Baid S, Pascual M, Williams W W, Tolkoff-Rubin N, Johnson S M, Collins B, Chung R T, Delmonico F L, Cosimi A B, Colvin R B
Renal Unit, Massachusetts General Hospital, Boston 02114, USA.
J Am Soc Nephrol. 1999 Jan;10(1):146-53. doi: 10.1681/ASN.V101146.
Hepatitis C virus (HCV) infection has been associated with de novo or recurrent membranoproliferative glomerulonephritis and acute transplant glomerulopathy in transplanted kidneys. Recently, anticardiolipin antibodies (ACA) have been linked with chronic HCV infection. A few reports have suggested an association between ACA and renal allograft thrombosis. This study examines the clinical and pathologic features of HCV-positive renal allograft recipients at our institution. From 1990 to 1996, 379 kidney transplants were performed. We identified 18 recipients (4.8%) with HCV-positive serology pretransplant. Determination of IgG and IgM ACA was performed by enzyme-linked immunosorbent assay, using pretransplant sera. Among the 18 patients, five patients presented with biopsy-proven de novo renal thrombotic microangiopathy (RTMA), occurring 5 to 120 d (median, 14 d) after transplant. No differences in pretransplant characteristics were observed between patients with (n = 5) or without (n = 13) RTMA. All five patients had a positive ACA test (either IgG or IgM titer > 2 SD above normal), compared with only one of 13 patients without RTMA. The mean value for IgG ACA was significantly higher in the RTMA patients than in patients without RTMA (22.9 +/- 14.1 versus 6.9 +/- 4.9 IgG phospholipid units, P = 0.02); however, there were no significant differences in IgM ACA titers. Rheumatoid factor and complement C4 levels were normal in pretransplant sera of patients with RTMA. Patients with RTMA had their cyclosporine withdrawn (four of five) or the dose was decreased (one of five), and one of five underwent plasmapheresis. Four of five patients died within 5 yr after transplant, compared with no deaths in the other 13 patients. Finally, as a control group, seven HCV-negative renal allograft recipients who presented with RTMA/hemolytic uremic syndrome during the same time period were found to have normal ACA values (IgG or IgM). RTMA associated with ACA in HCV-positive renal allograft recipients may represent a new clinical entity. The occurrence of this syndrome may have deleterious consequences for patient and graft survival.
丙型肝炎病毒（HCV）感染与移植肾的新发或复发性膜增生性肾小球肾炎及急性移植肾小球病有关。最近，抗心磷脂抗体（ACA）与慢性HCV感染相关。一些报告提示ACA与肾移植血栓形成有关。本研究探讨了我院HCV阳性肾移植受者的临床和病理特征。1990年至1996年期间，共进行了379例肾移植。我们确定了18例（4.8%）移植前血清学HCV阳性的受者。采用酶联免疫吸附试验，使用移植前血清测定IgG和IgM ACA。18例患者中，5例经活检证实发生了新发肾血栓性微血管病（RTMA），发生在移植后5至120天（中位数为14天）。发生RTMA的患者（n = 5）与未发生RTMA的患者（n = 13）移植前特征无差异。所有5例发生RTMA的患者ACA检测均为阳性（IgG或IgM滴度高于正常2个标准差），而13例未发生RTMA的患者中只有1例阳性。发生RTMA的患者IgG ACA平均值显著高于未发生RTMA的患者（22.9±14.1对6.9±4.9 IgG磷脂单位，P = 0.02）；然而，IgM ACA滴度无显著差异。发生RTMA的患者移植前血清类风湿因子和补体C4水平正常。发生RTMA的患者停用环孢素（5例中的4例）或降低剂量（5例中的1例），5例中的1例进行了血浆置换。5例患者中有4例在移植后5年内死亡，而其他13例患者无死亡。最后，作为对照组，发现同期发生RTMA/溶血尿毒综合征的7例HCV阴性肾移植受者ACA值正常（IgG或IgM）。HCV阳性肾移植受者中与ACA相关的RTMA可能代表一种新的临床实体。该综合征的发生可能对患者和移植物存活产生有害后果。
