Survival in Sensitized Lung Transplant Recipients With Perioperative Desensitization
Survival in Sensitized Lung Transplant Recipients With Perioperative Desensitization
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DOI：
10.1111/ajt.13076
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发表时间：
2015-02-01
影响因子：
8.8
通讯作者：
Singer, L. G.
中科院分区：
文献类型：
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作者：
Tinckam, K. J.;Keshavjee, S.;Singer, L. G.
供体特异性HLA抗体（DSA）对肺移植的短期和长期结局有不良影响。我们实施了围手术期策略来治疗DSA阳性的受者，导致等效的排斥反应和移植物存活结果。移植前DSA检测HLA-A、B、C、DR和DQ抗原。如果群体反应性抗体（PRA）≥ 30%或医疗紧急，DSA阳性患者接受移植，并通过围手术期血浆置换、静脉注射免疫球蛋白、抗胸腺细胞球蛋白（ATG）和霉酚酸（MPA）脱敏。PRA阳性/DSA阴性受试者接受MPA。未致敏的患者接受常规环孢素，硫唑嘌呤和泼尼松，无ATG。从2008年至2011年，进行了340例首次仅肺移植：53例DSA阳性，93例PRA阳性/DSA阴性，194例未致敏。三组的30天生存率分别为96%、99%和96%。1年移植物存活率为89%/88%/86%（p = 0.47）。DSA阳性和PRA阳性/DSA阴性患者发生≥ 2级急性排斥反应的可能性较低（9%和9% vs. 18%未致敏，p = 0.04）。两组之间的最大预测用力呼气量（1 s）（81%/74%/76%，p = NS）和预测用力肺活量（分别为81%/77%/78%，p = NS）相等。应用该围手术期治疗方案，DSA/PRA阳性患者可以安全地进行肺移植，其结局与未致敏受者相似。
Donor-specific HLA antibodies (DSA) have an adverse effect on short-term and long-term lung transplant outcomes. We implemented a perioperative strategy to treat DSA-positive recipients, leading to equivalent rejection and graft survival outcomes. Pretransplant DSA were identified to HLA-A, B, C, DR and DQ antigens. DSA-positive patients were transplanted if panel reactive antibody (PRA) >= 30% or medically urgent and desensitized with perioperative plasma exchange, intravenous immune globulin, antithymocyte globulin (ATG), and mycophenolic acid (MPA). PRA-positive/DSA-negative recipients received MPA. Unsensitized patients received routine cyclosporine, azathioprine and prednisone without ATG. From 20082011, 340 lung-only first transplants were performed: 53 DSA-positive, 93 PRA-positive/DSA-negative and 194 unsensitized. Thirty-day survival was 96 %/99%/96% in the three groups, respectively. One-year graft survival was 89%/88%/86% (p = 0.47). DSA-positive and PRA-positive/DSA-negative patients were less likely to experience any >= grade 2 acute rejection (9% and 9% vs. 18% unsensitized p = 0.04). Maximum predicted forced expiratory volume (1 s) (81%/74%/76%, p = NS) and predicted forced vital capacity (81%/77%/78%, respectively, p = NS) were equivalent between groups. With the application of this perioperative treatment protocol, lung transplantation can be safely performed in DSA/PRA-positive patients, with similar outcomes to unsensitized recipients.