OKT3 FOR PRIMARY THERAPY OF THE FIRST REJECTION EPISODE IN KIDNEY TRANSPLANTS
OKT3 FOR PRIMARY THERAPY OF THE FIRST REJECTION EPISODE IN KIDNEY TRANSPLANTS
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OKT3 用于肾移植第一次排斥反应的初级治疗
作者：
R. Tesi;E. Elkhammas;M. Henry;R. Ferguson
一年移植物存活率的提高使移植中心能够专注于长期移植物存活率。一项对来自一个中心的665例接受环孢素治疗的原发性尸体肾移植的研究表明，如果没有急性排斥反应，患者不会发生慢性排斥反应。本研究回顾性分析了来自一个中心的314例连续肾移植，以确定早期积极治疗首次急性排斥反应是否会提高移植物存活率而不增加受体发病率。研究了在27个月期间进行的314例连续肾移植的过程（245例CAD和68例活体相关）。两组的人口统计学特征相同，所有患者均接受了ALG和CsA的连续四重免疫抑制。2年时患者和移植物存活率分别为89.7%和84%。41%的患者至少发生了一次排斥反应，其中一半发生在移植后30天内。排斥反应发作通过口服泼尼松逐渐减量、原发性ALG或OKT 3或用ALG或OKT 3的“补救”治疗来治疗。在52例接受OKT 3治疗的首次排斥反应患者中，移植物存活率比接受PRED治疗的50例患者高20%（P=0.0847）。比较39例接受原发性OKT 3治疗的原发性CAD肾移植患者与38例接受PRED治疗的原发性CAD肾移植患者，表明2年移植物存活率提高了32%（P=0.033）。在接受OKT 3治疗的患者中，第二次排斥事件没有增加。无论采用何种抗排斥治疗，发生排斥反应的患者的肾功能均相当。在接受排斥治疗的患者中，22%有症状的CMV感染，两组之间平均分配。82例患者接受单疗程OKT3治疗，28例患者接受2个疗程OKT3治疗，2例患者接受3次OKT3治疗。只有两名患者产生了抗鼠抗体，需要放弃OKT 3治疗排斥反应。这项研究清楚地表明，早期使用OKT 3作为排斥反应的主要治疗方法，可显著提高首次CAD肾移植受者的2年移植物存活率。在接受OKT 3作为主要治疗的患者中，CMV发作没有增加，患者死亡率也没有增加。早期使用OKT3不能预防或减少随后的排斥事件的发生。与PRED相比，OKT3治疗的患者中存活移植物的肾功能没有改善。本研究的结果表明，使用OKT3作为治疗肾移植受者首次急性排斥反应的初级治疗将
The improvement in one-year graft survival has allowed transplant centers to focus on long-term graft survival. A study of 665 primary cadaveric kidney transplants from a single center treated with cyclosporine demonstrated that patients did not develop chronic rejection if there was not an episode of acute rejection. This study is a retrospective review of 314 consecutive kidney transplants from a single center to determine if early, aggressive treatment of the first episode of acute rejection will improve graft survival without increasing recipient morbidity. The course of 314 consecutive kidney transplants performed during a 27-month period (245 CAD and 68 living-related) was studied. Demographic characteristics were equivalent between the two groups, and all patients received sequential quadruple immunosuppression using ALG and CsA. Patient and graft survivals at 2 years were 89.7% and 84%, respectively. At least one rejection episode occurred in 41% of the patients, one-half within 30 days of transplant. Rejection episodes were treated by oral prednisone taper, primary ALG or OKT3, or “rescue” therapy with ALG or OKT3. Graft survival in the 52 recipients treated with OKT3 for primary treatment of first rejection episode was 20% better than the 50 patients treated with PRED (P=0.0847). Comparing the 39 recipients of primary CAD kidneys treated with primary OKT3 vs. 38 treated with PRED demonstrated a 32% improvement in 2-year graft survival (P=0.033). There was no increase in second rejection episodes in patients treated with OKT3. Renal function was equivalent in patients with rejection regardless of type of antirejection therapy used. Of patients treated for rejection, 22% had symptomatic CMV infections, which were divided equally between the two groups. Eighty-two patients received a single course of OKT3, 28 received two courses, and 2 patients received OKT3 three times. Only two patients developed anti-murine antibodies that required abandoning OKT3 for the treatment of rejection. This study clearly demonstrates that the early use of OKT3 as primary treatment of rejection results in significant improvement of 2-year graft survival in recipients of first CAD kidney transplants. There is no increase in episodes in CMV in patients treated with OKT3 as primary therapy and no increase in patient mortality. Early use of OKT3 does not prevent or decrease incidence of subsequent rejection episodes. Renal function in surviving grafts is not improved in patients treated with OKT3 vs. PRED. The results of this study suggest that the use of OKT3 for primary therapy for treatment of first acute rejection episode in kidney recipients will