Alasfar Sami, Kodali Lavanya, Schinstock Carrie A
Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA.
Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
J Clin Med. 2023 Jul 27;12(15):4927. doi: 10.3390/jcm12154927.
Despite significant advancements in immunosuppressive therapies, kidney transplant rejection continues to pose a substantial challenge, impacting the long-term survival of grafts. This article provides an overview of the diagnosis, current therapies, and management strategies for acute T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). TCMR is diagnosed through histological examination of kidney biopsy samples, which reveal the infiltration of mononuclear cells into the allograft tissue. Corticosteroids serve as the primary treatment for TCMR, while severe or steroid-resistant cases may require T-cell-depleting agents, like Thymoglobulin. ABMR occurs due to the binding of antibodies to graft endothelial cells. The most common treatment for ABMR is plasmapheresis, although its efficacy is still a subject of debate. Other current therapies, such as intravenous immunoglobulins, anti-CD20 antibodies, complement inhibitors, and proteasome inhibitors, are also utilized to varying degrees, but their efficacy remains questionable. Management decisions for ABMR depend on the timing of the rejection episode and the presence of chronic changes. In managing both TCMR and ABMR, it is crucial to optimize immunosuppression and address adherence. However, further research is needed to explore newer therapeutics and evaluate their efficacy.
尽管免疫抑制疗法取得了重大进展，但肾移植排斥反应仍然是一个巨大的挑战，影响着移植肾的长期存活。本文概述了急性T细胞介导的排斥反应（TCMR）和抗体介导的排斥反应（ABMR）的诊断、当前治疗方法及管理策略。TCMR通过肾活检样本的组织学检查来诊断，结果显示单核细胞浸润到同种异体移植组织中。皮质类固醇是TCMR的主要治疗方法，而严重或类固醇抵抗的病例可能需要使用T细胞清除剂，如胸腺球蛋白。ABMR是由于抗体与移植肾内皮细胞结合所致。ABMR最常见的治疗方法是血浆置换，但其疗效仍存在争议。其他当前的治疗方法，如静脉注射免疫球蛋白、抗CD20抗体、补体抑制剂和蛋白酶体抑制剂，也在不同程度上被使用，但其疗效仍存在疑问。ABMR的管理决策取决于排斥反应发作的时间和慢性变化的存在。在管理TCMR和ABMR时，优化免疫抑制和解决依从性问题至关重要。然而，需要进一步研究以探索更新的治疗方法并评估其疗效。
