CAJ | 학술논문

目的研究肾移植前群体反应性抗体(PRA)阳性致敏受者的处理措施及预后观察.方法 2007年1月至2012年7月为41例术前PRA阳性受者施行了肾移植,术前预先服用免疫抑制剂或采用抗CD25单克隆抗体行免疫诱导,行血浆置换、免疫吸附、静注大剂量免疫球蛋白,并要求供者HLA抗原避开受者所有预存的抗HLA抗体,淋巴毒交叉试验(CDC)阴性.术后采用抗人淋巴细胞球蛋白(ATG)强化免疫诱导,采用他克莫司+吗替麦考酚酯(MMF)+皮质激素的三联免疫抑制方案；移植肾功能正常后静脉使用米卡芬净,口服更昔洛韦及复方磺胺甲(嗯)唑预防性抗感染治疗.结果 41例PRA阳性致敏受者中,术前HLA Ⅰ类抗体阳性者13例,HLAⅡ类抗体阳性者15例,13例同时存在HLA Ⅰ类和Ⅱ类抗体阳性,且PRA≥50％.15例术后1周内血肌酐降至正常.术后均未发生超急性排斥反应及加速性排斥反应,有14例发生急性排斥反应(AR),发生率为34.1％(14/41).其中12例经皮质激素冲击治疗后移植肾功能恢复正常,2例经环磷酰胺或ATG治疗3～5 d后排斥反应逆转.1例术后4个月因发生肺部真菌感染经治疗无效死亡.术后1年人、肾存活率为97.6％(40/41).结论 PRA阳性致敏受者肾移植时必须要求供者HLA抗原避开受者所有预存的抗HLA抗体,且CDC配型阴性,结合脱敏治疗、免疫诱导治疗及术后应用强效免疫抑制剂等能有效预防急性排斥反应,提高术后人、肾存活率.
목적 연구신이식전군체반응성항체(PRA)양성치민수자적처리조시급예후관찰.방법 2007년1월지2012년7월위41례술전PRA양성수자시행료신이식,술전예선복용면역억제제혹채용항CD25단극륭항체행면역유도,행혈장치환、면역흡부、정주대제량면역구단백,병요구공자HLA항원피개수자소유예존적항HLA항체,림파독교차시험(CDC)음성.술후채용항인림파세포구단백(ATG)강화면역유도,채용타극막사+마체맥고분지(MMF)+피질격소적삼련면역억제방안；이식신공능정상후정맥사용미잡분정,구복경석락위급복방광알갑(은)서예방성항감염치료.결과 41례PRA양성치민수자중,술전HLA Ⅰ류항체양성자13례,HLAⅡ류항체양성자15례,13례동시존재HLA Ⅰ류화Ⅱ류항체양성,차PRA≥50％.15례술후1주내혈기항강지정상.술후균미발생초급성배척반응급가속성배척반응,유14례발생급성배척반응(AR),발생솔위34.1％(14/41).기중12례경피질격소충격치료후이식신공능회복정상,2례경배린선알혹ATG치료3～5 d후배척반응역전.1례술후4개월인발생폐부진균감염경치료무효사망.술후1년인、신존활솔위97.6％(40/41).결론 PRA양성치민수자신이식시필수요구공자HLA항원피개수자소유예존적항HLA항체,차CDC배형음성,결합탈민치료、면역유도치료급술후응용강효면역억제제등능유효예방급성배척반응,제고술후인、신존활솔.
Objective To study the preoperative treatment and prognosis observation? in sensitized recipients of kidney transplantation.Method Forty-one recipients positive for preoperative PRA accepted renal allograft transplantation from January 2007 to July 2012.All recipients were given immunosuppressant or immune induction by anti-CD25rnAb in advance,and plasma exchange,immunoadsorption and intravenous high-dose immune globulin were administered.Meanwhile,donor HLA antigens had to avoid all stored HLA antibodies of the recipient,and lymphocyte cytotoxicity cross test (CDC) had to be negative.Anti-human lymphocyte globulin (ATG) was used to strengthen the immune induction,and tacrolimus + mycophenolate mofetil (MMF) + corticosteroids triple immunosuppressive regimen was adopted after transplantation.Then intravenous micafungin would be given after transplanted kidney function was normal,and ganciclovir and sulfamethoxazole were taken orally to prevent infection.Result In 41 recipients positive for preoperative PRA,13 cases were positive for only HLA class Ⅰ antibodies,15 cases for only HLA class Ⅱ antibodies,and there existed 13 cases of both HLA class Ⅰ and class Ⅱ antibodies also with PRA≥50％.Fifteen patients achieved normal serum creatinine in one week,and no hyperacute rejection and accelerated rejection occurred.Fourteen recipients experienced an episode of acute rejection (34.15％,14/41): 12 recovered by steroids bolus therapy,and the other two reversed in 3-5 days by cyclophosphamide or ATG treatment.One case died of mycotic pneumonia in 4 months later.One-year recipient/kidney survival rate was 97.6％ (40/41).Conclusion The recipients positive for preoperative PRA only can accept renal allograft transplant while the donor's HLA antigens had to avoid all stored HLA antibodies of recipients themselves and CDC test was negative.After that the combination of desensitization therapy,immune induction therapy and postoperative potent immunosuppressant can prevent acute rejection effectively and increase postoperative recipient/kidney survival rate.