Capocasale Enzo, Iaria Maurizio, Sassi Maria, Dalle Valle Raffaele, Mazzoni Maria Patrizia, Sianesi Mario, Franchini Massimo
Dipartimento di Scienze Chirurgiche, UO Clinica Chirurgica e dei Trapianti d'Organo, Azienda Ospedaliero-Universitaria di Parma, Italia.
Ann Ital Chir. 2011 Jul-Aug;82(4):283-7.
Living donor kidney transplantation is the preferred therapeutic option for patients with end stage renal disease because it provides a superior immunological compatibility, it lessens the preservation-mediated graft injury and it shortens waiting time on dialysis. Unfortunately, about 30-35% of potential living kidney donors are rejected because of incompatible immunological barriers such as ABO-incompatibility or a positive crossmatch. The newest desensitization protocols based on both therapeutic apheresis and perioperative immunosuppressive drugs allowed to overcome antibodies barriers. The aim of those protocols is to wash-out and suppress as much anti-A or anti-B antibodies as possible and to prevent the rebound phenomena after transplantation. Standard plasmapheresis, double-filtration plasmapheresis and selective immunoadsorption are among the most common apheretic modalities applied in ABO-incompatible transplantation. Furthermore, selective immunoadsorption appears to be much safer and to have markedly increased efficacy comparing with plasmapheresis being able to eliminate almost exclusively blood-group antibodies avoiding plasma and coagulation abnormalities. According to literature, long-term patient and graft survival rates are similar to those achieved by ABO-compatible kidney transplants. The comparable outcome seems related to more effective desensitization protocols as well as the protective immune mechanisms of "accommodation". We have been using selective immunoadsorption in the two ABO-incompatible kidney transplants performed in our institution. No acute rejection was experienced at 6 and 26 month follow-up and both grafts are functioning well. Despite the ABO-incompatible kidney transplant widespread use, the best desensitization protocol, the upper baseline and perioperative isoagglutinin titer limit and the most accurate isoagglutinin measurement assay are still to define.
活体供肾移植是终末期肾病患者的首选治疗方案，因为它具有更好的免疫相容性，能减轻保存介导的移植物损伤，并缩短透析等待时间。不幸的是，约30%-35%的潜在活体供肾者因ABO血型不相容或交叉配血阳性等免疫不相容障碍而被拒绝。基于治疗性血液成分单采和围手术期免疫抑制药物的最新脱敏方案能够克服抗体障碍。这些方案的目的是尽可能清除和抑制抗A或抗B抗体，并防止移植后的反弹现象。标准血浆置换、双重滤过血浆置换和选择性免疫吸附是ABO血型不相容移植中最常用的血液成分单采方式。此外，与血浆置换相比，选择性免疫吸附似乎更安全，疗效显著提高，能够几乎完全清除血型抗体，避免血浆和凝血异常。根据文献，患者和移植物的长期存活率与ABO血型相容的肾移植相似。这种相似的结果似乎与更有效的脱敏方案以及“适应性”的保护性免疫机制有关。我们在本机构进行的两例ABO血型不相容肾移植中使用了选择性免疫吸附。在6个月和26个月的随访中均未发生急性排斥反应，两个移植物功能良好。尽管ABO血型不相容肾移植已广泛应用，但最佳的脱敏方案、较高的基线和围手术期同种凝集素滴度限值以及最准确的同种凝集素测量方法仍有待确定。
