Orandi B J, Chow E H K, Hsu A, Gupta N, Van Arendonk K J, Garonzik-Wang J M, Montgomery J R, Wickliffe C, Lonze B E, Bagnasco S M, Alachkar N, Kraus E S, Jackson A M, Montgomery R A, Segev D L
Departments of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
Am J Transplant. 2015 Feb;15(2):489-98. doi: 10.1111/ajt.12982. Epub 2015 Jan 21.
Unlike antibody-mediated rejection (AMR) with clinical features, it remains unclear whether subclinical AMR should be treated, as its effect on allograft loss is unknown. It is also uncertain if AMR's effect is homogeneous across donor (deceased/live) and (HLA/ABO) antibody types. We compared 219 patients with AMR (77 subclinical, 142 clinical) to controls matched on HLA/ABO-compatibility, donor type, prior transplant, panel reactive antibody (PRA), age and year. One and 5-year graft survival in subclinical AMR was 95.9% and 75.7%, compared to 96.8% and 88.4% in matched controls (p = 0.0097). Subclinical AMR was independently associated with a 2.15-fold increased risk of graft loss (95% CI: 1.19-3.91; p = 0.012) compared to matched controls, but not different from clinical AMR (p = 0.13). Fifty three point two percent of subclinical AMR patients were treated with plasmapheresis within 3 days of their AMR-defining biopsy. Treated subclinical AMR patients had no difference in graft loss compared to matched controls (HR 1.73; 95% CI: 0.73-4.05; p = 0.21), but untreated subclinical AMR patients did (HR 3.34; 95% CI: 1.37-8.11; p = 0.008). AMR's effect on graft loss was heterogeneous when stratified by compatible deceased donor (HR = 4.73; 95% CI: 1.57-14.26; p = 0.006), HLA-incompatible deceased donor (HR = 2.39; 95% CI: 1.10-5.19; p = 0.028), compatible live donor (no AMR patients experienced graft loss), ABO-incompatible live donor (HR = 6.13; 95% CI: 0.55-67.70; p = 0.14) and HLA-incompatible live donor (HR = 6.29; 95% CI: 3.81-10.39; p < 0.001) transplant. Subclinical AMR substantially increases graft loss, and treatment seems warranted.
与具有临床特征的抗体介导排斥反应（AMR）不同，目前尚不清楚亚临床AMR是否应接受治疗，因为其对移植器官丢失的影响尚不清楚。AMR的影响在不同供体（已故/活体）和（HLA/ABO）抗体类型中是否相同也不确定。我们将219例AMR患者（77例亚临床患者，142例临床患者）与在HLA/ABO相容性、供体类型、既往移植、群体反应性抗体（PRA）、年龄和年份方面匹配的对照组进行了比较。亚临床AMR患者1年和5年移植器官存活率分别为95.9%和75.7%，而匹配对照组为96.8%和88.4%（p = 0.0097）。与匹配对照组相比，亚临床AMR与移植器官丢失风险增加2.15倍独立相关（95%CI：1.19 - 3.91；p = 0.012），但与临床AMR无差异（p = 0.13）。53.2%的亚临床AMR患者在其AMR定义性活检后3天内接受了血浆置换治疗。接受治疗的亚临床AMR患者与匹配对照组相比，移植器官丢失无差异（HR 1.73；95%CI：0.73 - 4.05；p = 0.21），但未接受治疗的亚临床AMR患者有差异（HR 3.34；95%CI：1.37 - 8.11；p = 0.008）。当按相容已故供体（HR = 4.73；95%CI：1.57 - 14.26；p = 0.006）、HLA不相容已故供体（HR = 2.39；95%CI：1.10 - 5.19；p = 0.028）、相容活体供体（无AMR患者发生移植器官丢失）、ABO不相容活体供体（HR = 6.13；95%CI：0.55 - 67.70；p = 0.14）和HLA不相容活体供体（HR = 6.29；95%CI：3.81 - 10.39；p < 0.001）移植分层时，AMR对移植器官丢失的影响是异质性的。亚临床AMR显著增加移植器官丢失，治疗似乎是必要的。
