Al Meshari K, Pall A, Chaballout A, El Gamal H, Al Mana H, Humaidan H, Alzayer F, Al Talhi M
Department of Kidney and Pancreas Transplantation, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
Transplant Proc. 2013 May;45(4):1423-6. doi: 10.1016/j.transproceed.2013.01.081.
Antibody-mediated rejection (AMR) and inferior graft outcome remain the 2 most important obstacles to successful kidney transplantation in human leukocyte antigen (HLA)- and ABO-incompatible recipients. We report a single-center experience in the outcome of desensitized living donor HLA- and ABO-incompatible kidney transplantation.
Since 2007 we included 2 groups in our desensitization program. HLA-incompatible living donor kidney transplant candidates displaying donor-specific antibodies (DSA) with or without a positive T-cell and/or B-cell flow crossmatch (FCXM). Second, those displaying DSA with positive T-cell immunoglobulin (Ig)G AHG CDC CXM with a titer of ≤1:8, as well as all ABO-incompatible living donor kidney transplant candidates with an IgM isoagglutinin titer ≤ 256. They were risk stratified for AMR and underwent individualized desensitization protocol: ABO-incompatible and HLA-incompatible candidates with either positive AHG CDC CXM or positive T and/or B IgG flow CXM with repeat HLA mismatch from a previous transplantation were deemed to be high risk and received a single dose of Rituximab, therapeutic plasma exchange and high-dose intravenous immunoglobulin (IVIG) (2 g/kg). HLA-incompatible candidates with negative CDC but positive T and/or B IgG FCXM were deemed intermediate risk, receiving rituximab and high-dose IVIG. Those with positive DSA but negative flow and CDC CXM were deemed low risk, receiving low-dose IVIG (1 g/kg). All patients received induction with thymoglobulin and were maintained on a tacrolimus-based immunosuppressive regimen.
Among 124 incompatible recipients, 85 received HLA-incompatible and 39 ABO-incompatible living donor kidney transplantations after desensitization. Risk stratification for HLA-incompatible transplants revealed 61 high-risk, 42 intermediate-risk, and 21 low-risk cases. Ninety-nine (80%) were primary transplants. At a median follow-up of 23 (range 1-53) months, patient survival was 98% and death censored graft survival 96%. Mean serum creatinine was 84 μmol/L (range 41-169). Acute cellular rejection was observed in 15 (12%) and AMR in 5 (4%) patients. All rejection episodes responded to treatment except 1 AMR in an ABO-incompatible transplant that led to graft failure.
Our risk stratification for desensitization strategy achieved a low incidence of AMR among HLA- and ABO-incompatible kidney transplant recipients. Their 2-year data appear to be comparable to HLA- and ABO-compatible transplantations.
抗体介导的排斥反应（AMR）和移植肾预后不佳仍然是人类白细胞抗原（HLA）和ABO血型不相容受者肾移植成功的两个最重要障碍。我们报告了单中心关于脱敏的活体供者HLA和ABO血型不相容肾移植结果的经验。
自2007年起，我们的脱敏方案纳入了两组患者。第一组为显示供者特异性抗体（DSA）且T细胞和/或B细胞流式交叉配型（FCXM）阳性或阴性的HLA不相容活体供者肾移植候选者。第二组为显示DSA且T细胞免疫球蛋白（Ig）G抗人球蛋白补体依赖性细胞毒交叉配型（AHG CDC CXM）滴度≤1:8，以及所有IgM同种凝集素滴度≤256的ABO血型不相容活体供者肾移植候选者。对他们进行AMR风险分层，并采用个体化脱敏方案：ABO血型不相容和HLA不相容且AHG CDC CXM阳性或T和/或B IgG流式CXM阳性且与既往移植存在重复HLA错配的候选者被视为高风险，接受单剂量利妥昔单抗、治疗性血浆置换和大剂量静脉注射免疫球蛋白（IVIG）（2 g/kg）。HLA不相容且CDC阴性但T和/或B IgG FCXM阳性的候选者被视为中风险，接受利妥昔单抗和大剂量IVIG。DSA阳性但流式和CDC CXM阴性的患者被视为低风险，接受小剂量IVIG（1 g/kg）。所有患者均接受胸腺球蛋白诱导治疗，并维持基于他克莫司的免疫抑制方案。
在124例不相容受者中，85例接受了脱敏后的HLA不相容活体供者肾移植，39例接受了ABO血型不相容活体供者肾移植。HLA不相容移植的风险分层显示，高风险61例，中风险42例，低风险21例。99例（80%）为初次移植。中位随访23（1 - 53）个月时，患者生存率为98%，死亡截尾的移植肾生存率为96%。平均血清肌酐为84 μmol/L（41 - 169）。15例（12%）发生急性细胞排斥反应，5例（4%）发生AMR。除1例ABO血型不相容移植中的AMR导致移植肾失功外，所有排斥反应均对治疗有反应。
我们的脱敏策略风险分层在HLA和ABO血型不相容肾移植受者中实现了较低的AMR发生率。其2年数据似乎与HLA和ABO血型相容的移植相当。
