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Chronische Abstoßung

Unterschiede und Ähnlichkeiten bei verschiedenen soliden Organtransplantationen

Chronic rejection

Differences and similarities in various solid organ transplants

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Zusammenfassung

Im vorliegenden Beitrag werden chronische Abstoßungen nach Transplantation von Lunge, Herz, Leber und Niere beschrieben. Das chronische Transplantatversagen (CTV) spielt bei all diesen Transplantationen eine wichtige Rolle und hat großen Einfluss auf das Überleben der Patienten. Bei den einzelnen Organen liegen pathophysiologisch gänzlich verschiedene Gründe für ein CTV vor.

Nach einer Lungentransplantation wird die Diagnose anhand der Lungenfunktion gestellt [Abnahme der Einsekundenkapazität (FEV1)]. Hier sind neben der Prävention ein frühes Erkennen und die schnelle Behandlung extrem wichtig. Therapeutisch sind v. a. Azithromycin und die extrakorporale Photopherese gebräuchlich, da sie das Fortschreiten der Lungenumbauvorgänge positiv beeinflussen.

Ausdruck einer chronischen Abstoßung am Herzen ist die Transplantatvaskulopathie (TVP). In deren Entwicklung spielen immunologische und nichtimmunologische Faktoren eine große Rolle. Wegen der Begrenztheit therapeutischer Möglichkeiten liegt auch hier eine große Bedeutung in der Prävention (Verwendung von mTOR-Inhibitoren und Minimierung kardiovaskulärer Risikofaktoren).

Ausdruck einer schwierigen Diagnose der chronischen Transplantatdysfunktion nach Lebertransplantation ist, dass sich die Überlebensraten in der mittleren und späten Phase nach Lebertransplantation in den letzten Jahrzehnten kaum verändert haben. Die chronische duktopene Abstoßung macht einen kleinen Teil der späten Transplantatdysfunktionen aus. Hinzu kommen die idiopathische Posttransplantationshepatitis und die De-novo-Autoimmunhepatitis sowie das Wiederauftreten der Grunderkrankung.

Die chronische Abstoßung des Nierentransplantats ist das Ergebnis schwerer Abstoßungsvorgänge, die in einer zunehmenden Fibrose mit Remodeling enden. Eine frühzeitige Diagnose und Therapie ist momentan die einzige Option. Der Nachweis donorspezifischer Antikörper im Verbund mit dem histologischen Befund ist die derzeit einzige Möglichkeit der Diagnosesicherung.

Abstract

In this paper, chronic rejections after transplantation of the lungs, heart, liver, and kidney are described. Chronic allograft dysfunction (CAD) plays an important role in all of these transplantations and has a significant influence on patient survival. The pathophysiological reasons for CAD varies greatly in the various organs.

Chronic lung allograft dysfunction (CLAD) is the most important determinant of survival and quality of life after lung transplantation. Diagnosis is based on lung function, especially forced expiratory flow in 1 s (FEV1) decline. Prevention, early detection, and rapid treatment are extremely important. Azithromycin and extracorporeal photopheresis are commonly used for treatment because they usually positively influence the progression of lung remodeling.

The expression for chronic rejection of the heart is cardiac allograft vasculopathy (CAV). Immunological and nonimmunological factors are important for its development. Due to limited therapeutic options, prevention is of utmost importance (administration of mTOR inhibitors and minimizing cardiovascular risk factors).

The mid- and long-term survival rates after liver transplantation have hardly changed in recent decades, which is an indication of the difficulty in diagnosing chronic graft dysfunction. Chronic ductopenic rejection accounts for a small proportion of late graft dysfunction. Idiopathic posttransplant hepatitis and de novo autoimmune hepatitis are important in addition to recurrence of the underlying disease that led to transplantation.

Chronic allograft nephropathy is the result of severe rejection which cumulates in increasing fibrosis with remodeling. The earliest possible diagnosis and therapy is currently the only option. Diagnosis is based on evidence of donor-specific antibodies and histological findings.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. H. Suhling, J. Gottlieb, R. Taubert, E. Jäckel, M. Schiffer und J.H. Bräsen geben an, dass kein Interessenkonflikt besteht. C. Bara: Novartis: Studienfinanzierung, Reisekostenübernahme, Referententätigkeit, Mitglied des Data Safety Monitoring Board; Astellas: Studienfinanzierung, Reisekostenübernahme; Hoffmann-La Roche: Drittmittelunterstützung.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Klinik für Pneumologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    H. Suhling & J. Gottlieb

  2. Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie (HTTG), Zentrum Chirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    C. Bara

  3. Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    R. Taubert &  E. Jäckel

  4. Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    M. Schiffer

  5. Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Deutschland

    J.H. Bräsen

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  1. H. Suhling
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  2. J. Gottlieb
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  3. C. Bara
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Correspondence to H. Suhling, C. Bara, E. Jäckel or M. Schiffer.

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Suhling, H., Gottlieb, J., Bara, C. et al. Chronische Abstoßung. Internist 57, 25–37 (2016). https://doi.org/10.1007/s00108-015-3806-9

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