成人肝移植术后抗体介导排斥反应的治疗

Treatment of antibody-mediated rejection after liver transplantation

目的探讨合理有效的肝移植术后抗体介导排斥反应(AMR)治疗方案。方法回顾性分析2015年3月至2018年12月天津市第一中心医院成人肝移植术后发生AMR受者和同期肝移植术后发生急性细胞性排斥反应(ACR)受者的临床资料。收集两组受者围手术期资料、糖皮质激素使用剂量及维持时间、干预治疗以及病情转归等数据,比较常规抗排斥反应治疗方案对肝移植术后AMR与ACR的疗效差异。采用成组t检验比较两组供者年龄、受者年龄、术前终末期肝病模型(model for end-stage liver disease,MELD)评分以及肝移植至诊断ACR或AMR的时间间隔等指标。计数资料以百分比表示,采用Fisher确切概率法比较两组受者原发病、抗排斥反应治疗及联合干预情况。P<0.05为差异有统计学意义。结果AMR发生时间晚于ACR,AMR组和ACR组确诊时间分别为肝移植术后(413±97)d和(12±5)d(t=30.430,P<0.05)。AMR组糖皮质激素治疗时间长于ACR组,分别为(29±15)d和(11±6)d(t=6.122,P<0.05)。在接受标准免疫抑制方案的情况下,与ACR组相比,AMR组需要糖皮质激素冲击治疗的受者比例高于ACR组(8/8和21/50,P<0.05),需要给予联合干预治疗的受者比例也高于ACR组(3/8和0,P<0.05)。结论与ACR相比,AMR通常需要延长糖皮质激素使用疗程,并联合丙种球蛋白、血浆置换及其他方法进行联合干预。

Objective To explore a reasonable and effective treatment scheme of antibody-mediated rejection(AMR)after liver transplantation.Methods The clinical data of AMR recipients after adult liver transplantation and acute cellular rejection(ACR)recipients after adult liver transplantation from March 2015 to December 2018 in Tianjin First Central Hospital were retrospectively analyzed.The perioperative data,glucocorticoid dosage and maintenance time,intervention treatment and disease outcomes of the two groups were collected and compared the efficacy difference of conventional anti-rejection therapy on AMR and ACR after liver transplantation.Results The onset time of AMR was later than that of ACR,and the diagnosis time of AMR group and ACR group was(413±97)d and(12±5)d after liver transplantation,respectively(t=30.430,P<0.05).The duration of glucocorticoid treatment in AMR group was(29±15)d,which was longer than that in ACR group[(11±6)d](t=6.122,P<0.05).In the case of standard immunosuppressive regimens,the proportion of recipients requiring glucocorticoid shock therapy was higher in the AMR group than in the ACR group(8/8 vs.21/50,P<0.05),and the proportion of recipients requiring combined intervention was higher in the AMR group than in the ACR group(3/8 vs.0,P<0.05).Conclusions Compared with ACR,AMR is usually necessary to extend the course of glucocorticoid therapy,combined with gamma globulin,plasma exchange and other interventions.