Chouhan Kanwaljit K, Zhang Rubin
Kanwaljit K Chouhan, Rubin Zhang, Section of Nephrology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, United States.
World J Transplant. 2012 Apr 24;2(2):19-26. doi: 10.5500/wjt.v2.i2.19.
Antibody induction therapy is frequently used as an adjunct to the maintenance immunosuppression in adult kidney transplant recipients. Published data support antibody induction in patients with immunologic risk to reduce the incidence of acute rejection (AR) and graft loss from rejection. However, the choice of antibody remains controversial as the clinical studies were carried out on patients of different immunologic risk and in the context of varying maintenance regimens. Antibody selection should be guided by a comprehensive assessment of immunologic risk, patient comorbidities, financial burden as well as the maintenance immunosuppressives. Lymphocyte-depleting antibody (thymoglobulin, ATGAM or alemtuzumab) is usually recommended for those with high risk of rejection, although it increases the risk of infection and malignancy. For low risk patients, interleukin-2 receptor antibody (basiliximab or daclizumab) reduces the incidence of AR without much adverse effects, making its balance favorable in most patients. It should also be used in the high risk patients with other medical comorbidities that preclude usage of lymphocyte-depleting antibody safely. There are many patients with very low risk, who may be induced with intravenous steroids without any antibody, as long as combined potent immunosuppressives are kept as maintenance. In these patients, benefits with antibody induction may be too small to outweigh its adverse effects and financial cost. Rituximab can be used in desensitization protocols for ABO and/or HLA incompatible transplants. There are emerging data suggesting that alemtuzumab induction be more successful than other antibody for promoting less intensive maintenance protocols, such as steroid withdrawal, tacrolimus monotherapy or lower doses of tacrolimus and mycophenolic acid. However, the long-term efficacy and safety of these unconventional strategies remains unknown.
抗体诱导疗法常用于成年肾移植受者维持性免疫抑制的辅助治疗。已发表的数据支持对具有免疫风险的患者使用抗体诱导疗法，以降低急性排斥反应（AR）的发生率和因排斥反应导致的移植物丢失。然而，抗体的选择仍存在争议，因为临床研究是在不同免疫风险的患者以及不同维持治疗方案的背景下进行的。抗体的选择应基于对免疫风险、患者合并症、经济负担以及维持性免疫抑制剂的综合评估。淋巴细胞清除抗体（抗胸腺细胞球蛋白、ATGAM或阿仑单抗）通常推荐用于排斥反应风险高的患者，尽管它会增加感染和恶性肿瘤的风险。对于低风险患者，白细胞介素-2受体抗体（巴利昔单抗或达利珠单抗）可降低AR的发生率，且不良反应较少，这使得其在大多数患者中具有较好的效益风险比。对于因其他合并症而无法安全使用淋巴细胞清除抗体的高风险患者，也应使用该抗体。有许多低风险患者，只要联合使用强效免疫抑制剂进行维持治疗，就可以不使用任何抗体，仅通过静脉注射类固醇进行诱导。在这些患者中，抗体诱导的益处可能太小，无法超过其不良反应和经济成本。利妥昔单抗可用于ABO和/或HLA不相容移植的脱敏方案。有新数据表明，阿仑单抗诱导在促进采用强度较低的维持治疗方案（如停用类固醇、他克莫司单药治疗或降低他克莫司和霉酚酸的剂量）方面比其他抗体更成功。然而，这些非传统策略的长期疗效和安全性仍不明确。
