【作者】 孟慧林；

【导师】 吕家驹；

【作者基本信息】 山东大学 ， 泌尿外科， 2008， 博士

【摘要】 目的探讨人类白细胞抗原(HLA)配型对慢性移植肾失功(CRAD)患者群体反应性抗体(PRA)产生的影响。方法对24例术前PRA阴性的初次肾移植汉族病例行供受者HLA分型,移植肾失功后检测受者PRA并确定抗体特异性。PRA定性、定量及确定抗体特异性采用酶联免疫吸附(ELISA)原理、用莱姆德抗原板(LAT1240)检测。HLAI类及Ⅱ类抗原分型用顺序特异引物聚合酶链反应(PCR-SSP)技术检测。观察PRA产生情况,比较致敏与非致敏病例的HLA配型情况,并分析HLA错配与PRA产生的关系。结果(1)24例CRAD患者中,17例移植肾失功后PRA阳性,7例阴性,致敏率70.8%。17例致敏患者中Ⅰ类抗体阳性8例(8/17,47.1%),Ⅱ类抗体阳性15例(15/17,88.2%),Ⅰ类及Ⅱ类抗体同时阳性6例(6/17,35.3%)。A1、A24、DR7、DR9、DR12及DR13抗体多见,供者特异性抗体(DSA)中A1、DR7及DR9多见。(2)按HLA六抗原(Ag M)配型标准,比较,Ⅰ类抗体阳性组的Ⅰ类抗原错配数(3.75,n=8)与阴性组(3.31,n=16)组间差异无统计学意义(P＞0.05);按交叉反应组(CREG)配型标准,阳性组错配数(2.75)多于阴性组(1.31)(P＜0.01)。按Ag M配型标准,Ⅱ类抗体阳性组的Ⅱ类抗原错配数(1.8,n=15)多于Ⅱ类抗体阴性组(1.33,n=9)(P＜0.05);按氨基酸残基配型标准(Res M),阳性组错配数(1.2)也多于阴性组(0.44)(P＜0.01)。(3)供者HLA出现频率及错配频率最高的A2及A30未发现相应抗体产生,供者Al-受者A2、DR7及DR9错配易导致DSA产生。结论(1)存在错配的CRAD患者多数处于致敏状态。(2)供受者HLA错配是CRAD患者致敏的主要原因。(3)DSA及NDSA可分别或同时出现于同一病例。(4)供者抗原错配频率与抗HLA-IgG抗体及DSA出现频率不完全一致:我们发现供者Al-受者A2错配及DR7、DR9错配易导致患者致敏及DSA出现。创新及意义(1)证实汉族供受者HLA错配与CRAD患者致敏的关系。(2)提出供者Al-受者A2错配及DR7、DR9错配更易导致患者致敏及DSA出现。本研究结果对指导肾移植配型及减少致敏发生有重要意义。目的探讨术前HLA配型及受者PRA情况对致敏尿毒症患者肾移植术后早期疗效的影响。方法应用LAT1240抗原板检测73例汉族致敏尿毒症患者肾移植术前致敏程度及抗HLA IgG抗体特异性,并应用PCR-SSP技术对供受者HLA进行分型。分析不同HLA抗原错配、PRA种类、致敏程度及与受者PRA对应的供者靶抗原存在情况对肾移植后早期排斥反应及1年移植肾存活率的影响,并与81例未致敏尿毒症患者(对照组)进行比较。结果(1)致敏患者及对照组术后早期排斥发生率分别为35.6%及18.5%,差异有统计学意义(P＜0.05),1年移植肾存活率分别为80.8%及95.1%,差异有统计学意义(P=0.01)。(2)致敏患者中,按Ag M及Res M配型标准比较排斥组与非排斥组、存活组与失功组的HLA错配总数及Ⅰ、Ⅱ类抗原错配数,组间差异均无统计学意义。(3)Ⅰ及Ⅱ类PRA同时阳性病例(n=23)排斥反应发生率52.2%,高于对照组(P＜0.01);1年移植肾存活率73.9%,低于对照组(P＜0.01)。PRA峰值＞50%组(n=12)排斥反应发生率50%,高于对照组(P＜0.05);PRA峰值≤50%组(n=61)1年移植肾存活率82%,＞50%组存活率75%,均低于对照组(P＜0.05%)。术时PRA值＞50%组(n=4)排斥反应发生率100%,高于对照组(P＜0.01)及≤50%组(31.9%,n=69)(P＜0.05);术时PRA值≤50%组及＞50%组1年移植肾存活率分别为82.6%、50%,低于对照组(P＜0.05,P＜0.05)。(4)靶抗原阳性组(n=13)排斥发生率69.2%,与对照组、靶抗原阴性组(24.4%,n=45)及峰值靶抗原组(12.5%,n=8)比较差异均有统计学意义(P＜0.01,P＜0.01,P＜0.05);靶抗原阳性组1年移植肾存活率69.2%,低于对照组(P＜0.05)。靶抗原未知组(n=7)的排斥发生率(71.4%)及1年存活率(71.4%)与靶抗原阳性组近似。Ⅰ类靶抗原阳性组(n=5)排斥发生率100%,显著高于对照组及靶抗原阴性组(P＜0.01,P＜0.01):Ⅰ类靶抗原阳性组存活率40%,显著低于对照组及靶抗原阴性组(P＜0.01,P＜0.05)。Ⅱ类靶抗原阳性组(n=8)的排斥发生率为50%,存活率为87.5%,与对照组及靶抗原阴性组比较,组间差异无统计学意义(P＞0.05)。(5)术前采用血浆置换或免疫吸附方法处理抗体20例,排发生率20%,存活率85%,与对照组比较无统计学差异(P＞0.05,P＞0.05);未处理抗体组(n=53)排斥发生率41%,显著高于对照组(P＜0.01),存活率79.2%,显著低于对照组(P＜0.01)。(6)按Res M配型标准无错配者有3例发生超急性排斥反应(HR);5例Ⅰ类靶抗原阳性病例,3例发生HR(均为ORes错配),1例已存活7年;8例Ⅱ类靶抗原阳性病例无HR发生,但有Ⅰ例仅Ⅱ类PRA阳性、靶抗原未知病例发生HR。结论(1)供受者存在2个以上HLA错配(Ag M)的情况下,致敏患者肾移植术后早期排斥组、非排斥组及移植肾存活组、失功组的HLA错配数无显著差异。(2)仅依据Res M配型错配数为0对致敏患者实施肾移植不能预防致敏患者HR发生。(3)PRA阳性对肾移植近期效果有不良影响,导致排斥发生率增加,存活率降低。(4)Ⅰ类及Ⅱ类PRA同时阳性、术时PRA值＞50%或供者Ⅰ类靶抗原阳性时,移植效果更差。(5)术前采用血浆置换等措施降低PRA,并行HLA配型避免接受靶抗原阳性供肾,可成功实施肾移植,并获良好的近期疗效。(6)Ⅱ类PRA阳性受者也有发生HR可能性;避免接受靶抗原阳性供肾是防止HR及近期排斥反应发生、提高移植肾生存率的根本措施。创新及意义(1)探讨汉族致敏尿毒症患者PRA种类及靶抗原种类对肾移植效果的影响。(2)提出存在2个以上HLA错配时,HLA错配数对汉族致敏患者肾移植术后早期排斥发生率及移植肾存活率无显著影响。(3)证实靶抗原阳性是汉族致敏患者肾移植失败的主要原因,Ⅱ类PRA阳性受者也有发生HR可能性。本研究结果对指导致敏患者肾移植术前配型有重要意义。更多还原

