肾移植术后早期抗体介导的急性排斥反应三例  

Recognition and treatment of early acute antibody-mediated rejection after kidney transplantation： reportof 3 cases

作　　者：朱兰[1] 林正斌[1] 陈松[1] 郭晖[1] 刘慎微 黄伟[1] 谢林[1] 陈刚[1] 

机构地区：[1]华中科技大学同济医学院附属同济医院器官移植研究所,武汉430030 [2]肾内科

出　　处：《中华器官移植杂志》2013年第4期219-222,共4页Chinese Journal of Organ Transplantation

基　　金：国家自然科学基金（81001323）

摘　　要：目的探讨。肾移植术后早期抗体介导的排斥反应（AMR）诊断和治疗。方法2011年1月至2012年8月间确诊的肾移植术后早期急性AMR病例3例。移植前受者均有HLA致敏史，其中2例群体反应性抗体（PRA）曾为阳性，但移植前已转为阴性，另1例移植前PRA-1I类抗体为强阳性。3例术前补体依赖的细胞毒性实验均为阴性。移植后1周内均出现了抗HLA抗体水平的迅速升高伴急性移植肾功能衰竭。急性AMR确诊后采用反复多次血浆置换及静脉注射丙种球蛋白（或联用硼替佐米）治疗。结果3例移植肾穿刺病理结果均符合急性AMR的诊断标准。1例因确诊时移植肾已破裂出血而切除移植肾；1例经4次血浆置换及丙种球蛋白治疗后抗体水平显著下降且病理损伤明显好转，于术后50d移植肾功能完全恢复正常；1例经5次血浆置换及丙种球蛋白联合硼替佐米治疗后无明显好转，于术后24d切除移植肾。结论HLA预致敏患者即使PRA移植前已转阴都属于。肾移植术后早期急性AMR的危险人群，当出现移植肾早期原发性无功能或移植肾功能急剧下降时，及时检测HLA抗体水平和移植肾穿刺活检对确诊急性AMR十分重要。血浆置换及丙种球蛋白（或联合硼替佐米）治疗是目前首选的方法，预后与干预早晚及病理损伤程度密切相关。Objective To recognize the characteristics of acute antibody-mediated rejection （AAMR） after kidney transplantation and to investigate the factors influecing the prognosis of AAMR after treatment. Method Three patients with negative cytotoxic cross-match developed early AAMR after kidney transplantation from Jan. 2011 to Aug. 2012. Pretransplant panel-reactive antibodies （PRA） were strong positive in 1 patient against class II and negative in ：2 patients who had positive PRA previously. All 3 patients had marked increase of PRA within 1 week post-transplantation and the renal allograft function deteriorated rapidly. After the diagnosis, plasmapheresis （PP）/intravenous immunoglobulin （IVIG） or combined with Bortezomib was used to treat AAMR. Result One patient underwent nephrectomy because of severe hemorrhage in the allograft at the time of diagnosis. One patient treated with PP/IVIG 4 times achieved a full recovery of renal function at postoperative day （POD） 50, while the rest failed to respond to PP/IVIG/Bortezomib treatments 5 times and the allograft had to be removed at POD 24 due to extensive hemorrhage and ischemic necrosis. Conclusion HLA sensitized patients are at high risk of AAMR after kidney transplantation, even with a negative pretransplant PRA. Immediate HLA antibody screening and allograft biopsy are needed to identify AAMR when the allograft represents non-function or early impaired function. PP/IVIG may be effective to treat AAMR, and the prognosis of AAMR depends on the time of when the treatment is started and the severity of antibody-mediated iniurv in the grafts.

关 键 词：致敏 移植物排斥 抗体 肾移植 血浆置换 丙种球蛋白类 

分 类 号：R699.2[医药卫生—泌尿科学]