先前肾移植导致的HLA致敏是再次移植的主要不利因素。最近，我们通过加强免疫抑制方法对一例高度致敏的受者成功进行了第三次肾移植。该患者是一名31岁的男性患者，其在1999年于我中心进行了活体供肾的移植，供者为其父亲。他的移植肾功能由于慢性移植肾肾病而损坏，在2005年回复到血透状态。在2006年8月14日其在另一个国家接受了二次移植，供肾为尸体供肾。术后3天由于加速性排斥反应导致移植肾的丢失。其后其兄弟给与其第三个供肾。在第三次肾移植前其PRA检测提示I类(88%) 而II类为 (96%)。第三次移植前3周即开始使用MMF，并在移植前行三次血浆置换。其在2007年3月9日接受了活体供肾。免疫抑制方案包括他克莫司、MMF、甲基强的松龙以及巴利昔单抗。其后即刻出现突然的移植物血流以及尿量的下降提示超急性排斥可能。其后采用血浆置换以及单剂量的利妥昔单抗（200mg），移植肾的功能得以恢复。而在移植后3周时PRA依然为阳性。移植后6周，其肌酐水平为0.9 mg/dL。我们的方案可能可以减少高度致敏的肾移植受者移植物丢失的风险。

Kawase T, Tojimbara T, Niki R, Akamatsu M, Nakajima I, Fuchinoue S, Agishi T, Teraoka S.
Department of Surgery, Kidney Center, Itabashi Chuo General Hospital, Tokyo, Japan.

HLA sensitization associated with previous kidney transplantation is a major drawback to retransplantation. Recently we successfully performed a third graft using intensive immunosuppression for a highly sensitized recipient. The patient was a 31-year-old man who had previously undergone a living donor graft from his father at our institute in 1999. His kidney graft function had deteriorated due to chronic allograft nephropathy, returning to hemodialysis therapy in 2005. He received a second graft from a deceased donor in another country on August 14, 2006. It rejected on postoperative day 3 possibly due to acute accelerated rejection. He was offered a third kidney from his brother. Panel-reactive antibody (PRA) tested before the third procedure revealed positive class I (88%) and class II (96%) PRAs. Mycophenolate mofetil (MMF) was started 3 weeks before the third transplantation, and preoperative plasmapheresis performed thrice. He underwent the living donor graft on March 9, 2007. Immunosuppression consisted of tacrolimus, MMF, methylprednisolone, and basiliximab. Immediately afterward there was a sudden decrease in allograft blood flow and urine output, implying hyperacute rejection. Following treatment with plasmapheresis and a single dose of rituximab (200 mg), the kidney allograft function recovered, although the PRA at 3 weeks was still positive. Six months posttransplantation, he is well with a creatinine of 0.9 mg/dL. Our protocol may reduce the risk for graft loss in a highly sensitized transplant recipient.