【Abstract】 Part OneIMPACT OF HLA MATCHING ON PRA FORMATION OF PATIENTS WITH CHRONIC RENAL ALLOGRAFT DYSFUNCTIONObjective To evaluate the effect of human leukocyte antigen(HLA) matching on panel reactive antibodies(PRA) formation in patients with chronic renal allografl dysfunction(CRAD).Methods PRA measurement and HLA matching have been carried out for the patients who received their first renal graft.For recipients who were not sensitized before transplantation,PRA measurement was carried out after the grafts dysfunctioned.PRA were demonstrated by enzyme-linked immunosorbent assay (ELISA) by means of LAT1240 for value and specificity.HLA of donors and recipients were measured by means of polymerase chain reaction with sequence specific primers(PCR-SSP).This study included 24 patients.The effect of HLA matching on PRA formation in these patients was analyzed.Results(1) There were 17 patients sensitized,compared to 7 patients unsensitized. Among the 17 sensitized patients,HLA-Ⅰantibodies,HLA-Ⅱantibodies and both two kinds of antibodies were found in 8,15 and 6 patients respectively.A1,A24,DR7, DR9,DR12 and DR13 antibodies were the most frequently found PRA.As to donor specific antibodies(DSA),A1,DR7 and DR9 antibodies were most frequently found. (2) The number of mismatched HLA-Ⅰantigens compared by 6-antigen matching (Ag M) standard was of no statistical differenc(P＞0.05) between HLA-Ⅰantibody positive and negative group,compared to being of statistical difference(P＜0.01) between these two groups compared by cross reactive group(CREG) matching standard.The number of mismatched HLA-Ⅱantigens between HLA-Ⅱantibody positive and negative group was of statistical difference compared by Ag M standard (P＜0.05) or amino acid residue matching(Res M) standard(P＜0.01).(3) Most frequently found donor HLA antigen A2 and A30 did not cause formation of A2 and A30 antibodies in recipients.Both 2 cases of donor A1 to recipient A2 antigen mismatch has caused formation of A1 antibody,the DSA to the donor A1 antigen. And mismatch of donor antigen DR7 and DR9 has caused more formation of DSA than others as well.Conclusions(1) HLA mismatch is an important cause of sensitization in patients with CRAD.(2) Better HLA matching of preceding renal transplant may decrease the occurrence of sensitization rate in patients waiting for retransplantation.(3) Mismatch of certain HLA antigen,such as A1,DR7 and DR9,is more likely to cause the formation of PRA in kidney recipients. Part TwoIMPACT OF HLA MATCHING AND RECIPIENT’S PRA ON ONE YEAR OUTCOME OF PRESENSITIZED RENAL ALLOGRAFT RECIPIENTSObjective To evaluate the impact of HLA matching and Recipicnt’s PRA on one year outcome in of prcsensitized renal allografi recipients.Methods In the 73 sensitized uremia recipients,we determined percentage of panel reactivity and the specificity of anti-HLA-Ig G antibodies.HLA genotyping was performed by PCR with sequence-specific primers(PCR-SSP).We analyzed which factors influence the early graft outcome,including HLA mismatching,class and degree of panel reactivity,target antigen of donors,as compared to the 81 unscnsitizcd recipients(the control group).Results(1) The early rejection rate was 35.6%in sensitized recipients and 18.5%in unsensitized recipients,with statistical significance(P＜0.05).The 1-year survival rate of the graft in the sensitized and unsensitizcd group was 80.8%and 95.1%respectively,with statistical significance(P=0.01).