West L J, Pollock-Barziv S M, Dipchand A I, Lee K J, Cardella C J, Benson L N, Rebeyka I M, Coles J G
Department of Paediatrics, Hospital for Sick Children and University of Toronto, ON, Canada.
N Engl J Med. 2001 Mar 15;344(11):793-800. doi: 10.1056/NEJM200103153441102.
Transplantation of hearts from ABO-incompatible donors is contraindicated because of the risk of hyperacute rejection mediated by preformed antibodies in the recipient to blood-group antigens of the donor. This contraindication may not apply to newborn infants, who do not yet produce antibodies to T-cell-independent antigens, including the major blood-group antigens.
We studied 10 infants 4 hours to 14 months old (median, 2 months) who had congenital heart disease or cardiomyopathy and who received heart transplants from donors of incompatible blood type between 1996 and 2000. Serum isohemagglutinin titers were measured before and after transplantation. Plasma exchange was performed during cardiopulmonary bypass; no other procedures for the removal of antibodies were used. Standard immunosuppressive therapy was given, and rejection was monitored by means of endomyocardial biopsy. The results were compared with those in 10 infants who received heart transplants from ABO-compatible donors.
The overall survival rate among the 10 recipients with ABO-incompatible donors was 80 percent, with 2 early deaths due to causes presumed to be unrelated to ABO incompatibility. The duration of follow-up ranged from 11 months to 4.6 years. Two infants had serum antibodies to antigens of the donor's blood group before transplantation. No hyperacute rejection occurred; mild humoral rejection was noted at autopsy in one of the infants with antibodies. No morbidity attributable to ABO incompatibility has been observed. Despite the eventual development of antibodies to antigens of the donor's blood group in two infants, no damage to the graft has occurred. Because of the use of ABO-incompatible donors, the mortality rate among infants on the waiting list declined from 58 percent to 7 percent.
ABO-incompatible heart transplantation can be performed safely during infancy before the onset of isohemagglutinin production; this technique thus contributes to a marked reduction in mortality among infants on the waiting list.
由于受者体内预先形成的针对供者血型抗原的抗体介导的超急性排斥反应风险，禁忌使用ABO血型不相合供者的心脏进行移植。这种禁忌可能不适用于新生儿，因为新生儿尚未产生针对包括主要血型抗原在内的非T细胞依赖性抗原的抗体。
我们研究了1996年至2000年间10例年龄在4小时至14个月（中位年龄2个月）患有先天性心脏病或心肌病且接受了血型不相合供者心脏移植的婴儿。在移植前后测量血清同种血凝素滴度。在体外循环期间进行血浆置换；未使用其他去除抗体的程序。给予标准的免疫抑制治疗，并通过心内膜活检监测排斥反应。将结果与10例接受ABO血型相合供者心脏移植的婴儿的结果进行比较。
10例接受ABO血型不相合供者心脏移植的受者的总体生存率为80%，有2例早期死亡，原因推测与ABO血型不相合无关。随访时间为11个月至4.6年。2例婴儿在移植前有针对供者血型抗原的血清抗体。未发生超急性排斥反应；在1例有抗体的婴儿尸检时发现轻度体液排斥反应。未观察到与ABO血型不相合相关的发病情况。尽管有2例婴儿最终产生了针对供者血型抗原的抗体，但未对移植物造成损害。由于使用了ABO血型不相合供者，等待名单上婴儿的死亡率从58%降至7%。
在婴儿期同种血凝素产生之前，可以安全地进行ABO血型不相合心脏移植；因此，该技术有助于显著降低等待名单上婴儿的死亡率。
