未行脱敏治疗的致敏受者的改良围手术期方案用于尸体供肾移植。

A modified perioperative regimen for deceased donor kidney transplantation in presensitized recipients without prior desensitization therapy.

机构信息

Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.

Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China.

出版信息

Front Immunol. 2023 Jul 5;14:1223567. doi: 10.3389/fimmu.2023.1223567. eCollection 2023.

DOI:10.3389/fimmu.2023.1223567

PMID:37475867

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10355838/

Abstract

BACKGROUND

Renal transplantation in HLA-presensitized recipients entails an increased risk of antibody-mediated rejection (AMR) and graft loss. There is currently no accepted standard treatment protocol that can help transplant surgeons safely perform deceased donor (DD) kidney transplantation in presensitized patients without pretransplant desensitization.

METHODS

Fifty-one panel-reactive antibody (PRA)-positive recipients and 62 PRA-negative retransplant recipients (control) who received DD renal transplantation were included. Patients in the presensitized group (donor-specific antibody [DSA]-positive, n=25; DSA-negative, n=26) without desensitization received a modified perioperative treatment starting on day 0 or -1 with rituximab, thymoglobulin, and low daily doses of intravenous immunoglobulin (IVIG, 10-20 g/d, for 14 days). Plasmapheresis was performed once before surgery in DSA-positive recipients.

RESULTS

The median follow-up time was 51 months in the presensitized group and 41 months in the control group. The incidence of early acute rejection (AR) and AMR (including mixed rejection) was 35.3% and 13.7% in the presensitized group, respectively, significantly higher than in the control group (14.5% and 1.6%, respectively). Within the presensitized group, the DSA-positive subgroup had more AMR than the DSA-negative subgroup (24.0% vs. 3.8%), but the incidence of T cell-mediated rejection was comparable (20.0% vs. 23.4%). In the presensitized group, all rejections were successfully reversed, and graft function remained stable during follow-up. The 1-year and 3-year survival rates of the grafts and recipients in this group were 98.0%.

CONCLUSION

With a modified IVIG-based perioperative regimen, excellent intermediate-term graft and recipient survival outcomes can be achieved in presensitized patients who received DD kidney transplantation without prior desensitization.

摘要

背景

在 HLA 致敏受者中进行肾移植会增加抗体介导的排斥反应 (AMR) 和移植物丢失的风险。目前尚无公认的标准治疗方案，可以帮助移植外科医生在没有移植前脱敏的情况下安全地为致敏患者进行已故供体 (DD) 肾移植。

方法

纳入 51 名 panel-reactive antibody (PRA)-阳性受者和 62 名 PRA-阴性再移植受者（对照组），他们均接受 DD 肾移植。在无脱敏的情况下，致敏组患者（供体特异性抗体 [DSA]-阳性，n=25；DSA-阴性，n=26）接受从第 0 天或-1 天开始的改良围手术期治疗，包括利妥昔单抗、胸腺球蛋白和低剂量静脉免疫球蛋白（IVIG，10-20g/d，持续 14 天）。在 DSA 阳性患者中，在术前进行一次血浆置换。

结果

致敏组的中位随访时间为 51 个月，对照组为 41 个月。致敏组的早期急性排斥反应 (AR) 和 AMR（包括混合排斥）的发生率分别为 35.3%和 13.7%，显著高于对照组（分别为 14.5%和 1.6%）。在致敏组中，DSA 阳性亚组的 AMR 发生率高于 DSA 阴性亚组（24.0%比 3.8%），但 T 细胞介导的排斥反应发生率相似（20.0%比 23.4%）。在致敏组中，所有排斥反应均得到成功逆转，随访期间移植物功能保持稳定。该组的 1 年和 3 年移植物和受者存活率均为 98.0%。