肾移植后早期抗体介导排斥反应的临床特点与治疗四例报道  

Clinical characteristics and strategies of early stage antibody-mediated rejection after renal transplantation

作　　者：卢峡[1] 朱兰[1] 明长生[1] 陈知水[1] 陈忠华 宫念樵[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教育部/卫生部器官移植重点实验室,武汉430030

出　　处：《中华器官移植杂志》2016年第4期216-219,共4页Chinese Journal of Organ Transplantation

摘　　要：目的探讨肾移植术后早期抗体介导的排斥反应（AMR）的临床特点和治疗。方法回顾分析3例肾移植及1例肾移植术后胰腺移植后早期发生AMR受者的临床资料。（1）病例1诊断为早期重度急性AMR，术后第8天开始出现血肌酐水平持续上升，且尿量迅速减少，移植肾血流减少；术后第12天群体反应性抗体（PRA）Ⅰ类为74．6％，11类为2．7％。术后第14天行移植肾穿刺活检显示移植肾广泛缺血和局部出血，同时检测DSA结果显示抗1362平均荧光强度（MFI）为6800。（2）病例2诊断为早期轻度急性AMR，术后第13天复查PRAI类为65．6％，Ⅱ类为78．9％，DSAI为阳性，抗A11MFI为3059，DSAⅡ为阴性，术后第21天时行移植肾穿刺活检显示轻度缺血再灌注损伤表现。（3）病例3诊断为早期重度慢性AMR，受者因Ⅰ型糖尿病、尿毒症先后接受肾移植和胰腺移植，胰腺移植后8个月时，检测针对胰腺供者DSA为阳性，抗A2MFI为7514，抗1346MFI为3159，抗DQ7MFI为1503。（4）病例4诊断为早期混合性排斥反应，术后第8天出现血肌酐升高，术后第14天检测PRAⅠ类为3％，Ⅱ类为70％，DSA为阳性，抗DR16MFI为15170；术后第16天行移植肾穿刺活检显示移植肾急性混合性排斥反应。结果病例1和病例3因AMR的诊断和治疗不及时导致移植物功能丧失；病例2和病例4在诊断AMR后，使用血浆置换、丙种球蛋白和硼替佐米等联合治疗后移植肾功能恢复正常。结论AMR的诊断需要结合移植物功能下降、DSA阳性以及移植物活检病理表现进行综合判断。早期诊断、早期治疗以及联合治疗可以提高AMR的治愈率。Objective To investigate the clinical characteristics and strategies of early stage antibody-mediated rejection after renal transplantation. Method The clinical data of early stage AMR of 3 cases of renal transplantation, and 1 case of pancreas transplantation after renal transplantation were retrospectively analyzed. （1） The case 1 was diagnosed as having early severe acute AMR. Serum creatinine was increased, urine volume rapidly reduced, the blood flow of transplanted kidney reduced on the postoperative day 8; the positive rate of panel reactive antibody （PRA） class Ⅰ and Ⅱ was 74. 6%, and 2. 7% respectively on the postoperative day 12. Biopsy showed widely ischemia and local bleeding in transplanted kidney and DSA showed anti-B62 mean fluorescence intensity （MFI） increased to 6800 on the postoperative day 14. （2） The case 2 was diagnosed as having early mild acute AMR. The positive rate of PRA class Ⅰ and Ⅱ was 65.6% and 78. 9% respectively. DSA Ⅰ was positive, anti All MFI was 3059, and DSA Ⅱ was negative on the postoperative day 13. Biopsy showed mild ischemia reperfusion injury in transplanted kidney on the postoperative day 21. （3） The case 3 was diagnosed as having early severe chronic AMR, and the recipient received pancreas transplantation 1 year after kidney transplantation. Eight months after pancreas transplantation, DSA for pancreas donor was detectable, anti A2 MFI was 7514, anti 1346 MFI was 3 159 and anti DQ7 MFI was 1 503. （4） The case 4 was diagnosed as having early mixed rejection. Serum creatinine was elevated on the postoperative day 8; PRA testing showed that the positive rate of class Ⅰ and Ⅱ was 3% and 70% respectively, DSA was positive, and anti DR16 MFI was 15 170 on the postoperative day 14; transplanted kidney biopsy showed acute mixed rejection on the postoperative day 16. Result Case 1 and ease 3 were not diagnosed and treated in time and graft loss developed. Case 2 and case 4 were functionally recovered after combined treatment of plasmap

关 键 词：移植 体液性排斥反应 供体特异性抗体 群体反应抗体 

分 类 号：R699.2[医药卫生—泌尿科学]