Department of Pulmonary Medicine, Integrated Hospital Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Curr Opin Pulm Med. 2024 Jul 1;30(4):391-397. doi: 10.1097/MCP.0000000000001078. Epub 2024 Apr 25.
To review what is currently known about the pathogenesis, diagnosis, treatment, and prevention of acute rejection (AR) in lung transplantation.
Epigenomic and transcriptomic methods are gaining traction as tools for earlier detection of AR, which still remains primarily a histopathologic diagnosis.
Acute rejection is a common cause of early posttransplant lung graft dysfunction and increases the risk of chronic rejection. Detection and diagnosis of AR is primarily based on histopathology, but noninvasive molecular methods are undergoing investigation. Two subtypes of AR exist: acute cellular rejection (ACR) and antibody-mediated rejection (AMR). Both can have varied clinical presentation, ranging from asymptomatic to fulminant ARDS, and can present simultaneously. Diagnosis of ACR requires transbronchial biopsy; AMR requires the additional measuring of circulating donor-specific antibody (DSA) levels. First-line treatment in ACR is increased immunosuppression (pulse-dose or tapered dose glucocorticoids); refractory cases may need antibody-based lymphodepletion therapy. First line treatment in AMR focuses on circulating DSA removal with B and plasma cell depletion; plasmapheresis, intravenous human immunoglobulin (IVIG), bortezomib, and rituximab are often employed.
回顾目前已知的肺移植后急性排斥反应（AR）的发病机制、诊断、治疗和预防措施。
表观遗传学和转录组学方法作为早期检测 AR 的工具越来越受到关注，AR 仍然主要是一种组织病理学诊断。
急性排斥反应是肺移植后早期移植物功能障碍的常见原因，并增加了慢性排斥反应的风险。AR 的检测和诊断主要基于组织病理学，但正在研究非侵入性的分子方法。AR 存在两种亚型：急性细胞排斥（ACR）和抗体介导的排斥（AMR）。两者的临床表现差异很大，从无症状到暴发性 ARDS 不等，且可能同时存在。ACR 的诊断需要经支气管活检；AMR 需要额外测量循环供体特异性抗体（DSA）水平。ACR 的一线治疗是增加免疫抑制（脉冲剂量或逐渐减量的糖皮质激素）；难治性病例可能需要基于抗体的淋巴细胞耗竭治疗。AMR 的一线治疗侧重于用 B 细胞和浆细胞耗竭清除循环 DSA；常采用血浆置换、静脉注射人免疫球蛋白（IVIG）、硼替佐米和利妥昔单抗。
