Pavlakis Martha
Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
Clin Transpl. 2009:343-5.
We present two patients with high levels of donor specific antibodies and C4d deposition after treatment for antibody mediated rejection with standard plasmapheresis based therapy. Both patients were given a combination of multiple courses of bortezomib (each course consisted of four doses over 2 weeks) and more plasmapheresis with maintenance immunosuppression therapy. The first patient had 4 donor specific anti-HLA antibodies (DSAs) (of which 1 was against class 1 HLA). After bortezomib therapy, the class 1 antibody did disappear and one of the class 2 antibodies went to below an MFI of 4,000. However, the other 2 DSAs remained strong and she progressed to needing dialysis therapy. The second patient had no change in his strong DSA or in his biopsy findings but his creatinine has remained stable throughout the entire course, without deterioration or improvement. In summary, we saw very little decline in DSA profile and no biopsy improvement in 2 patients treated with bortezomib as salvage therapy for ongoing antibody mediated rejection. It is possible that initiation of bortezomib earlier for these patients with chronic antibody mediated rejection would have proven more effective in eliminating DSA and improving biopsy findings. However, our limited experience suggests that as salvage therapy for ongoing antibody mediated rejection, bortezomib therapy is not useful.
我们报告了两名患者，他们在接受基于标准血浆置换的抗体介导排斥反应治疗后，出现了高水平的供体特异性抗体和C4d沉积。两名患者均接受了多疗程硼替佐米（每个疗程在2周内包含4剂）联合更多血浆置换及维持性免疫抑制治疗。第一名患者有4种供体特异性抗HLA抗体（DSAs）（其中1种针对1类HLA）。硼替佐米治疗后，1类抗体确实消失，2类抗体中的1种降至MFI低于4000。然而，另外2种DSAs仍然很强，她进展到需要透析治疗。第二名患者的强DSA或活检结果没有变化，但他的肌酐在整个病程中一直保持稳定，没有恶化或改善。总之，我们发现，对于两名接受硼替佐米作为持续性抗体介导排斥反应挽救治疗的患者，DSA谱几乎没有下降，活检也没有改善。对于这些慢性抗体介导排斥反应患者，更早开始使用硼替佐米可能在消除DSA和改善活检结果方面更有效。然而，我们有限的经验表明，作为持续性抗体介导排斥反应的挽救治疗，硼替佐米治疗并无用处。
