Hill Douglas A, Drazner Mark H, de Lemos James A
Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
Curr Opin Organ Transplant. 2013 Oct;18(5):581-8. doi: 10.1097/MOT.0b013e328364fe23.
Acute cardiac allograft rejection surveillance has historically been based on serial endomyocardial biopsy (EMB). Limitations with this approach have stimulated interest in identifying noninvasive surrogate markers of rejection. This review summarizes the evidence assessing the use of direct cardiac markers B-type natriuretic peptide (BNP) and cardiac troponins in detecting acute allograft rejection.
BNP, its amino-terminal fragment NT-proBNP, and cardiac troponins T and I have all been extensively evaluated for this purpose, and so far have demonstrated inadequate diagnostic accuracy to replace EMB. Longitudinal surveillance of BNP and NT-proBNP appears to offer promise for improved accuracy, but has not been adequately evaluated in prospective studies. Preliminary investigations into highly sensitive troponin assays suggest a potential role in rejection surveillance, but prospective validation in larger studies is needed.
EMB remains the gold standard for cardiac allograft rejection surveillance. However, recent data indicate potential clinical utility for serial monitoring of natriuretic peptides. If further investigation into highly sensitive troponin assays confirms the positive data so far reported, further efforts directed toward a longitudinal-based rejection surveillance algorithm incorporating both troponin and BNP may identify a strategy that could serve as an alternative to EMB.
急性心脏移植排斥反应监测历来基于系列心内膜心肌活检（EMB）。这种方法的局限性激发了人们对识别排斥反应非侵入性替代标志物的兴趣。本综述总结了评估直接心脏标志物B型利钠肽（BNP）和心肌肌钙蛋白在检测急性移植排斥反应中应用的证据。
BNP及其氨基末端片段NT-proBNP以及心肌肌钙蛋白T和I均已为此目的进行了广泛评估，目前已证明其诊断准确性不足以取代EMB。对BNP和NT-proBNP的纵向监测似乎有望提高准确性，但尚未在前瞻性研究中得到充分评估。对高敏肌钙蛋白检测的初步研究表明其在排斥反应监测中具有潜在作用，但需要在更大规模的研究中进行前瞻性验证。
EMB仍然是心脏移植排斥反应监测的金标准。然而，最近的数据表明利钠肽的系列监测具有潜在临床应用价值。如果对高敏肌钙蛋白检测的进一步研究证实了目前报道的阳性数据，那么进一步努力构建一种结合肌钙蛋白和BNP的基于纵向的排斥反应监测算法，可能会找到一种可替代EMB的策略。
