Division of Pulmonary & Critical Care, Baylor University Medical Center, Dallas, TX, USA.
Department of Pathology, St. Louis University School of Medicine, St. Louis, MO, USA.
Am J Transplant. 2018 Apr;18(4):936-944. doi: 10.1111/ajt.14534. Epub 2017 Nov 11.
Antibody-mediated rejection (AMR) is an increasingly recognized form of lung rejection. C4d deposition has been an inconsistent finding in previous reports and its role in the diagnosis has been controversial. We conducted a retrospective single-center study to characterize cases of C4d-negative probable AMR and to compare these to cases of definite (C4d-positive) AMR. We identified 73 cases of AMR: 28 (38%) were C4d-positive and 45 (62%) were C4d-negative. The two groups had a similar clinical presentation, and although more patients in the C4d-positive group had neutrophilic capillaritis (54% vs. 29%, P = .035), there was no significant difference in the presence of other histologic findings. Despite aggressive antibody-depleting therapy, 19 of 73 (26%) patients in the overall cohort died within 30 days, but there was no significant difference in freedom from chronic lung allograft dysfunction (CLAD) or survival between the two groups. We conclude that AMR may cause allograft failure, but that the diagnosis requires a multidisciplinary approach and a high index of suspicion. C4d deposition does not appear to be a necessary criterion for the diagnosis, and although some cases may respond initially to therapy, there is a high incidence of CLAD and poor survival after AMR.
抗体介导的排斥反应（AMR）是一种越来越被认可的肺排斥形式。C4d 沉积在以前的报告中一直是一个不一致的发现，其在诊断中的作用存在争议。我们进行了一项回顾性单中心研究，以描述 C4d 阴性的可能 AMR 病例，并将这些病例与明确的（C4d 阳性）AMR 病例进行比较。我们确定了 73 例 AMR 病例：28 例（38%）为 C4d 阳性，45 例（62%）为 C4d 阴性。两组的临床表现相似，尽管 C4d 阳性组中有更多的患者存在中性粒细胞毛细血管炎（54%比 29%，P=0.035），但其他组织学发现没有显著差异。尽管进行了积极的抗体耗竭治疗，但在整个队列中，73 例患者中有 19 例（26%）在 30 天内死亡，但两组之间在慢性肺移植物功能障碍（CLAD）无失败或生存方面没有显著差异。我们得出结论，AMR 可能导致移植物衰竭，但诊断需要多学科方法和高度怀疑。C4d 沉积似乎不是诊断的必要标准，尽管一些病例可能最初对治疗有反应，但 AMR 后 CLAD 的发生率高，生存情况差。
