Madden R L, Mulhern J G, Benedetto B J, O'Shea M H, Germain M J, Braden G L, O'Shaughnessy J, Lipkowitz G S
Department of Surgery, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA 01199, USA.
Transpl Int. 2000;13(5):344-50. doi: 10.1007/s001470050712.
Although acute rejection (AR) has been shown to correlate with decreased long-term renal allograft survival, we have noted AR in recipients who subsequently had stable function for more than 5 years. We reviewed 109 renal graft recipients with a minimum of 1 year graft survival and follow-up of 5-8 years. Post-transplant sodium iothalamate clearances (IoCI) measured at 3 months and yearly thereafter were used to separate recipients into 2 groups. In 61 patients (stable group), there was no significant decrease ( > 20 % reduction in IoCl over 2 consecutive years) in IoCl. Forty-eight patients had significant declines in IoCl (decline group). Groups were compared for incidence, severity, timing, and completeness of reversal of AR. Rejection was considered completely reversed if the post-AR serum creatinine (Scr) returned to or below the pre-AR nadir Scr after anti-rejection therapy. The incidence of AR was not significantly different between groups (47% vs 52%). A trend toward a lower mean number of AR episodes per patient was noted in the stable group (0.69 vs 1.04, P = 0.096), but the timing of AR was not different. Steroid-resistant AR occurred in approximately 25 % of both groups. A striking difference was seen in complete reversal of AR, with the stable group having 100% (42/42 episodes of AR in 29 patients) complete reversal whereas only 32 % (8/25) of the patients in the decline group had complete reversal (P < < 0.001). Of 8 declining patients with complete reversal, graft loss was due to chronic rejection (CR) in only 3. Seventeen declining patients had incomplete reversal of AR, and 82 % (14/17) lost their grafts to CR. Overall, only 8% (3/37) of the recipients with complete reversal of AR developed CR. No patients with incompletely reversed AR had stable long-term function as measured by IoCl. AR is not invariably deleterious to long-term renal graft function if each episode of AR can be completely reversed.
尽管急性排斥反应（AR）已被证明与肾移植长期存活的降低相关，但我们注意到一些受者发生了AR，随后其肾功能稳定超过5年。我们回顾了109例肾移植受者，这些受者移植肾存活至少1年，随访时间为5至8年。移植后3个月及之后每年测量的碘他拉酸钠清除率（IoCI）被用于将受者分为两组。在61例患者（稳定组）中，IoCI没有显著下降（连续两年IoCl下降>20%）。48例患者的IoCI有显著下降（下降组）。比较两组AR的发生率、严重程度、发生时间及逆转的完整性。如果抗排斥治疗后AR发作后的血清肌酐（Scr）恢复到或低于AR发作前的最低Scr，则认为排斥反应完全逆转。两组间AR的发生率没有显著差异（47%对52%）。稳定组中观察到每名患者AR发作的平均次数有降低趋势（0.69对1.04，P = 0.096），但AR的发生时间没有差异。两组中约25%的患者发生了激素抵抗性AR。在AR的完全逆转方面观察到显著差异，稳定组有100%（29例患者的42次AR发作）完全逆转，而下降组只有32%（8/25）的患者完全逆转（P << 0.001）。在8例完全逆转的下降患者中，移植肾丢失仅3例是由于慢性排斥反应（CR）。17例下降患者的AR逆转不完全，82%（14/17）的患者移植肾因CR丢失。总体而言，AR完全逆转的受者中只有8%（3/37）发生了CR。通过IoCI测量，没有AR逆转不完全的患者具有稳定的长期肾功能。如果AR的每一次发作都能完全逆转，AR对肾移植长期功能并非总是有害的。
