Larpparisuth N, Premasathian N, Vareesangthip K, Cheunsuchon B, Parichatikanon P, Vongwiwatana A
Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Transplant Proc. 2014;46(2):477-80. doi: 10.1016/j.transproceed.2014.01.003.
Late antibody-mediated rejection (ABMR) has worse prognosis than early ABMR. The objective of this study was to examine the clinical and pathological features of late acute ABMR in our experience.
We retrospectively reviewed all patients who underwent kidney transplantation (KT) between January 2001 and December 2012. Patients who had glomerulitis and/or peritubular capillaritis on kidney biopsy performed 6 months after KT were enrolled.
Of 592 patients, late acute ABMR was diagnosed in 34 cases (5.74%) with a mean onset of 49.2 ± 30.2 months post-KT. Six patients (17.6%) had nonadherence. Allograft histopathology demonstrated concomitant transplant glomerulopathy in 23 patients (67.6%) and positive peritubular C4d staining in 25 patients (73.5%). Donor-specific antibody (DSA) was detected in 25 patients (73.5%). Anti-HLA class II antibody was more prevalent than class I (67.6% vs 20.6%; P = .003) and most of them were anti-HLA DQ. We prescribed intravenous immunoglobulin (IVIG) 1-2 g/kg for 30 patients (88.2%), plasma exchange (PE) for 27 patients (79.4%), and rituximab 375 mg/m(2) for 18 patients (52.9%). We repeated treatment with PE and IVIG in 12 refractory cases. For clinical outcome, 21 patients (61.7%) had deterioration of graft function; 9 of them (26.5%) eventually lost their graft. Thirteen patients (38.2%) had stable graft function.
Late acute ABMR has unsatisfactory prognosis in spite of aggressive standard antihumoral treatment. Surveillance of late ABMR using DSA monitoring may be helpful in early detection and management.
晚期抗体介导的排斥反应（ABMR）的预后比早期ABMR更差。本研究的目的是根据我们的经验探讨晚期急性ABMR的临床和病理特征。
我们回顾性分析了2001年1月至2012年12月期间接受肾移植（KT）的所有患者。纳入在KT术后6个月进行肾活检显示有肾小球炎和/或肾小管周围毛细血管炎的患者。
在592例患者中，34例（5.74%）被诊断为晚期急性ABMR，平均发病时间为KT术后49.2±30.2个月。6例患者（17.6%）存在治疗依从性差的情况。移植肾组织病理学检查显示，23例患者（67.6%）伴有移植肾小球病，25例患者（73.5%）肾小管周围C4d染色阳性。25例患者（73.5%）检测到供者特异性抗体（DSA）。抗HLA II类抗体比I类抗体更常见（67.6%对20.6%；P = 0.003），其中大多数是抗HLA DQ。我们为30例患者（88.2%）静脉注射免疫球蛋白（IVIG）1-2 g/kg，为27例患者（79.4%）进行血浆置换（PE），为18例患者（52.9%）使用利妥昔单抗375 mg/m²。我们对12例难治性病例重复进行PE和IVIG治疗。就临床结局而言，21例患者（61.7%）移植肾功能恶化；其中9例（26.5%）最终失去移植肾。13例患者（38.2%）移植肾功能稳定。
尽管采用了积极的标准抗体液治疗，但晚期急性ABMR的预后仍不理想。通过DSA监测对晚期ABMR进行监测可能有助于早期发现和管理。
