Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Transplantation. 2019 Aug;103(8):1722-1729. doi: 10.1097/TP.0000000000002566.
Antibody-mediated rejection (AMR) is a leading cause of morbidity and mortality after kidney transplantation. Early diagnosis and treatment of subclinical AMR based on the donor-specific antibody (DSA) testing may result in better outcomes.
We tested this hypothesis in 220 kidney transplant recipients who underwent an indication or DSA-based surveillance protocol biopsies between March 1, 2013 and December 31, 2016. Patients were divided into 3 groups: clinical AMR (n = 118), subclinical AMR (n = 25), or no rejection on protocol biopsy (controls; n = 77).
Both clinical and subclinical AMR groups underwent similar treatment including plasmapheresis, pulse steroids, IVIG, and rituximab (P = ns). Mean follow-up after AMR was 29.5 ± 16.8 months. There were 2 (3%), 2 (8%), and 54 (46%) death-censored graft failures in the control, subclinical, and clinical AMR groups, respectively (P < 0.001). Graft outcomes were similar in the subclinical rejection and control groups. In adjusted Cox regression analysis, only clinical rejection (hazards ratio [HR], 4.31; 95% confidence interval [CI], 1.01-18.94; P = 0.05) and sum chronicity scores (HR, 1.16; 95% CI, 1.01-1.35; P = 0.03) were associated with increased risk of graft failure, while estimated glomerular filtration rate at time of biopsy (HR, 0.98; 95% CI, 0.96-0.99; P = 0.01) was associated with decreased risk of graft failure.
Our study suggests that early diagnosis and treatment of subclinical AMR using DSA monitoring may improve outcomes after kidney transplantation.
抗体介导的排斥反应（AMR）是肾移植后发病率和死亡率的主要原因。基于供体特异性抗体（DSA）检测对亚临床 AMR 进行早期诊断和治疗可能会带来更好的结果。
我们在 2013 年 3 月 1 日至 2016 年 12 月 31 日期间接受指征或 DSA 为基础的监测方案活检的 220 例肾移植受者中检验了这一假设。患者分为 3 组：临床 AMR（n=118）、亚临床 AMR（n=25）或方案活检无排斥（对照组；n=77）。
临床和亚临床 AMR 组接受了类似的治疗，包括血浆置换、脉冲类固醇、IVIG 和利妥昔单抗（P=ns）。AMR 后平均随访 29.5±16.8 个月。对照组、亚临床和临床 AMR 组分别有 2（3%）、2（8%）和 54（46%）例死亡相关移植物失败（P<0.001）。亚临床排斥组和对照组的移植物结局相似。在调整后的 Cox 回归分析中，只有临床排斥（风险比[HR]，4.31；95%置信区间[CI]，1.01-18.94；P=0.05）和总慢性评分（HR，1.16；95%CI，1.01-1.35；P=0.03）与移植物失败风险增加相关，而活检时估算肾小球滤过率（HR，0.98；95%CI，0.96-0.99；P=0.01）与移植物失败风险降低相关。
我们的研究表明，使用 DSA 监测对亚临床 AMR 进行早期诊断和治疗可能会改善肾移植后的结果。
