高PRA介导肾移植后延迟性超急排斥反应  

High-PRA mediates delayed hyperacute rejection after renal transplantation

作　　者：肖露露[1] 罗敏[1] 于立新[2] 王彦斌[2] 魏强[2] 余玉明[2] 

机构地区：[1]南方医科大学南方医院组织配型实验中心,广州510515 [2]南方医科大学南方医院肾移植科,广州510515

出　　处：《中国免疫学杂志》2008年第12期1108-1112,共5页Chinese Journal of Immunology

基　　金：广东省自然科学团队基金资助项目(23003)

摘　　要：目的:了解HLA-A、B、DR、DQ表现型为纯合子的终末期肾脏疾病患者的PRA水平,并研究其与肾移植预后的关系。方法:对2006年8月至2007年8月间在我院登记等待首次肾移植的438例终末期肾脏疾病患者HLA、PRA情况以及其中1例PRA65的HLA纯合子患者肾移植效果进行分析。HLA基因分型采用PCR-SSP技术,PRA、抗体强度及抗体特异性分析采用ELISA技术,数据统计采用SPSS11.5统计软件。结果:438例患者中有HLA纯合子12例,杂合子426例;12例纯合子中PRA阳性者6例,阳性率50,平均HLA抗体强度为55,广泛致敏率达100;426例杂合子中PRA阳性者65例,阳性率15.26,平均HLA抗体强度为28,广泛致敏率为40;纯合子与杂合子之间的PRA阳性率、平均HLA抗体强度和广泛致敏率相比差异均有统计学意义(P<0.05),纯合子高PRA的风险大(OR=5.29,95CI:1.67～16.70);1例PRA65的纯合子患者术前经血浆置换、蛋白免疫吸附、静滴丙种球蛋白治疗使PRA降低至阴性,在舒莱免疫诱导下行尸体肾移植术,供受者HLA抗原2个错配,术后移植肾功能逐渐恢复,第3天开始PRA呈阳性并逐渐升高,伴随临床逐渐出现尿少、血压升高、移植肾区疼痛等排斥反应征象,血清肌酐逐渐升高,移植肾B超见动脉阻力指数逐渐升高,提示急性排斥反应,采用术前有效清除HLA抗体的所有方法再次治疗无效,于术后第36天因移植物失功行移植肾切除。结论:HLA纯合子产生高PRA的风险大;文中1例PRA阳性的HLA纯合子早期移植肾功能恢复随后出现不可逆排斥反应致移植肾失功的情况,提示近年来随着各种有效清除HLA抗体的治疗方法不断用于临床导致了抗体介导的延迟性超急排斥反应(AMDR)的出现从而使移植肾失功;高PRA患者行肾移植术需高度慎重,应尽可能避开受者PRA峰值时的全部抗体谱来选择供体。Objective：To investigate the panel reactive antibody（PRA） level of HLA-A、B、DR、DQ homozygote with end-stage renal disease（ESRD）and its influence to renal transplantation.Methods：438 patients with ESRD,who were in our center＇s waiting list for first renal transplantation from Aug 2006 to Aug 2007,were enrolled in the study.Typing of human leucocyte antigen（HLA） was examined by PCR-SSP and PRA was identified with ELISA.The results were then analyzed in accordance with the outcome of renal transplantation by statistical mode with SPSS11.5.Results：There were 12 HLA homozygotes and 426 HLA heterozygotes identified in the 438 patients.6 patients were PRA positive in 12 homozygotes with positive rate of 50% and average of antibody strength of 55%,in whom the widespread sensitization rate of was 100%.There were 65 patients with positive PRA in 426 heterozygotes,whose positive rate was 15.26%,with average antibody strength of 28% and widespread sensitization rate of 40%.Significant differences were present in positive rate.average antibody strength and widespread sensitization rate between HLA homozygotes and heterozygotes（P〈0.05）.HLA homozygotes were at a high risk of high-PRA（OR=5.29,95% CI：1.67～16.70）.The PRA level of one sensitive HLA homozygote was successfully reduced from 65% to 0% by the treatment of plasma exchange（PE）,immune adsorption（IA） and intravenous gammaglobulin（IVIG）.Then the patient was transplanted with a cadaveric kidney under Simulect immune induction,where the mismatch number of HLA was 2.Functions of the allograft were gradually recovered after transplantation,but the patient＇s PRA changed to positive 3 days later,and PRA level became higher and higher.Other signs of rejection appeared gradually,such as decrease of urinary volume,increase of serum creatinine and so on.All therapies such as PE,IA,IVIG wer used again with no effect,and the allograft was removed 36 days later.Conclusion：HLA homozygotes are at a high risk of high-PRA.The failure of

关 键 词：群体反应性抗体 人类白细胞抗原 纯合子 肾移植 抗体介导的延迟性排斥反应 

分 类 号：R392.4[医药卫生—免疫学]