Solomon H, Gonwa T A, Mor E, Holman M J, Gibbs J, Watemberg I, Netto G, Goldstein R M, Husberg B S, Klintmalm G B
Transplantation Services, Baylor University Medical Center, Dallas, Texas.
Transplantation. 1993 Jan;55(1):87-91. doi: 10.1097/00007890-199301000-00017.
The results of OKT3 use for steroid-resistant rejection rescue in adult liver transplantation were analyzed retrospectively from a single transplant center. Comparison was made with concurrent patients who had no rejection (NR) or steroid-responsive rejections (SR). The records of 290 patients who underwent 323 liver transplants from April 1985 to December 1989 were examined. The first technically successful grafts were used for this analysis (265 grafts). Follow-up was a minimum of 1 year, or until death or loss of graft. All patients received triple-drug induction immunosuppression (CsA, Aza, steroids). Initial rejection was treated with 1 g methylprednisolone bolus i.v., followed by a 5-day taper of steroids from 200 mg to 20 mg. No rejection occurred in 108 (40.8%) and SR in 86 (32.4%), and OKT3 was given for persistent rejection in 71 (26.8%). The age, sex distribution, mean follow-up, and preoperative status were similar in all three groups. The preoperative diagnoses were similar, except for fulminant liver failure, in which 19 of 20 patients experienced rejection (P < 0.0001). The median hospitalization stay was 37 days for OKT3, 27 days for SR, and 21 days for NR (P < 0.0001). The median ICU stay was similar in the three groups (OKT3, 4; SR, 4; NR, 3). Infections in the first 6 weeks, and in the period of 6 weeks to 1 year posttransplant, were of similar frequency for all three groups. By the Kaplan-Meier estimation, the graft and patient actuarial survival rates were comparable. At 1 year, the graft survival rate was 79.6% for NR, 79.8% for SR, and 67.6% for OKT3. The 1-year patient survival rate was 85.2% for NR, 83.7% for SR, and 84.5% for OKT3. Following treatment by OKT3, rejection was permanently reversed in 42 patients. A temporary response occurred in 12 patients, 16 patients failed to respond to OKT3, 2 patients died during therapy, and 6 of the nonresponders died within 12 months. Additional OKT3 treatment was attempted in 6 patients for persistent rejection within a 1-month interval from the previous OKT3 course. Of these 6, 4 developed lymphoproliferative disorder, and only 1 survived in response to drastic reduction of immunosuppression. In conclusion, OKT3 was effective as rescue therapy for adult liver transplant steroid-resistant rejection. Because of the associated morbidity and expense, OKT3 should be used in a selective fashion. Failure to respond to OKT3 is a serious complication, and should not be managed by prolonged or repeated courses, but rather by alternative means.
对某单一移植中心成人肝移植中使用OKT3挽救激素抵抗性排斥反应的结果进行回顾性分析。与同期无排斥反应（NR）或激素反应性排斥反应（SR）的患者进行比较。检查了1985年4月至1989年12月期间接受323例肝移植的290例患者的记录。首次技术成功的移植物用于该分析（265例移植物）。随访时间至少为1年，或直至死亡或移植物丢失。所有患者均接受三联药物诱导免疫抑制（环孢素A、硫唑嘌呤、类固醇）。初始排斥反应采用1g甲泼尼龙静脉推注治疗，随后进行5天的类固醇减量，从200mg减至20mg。108例（40.8%）未发生排斥反应，86例（32.4%）发生SR，71例（26.8%）因持续性排斥反应给予OKT3治疗。三组患者的年龄、性别分布、平均随访时间和术前状态相似。术前诊断相似，但暴发性肝衰竭除外，20例患者中有19例发生排斥反应（P<0.0001）。OKT3组的中位住院时间为37天，SR组为27天，NR组为21天（P<0.0001）。三组患者的中位重症监护病房停留时间相似（OKT3组为4天，SR组为4天，NR组为3天）。三组在移植后前6周以及6周至1年期间的感染频率相似。通过Kaplan-Meier估计，移植物和患者的精算生存率具有可比性。1年时，NR组的移植物生存率为79.6%，SR组为79.8%，OKT3组为67.6%。1年时，NR组的患者生存率为85.2%，SR组为83.7%，OKT3组为84.5%。接受OKT3治疗后，42例患者的排斥反应得到永久性逆转。12例患者出现暂时反应，16例患者对OKT3无反应，2例患者在治疗期间死亡，6例无反应者在12个月内死亡。6例患者在距上次OKT3疗程1个月内因持续性排斥反应尝试再次使用OKT3治疗。其中6例患者中有4例发生淋巴增生性疾病，只有1例在大幅降低免疫抑制后存活。总之，OKT3作为成人肝移植激素抵抗性排斥反应的挽救治疗有效。由于其相关的发病率和费用，OKT3应选择性使用。对OKT3无反应是一种严重并发症，不应通过延长或重复疗程来处理，而应采用其他方法。
