个体化免疫抑制方案在心脏移植高危患者中的应用

目的 探讨个体化免疫抑制方案在心脏移植高危患者中的应用.方法 回顾分析2001年9月至2006年12月51例在围手术期合并HBV感染、糖尿病、肾功能不全或肺部感染的心脏移植病例,全组患者术前均采用达利珠单抗进行免疫诱导治疗,基础免疫抑制方案为环孢霉素A(CsA)、硫唑嘌呤(Aza)或吗替麦考酚酯(MMF)和泼尼松的三联方案.其中术前合并HBV感染10例,术后强调使用MMF,术后1个月停用泼尼松;术前合并糖尿病9例,术后并发移植后糖尿病4例,术后强调使用CsA,不用FK506,减量使用或停用泼尼松,配合胰岛素治疗;术前肾功能不全16例,术后常规使用MMF,术后第5～19天开始使用CsA;术后并发肺部感染12例,减量或暂停使用CsA、MMF和泼尼松.结果 术前合并HBV感染10例,随访1年肝功能稳定,1例于术后第13个月发生急性排斥反应.糖代谢异常13例,术后血糖控制满意,随访6个月无急性排斥反应发生.术前肾功能不全16例,随访1个月无急性排斥反应发生,肾功能恢复正常.术后并发肺部感染12例,2例死于严重的肺部感染,其他患者均存活;随访1个月,1例患者于术后第17天发生急性排斥反应.结论 免疫抑制方案的个体化能使心脏移植的高危患者平稳渡过围手术期,不会增加急性排斥反应的发生率.

Individual immunosuppressive regime in heart transplantation with high risk

Objective To Summarize the clinical experience of individual immunosuppressive regime in heart transplantation with high risk.Methods From September 2001 to December 2006,51 cases with the complication of Hepatitis B viruses(HBV)infection,diabetes mellitus,renal dysfunction or pulmonary infection in perioperative period were analyzed retrospectively.All cases received daclizumab(Zenapax)induction therapy,and baseline triple immunosuppressive regime was consist of cyclosporine(CsA),azathioprine(Aza)or mycophenolate mofetil(MMF)and prednisone(Pred).Ten cases received HBV infection in preoperative period,the immunosuppressive protocol was emphasized on the use of MMF and the withdraw of Pred one month later in postoperation.Nine cases received diabetes mellitus in preoperation,4 cases had post-transplant diabetes mellitus.The immunosuppressive protocol was emphasized on the use of CsA rather than FK506,the use of Pred was less dosage,and the therapy of insulin was necessary.Sixteen cases had renal dysfunction in preoperation,the use of MMF was routine but the use of CsA was delayed to the time 5 to 19 d postoperative.Twelve cases received pulmonary infection after allograft transplantation.The immunosuppressive agent was to be taped or suspended in thempy time.Results The liver function of the 10 cases with HBV infection was stable in 1 year follow-up,and 1 case received acute rejection after 13 months allograft transplantation.In the 6 months follow-up,the blood glucose level of the 13 cases with diabetes mellitus was stable,none of the cases suffered from acute rejection.In the one month follow-up,none of the 16 cases with renal dysfunction suffered from acute rejection,and the renal function was normal. Two of the 12 cases with the pulmonary infection were died of serious infection,others were survival.One case received acute rejection on the 17th day in postoperation.Conclusions Low mortality can be realized by selecting appropriately individual immunosuppressive regime and the episode of acute rejection is rare.