HLA 不相容的肾移植受者的脱敏治疗与生存。

Desensitization in HLA-incompatible kidney recipients and survival.

机构信息

Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA.

出版信息

N Engl J Med. 2011 Jul 28;365(4):318-26. doi: 10.1056/NEJMoa1012376.

DOI:10.1056/NEJMoa1012376

PMID:21793744

Abstract

BACKGROUND

More than 20,000 candidates for kidney transplantation in the United States are sensitized to HLA and may have a prolonged wait for a transplant, with a reduced transplantation rate and an increased rate of death. One solution is to perform live-donor renal transplantation after the depletion of donor-specific anti-HLA antibodies. Whether such antibody depletion results in a survival benefit as compared with waiting for an HLA-compatible kidney is unknown.

METHODS

We used a protocol that included plasmapheresis and the administration of low-dose intravenous immune globulin to desensitize 211 HLA-sensitized patients who subsequently underwent renal transplantation (treatment group). We compared rates of death between the group undergoing desensitization treatment and two carefully matched control groups of patients on a waiting list for kidney transplantation who continued to undergo dialysis (dialysis-only group) or who underwent either dialysis or HLA-compatible transplantation (dialysis-or-transplantation group).

RESULTS

In the treatment group, Kaplan-Meier estimates of patient survival were 90.6% at 1 year, 85.7% at 3 years, 80.6% at 5 years, and 80.6% at 8 years, as compared with rates of 91.1%, 67.2%, 51.5%, and 30.5%, respectively, for patients in the dialysis-only group and rates of 93.1%, 77.0%, 65.6%, and 49.1%, respectively, for patients in the dialysis-or-transplantation group (P<0.001 for both comparisons).

CONCLUSIONS

Live-donor transplantation after desensitization provided a significant survival benefit for patients with HLA sensitization, as compared with waiting for a compatible organ. By 8 years, this survival advantage more than doubled. These data provide evidence that desensitization protocols may help overcome incompatibility barriers in live-donor renal transplantation. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Charles T. Bauer Foundation.).

摘要

背景

在美国，有超过 20000 名接受肾移植的患者对 HLA 产生了致敏反应，他们可能需要长时间等待移植，移植率降低，死亡率增加。一种解决方案是在耗尽供体特异性抗 HLA 抗体后进行活体供肾移植。与等待 HLA 匹配的肾脏相比，这种抗体耗竭是否会带来生存获益尚不清楚。

方法

我们使用了一种方案，包括血浆置换和低剂量静脉免疫球蛋白治疗，使 211 名 HLA 致敏患者脱敏，随后进行了肾移植（治疗组）。我们比较了脱敏治疗组与两个精心匹配的对照组的死亡率，对照组的患者在等待肾移植名单上，要么继续接受透析（仅透析组），要么接受透析或 HLA 匹配移植（透析或移植组）。

结果

在治疗组中，Kaplan-Meier 估计患者的 1 年生存率为 90.6%，3 年生存率为 85.7%，5 年生存率为 80.6%，8 年生存率为 80.6%，而仅透析组的相应生存率分别为 91.1%、67.2%、51.5%和 30.5%，透析或移植组的相应生存率分别为 93.1%、77.0%、65.6%和 49.1%（两者均 P<0.001）。