Barraclough Kathryn, Menahem Solomon A, Bailey Michael, Thomson Napier M
Department of Renal Medicine, The Alfred Hospital, Melbourne, Victoria 3181, Australia.
J Heart Lung Transplant. 2006 Dec;25(12):1431-5. doi: 10.1016/j.healun.2006.09.023.
Survival after lung transplantation has improved, but with the consequence that long-term toxicities of treatment are of growing importance. In particular, renal impairment is common, has many causes, and carries with it increased morbidity and mortality.
We retrospectively analyzed clinical and laboratory data of 136 patients who underwent lung and heart-lung transplantation at our institution between 1990 and 2004 inclusive. Using multivariate analysis we considered the impact of age, gender, pulmonary diagnosis, transplant type (single lung, double lung, heart-lung), hypertension, diabetes mellitus, cigarette smoking, current immunosuppression, duration of calcineurin inhibitor (CNI) exposure and pre-existing renal impairment on renal function.
At transplantation, creatinine clearance (CrCl) for the patient population was 108 +/- 3.28 (mean +/- SEM) ml/min/1.73 m(2). At end of follow-up (6 +/- 0.32 years) there was a significant decline in glomerular filtration rate (GFR) to 56.7 +/- 1.78 ml/min/1.73 m(2) (p < 0.001). Five of 136 patients (3.7%) developed end-stage renal failure (ESRF). On multivariate analysis, factors most strongly associated with this decline included (in order of significance): CrCl at transplantation; pack-years of cigarette smoking; exposure to sirolimus (SLM); CNI exposure; and age at transplantation. The rate of decline in GFR was linked to CrCl and age at the time of transplantation.
This analysis has demonstrated that patients with a lower baseline CrCl, older age at transplantation, and a smoking history are at high risk for rapid loss of renal function after transplantation. To best preserve kidney function, these patients should be targeted for aggressive risk factor modification as well as minimization of CNI exposure wherever possible.
肺移植后的生存率有所提高，但随之而来的是治疗的长期毒性变得越来越重要。特别是，肾功能损害很常见，原因众多，且会增加发病率和死亡率。
我们回顾性分析了1990年至2004年（含）期间在我院接受肺移植和心肺移植的136例患者的临床和实验室数据。通过多变量分析，我们考虑了年龄、性别、肺部诊断、移植类型（单肺、双肺、心肺）、高血压、糖尿病、吸烟、当前免疫抑制、钙调神经磷酸酶抑制剂（CNI）暴露时间以及移植前存在的肾功能损害对肾功能的影响。
移植时，患者群体的肌酐清除率（CrCl）为108±3.28（平均值±标准误）ml/min/1.73 m²。随访结束时（6±0.32年），肾小球滤过率（GFR）显著下降至56.7±1.78 ml/min/1.73 m²（p<0.001）。136例患者中有5例（3.7%）发生终末期肾衰竭（ESRF）。多变量分析显示，与这种下降最密切相关的因素依次为：移植时的CrCl；吸烟包年数；西罗莫司（SLM）暴露；CNI暴露；以及移植时的年龄。GFR的下降速率与移植时的CrCl和年龄有关。
该分析表明，基线CrCl较低、移植时年龄较大且有吸烟史的患者在移植后肾功能快速丧失的风险较高。为了最佳地保护肾功能，应针对这些患者积极改变危险因素，并尽可能减少CNI暴露。
