Knoll Greg
Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada.
Drugs. 2008;68 Suppl 1:3-10. doi: 10.2165/00003495-200868001-00002.
Kidney transplantation offers patients with end-stage renal disease the greatest potential for increased longevity and enhanced quality of life; however, the demand for kidneys far exceeds the available supply. This has led to an increase in the number of people on waiting lists and an increase in waiting time. In the US, the overall median wait time was 2.85 years in 2004. The projected median waiting time for adult patients awaiting a deceased donor kidney in 2006 is 4.58 years. The renal transplant community has pursued multiple avenues in an attempt to increase the donor pool, but this remains a major challenge. In the last decade, the number of live donor kidney transplants performed in the US and Canada has doubled and represents just over 40% of all donor kidneys. Among deceased donor kidneys, the largest percentage increases were seen in expanded criteria donor and donation after cardiac death kidneys. In the last decade, the age distribution among donors, and among patients on waiting lists or receiving a renal transplant, has shifted towards older age groups. There have been dramatic shifts in baseline immunosuppression with increased usage of induction agents and the nearly universal replacement of azathioprine by mycophenolate. Additionally, tacrolimus use has increased from 13% to 79% at discharge, while ciclosporin (cyclosporine) use has fallen from 76% to 15%. Although 1-year graft survival rates are excellent, only modest improvements have been observed in long-term graft survival rates in the last decade. Thus, efforts have shifted from improving early graft outcomes to altering the natural course of late graft failure. Death of transplant recipients from cardiovascular disease, infection and cancer remains an important limitation in kidney transplantation. Continued success in kidney transplantation will require increased numbers of donors, both living and deceased, as well as reduction in the primary causes of late transplant loss, namely premature patient death with a functioning graft and chronic allograft nephropathy.
肾移植为终末期肾病患者提供了延长寿命和提高生活质量的最大潜力；然而，肾脏的需求远远超过了可获得的供应。这导致了等待名单上的人数增加以及等待时间的延长。在美国，2004年总体中位等待时间为2.85年。预计2006年等待已故供体肾脏的成年患者的中位等待时间为4.58年。肾移植界已经采取了多种途径来试图增加供体库，但这仍然是一项重大挑战。在过去十年中，美国和加拿大进行的活体供体肾移植数量增加了一倍，占所有供体肾脏的比例略超过40%。在已故供体肾脏中，标准扩大供体和心脏死亡后捐赠肾脏的百分比增幅最大。在过去十年中，供体以及等待名单上或接受肾移植的患者的年龄分布已向老年群体转移。基线免疫抑制方面发生了巨大变化，诱导剂的使用增加，硫唑嘌呤几乎被霉酚酸酯普遍取代。此外，他克莫司在出院时的使用从13%增加到79%，而环孢素的使用从76%下降到15%。尽管1年移植物存活率很高，但在过去十年中，长期移植物存活率仅略有改善。因此，努力方向已从改善早期移植物结果转向改变晚期移植物失败的自然病程。移植受者因心血管疾病、感染和癌症死亡仍然是肾移植的一个重要限制。肾移植的持续成功将需要增加活体和已故供体的数量，以及减少晚期移植失败的主要原因，即有功能移植物的患者过早死亡和慢性同种异体移植肾病。
