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目的 :探讨移植肾加速性排斥反应 (acceleratedacuterejection ,AccAR)的治疗方法。 方法 :在该院 2 0 0 1年12月至 2 0 0 3年 6月间 196例肾移植患者中 ,有 2例术前群体反应性抗体 (PRA)曾经为高敏状态 ,术后结合临床和病理证实为AccAR。其诊断依据为 :①发生在肾移植术后 3～ 5天内 ;②血肌酐 (SCr)迅速升高 ;③典型病理改变为肾小管周围毛细血管 (peritubularcapillary ,PTC)内补体裂解片段C4d沉积和PTC内中性粒细胞积聚 ,毛细血管纤维蛋白沉积或血栓形成 ,动脉内膜炎或 (和 )血管炎 ,血管壁免疫球蛋白和其他补体片段沉积。 2例患者均立即采用免疫吸附 (IA)和他克莫司 (Tacrolimus ,Tac,0 .15mg /kg·d 1,谷浓度 6～ 12 μg/L ) +霉酚酸酯 (MMF ,1.5～ 2g/d)+甲泼尼龙 (MP ,5 0 0mg/d× 3,静脉注射 )联合抗排斥治疗。 结果 :2例患者每次IA后各种免疫球蛋白 (以IgG为主 )及PRA 组织相容性抗原 Ⅰ (PRA HLA Ⅰ )、PRA HLA Ⅱ均明显下降。重复肾活检见排斥反应明显减轻 ,SCr分别在术后 1个月及半个月开始下降 ,术后 2个月和 1个月恢复正常 ,至今已分别随访 2 3个月及 14个月 ,病情稳定 ,SCr正常。 结论 :及时充分的IA与足够剂量的Tac、MMF及MP联合应用 ,是治疗移植肾AccAR的有效方法。
Objective: To investigate the treatment of acceleratedacuterejection (AccAR) in renal allograft. Methods: Among 196 patients with renal allograft from December 2001 to June 2003, 2 cases of PRA were hypersensitive state. Combined with clinical and Pathology confirmed as AccAR. The diagnosis was based on the following: ① occurred within 3 to 5 days after renal transplantation; ② serum creatinine (SCr) increased rapidly; ③ typical pathological changes of peritubular capillaries (peritubularcapillary, PTC) C4d deposition of complement fragments and PTC Neutrophil accumulation, capillary fibrin deposition or thrombosis, endocarditis or vasculitis, deposition of vascular wall immunoglobulins and other complement fragments. Both patients were treated with IA and Tacrolimus (Tacrolimus, 0.15 mg / kg · d 1, trough concentration of 6-12 μg / L) and mycophenolate mofetil (MMF, 1.5-2 g / d) + methylprednisolone (MP, 500 mg / d × 3, iv) in combination with anti-rejection therapy. Results: The immunoglobulins (mainly IgG) and PRA HLA Ⅰ and PRA HLA Ⅱ in 2 patients after IA were significantly decreased. Repeated renal biopsy showed significantly reduced rejection, SCr decreased at 1 month and 2 months after surgery, 2 months and 1 month after surgery returned to normal, so far have been respectively followed 23 months and 14 months, the disease Stable, SCr normal. Conclusion: Timely and adequate IA and enough doses of Tac, MMF and MP are effective methods for the treatment of renal allograft.