Ruiz P, Carreno M, Weppler D, Gomez C, Island E, Selvaggi G, Nishida S, Moon J, Levi D, Tekin A, Tryphonopoulos P, Tzakis A G
Department of Surgery, University of Miami School of Medicine, Miami, FL, USA.
Transplant Proc. 2010 Jan-Feb;42(1):95-9. doi: 10.1016/j.transproceed.2009.12.025.
The role of preformed donor-specific antibodies (DSAs) as a barrier to isolated intestinal transplantation (ITx) remains ambiguous; thus, a positive cross-match has not been a contraindication to ITx.
To report the case of a patient with Crohn's disease who underwent ITx and developed immediate antibody-mediated rejection on reperfusion of the allograft.
Percent reactive antibody testing was performed using pretransplantation serum samples and at transplantation using bead-based assays (Luminex, Luminex Corp, Austin, Tex) and flow cytometry solid-phase assays (FlowPRA single-antigen beads (One Lambda, Inc, Canoga Park, Calif). Serologic tests, flow cytometry cross-matching, and flow cytometry assays of C4d-binding serum antibodies were also performed. Histologic and immunofluorescent analysis of biopsy specimens was performed.
HLA typing revealed no sharing of class I or II antigens between donor and recipient. Pretransplantation donor-specific antibodies (DSA) were present at transplantation. Cross-matching (performed during surgery) was positive for class I and II by serologic testing and flow cytometry. After reperfusion, the graft immediately developed severe ischemic injury and arteritis on mucosal biopsy specimens, with immunoglobulin deposition. The DSA C4d binding antibodies were also present. After intense immunosuppression and plasmapheresis, the graft and the biopsy histologic findings showed marked improvement (day 2). By day 7 posttransplantation, patient and graft status were stable. The patient has remained clinically stable for more than a year after transplantation.
Pretransplant DSA in ITx can be a risk factor for immediate (hyperacute) but potentially reversible antibody-mediated rejection. Thus, pretransplantation DSA and cross-match results are critical components to be considered in patients awaiting or undergoing ITx.
预先形成的供者特异性抗体（DSA）作为孤立性肠移植（ITx）的障碍，其作用仍不明确；因此，阳性交叉配型并非ITx的禁忌证。
报告1例克罗恩病患者接受ITx并在移植肠再灌注时发生即刻抗体介导排斥反应的病例。
使用移植前血清样本进行群体反应性抗体检测，并在移植时采用基于微珠的检测方法（Luminex，Luminex公司，得克萨斯州奥斯汀）和流式细胞术固相检测方法（FlowPRA单抗原微珠（One Lambda公司，加利福尼亚州卡诺加公园））。还进行了血清学检测、流式细胞术交叉配型以及C4d结合血清抗体的流式细胞术检测。对活检标本进行组织学和免疫荧光分析。
HLA分型显示供者与受者之间不存在Ⅰ类或Ⅱ类抗原共享。移植时存在移植前供者特异性抗体（DSA）。血清学检测和流式细胞术显示手术期间进行的交叉配型Ⅰ类和Ⅱ类均为阳性。再灌注后，移植肠在黏膜活检标本上立即出现严重缺血性损伤和动脉炎，并伴有免疫球蛋白沉积。也存在DSA C4d结合抗体。经过强化免疫抑制和血浆置换后，移植肠及活检组织学表现有显著改善（第2天）。移植后第7天，患者和移植肠状态稳定。移植后患者临床稳定已超过1年。
ITx中移植前DSA可能是即刻（超急性）但潜在可逆的抗体介导排斥反应的危险因素。因此，移植前DSA和交叉配型结果是等待或接受ITx患者需要考虑的关键因素。
