Manfredini Valentina, Leone Ornella, Agostini Valentina, Potena Luciano
aHeart and Lung Transplant Program bPathology Department, Bologna University Hospital S.Orsola-Malpighi, Bologna, Italy.
Curr Opin Organ Transplant. 2017 Jun;22(3):207-214. doi: 10.1097/MOT.0000000000000407.
Antibody-mediated rejection (AMR) currently represents one of the main problems for clinical management of heart transplant because of its diagnostic complexity and poor evidences supporting treatments.
Disorder-based diagnosis is a cornerstone in defining AMR. The limitations of the current classification have been partially overcome by novel studies improving the description of the immune-pathological graft abnormalities, and by new molecular approaches allowing a better understanding of the mechanisms behind AMR and of its relationship with cellular rejection and chronic vasculopathy. In-depth characterization of donor-specific antibodies showed to provide additional prognostic information and guide for treatment. Clinical relevance of AMR is bound to appropriate detection of graft dysfunction. In addition to traditional longitudinal evaluation by echocardiogram, cardiac magnetic resonance and detection of cell-free DNA may represent novel sensitive markers for graft injury that could prompt treatment before dysfunction becomes clinically manifest.
Despite improvements in the diagnostic process, therapeutic strategies made little progress in addition to the consolidation of practices supported by limited evidences. Novel complement inhibitors appear promising in changing this scenario. Nevertheless, collaborative multicenter studies are needed to develop standardized approaches tailored to the highly variable clinical and laboratory features of AMR.
由于抗体介导的排斥反应（AMR）诊断复杂且治疗依据不足，目前它是心脏移植临床管理的主要问题之一。
基于病症的诊断是定义AMR的基石。当前分类的局限性已通过一些新研究得到部分克服，这些研究改进了对免疫病理移植异常的描述，以及通过新的分子方法，能更好地理解AMR背后的机制及其与细胞排斥和慢性血管病变的关系。对供体特异性抗体的深入表征显示可提供额外的预后信息并指导治疗。AMR的临床相关性与对移植物功能障碍的恰当检测相关。除了通过超声心动图进行传统的纵向评估外，心脏磁共振成像和游离DNA检测可能代表移植物损伤的新型敏感标志物，可在功能障碍出现临床症状之前促使进行治疗。
尽管诊断过程有所改进，但除了巩固证据有限的现有治疗方法外，治疗策略进展甚微。新型补体抑制剂似乎有望改变这种局面。然而，需要开展协作性多中心研究，以制定针对AMR高度可变的临床和实验室特征的标准化方法。
