免疫治疗诱导对不同免疫排斥风险的肾移植患者结局和移植物存活的影响。
Effects of immunotherapy induction on outcome and graft survival of kidney-transplanted patients with different immunological risk of rejection.
机构信息
University Hospital of the Faculty of Medical Science, Belo Horizonte, Minas Gerais state, Brazil.
Institute of Research and Education of the Hospital Santa Casa, Belo Horizonte, Minas Gerais state, Brazil.
出版信息
BMC Nephrol. 2019 Aug 13;20(1):314. doi: 10.1186/s12882-019-1497-5.
BACKGROUND
In kidney transplantation, immunotherapy with thymoglobulin (rATG) has been used to down-regulate the patient immune system. rATG is a powerful immunobiologic drug used to deplete lymphocytes to prevent early acute rejection. The aim of this research was to evaluate the effects of immunotherapy by rATG on graft suvival during a 9-year period in kidney-transplanted patients with different immunological profiles.
METHODS
A sample of 469 patients were allocated into four groups (G) based on immunological risk of rejection: G1, low risk, not sensitized recipients, solid-phase immunoassay with single antigen beads (SPI-SAB) < 10%; G2, medium risk I, sensitized recipients, SPI-SAB ≥ 10 < 50%; G3, medium risk II sensitized (SPI-SAB ≥50%); and G4, high risk, sensitized recipients, SPI-SAB- donor-specific antibody positive (DSA+). Only patients from G3 and G4 received immunotherapy.
RESULTS
Of 255 patients who received a kidney from a living donor (LD), 42 (16.47%) from all groups (G) had T-cell-mediated rejection (TCMR) and four (G1) lost their grafts, 8 (3.14%) had antibody-mediated rejection (AMR), and two lost their graft in G1 and G4. Of 214 patients who received a kidney from deceased donors (DD), 37 (17.29%) had TCMR with one lost graft in G1. AMR was shown in 13 (6.07%) patients, with three losses observed in G2. Statistical differences between the groups in the 9-year graft survival rate were found only in the comparison of G1 versus G2 (P = 0.005) and G2 versus G4 (P = 0.047) for DD. For LD, no statistical differences were found.
CONCLUSION
This clinical retrospective study shows that immunotherapy induction was associated with improvement of outcomes, graft function, and survival in patients treated with immunotherapy in comparison with patients who did not received induction therapy. These findings strongly suggest that immunotherapy should be used for all patients transplanted with kidneys from deceased donors.
背景
在肾移植中，使用胸腺球蛋白（rATG）进行免疫治疗以抑制患者免疫系统。rATG 是一种强大的免疫生物药物，用于耗尽淋巴细胞以预防早期急性排斥反应。本研究的目的是评估 rATG 免疫治疗在 9 年期间对具有不同免疫特征的肾移植患者移植物存活的影响。
方法
将 469 例患者根据免疫排斥风险分为四组（G）：G1，低风险，未致敏受者，固相免疫测定用单抗原珠（SPI-SAB）<10%；G2，中风险 I，致敏受者，SPI-SAB≥10<50%；G3，中风险 II 致敏（SPI-SAB≥50%）；G4，高风险，致敏受者，SPI-SAB-供体特异性抗体阳性（DSA+）。仅 G3 和 G4 组的患者接受免疫治疗。
结果
在 255 例接受活体供肾的患者中（LD），所有组（G）中 42 例（16.47%）发生 T 细胞介导的排斥反应（TCMR），4 例（G1）移植失败；8 例（G1 和 G4）发生抗体介导的排斥反应（AMR），2 例在 G1 和 G4 中移植失败。在 214 例接受尸肾的患者中，37 例（17.29%）发生 TCMR，G1 中有 1 例移植失败。13 例（6.07%）患者发生 AMR，G2 中有 3 例移植失败。在 9 年移植物存活率方面，仅在 G1 与 G2（P=0.005）和 G2 与 G4（P=0.047）之间比较时，DD 组中观察到组间差异。对于 LD，未发现统计学差异。
结论
本临床回顾性研究表明，与未接受诱导治疗的患者相比，免疫治疗诱导与接受免疫治疗的患者的移植物功能和存活率改善相关。这些发现强烈表明，应将免疫治疗用于所有接受尸肾移植的患者。
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