Steggerda J A, Kang A, Pan S-H, Sundaram V, Nissen N N, Klein A S, Todo T, Annamalai A, Vo A, Jordan S C, Kim I K
Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Transplant Proc. 2017 Jul-Aug;49(6):1394-1401. doi: 10.1016/j.transproceed.2017.01.079.
Preformed donor-specific human leukocyte antigen antibodies (DSAs) in patients undergoing simultaneous liver and kidney transplantation (SLKT) are an independent risk factor for poorer patient and renal allograft survival. The outcomes of patients highly sensitized (HS) against HLA antigens undergoing SLKT and select HS SLKT recipients undergoing desensitization at a high-volume desensitization center were investigated.
Seventy-five patients undergoing SLKT at a high-volume desensitization center between January 1, 2001, and December 31, 2015, were retrospectively reviewed. HS patients were defined by panel-reactive antibody (PRA) >30% (n = 17 patients), 11 of whom received pre- or perioperative desensitization with high-dose intravenous immunoglobulin (IVIG) ± rituximab.
HS patients had significantly higher class I and class II PRA (class I = 41.3% ± 40.0% vs 2.5% ± 6.3%; class II = 45.7% ± 36.4% vs 1.0% ± 2.9%; P < .001), were more likely to be female (P = .05), and more likely to have had a prior transplant (P = .03). HS patients demonstrated greater susceptibility to renal cell-mediated rejection (CMR) (23.5% vs 5.2%, P = .02) compared to nonsensitized patients. Higher renal antibody-mediated rejection (ABMR) was also observed in HS patients, 11.8% vs 3.4%, but did not reach significance (P = .18). Desensitization in select HS SLKT patients was well tolerated but did not improve patient and allograft survival or significantly curtail rejection.
HS SLKT recipients demonstrated increased allograft rejection, particularly CMR, but patient and graft survival were not impacted in the first year post-transplant. Select HS SLKT patients tolerated desensitization with high-dose IVIG ± rituximab and may have received additional immunoprotection against ABMR but survival was not affected.
在接受肝肾联合移植（SLKT）的患者中，预先形成的供者特异性人类白细胞抗原抗体（DSA）是患者及肾移植存活率降低的独立危险因素。本研究调查了对HLA抗原高度致敏（HS）的患者接受SLKT的结局，以及在一家大型脱敏中心接受脱敏治疗的部分HS SLKT受者的情况。
回顾性分析了2001年1月1日至2015年12月31日期间在一家大型脱敏中心接受SLKT的75例患者。HS患者定义为群体反应性抗体（PRA）>30%（n = 17例患者），其中11例在术前或围手术期接受了大剂量静脉注射免疫球蛋白（IVIG）±利妥昔单抗的脱敏治疗。
HS患者的I类和II类PRA显著更高（I类=41.3%±40.0% vs 2.5%±6.3%；II类=45.7%±36.4% vs 1.0%±2.9%；P <.001），女性比例更高（P =.05），且更有可能有过移植史（P =.03）。与未致敏患者相比，HS患者对肾细胞介导的排斥反应（CMR）更敏感（23.5% vs 5.2%，P =.02）。HS患者中肾抗体介导的排斥反应（ABMR）也更高，为11.8% vs 3.4%，但未达到统计学显著性（P =.18）。部分HS SLKT患者的脱敏治疗耐受性良好，但未改善患者及移植物存活率或显著减少排斥反应。
HS SLKT受者的移植物排斥反应增加，尤其是CMR，但移植后第一年患者及移植物存活率未受影响。部分HS SLKT患者对大剂量IVIG±利妥昔单抗的脱敏治疗耐受性良好，可能获得了针对ABMR的额外免疫保护，但存活率未受影响。
