阳性补体依赖细胞毒性交叉配型的肾移植长期预后

Long-term outcomes of kidney transplantation across a positive complement-dependent cytotoxicity crossmatch.

作者信息

Riella Leonardo V, Safa Kassem, Yagan Jude, Lee Belinda, Azzi Jamil, Najafian Nader, Abdi Reza, Milford Edgar, Mah Helen, Gabardi Steven, Malek Sayeed, Tullius Stefan G, Magee Colm, Chandraker Anil

机构信息

1 Schuster Family Transplantation Research Center, Renal Division, Brigham and Women's Hospital and Children's Hospital Boston, Harvard Medical School, Boston, MA. 2 Division of Transplant Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA. 3 Department of Nephrology, Beaumont Hospital, Dublin, Ireland. 4 Address correspondence to: Anil Chandraker, MD, Transplantation Research Center, Brigham and Women's Hospital and Children's Hospital Boston, 221 Longwood Ave, Boston MA 02115.

出版信息

Transplantation. 2014 Jun 27;97(12):1247-52. doi: 10.1097/01.TP.0000442782.98131.7c.

DOI:10.1097/01.TP.0000442782.98131.7c

PMID:24854670

Abstract

BACKGROUND

More than 30% of potential kidney transplant recipients have pre-existing anti-human leukocyte antigen antibodies. This subgroup has significantly lower transplant rates and increased mortality. Desensitization has become an important tool to overcome this immunological barrier. However, limited data is available regarding long-term outcomes, in particular for the highest risk group with a positive complement-dependent cytotoxicity crossmatch (CDC XM) before desensitization.

METHODS

Between 2002 and 2010, 39 patients underwent living-kidney transplantation across a positive CDC XM against their donors at our center. The desensitization protocol involved pretransplant immunosuppression, plasmapheresis, and low-dose intravenous immunoglobulin±rituximab. Measured outcomes included patient survival, graft survival, renal function, rates of rejection, infection, and malignancy.

RESULTS

The mean and median follow-up was 5.2 years. Patient survival was 95% at 1 year, 95% at 3 years, and 86% at 5 years. Death-censored graft survival was 94% at 1 year, 88% at 3 years, and 84% at 5 years. Uncensored graft survival was 87% at 1 year, 79% at 3 years, and 72% at 5 years. Twenty-four subjects (61%) developed acute antibody-mediated rejection of the allograft and one patient lost her graft because of hyperacute rejection. Infectious complications included pneumonia (17%), BK nephropathy (10%), and CMV disease (5%). Skin cancer was the most prevalent malignancy in 10% of patients. There were no cases of lymphoproliferative disorder. Mean serum creatinine was 1.7±1 mg/dL in functioning grafts at 5 years after transplantation.

CONCLUSION

Despite high rates of early rejection, desensitization in living-kidney transplantation results in acceptable 5-year patient and graft survival rates.

摘要

背景

超过30%的潜在肾移植受者预先存在抗人类白细胞抗原抗体。这一亚组的移植率显著较低且死亡率增加。脱敏已成为克服这一免疫障碍的重要工具。然而，关于长期预后的数据有限，尤其是对于脱敏前补体依赖细胞毒性交叉配型（CDC XM）呈阳性的最高风险组。

方法

2002年至2010年期间，39例患者在我们中心接受了针对供体CDC XM呈阳性的活体肾移植。脱敏方案包括移植前免疫抑制、血浆置换以及低剂量静脉注射免疫球蛋白±利妥昔单抗。测量的结局包括患者生存率、移植物生存率、肾功能、排斥反应率、感染率和恶性肿瘤发生率。

结果

平均和中位随访时间为5.2年。1年时患者生存率为95%，3年时为95%，5年时为86%。死亡校正后的移植物生存率1年时为94%，3年时为88%，5年时为84%。未校正的移植物生存率1年时为87%，3年时为79%，5年时为72%。24名受试者（61%）发生了同种异体移植物的急性抗体介导排斥反应，1例患者因超急性排斥反应失去了移植物。感染并发症包括肺炎（17%）、BK肾病（10%）和巨细胞病毒病（5%）。皮肤癌是10%患者中最常见的恶性肿瘤。没有淋巴增殖性疾病病例。移植后5年时，功能良好的移植物中平均血清肌酐为1.7±1mg/dL。