Nair Prasad, Gheith Osama, Al-Otaibi Torki, Mostafa Mohamed, Rida Suzann, Sobhy Islam, Halim Medhat A, Mahmoud Tarek, Abdul-Hameed Mohamed, Maher Ayman, Emam Mohamed
From the Kuwait Ministry of Health, Hamed Al-Essa Organ Transplant Center, Sabah area, Kuwait.
Exp Clin Transplant. 2019 Jan;17(Suppl 1):113-119. doi: 10.6002/ect.MESOT2018.O58.
Data on the management of chronic antibody-mediated rejection after kidney transplantation are limited. We aimed to assess the impact of treatment of biopsy-proven chronic active antibodymediated rejection with combined plasma exchange, intravenous immunoglobulin, and rituximab treatment versus intravenous immunoglobulin alone or conservative management on the evolution of renal function in renal transplant recipients.
In this retrospective study, we compared patients diagnosed with chronic active antibody-mediated rejection who were treated with standard of care steroids, intravenous immunoglobulin, plasma exchange, and rituximab (n = 40) at our center versus those who received intravenous immunoglobulin only or just intensified maintenance immunosuppression (n = 28). All patients were followed for 12 months clinically and by laboratory tests for graft and patient outcomes.
The two groups were matched regarding mean recipient age (41.9 ± 15.4 vs 37.8 ± 15.5 y in patients with conservative versus combined treatment), recipient sex, mean body weight, and the cause of end-stage kidney disease. Most patients and their donors were males. Glomerulonephritis represented the most common cause of end-stage kidney disease in both groups followed by diabetic nephropathy. The type of induction and pretransplant comorbidities were not different between groups (P > .05) except for the significantly higher number of chronic hepatitis C infections in patients who received conservative treatment (P = .007). Mean serum creatinine values before and after treatment of chronic active antibodymediated rejection were comparable between groups (P > .05). Active treatment with heavier immunosuppression (rituximab and plasma exchange) was associated with posttreatment viral (cytomegalovirus and BK virus) and bacterial infections that necessitated more hospitalization (P > .05). However, graft and patient outcomes were significantly better in the active treatment group than in patients with conservative treatment (P = .002 and .028, respectively).
Combined treatment of chronic active antibody-mediated rejection with plasma exchange, intravenous immunoglobulin, and rituximab can significantly improve outcomes after renal transplant.
肾移植后慢性抗体介导性排斥反应管理的数据有限。我们旨在评估经活检证实的慢性活动性抗体介导性排斥反应采用血浆置换、静脉注射免疫球蛋白和利妥昔单抗联合治疗与单独静脉注射免疫球蛋白或保守治疗相比，对肾移植受者肾功能演变的影响。
在这项回顾性研究中，我们比较了在本中心接受标准护理类固醇、静脉注射免疫球蛋白、血浆置换和利妥昔单抗治疗的慢性活动性抗体介导性排斥反应患者（n = 40）与仅接受静脉注射免疫球蛋白或仅强化维持免疫抑制的患者（n = 28）。所有患者均接受了12个月的临床随访，并通过实验室检查评估移植物和患者的预后。
两组在平均受者年龄（保守治疗组与联合治疗组分别为41.9±15.4岁和37.8±15.5岁）、受者性别、平均体重以及终末期肾病病因方面相匹配。大多数患者及其供者为男性。肾小球肾炎是两组中终末期肾病最常见的病因，其次是糖尿病肾病。除接受保守治疗的患者中慢性丙型肝炎感染数量显著更多（P = 0.007）外，两组之间的诱导类型和移植前合并症无差异（P > 0.05）。慢性活动性抗体介导性排斥反应治疗前后两组的平均血清肌酐值相当（P > 0.05）。采用更强免疫抑制的积极治疗（利妥昔单抗和血浆置换）与治疗后病毒（巨细胞病毒和BK病毒）及细菌感染相关，需要更多住院治疗（P > 0.05）。然而，积极治疗组的移植物和患者预后明显优于保守治疗患者（分别为P = 0.002和0.028）。
血浆置换、静脉注射免疫球蛋白和利妥昔单抗联合治疗慢性活动性抗体介导性排斥反应可显著改善肾移植后的预后。
