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ABO血型不相容肾移植的当前观点

Current Perspectives in ABO-Incompatible Kidney Transplant.

作者信息

Maritati Federica, Bini Claudia, Cuna Vania, Tondolo Francesco, Lerario Sarah, Grandinetti Valeria, Busutti Marco, Corradetti Valeria, La Manna Gaetano, Comai Giorgia

机构信息

Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

出版信息

J Inflamm Res. 2022 May 25;15:3095-3103. doi: 10.2147/JIR.S360460. eCollection 2022.

Abstract

For a long time, ABO incompatible living donor kidney transplantation has been considered contraindicated, due to the presence of isohemagglutinins, natural antibodies reacting with non-self ABO antigens. However, as the demand for kidney transplantation is constantly growing, methods to expand the donor pool have become increasingly important. Thus, in the last decades, specific desensitization strategies for ABOi transplantation have been developed. Nowadays, these regimens consist of transient removal of preformed anti-A or anti-B antibodies by using plasmapheresis or immunoadsorption and B-cell immunity modulation by CD20+ cells depletion with rituximab, in association with maintenance immunosuppression including corticosteroids, tacrolimus and mycophenolate mofetil. The outcome in ABOi kidney transplantation have markedly improved over the years. In fact, although randomized trials are still lacking, recent meta analysis has revealed that there is no difference in terms of graft and patient's survival between ABOi and ABO compatible kidney transplant, even in the long term. However, many concerns still exist, because ABOi kidney transplantation is associated with an increased risk of bleeding and infectious complications, partly related to the effects of extracorporeal treatments and the strong immunosuppression. Thus, a continuous improvement in desensitization strategies, with the aim of minimize the immunosuppressive burden, on the basis of immune pathogenesis, antibodies titers and/or ABO blood group, is warranted. In this review, we discuss the main immune mechanisms involved in ABOi kidney transplantation, the pathogenesis of tolerance and the desensitization regimens, including immunoadsorption and plasmapheresis and the immunosuppressive protocol. Finally, we provide an overview on outcome and future perspectives in ABOi kidney transplant.

摘要

长期以来,由于存在同种血凝素,即与非自身ABO抗原发生反应的天然抗体,ABO血型不相容的活体供肾移植一直被视为禁忌。然而,随着肾移植需求的不断增长,扩大供体库的方法变得越来越重要。因此,在过去几十年中,已经开发出了针对ABO血型不相容移植的特异性脱敏策略。如今,这些方案包括通过血浆置换或免疫吸附短暂去除预先形成的抗A或抗B抗体,以及使用利妥昔单抗清除CD20+细胞来调节B细胞免疫,同时联合包括皮质类固醇、他克莫司和霉酚酸酯在内的维持性免疫抑制治疗。多年来,ABO血型不相容肾移植的结果有了显著改善。事实上,尽管仍缺乏随机试验,但最近的荟萃分析表明,即使从长期来看,ABO血型不相容肾移植和ABO血型相容肾移植在移植物和患者生存率方面没有差异。然而,许多问题仍然存在,因为ABO血型不相容肾移植与出血和感染并发症风险增加有关,部分原因与体外治疗的影响和强效免疫抑制有关。因此,有必要在免疫发病机制、抗体滴度和/或ABO血型的基础上,持续改进脱敏策略,以尽量减轻免疫抑制负担。在这篇综述中,我们讨论了ABO血型不相容肾移植中涉及的主要免疫机制、耐受的发病机制和脱敏方案,包括免疫吸附和血浆置换以及免疫抑制方案。最后,我们概述了ABO血型不相容肾移植的结果和未来前景。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4e9a/9148605/22902567de41/JIR-15-3095-g0001.jpg

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