Rodríguez Ferrero M, Rincón A, Bucalo L, Rementería A, Anaya F
Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
Transplant Proc. 2010 Oct;42(8):2848-50. doi: 10.1016/j.transproceed.2010.07.068.
Acute antibody-mediated rejection (AMR) leads to graft loss. The combination of plasmapheresis (PP), intravenous immunoglobulin (IVIG), and rituximab (RTX) has been reported to be effective therapy.
Between October 2005 and September 2009, 8 (4.7%) kidney transplant recipients developed AMR, diagnosed by severe acute rejection and extensive C4d staining in peritubular capillaries.
All patients were treated with two to six sessions of PP with IVIG added after the last PP. In two patients, RTX was prescribed after PP and IVIG. Baseline immunosuppression was based on steroids, mycophenolate mofetil or azathioprine, and tacrolimus or cyclosporine or everolimus. The presence of subsequent significant decrease in anti-HLA class I antibodies was demonstrated in a highly sensitized patient before and after transplantation with PP treatment. An increase was observed before the diagnosis of AMR. After a mean follow-up of 10 months (range=1-23), patient and graft survivals were 100% and 50%, respectively. Three patients lost their transplants to AMR refractory to treatment and one patient, due to interstitial fibrosis and tubular atrophy at 23 months after AMR. Finally, four patients recovered renal function, showing a mean serum creatinine of 2.2±0.45 mg/dL.
Early diagnosis and treatment with PP, IVIG, and RTX may resolve AMR. PP before and after transplantation in high-risk patients may result in anti-HLA class I and class II antibody removal from plasma and prevention of AMR.
急性抗体介导的排斥反应（AMR）可导致移植物丢失。据报道，血浆置换（PP）、静脉注射免疫球蛋白（IVIG）和利妥昔单抗（RTX）联合使用是有效的治疗方法。
2005年10月至2009年9月期间，8名（4.7%）肾移植受者发生了AMR，通过严重急性排斥反应和肾小管周围毛细血管广泛C4d染色确诊。
所有患者均接受了2至6次PP治疗，并在最后一次PP后加用IVIG。两名患者在PP和IVIG治疗后使用了RTX。基线免疫抑制方案基于类固醇、霉酚酸酯或硫唑嘌呤，以及他克莫司或环孢素或依维莫司。一名高敏患者在移植前后接受PP治疗，其抗HLA I类抗体随后显著下降。在AMR诊断前观察到抗体增加。平均随访10个月（范围=1 - 23个月）后，患者生存率和移植物生存率分别为100%和50%。3名患者因治疗难治性AMR而失去移植物，1名患者在AMR后23个月因间质纤维化和肾小管萎缩而失去移植物。最后，4名患者肾功能恢复，平均血清肌酐为2.2±0.45 mg/dL。
PP、IVIG和RTX早期诊断及治疗可能使AMR得到缓解。高危患者移植前后进行PP治疗可能导致血浆中抗HLA I类和II类抗体清除，并预防AMR。
