Sivakumaran Praveen, Vo Ashley A, Villicana Rafael, Peng Alice, Jordan Stanley C, Pepkowitz Samuel H, Klapper Ellen B
Division of Transfusion Medicine, Pathology and Lab Medicine, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
J Clin Apher. 2009;24(4):155-60. doi: 10.1002/jca.20206.
Although there have been desensitization protocols used for ABO-incompatible (ABOi) renal transplants, there are a lack of studied protocols. Our center developed a preconditioning protocol that involved mycophenolic acid, therapeutic plasma exchange (TPE), anti-CD20 monoclonal antibody (rituximab), and intravenous immunoglobulin (IVIG) that allowed for ABOi renal transplantation.
Ten patients in our institution with end-stage renal disease who were unable to procure ABO-compatible donor kidneys underwent treatment with this protocol (which included a uniform 5 TPE sessions) prior to an ABOi renal transplant. A retrospective chart review was performed on these patients and clinical endpoints including ABO antibody titers, serum creatinine, clinical complications, and graft performance were analyzed.
The median ABO antibody titers at presentation, after completion of the protocol, and after transplant for the patients were 32 (range, 2-128), 8 (range, 1-64), and 4 (range, 2-32), respectively. The mean serum creatinine at study conclusion was 1.45 +/- 1.04 mg/dl at an average of 262.20 days from transplant. There were four incidents of antibody-mediated rejection (AMR) and two incidents of delayed graft function (DGF). There was one incident of graft failure and no patient deaths.
The desensitization protocol used by our institution allowed for successful ABOi renal transplantation. Although there were incidents of AMR and DGF, the majority of the transplants resulted in viable grafts. A larger patient study group may be needed to fully evaluate the efficacy and safety of this protocol.
尽管已经有用于ABO血型不相容（ABOi）肾移植的脱敏方案，但缺乏经研究的方案。我们中心制定了一种预处理方案，该方案包括霉酚酸、治疗性血浆置换（TPE）、抗CD20单克隆抗体（利妥昔单抗）和静脉注射免疫球蛋白（IVIG），从而实现ABOi肾移植。
我们机构的10例终末期肾病患者，因无法获得ABO血型相容的供肾，在进行ABOi肾移植前接受了该方案的治疗（包括统一进行5次TPE疗程）。对这些患者进行了回顾性病历审查，并分析了包括ABO抗体滴度、血清肌酐、临床并发症和移植物功能在内的临床终点指标。
患者就诊时、方案完成后及移植后的ABO抗体滴度中位数分别为32（范围2 - 128）、8（范围1 - 64）和4（范围2 - 32）。研究结束时的平均血清肌酐为1.45±1.04mg/dl，距移植平均262.20天。发生了4例抗体介导的排斥反应（AMR）和2例移植肾功能延迟恢复（DGF）。有1例移植物失功，无患者死亡。
我们机构使用的脱敏方案实现了成功的ABOi肾移植。尽管发生了AMR和DGF事件，但大多数移植的移植物仍存活。可能需要更大的患者研究组来全面评估该方案的疗效和安全性。
