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 Oct;16(10):3041-3045. doi: 10.1111/ajt.13882. Epub 2016 Jun 27.
Patients requiring desensitization prior to renal transplantation are at risk for developing severe antibody-mediated rejection (AMR) refractory to treatment with plasmapheresis and intravenous immunoglobulin (PP/IVIg). We have previously reported success at graft salvage, long-term graft survival and protection against transplant glomerulopathy with the use of eculizumab and splenectomy in addition to PP/IVIg. Splenectomy may be an important component of this combination therapy and is itself associated with a marked reduction in donor-specific antibody (DSA) production. However, splenectomy represents a major operation, and some patients with severe AMR have comorbid conditions that substantially increase their risk of complications during and after surgery. In an effort to spare recipients the morbidity of a second operation, we used splenic irradiation in lieu of splenectomy in two incompatible live donor kidney transplant recipients with severe AMR in addition to PP/IVIg, rituximab and eculizumab. This novel approach to the treatment of severe AMR was associated with allograft salvage, excellent graft function and no short- or medium-term adverse effects of the radiation therapy. One-year surveillance biopsies did not show transplant glomerulopathy (tg) on light microscopy, but microcirculation inflammation and tg were present on electron microscopy.
需要在肾移植前进行脱敏治疗的患者有发生严重抗体介导排斥反应（AMR）的风险，这种排斥反应对血浆置换和静脉注射免疫球蛋白（PP/IVIg）治疗有抗药性。我们之前曾报道过，在使用依库珠单抗和脾切除术联合 PP/IVIg 治疗后，成功挽救了移植物、延长了移植物的长期存活率并预防了移植肾小球病。脾切除术可能是这种联合治疗的重要组成部分，它本身也与供体特异性抗体（DSA）产生的显著减少有关。然而，脾切除术是一种大手术，一些严重 AMR 的患者存在合并症，这大大增加了他们在手术期间和手术后发生并发症的风险。为了避免受者遭受第二次手术的发病率，我们在两名严重 AMR 的不相容活体供肾移植受者中，除了使用 PP/IVIg、利妥昔单抗和依库珠单抗外，还使用脾照射代替脾切除术。这种治疗严重 AMR 的新方法与移植物挽救、良好的移植物功能以及放射治疗的短期和中期不良影响无关。一年的监测活检在光镜下没有显示移植肾小球病（tg），但在电子显微镜下存在微循环炎症和 tg。
