小肠移植术后排斥反应的诊断与治疗四例报告  

Diagnosis and treatment of acute rejection following small bowel transplantation

作　　者：李元新[1] 李宁[1] 李幼生[1] 倪小冬[1] 李民[1] 汪志明[1] 吴波[1] 王剑[1] 黎介寿[1] 

机构地区：[1]南京军医南京总医院普通外科研究所,210002

出　　处：《中华器官移植杂志》2009年第12期733-736,共4页Chinese Journal of Organ Transplantation

基　　金：国家科技支撑计划项目（2008BAI60B06）;江苏省自然科学基金创新学者攀登资助项目（BK2008034）

摘　　要：目的总结小肠移植术后排斥反应的诊断和治疗体会。方法4例患者小肠移植术后均采用阿来佐单抗诱导及单用他克莫司（Tac）的无激素维持方案，术后前3个月血Tac浓度维持在10-15μg／L，术后4个月开始减少至5～10μg／L，术后7个月开始减少至5μg／L。术后采用临床症状观察、移植肠内镜观察及移植肠黏膜活检等方法监测排斥反应。排斥反应的诊断和分级则依据2003年国际小肠移植会议上确立的小肠移植急性排斥反应的病理学诊断标准。当发生IND级至轻度排斥反应时，提高血Tac浓度至15μg／L并联合短程小剂量激素治疗，如排斥反应控制不理想，则应用大剂量激素冲击治疗：当发生中度排斥反应时，则提高血Tac浓度至15μg／L并联合大剂量激素冲击治疗。同时积极预防全身感染，停止肠内营养使肠道彻底休息。结果4例患者术后共发生排斥反应9次，术后3个月内3例发生IND级至轻度排斥反应4次，术后3～6个月2例发生IND级至轻度排斥反应3次，术后7～12个月2例发生中度排斥反应2次。发生的9次排斥反应经治疗后均得到很好控制，移植肠功能恢复良好。IND级或轻度排斥反应的恢复时间为2～8d（平均4．8d）。中度排斥反应为t5d。4例患者巾有2例的存活时间已超过1年，1例为术后8个月余，1例为术后4个月．目前均在顺利康复中。结论移植肠黏膜活组织病理学检查仍然是诊断排斥反应的金标准。提高血Tac浓度及联合应用激素治疗可成功逆转小肠移植排斥反应。Objective To investigate the clinical experience in diagnosis and treatment of acute rejection （AIR） following small bowel transplantation. Methods Patients received 1g of Solu Medrol followed by 30 mg Alemtuzumab infusion during SBTx and another gram of Solu Medrol before reperfusion. Tacrolimus monotherapy without steroid was used for maintenance immunosuppression. The tacrolimus trough levels were 10-15 μg/L during the first 3 months, declined to 5- 10 μg/L at the 4th - 6th month, and then taped to 5 μg/L after 7 months. AR was monitored by clinical observation,endoscopies of the intestinal graft and histological evaluation of the graft biopsies. The histologic criteria for grading intestinal AR were based on the results of the pathology workshop at the 8th International Small Bowel Transplant Symposium in 2003. IND and mild AR episodes were treated by steroid and increasing level of tacrolimus to 15 μg/L,and moderate AR treated by a bolus of Solu- Medrol, followed by a declining cycle of steroid plus an increase in tacrolimus. The systemic anti- infectious prophylaxis and suspending enteral nutrition were also introduced. Results Two recipients survived more than 1 year,one patient is currently at 8 months and another at 4 months post-SBTx. Four episodes of IND to mild AR verified by pathology through ileoscopical biopsy were found at 1-3 months,3 episodes of IND to mild AR at 4 6 months,and 2 episodes of moderate AR at 7-12 months. Patients totally recovered after low dose steroid or bolus steroid was given. The recovery time from IND or mild ACR was 2-8 days, and that from moderate ACR was 15 days. Grafts achieved excellent function as all 4 patients withdrew TPN 2 3 weeks postoperatively and lived on normal oral intake. Conclusion Pathology of the graft biopsies through ileoscopy is a ＂golden standard＂ of diagnosis of AR following small bowel transplantation. A bolus of Solu-Medrol, followed by a declining cycle of steroid plus an increase in tacrolimus can effectively control mild and moderate

关 键 词：小肠 移植 移植物排斥 诊断 治疗 

分 类 号：R656.7[医药卫生—外科学]