Gaston R S, Shroyer T W, Hudson S L, Deierhoi M H, Laskow D A, Barber W H, Julian B A, Curtis J J, Barger B O, Diethelm A G
Department of Medicine, University of Alabama at Birmingham 35294.
Transplantation. 1994 Jan;57(1):47-54.
To assess the impact of quadruple immunosuppression in black and white recipients of cadaver kidney retransplants, we reviewed data from 178 second or subsequent renal allografts performed at our center between 1985 and 1991. Sixty-six black and 102 white recipients were divided into 3 groups: groups 1 and 2 consisted of patients with a negative complement-dependent cytotoxicity (CDC) T cell cross-match, receiving triple drug therapy (CsA-AZA-prednisone) and quadruple immunosuppressive therapy (quad therapy; Minnesota antilymphoblast globulin-CsA-AZA-prednisone), respectively. Group 3 patients also received quad therapy, but, in addition to a negative CDC cross-match, had a negative T cell flow cytometry cross-match (FCXM). Black and white patients in groups 1 and 2 experienced similar graft survival at 1 year, ranging from 47% to 63% (P = NS). In group 3, 1-year graft survival in whites, but not blacks, improved to 82%, with fewer grafts lost to immunologic causes in the first 90 days after transplant. A parametric analysis of potential risk factors identified a significant effect of better HLA-DR matching (P = 0.0005) on improved graft survival, with previous mismatched antigens (P = 0.04), female donor (P = 0.002), and short duration of previous graft (P = 0.05) as risk factors for graft loss. Race and immunosuppressive protocol did not affect graft survival. In group 3, blacks received fewer well-matched kidneys than whites (P = 0.05), which may have contributed to poorer outcomes for black recipients. Nine of 10 patients undergoing retransplantation with a negative CDC cross-match and a positive T cell FCXM suffered graft loss at a median of 26 days after transplant. Thus, quad therapy did not enhance graft survival for either black or white patients undergoing cadaveric retransplantation. Immunologic considerations, including HLA-DR matching and the FCXM, continue to exert a strong influence on outcomes in these high-risk recipients.
为评估四联免疫抑制疗法对尸体肾再次移植的黑种人和白种受者的影响，我们回顾了1985年至1991年间在本中心进行的178例第二次或后续肾移植的数据。66例黑种受者和102例白种受者被分为3组：第1组和第2组由补体依赖细胞毒性（CDC）T细胞交叉配型阴性的患者组成，分别接受三联药物治疗（环孢素A - 硫唑嘌呤 - 泼尼松）和四联免疫抑制治疗（四联疗法；明尼苏达抗淋巴细胞球蛋白 - 环孢素A - 硫唑嘌呤 - 泼尼松）。第3组患者也接受四联疗法，但除了CDC交叉配型阴性外，T细胞流式细胞术交叉配型（FCXM）也为阴性。第1组和第2组的黑种人和白种患者1年时的移植物存活率相似，在47%至63%之间（P = 无显著性差异）。在第3组中，白种人的1年移植物存活率提高到了82%，而黑种人未提高，移植后前90天因免疫原因丢失的移植物较少。对潜在危险因素的参数分析确定，更好的HLA - DR配型（P = 0.0005）对提高移植物存活率有显著影响，既往错配抗原（P = 0.04）、女性供者（P = 0.002）和既往移植物存活时间短（P = 0.05）是移植物丢失的危险因素。种族和免疫抑制方案不影响移植物存活率。在第3组中，黑种人接受的配型良好的肾脏比白种人少（P = 0.05），这可能是黑种受者预后较差的原因。10例CDC交叉配型阴性且T细胞FCXM阳性的再次移植患者中有9例在移植后中位时间26天出现移植物丢失。因此，四联疗法并未提高尸体肾再次移植的黑种或白种患者的移植物存活率。包括HLA - DR配型和FCXM在内的免疫因素继续对这些高风险受者的预后产生强烈影响。
