Treatment with plasmapheresis, immunoglobulins and rituximab for chronic-active antibody-mediated rejection in kidney transplantation: Clinical, immunological and pathological results.
Treatment with plasmapheresis, immunoglobulins and rituximab for chronic-active antibody-mediated rejection in kidney transplantation: Clinical, immunological and pathological results.
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DOI：
10.5500/wjt.v8.i5.178
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发表时间：
2018-09-10
期刊：
影响因子：
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通讯作者：
Biancone L
中科院分区：
文献类型：
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作者：
Mella A;Gallo E;Messina M;Caorsi C;Amoroso A;Gontero P;Verri A;Maletta F;Barreca A;Fop F;Biancone L
评价血浆置换、静脉注射免疫球蛋白和利妥昔单抗治疗方案在慢性活动性抗体介导的排斥反应（cAMR）中的作用。我们在一项回顾性病例对照分析中比较了21例诊断为cAMR的肾移植受者（KTR）：9例接受血浆置换、静脉注射免疫球蛋白和利妥昔单抗治疗的KTR（PE-IVIG-RTX组）与12例未接受抗体靶向治疗的患者（对照组）。我们检查了诊断后24个月的肾脏存活率和功能结果。还研究了组织学特征和供体特异性抗体（DSA）特征（MFI和C1 q固定能力）。两组间移植物存活率无差异：PE-IVIG-RTX组9名患者中有3名（33.3%）和对照组12名患者中有4名（33.3%）分别在诊断后14个月（最小值12-最大值18）和15个月（最小值7-最大值22）的中位时间发生了同种异体移植物功能丧失。两组在cAMR诊断后24个月的肾功能检查和蛋白尿也相似。PE-IVIG-RTX组8例患者中有7例（87.5%）在PE-IVIG-RTX后仅微血管炎症（肾小球炎+管周毛细血管炎评分）显著降低（治疗前活检中位评分3 vs治疗后活检中位评分1.5; P = 0.047），对肾脏存活率和/或DSA特征无任何影响。诊断时没有功能或组织学参数可预测临床结局。我们的数据显示，用PE-IVIG-RTX治疗的肾移植物用于cAMR诊断的2年治疗后结局无差异，但在治疗后方案活检中微血管炎症有显著改善。需要进一步的研究，特别是涉及创新的治疗方法，以改善这种严重疾病的管理和长期结果。
To evaluate the role of a therapeutic regimen with plasma exchange, intravenous immunoglobulins and rituximab in chronic-active antibody-mediated rejection (cAMR) settings. We compared 21 kidney transplant recipients (KTRs) with a diagnosis of cAMR in a retrospective case-control analysis: nine KTRs treated with plasmapheresis, intravenous immunoglobulins and rituximab (PE-IVIG-RTX group) vs 12 patients (control group) not treated with antibody-targeted therapies. We examined kidney survival and functional outcomes 24 mo after diagnosis. Histological features and donor-specific antibody (DSA) characteristics (MFI and C1q-fixing ability) were also investigated. No difference in graft survival between the two groups was noted: three out of nine patients in the PE-IVIG-RTX group (33.3%) and 4/12 in the control group (33.3%) experienced loss of allograft function at a median time after diagnosis of 14 mo (min 12-max 18) and 15 mo (min 7-max 22), respectively. Kidney functional tests and proteinuria 24 mo after cAMR diagnosis were also similar in both groups. Only microvascular inflammation (glomerulitis + peritubular capillaritis score) was significantly reduced after PE-IVIG-RTX in seven out of eight patients (87.5%) in the PE-IVIG-RTX group (median score 3 in pre-treatment biopsy vs 1.5 in post-treatment biopsy; P = 0.047), without any impact on kidney survival and/or DSA characteristics. No functional or histological parameter at diagnosis was predictive of clinical outcome. Our data showed no difference in the two year post-treatment outcome of kidney grafts treated with PE-IVIG-RTX for cAMR diagnosis, however there were notable improvements in microvascular inflammation in post-therapy protocol biopsies. Further studies, especially involving innovative therapeutic approaches, are required to improve the management and long-term results of this severe condition.