Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI, United States.
Transpl Immunol. 2013 Jan;28(1):1-5. doi: 10.1016/j.trim.2012.11.009. Epub 2012 Dec 5.
Antibody mediated rejection (AMR) has been identified as an entity that may lead to graft dysfunction. Optimal means for diagnosis and treatment of AMR have not been established.
We reviewed the medical records of all patients receiving lung transplantation at Henry Ford Hospital from March 2006 to December 2011. For each patient, we identified potential markers of AMR (immunopathology, histopathology, and serology). Immunopathology was defined as linear c4d immunostaining, histopathology was defined as capillaritis, and serology was defined as identification of donor specific antibody (DSA). We identified all treatment regimens, and we identified clinical and serological outcomes.
Of 62 patients, 14 were identified with at least one marker of AMR. Only two patients had all three potential markers; immunopathology, histopathology, and serology. Both patients received plasmapheresis (PP) and intravenous immunoglobulin followed by clinical improvement and ultimate elimination of DSA. 4 patients had positive DSA without clinical symptoms, and did not receive treatment with PP, IVIG, or rituximab. DSA has not persisted in these patients, and they remain clinically asymptomatic at up to 803days after identification.
Diagnosis of AMR is difficult due to poorly defined diagnostic markers and confounding factors such as infection. Outcomes are highly variable following treatment that may include therapeutic plasma exchange, intravenous immunoglobulin, and/or rituximab. It is not clear when any or all of these therapies are beneficial. In some cases, symptomatic patients with isolated positive DSA (latent humoral response) can remain asymptomatic and convert to negative DSA without antibody targeted therapy.
Firm conclusions are difficult due to the small number of patients and the retrospective nature of the study. Further study is warranted.
抗体介导的排斥反应（AMR）已被确定为导致移植物功能障碍的因素之一。目前尚未建立 AMR 的诊断和治疗的最佳方法。
我们回顾了 2006 年 3 月至 2011 年 12 月期间在亨利福特医院接受肺移植的所有患者的病历。对于每位患者，我们确定了 AMR 的潜在标志物（免疫病理学、组织病理学和血清学）。免疫病理学定义为线性 c4d 免疫染色，组织病理学定义为毛细血管炎，血清学定义为供体特异性抗体（DSA）的鉴定。我们确定了所有的治疗方案，并确定了临床和血清学结果。
在 62 名患者中，有 14 名患者至少有一个 AMR 标志物。只有两名患者有三个潜在标志物：免疫病理学、组织病理学和血清学。两名患者均接受了血浆置换（PP）和静脉注射免疫球蛋白治疗，随后临床症状改善，最终消除了 DSA。4 名患者的 DSA 呈阳性但无临床症状，且未接受 PP、IVIG 或利妥昔单抗治疗。在这些患者中，DSA 并未持续存在，且在鉴定后长达 803 天仍无临床症状。
由于诊断标志物定义不明确和感染等混杂因素，AMR 的诊断较为困难。治疗后的结果差异很大，可能包括治疗性血浆置换、静脉注射免疫球蛋白和/或利妥昔单抗。目前尚不清楚何时以及所有这些治疗方法都有益。在某些情况下，有症状的患者仅存在孤立的阳性 DSA（潜伏的体液反应），可在无抗体靶向治疗的情况下保持无症状并转为阴性 DSA。
由于患者数量少且研究为回顾性，因此难以得出明确的结论。需要进一步研究。
