蛋白A免疫吸附治疗肺移植术后新生DSA介导的急性排斥反应

Protein A immunoadsorption in the treatment of de novo DSA-mediated acute rejection after lung transplantation

目的探讨肺移植术后新生供者特异性抗体(dnDSA)介导的急性排斥反应的治疗方法。方法回顾性分析1例肺移植术后早期出现抗体介导的急性排斥反应(AMR)受者的资料,分析其诊疗经过。结果受者因系统性硬化症相关性终末期间质性肺病接受右肺移植,术前群体反应性抗体(PRA)Ⅰ类阳性(11%),术前未行特殊预处理,手术当日及术后予以抗胸腺细胞球蛋白诱导治疗。术后早期受者康复顺利,术后13 d出现胸闷、气促,并呈进行性加重,迅速进展为Ⅰ型呼吸衰竭,PRAⅠ类上升为58%,并出现dnDSA,其位点为A24:02,平均荧光强度(MFI)值为2110,据国际心肺移植学会指南,拟诊为(可能)AMR。予血浆置换、蛋白A免疫吸附、糖皮质激素冲击、利妥昔单抗及免疫球蛋白静脉滴注等综合治疗后,PRA及DSA水平逐渐下降,术后20 d DSA MFI值为0,受者临床情况逐渐好转,呼吸困难消失,气促逐渐缓解,呼吸衰竭纠正,肺部渗出影逐渐吸收;术后45 d,受者完全康复出院。随访1年,受者状态良好,生活质量与同龄健康人相同,PRAⅠ类为5%,Ⅱ类为阴性,未出现DSA。结论在传统药物治疗基础上加用蛋白A免疫吸附治疗,能有效去除受者循环血液中的DSA,减轻靶器官损害,近期及远期治疗效果理想。针对肺移植术后AMR,采用传统药物治疗联合免疫吸附,可以达到理想治疗效果。

Objective To investigate the treatment on de novo donor specific antibody(dnDSA)mediated acute rejection after lung transplantation.Methods Clinical data of 1 recipient with antibody-mediated rejection(AMR)early after lung transplantation was retrospectively analyzed.The process of diagnosis and treatment were assessed.Results The recipient underwent right lung transplantation due to systemic sclerosis-associated end-stage interstitial lung disease.Preoperatively,classⅠpanel reactive antibody(PRA)was positive(11%).No pretreatment was given before transplantation.Antithymocyte globulin induction therapy was delivered on the day of transplantation and postoperatively.The recipient was properly recovered early after transplantation.Chest tightness and shortness of breath occurred at postoperative 13 d,which were progressively worsened and rapidly progressed into typeⅠrespiratory failure.ClassⅠPRA was increased to 58%,and dnDSA was observed at the loci of A24:02.The mean fluorescence intensity(MFI)was 2110.According to the guidelines of International Society for Heart and Lung Transplantation,the recipient was diagnosed as possible AMR.After comprehensive treatment including plasmapheresis,protein A immunoadsorption,glucocorticoid pulse,rituximab and immunoglobulin intravenous drip,the PRA and DSA levels were gradually decreased,and the MFI of DSA was 0 at postoperative 20 d.Clinical condition of the recipient was gradually improved.The dyspnea was healed,shortness of breath was eased,respiratory failure was treated,and pulmonary effusion was gradually absorbed.At postoperative 45 d,the recipient was discharged after full recovery.During 1-year follow-up,the recipient was physically stable and obtained normal quality of life.ClassⅠPRA was 5%,and classⅡPRA was negative.No DSA was noted.Conclusions Based on traditional drug therapy,supplement of protein A immunoadsorption therapy may effectively eliminate DSA from the circulating blood of the recipient and mitigate the damage of target organs.Ideal short-and long-term prognosis may be achieved.Traditional drug therapy combined with immunoadsorption may yield ideal efficacy in treating AMR after lung transplantation.