Orandi B J, Alachkar N, Kraus E S, Naqvi F, Lonze B E, Lees L, Van Arendonk K J, Wickliffe C, Bagnasco S M, Zachary A A, Segev D L, Montgomery R A
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Am J Transplant. 2016 Jan;16(1):213-20. doi: 10.1111/ajt.13434. Epub 2015 Aug 28.
The updated Banff classification allows for the diagnosis of antibody-mediated rejection (AMR) in the absence of peritubular capillary C4d staining. Our objective was to quantify allograft loss risk in patients with consistently C4d-negative AMR (n = 51) compared with C4d-positive AMR patients (n = 156) and matched control subjects without AMR. All first-year posttransplant biopsy results from January 2004 through June 2014 were reviewed and correlated with the presence of donor-specific antibody (DSA). C4d-negative AMR patients were not different from C4d-positive AMR patients on any baseline characteristics, including immunologic risk factors (panel reactive antibody, prior transplant, HLA mismatch, donor type, DSA class, and anti-HLA/ABO-incompatibility). C4d-positive AMR patients were significantly more likely to have a clinical presentation (85.3% vs. 54.9%, p < 0.001), and those patients presented substantially earlier posttransplantation (median 14 [interquartile range 8-32] days vs. 46 [interquartile range 20-191], p < 0.001) and were three times more common (7.8% vs 2.5%). One- and 2-year post-AMR-defining biopsy graft survival in C4d-negative AMR patients was 93.4% and 90.2% versus 86.8% and 82.6% in C4d-positive AMR patients, respectively (p = 0.4). C4d-negative AMR was associated with a 2.56-fold (95% confidence interval, 1.08-6.05, p = 0.033) increased risk of graft loss compared with AMR-free matched controls. No clinical characteristics were identified that reliably distinguished C4d-negative from C4d-positive AMR. However, both phenotypes are associated with increased graft loss and thus warrant consideration for intervention.
更新后的班夫分类法允许在不存在肾小管周围毛细血管C4d染色的情况下诊断抗体介导的排斥反应（AMR）。我们的目的是量化持续C4d阴性的AMR患者（n = 51）与C4d阳性的AMR患者（n = 156）以及匹配的无AMR对照受试者相比的移植肾丢失风险。回顾了2004年1月至2014年6月所有移植后第一年的活检结果，并将其与供体特异性抗体（DSA）的存在情况相关联。C4d阴性的AMR患者在任何基线特征上与C4d阳性的AMR患者均无差异，包括免疫风险因素（群体反应性抗体、既往移植、HLA错配、供体类型、DSA类别以及抗HLA/ABO不相容性）。C4d阳性的AMR患者更有可能出现临床表现（85.3%对54.9%，p < 0.001），并且这些患者在移植后出现得更早（中位数14天[四分位间距8 - 32天]对46天[四分位间距20 - 191天]，p < 0.001），且更为常见（7.8%对2.5%）。C4d阴性的AMR患者在确定AMR的活检后1年和2年的移植肾存活率分别为93.4%和90.2%，而C4d阳性的AMR患者分别为86.8%和82.6%（p = 0.4）。与无AMR的匹配对照相比，C4d阴性的AMR与移植肾丢失风险增加2.56倍（95%置信区间，1.08 - 6.05，p = 0.033）相关。未发现能可靠区分C4d阴性和C4d阳性AMR的临床特征。然而，这两种表型均与移植肾丢失增加相关，因此值得考虑进行干预。
