毒B19感染,术后55 d麦考酚钠肠溶片更换为咪唑利宾片。受者术后74 d出现高热及突然无尿、移植肾区胀痛及血肌酐进行性升高,血型抗体效价IgM、IgG、IgM+IgG最高分别为1∶512,1∶512,1∶4096,经甲泼尼龙冲击治疗、双重血浆置换、IVIG及兔抗人胸腺细胞免疫球蛋白等抗排斥反应治疗,效果不佳,移植肾血流逐渐消失,血肌酐进行性升高,彩色多普勒超声显示移植肾血流终止,于术后78 d行移植肾切除术。术后病理活检结果为抗体介导急性排斥反应。结论ABOi肾移植术后在稳定期也可以出现导致移植肾丢失的严重排斥反应。

Objective To report one case of ABO-incompatible(ABOi)kidney transplantation with antibody-mediated rejection during stable phase and ultimate resection of transplanted kidney.Methods In November 2019,one type O recipient received a donation of right ABOi kidney from a mother with blood type B.Clinical data were retrospectively analyzed.A preoperative pretreatment of plasma exchange,rituximab and immunosuppressant was followed postoperatively by anti-rejection,anticoagulation and antibiotic therapies.Results The operation proceeded smoothly.Blood creatinine declined to 76 umol/L at Day 7;hemoglobin dropped to 52 g/L at Day 15,human parvovirus(HPV)B19 was positive and bone marrow aspiration yielded a diagnosis of pure erythrocyte aplastic anemia.An anti-rejection regimen of high-dose intravenous immunoglobulin(IVIG)and adjust tacrolimus was offered.Three bouts of urinary tract infections and HPV B19 infection occurred postoperatively.Mycophenolate sodium enteric-coated tablets were replaced with imidazolibin tablets at Day 55.There was an onset of high fever,sudden anuria and distension pain in transplanted kidney area.And blood creatinine spiked sharply at Day 74.The peak blood group titers of IgM,IgG and IgM+IgG were 1:512,1:512 and 1:4096 respectively.After a shock therapy of methylprednisolone,the responses of double filtration plasmapheresis(DFPP),IVIG and rabbit anti-human thymocyte immunoglobulin and other anti-rejection regimens were not satisfactory.Blood flow of transplanted kidney gradually disappeared and blood creatinine rose.Color Doppler ultrasound indicated a cessation of blood flow in transplanted kidney.After nephrectomy at Day 78,a diagnosis of antibody-mediated acute rejection was confirmed by the results of postoperative pathological biopsy.Conclusions After ABOi kidney transplantation,severe rejection causes the loss of transplanted kidney even during stable phase.