(2) The number of HLA mismatched alleles,including HLA-Ⅰand HLA-Ⅱ,were assessed in sensitized recipients between the rejection group and non-rejection group either with Ag M or Res M.No statistical significance was found,as the same between the 1-year graft survival group and loss group.(3) Compared to the control group,recipients with both PRAⅠandⅡantibodies(n=23) had a significantly higher rejection rate and lower survival rate of the graft(P＜0.01).The rejection rate of the recipients with a peak PRA＞50%(n=12) was significantly higher than the control group,while survival rates of both the recipients with peak PRA≤50%(n=61) and those＞50%(n=4) were found significantly lower than the control group(P＜0.05%);the rejection rate of those with pretransplant PRA＞50%(n=4) was significantly higher than the control group and those with peak PRA≤50%(P＜0.05),while survival rates of both those with pretransplant peak PRA＞50%and those≤50%(n=69) were found lower than the control group(P＜0.05%).(4) The rejection rate of target antigen positive group (n=13) increased.The difference was significant compared to control group,the target antigen negative group,and the peak target antigen group(n=8),respectively (P＜0.01,0.01 and 0.05);1-year graft survival rate of target antigen positive group was significantly lower than that of the control group(P＜0.05);both rejection rate and 1-year survival rate of target antigen unknown group(n=7) were found insignificant compared to the target antigen positive group.Compared to the control group or the negative group,the graft rejection in the HLA-Ⅰtarget antigen positive group was significantly higher(P＜0.01) and survival rate was lower(P＜0.01 and P＜0.05).No statistical significance was shown in the HLA-Ⅱtarget antigen positive group.(5)Recipients with pretransplant plasmapheresis(PP) or immunoadsorption(IA) had better graft effects postoperatively,which was significantly different with the control group(P＜0.01).(6) 3 cases of hyper reactive rejection(HR) occurred in recipients with 0-mismatches according to Res M.HR occurred in 3 out of the 5 cases with positive HLA-Ⅰtarget antigen,while 1 had functioning graft for 7 years.No HR was found in all the 8 cases with positive HLA-Ⅱtarget antigens,while 1 HR happened in the PRA-Ⅱpositive but target antigen unknown group.Conclusions(1) The number of HLA mismatched alleles has no significant impact on graft rejection or survival rate,as long as more than 2 mismatches exist.(2) 0 mismatching with Res M can not prevent HR in sensitized recipients.(3) Positive PRA screening has adverse effects on transplant outcomes,which is more evident when HLA-ⅠandⅡare dual positive.(4) Sensitization of recipients is reversely correlated with early graft outcome,worse when PRA＞50%.(5) Failures are more likely induced when donors possess target antigens for panel reactive antibodies, especially the HLA-Ⅰantigens.(6) Pretransplant antibody preparations such as PP improve the access of sensitized patients to DD organs and promote more equitable allocation to a highly disadvantaged group of patients waiting renal transplantation.(7) To avoid target antigen positive donors is the fundamental measure to prevent HR and early rejections.更多还原