具有HLA特异性抗体的潜在肾移植患者的移植机会减少。它们的有害作用是由IgG的Fc部分介导的,包括循环白细胞激活补体系统和Fc受体引发的细胞毒性过程。避免抗体不相容是常规方法,但是对于一些患者来说,这可能意味着延长等待时间,如果没有其他选择,甚至没有移植的机会,兼容的捐助者。对于这些案例,移植前抗体去除可以提供移植途径。目前使用血浆置换来实现这一目标,结果可以接受,但是这个过程可能需要几天才能将抗体水平降低到安全水平,所以对已故捐赠者的使用有限。现在有另一种选择,以IgG消化酶的形式,imlifidase,其可以被施用用于体内IgG失活。酶裂解人IgG,分离抗原结合部分,来自Fc的F(ab')2。通常,在给药的六个小时内,大多数,如果不是全部,循环中的IgG已被灭活,允许从以前不相容的供体进行安全移植。对于死者的移植,尽量减少冷缺血至关重要,植入前六小时的延迟应该是可控的,与兼容性测试过程调整,以适应治疗。该药物已成功用于2期临床试验,具有良好的短期到中期结果。虽然与需求相匹配的捐赠率可能是提供普遍获得肾移植的一个重要答案,这目前是不现实的。IgG失活,使用Imlifidase,是,然而,一个现实的和被证明的替代方案。
Potential kidney transplant patients with HLA-specific antibodies have reduced access to transplantation. Their harmful effects are mediated by the Fc portion of IgG, including activation of the complement system and Fc receptor-initiated cytotoxic processes by circulating leucocytes. Avoiding antibody incompatibility is the conventional approach, but for some patients this can mean extended waiting times, or even no chance of a transplant if there are no alternative, compatible donors. For these cases, pretransplant antibody removal may provide access to transplantation. Plasmapheresis is currently used to achieve this, with acceptable outcome results, but the process can take days to reduce the antibody levels to a safe level, so has limited use for deceased donors. There is now an alternative, in the form of an IgG-digesting enzyme,
Imlifidase, which can be administered for in vivo IgG inactivation.
Imlifidase cleaves human IgG, separating the antigen-binding part, F(ab\')2 from Fc. Typically, within six hours of dosing, most, if not all, of the circulating IgG has been inactivated, allowing safe transplantation from a previously incompatible donor. For deceased donor transplantation, where minimizing cold ischaemia is critical, this six-hour delay before implantation should be manageable, with the compatibility testing processes adjusted to accommodate the treatment. This agent has been used successfully in phase 2 clinical trials, with good short to medium term outcomes. While a donation rate that matches demand may be one essential answer to providing universal access to kidney transplantation, this is currently unrealistic. IgG inactivation, using
Imlifidase, is, however, a realistic and proven alternative.