Sharma Amit, King Anne, Kumar Dhiren, Behnke Martha, McDougan Felecia, Kimball Pamela M
Department of Transplant Surgery, Virginia Commonwealth University Hospitals, Richmond, VA, USA.
Department of Transplant Surgery, Virginia Commonwealth University Hospitals, Richmond, VA, USA Department of Internal Medicine, Virginia Commonwealth University Hospitals, Richmond, VA, USA.
Prog Transplant. 2016 Jun;26(2):157-61. doi: 10.1177/1526924816640678.
Graft failure due to chronic rejection is greater among renal transplant patients with donor-specific antibody (DSA) than among DSA-free patients. For patients dependent on deceased donor transplantation, preoperative desensitization to eliminate DSAs may be impractical. We speculated that perioperative desensitization might eliminate preexisting DSAs and prevent de novo DSAs and improve graft outcomes. We report that brief perioperative desensitization using either intravenous immunoglobulin (IVIG) or plasmapheresis/IVIG (PP/IVIG) treatment improves clinical outcomes among patients with positive crossmatches.
Immediately following deceased donor transplantation, 235 renal recipients were assigned points for PRA and flow crossmatches (FCXM): delayed graft function (DGF) ≤ 1 point received standard therapy; 2 points received high-dose IVIG; and ≥3 points received PP/IVIG. The DSAs were serially monitored by single antigen bead luminex for 1 year. Five-year clinical outcomes were determined from the chart review.
All desensitized patients had preoperatively positive FCXM with DSA. Rejection was more common (P < .05) among desensitized than nonsensitized groups. However, overall graft survivals were similar between the groups (P = not significant) and superior to historic untreated patients (P < .05). Treatment with PP/IVIG more effectively eliminated preexisting DSAs (67% vs 33%, P < 0.05) than IVIG, but neither regimen prevented de novo formation of DSA (20%, P = not significant). Graft survival was >90% in all desensitizated patients with DSA elimination as well as PP/IVIG patients with residual DSA. In contrast, IVIG patients with persistent DSA had poorer graft survival (45%, P < .05).
Preemptive perioperative desensitization improved overall graft survival of sensitized patients compared to historic untreated patients. Plasmapheresis/IVIG had greater impact on DSA eradication and graft survival than IVIG alone.
在有供者特异性抗体（DSA）的肾移植患者中，因慢性排斥导致的移植物失功比无 DSA 的患者更常见。对于依赖尸体供者移植的患者，术前进行脱敏以消除 DSA 可能不切实际。我们推测围手术期脱敏可能消除预先存在的 DSA 并预防新发 DSA，从而改善移植物结局。我们报告，使用静脉注射免疫球蛋白（IVIG）或血浆置换/IVIG（PP/IVIG）治疗进行的简短围手术期脱敏可改善交叉配型阳性患者的临床结局。
在尸体供者移植后，235 名肾移植受者根据群体反应性抗体（PRA）和流式细胞交叉配型（FCXM）获得评分：移植肾功能延迟（DGF）≤1 分的患者接受标准治疗；2 分的患者接受高剂量 IVIG；≥3 分的患者接受 PP/IVIG。通过单抗原微珠免疫分析连续监测 DSA 1 年。通过查阅病历确定 5 年临床结局。
所有脱敏患者术前 FCXM 均为阳性且伴有 DSA。脱敏组的排斥反应比未脱敏组更常见（P <.05）。然而，两组的总体移植物存活率相似（P = 无显著性差异），且优于历史上未治疗的患者（P <.05）。与 IVIG 相比，PP/IVIG 治疗更有效地消除了预先存在的 DSA（67% 对 33%，P < 0.05），但两种方案均未预防 DSA 的新发形成（20%，P = 无显著性差异）。所有消除 DSA 的脱敏患者以及有残余 DSA 的 PP/IVIG 患者的移植物存活率均>90%。相比之下，持续存在 DSA 的 IVIG 患者的移植物存活率较差（45%，P <.05）。
与历史上未治疗的患者相比，围手术期抢先脱敏改善了致敏患者的总体移植物存活率。血浆置换/IVIG 对 DSA 的根除和移植物存活的影响比单独使用 IVIG 更大。
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