Long-term Outcomes of Kidney Transplantation in Patients With High Levels of Preformed DSA: The Necker High-Risk Transplant Program
Long-term Outcomes of Kidney Transplantation in Patients With High Levels of Preformed DSA: The Necker High-Risk Transplant Program
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DOI：
10.1097/tp.0000000000001650
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发表时间：
2017-10-01
期刊：
影响因子：
6.2
通讯作者：
Legendre, Christophe
中科院分区：
文献类型：
--
作者：
Amrouche, Lucile;Aubert, Olivier;Legendre, Christophe
背景在等待名单上有越来越多的抗HLA致敏和高度致敏的肾移植候选者，并且在移植时供体特异性同种抗体（DSA）的存在导致急性和慢性抗体介导的排斥反应（AMR）。可接受的短期结果已经描述，特别是因为脱敏协议，但中期和长期的数据仍然需要。方法.我们的高免疫风险项目包括95例具有高峰或第0天DSA水平（平均荧光强度[MFI] > 3000）且补体依赖性细胞毒性阴性交叉配型的患者，这些患者从第0天开始接受移植后脱敏方案，包括大剂量静脉注射免疫球蛋白、血浆置换和最终的利妥昔单抗。他们的特征与对照组进行了比较，对照组包括39例免疫风险较低的患者（第0天MFI在500和3000之间），他们接受了相同的移植后脱敏治疗。结果免疫显性I类或II类DSA在峰值或0天血清中的中位数MFI为9421（四分位距4959 ~ 12610）。31例患者（32.6%）在移植后第一年发生AnAMR，1年时慢性AMR的发生率为39.5%。1年、3年、5年和7年死亡删失的同种异体移植物存活率分别为98%、91%、86%和78%，伴随受体存活率分别为97%、93%、85%和79%。结论.这些结果表明，DSA致敏的高MFI水平的患者可以接受移植的HLA屏障，与使用强化移植后免疫抑制治疗从第0天开始，结合密切的临床，免疫学和组织学监测。
Background. There is an increasing number of anti-HLA sensitized and highly sensitized renal transplant candidates on waiting lists, and the presence of donor-specific alloantibodies (DSAs) at the time of transplantation leads to acute and chronic antibody-mediated rejection (AMR). Acceptable short-term outcomes have been described, notably because of desensitization protocols, but mid-and long-termdata are still required. Methods. Our high immunologic risk program included 95 patients with high peak or day 0 DSA levels (mean fluorescence intensity [MFI] > 3000) with a complement-dependent cytotoxicity-negative crossmatch, who received a posttransplant desensitization protocol starting at day 0 with high-dose intravenous immunoglobulin, plasma exchanges, and eventually rituximab. Their characteristics were compared with a control group including 39 patients with a lower immunologic risk (MFI between 500 and 3000 at day 0) who received the same posttransplant desensitization. Results. Themedian MFI of the immunodominant class I or II DSA in the peak or day 0 serumwas 9421 (interquartile range, 4959-12 610). AnAMR occurred during the first posttransplant year in 31 patients (32.6%), and at one year, the rate of chronic AMR was 39.5%. The 1-, 3-, 5- and 7-year death-censored allograft survival rates were 98%, 91%, 86%, and 78%, respectively, with concomitant recipient survival rates of 97%, 93%, 85%, and 79%, respectively. Conclusions. These results suggest that DSA-sensitized patients with high MFI levels can receive transplantation across the HLA-barrier, with the use of an intensified posttransplant immunosuppressive therapy starting at day 0 combined with close clinical, immunologic, and histologic monitoring.