Wagner L, Lengyel L, Mikala G, Reményi P, Piros L, Csomor J, Fábry L, Tordai A, Langer R M, Masszi T
Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.
Transplant Proc. 2013;45(10):3705-7. doi: 10.1016/j.transproceed.2013.10.005.
Here we have described a successful HLA-identical living allogeneic kidney transplantation after bone marrow transplantation in a patient with end-stag liver disease caused by multiple myeloma (MM). Our case is unique, because this combined transplantation is rarely possible and because of our unique immunosuppressive and management strategies. A 45-year-old man with ESRD MM and κ light-chain nephropathy was diagnosed. Cytostatic treatment resulted in partial remission, so autologous peripheral stem cell transplantation (SCT) was performed leading to a complete remission; however the patient remained anuric. The patient's HLA-identical brother offered to be a donor of peripheral stem cells for collection and cryopreservation. Kidney transplantation was performed with a combination of tacrolimus sirolimuns, and methylprednisolone. With a well-functioning kidney graft, allogeneic SCT was performed in the incipient relapse phase of MM, after total body irradiation. Severe oropharyngeal infections, diarrhea, sepsis, and renal failure. Fearing acute renal rejection, we administered steroid bolus. He experienced therapy with gradual restoration of kidney function. Then, steroid-responsive acute graft-versus-host disease (grade II, predominantly bowel) was diagnosed on the background of diarrhea, which returned once. Later he experienced a left subclavian vein thrombosis at the site of a central venous catheter and sepsis. Having recovered from these events, the patient enjoys good health, with stable kidney function and normal protein excretion. After the steroid was stopped, a bone marrow biopsy revealed full-donor type normocellular hemopoiesis. Because of the chimerism, we gradually discontinued the immunosuppression including, sirolimus and finally tacrolimus, since with minimal trough levels there were no complications. Bone marrow biopsy showed a complete remission. In MM with ESRD HLA-identical combined kidney and bone marrow transplantation from a living donor may offer not only complete remission and good renal function, but also good health without immunosuppression.
在此，我们描述了一例成功的人类白细胞抗原（HLA）匹配的活体同种异体肾移植病例，该患者为一名患有多发性骨髓瘤（MM）所致终末期肝病的患者，在骨髓移植后接受了肾移植。我们的病例很独特，因为这种联合移植很少可行，且我们采用了独特的免疫抑制和管理策略。一名45岁患有终末期肾病型MM及κ轻链肾病的男性被诊断出来。细胞毒性治疗导致部分缓解，因此进行了自体外周干细胞移植（SCT），从而实现完全缓解；然而，患者仍无尿。患者的HLA匹配的兄弟主动提出作为外周干细胞供体进行采集和冷冻保存。肾移植采用他克莫司、西罗莫司和甲泼尼龙联合进行。在肾移植功能良好的情况下，在MM的初期复发阶段，全身照射后进行了同种异体SCT。出现了严重的口咽感染、腹泻、败血症和肾衰竭。由于担心急性肾排斥反应，我们给予了大剂量类固醇。他接受治疗后肾功能逐渐恢复。随后，在腹泻背景下诊断出类固醇反应性急性移植物抗宿主病（II级，主要累及肠道），腹泻曾一度复发。后来，他在中心静脉导管部位出现左锁骨下静脉血栓形成和败血症。从这些事件中康复后，患者健康状况良好，肾功能稳定，蛋白质排泄正常。停用类固醇后，骨髓活检显示为完全供体型正常细胞造血。由于存在嵌合现象，我们逐渐停用了包括西罗莫司在内的免疫抑制剂，最终停用他克莫司，因为在最低血药谷浓度时未出现并发症。骨髓活检显示完全缓解。在患有终末期肾病的MM患者中，来自活体供体的HLA匹配的联合肾和骨髓移植不仅可以实现完全缓解和良好的肾功能，还可以在无免疫抑制的情况下保持良好的健康状态。
