Guo Zhiliang, Sa Rula, Zhao Guangyuan, Che Fuheng, Guo Hui, Zhu Lan, Chen Gang
Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, NHC Key Laboratory of Organ Transplantation, Wuhan, China.
Front Immunol. 2025 Sep 4;16:1670507. doi: 10.3389/fimmu.2025.1670507. eCollection 2025.
In presensitized kidney transplantation with positive donor-specific antibody (DSA), the activation of immune memory responses leads to a significant increase in DSA levels, followed by early active antibody-mediated rejection (early aAMR). For some patients, it is difficult to eliminate DSA and reverse aAMR after conventional treatments such as plasmapheresis (PP) and intravenous immunoglobulin (IVIG). Here we report three cases of successful reversal of refractory early aAMR after DSA-positive presensitized kidney transplantation by using adjuvant splenic irradiation therapy. At 1 to 2 weeks after kidney transplantation, all three of our recipients experienced a significant increase in DSA levels, accompanied by deterioration of renal allograft function. The aAMR of two patients was diagnosed by renal biopsy, and the other was diagnosed clinically. After 5 to 11 sessions of PP/IVIG treatment, the DSA levels of all three patients failed to decrease, or even continued to rise. Therefore, in addition to PP/IVIG treatment, all three patients received 10 sessions of low-dose repetitive splenic irradiation (50cGy per session) as adjuvant therapy. As a result, the levels of all DSAs began a continuous decline, and renal function gradually returned to normal or approached normal. Eventually, all three patients recovered and were discharged from the hospital. During the 14- to 75-month follow-up period, the DSA of two patients became negative, while that of the remaining one patient remained at a low level. Renal function was stable during the follow-up period. Thus, when early aAMR that resists conventional treatment occurs after presensitized kidney transplantation, splenic irradiation may be an important adjuvant treatment option.
在供者特异性抗体（DSA）阳性的致敏肾移植中，免疫记忆反应的激活导致DSA水平显著升高，随后出现早期活动性抗体介导的排斥反应（早期aAMR）。对于一些患者来说，在进行诸如血浆置换（PP）和静脉注射免疫球蛋白（IVIG）等传统治疗后，很难消除DSA并逆转aAMR。在此，我们报告3例DSA阳性致敏肾移植后难治性早期aAMR通过辅助性脾照射疗法成功逆转的病例。肾移植后1至2周，我们的3例受者DSA水平均显著升高，同时伴有移植肾功能恶化。2例患者通过肾活检诊断为aAMR，另1例为临床诊断。在进行5至11次PP/IVIG治疗后，3例患者的DSA水平均未下降，甚至持续上升。因此，除PP/IVIG治疗外，3例患者均接受了10次低剂量重复脾照射（每次50cGy）作为辅助治疗。结果，所有DSA水平均开始持续下降，肾功能逐渐恢复正常或接近正常。最终，3例患者均康复出院。在14至75个月的随访期内，2例患者的DSA转阴，而其余1例患者的DSA仍维持在低水平。随访期间肾功能稳定。因此，当致敏肾移植后出现抵抗传统治疗的早期aAMR时，脾照射可能是一种重要的辅助治疗选择。
