Segoloni Giuseppe P
SCU Nefrologia Dialisi e Trapianto, A.O.U. Molinette S. Giovanni, Torino, Italy.
G Ital Nefrol. 2009 Nov-Dec;26(6):650-3.
Preemptive kidney transplantation is currently considered the optimal initial form of renal replacement therapy not only in terms of clinical outcome (recipient and graft survival) but also in terms of quality of life and social rehabilitation. The benefit of preemptive transplantation is clearly documented by an increasing number of studies based on many single-center experiences and also on the data of international registries. The advantages of receiving a transplant before dialysis (or at least within a few months of its initiation) are statistically evident both in patients receiving cadaver donor grafts and in those receiving living donor grafts. Among the factors that are considered responsible for these favorable results, the avoidance of dialysis-associated morbidity, the lower risk of acute and chronic rejection, the reduced frequency of delayed graft function, and the reduced frequency of cardiovascular mortality seem to play an important role. In the development of a preemptive transplantation program, however, some ethical issues must be carefully considered. At the moment, at least in most Italian regions, there is a persistent discrepancy between the number of kidney patients transplanted yearly and those still on the waiting list. How and when to allocate kidneys harvested from deceased donors to recipients not yet on dialysis remains a matter of debate. Preemptive allocation limited to elderly candidates who accept a double kidney transplant from marginal deceased donors is the most feasible choice at the moment. If a living donor is available, however, preemptive transplantation is mandatory and its implementation mainly depends on the efficacy of nephrologic counseling before the initiation of dialysis.
目前，无论是从临床结局（受者和移植物存活率）来看，还是从生活质量和社会康复的角度而言，择期肾移植都被视为肾脏替代治疗的最佳初始形式。越来越多基于众多单中心经验以及国际登记处数据的研究清楚地证明了择期移植的益处。对于接受尸体供体移植物的患者以及接受活体供体移植物的患者来说，在透析前（或至少在透析开始后的几个月内）接受移植的优势在统计学上是明显的。在被认为对这些良好结果负责的因素中，避免透析相关的发病率、急性和慢性排斥反应的较低风险、移植肾功能延迟的频率降低以及心血管死亡率的频率降低似乎起着重要作用。然而，在制定择期移植计划时，必须仔细考虑一些伦理问题。目前，至少在大多数意大利地区，每年接受移植的肾病患者数量与仍在等待名单上的患者数量之间存在持续的差异。如何以及何时将从已故供体获取的肾脏分配给尚未开始透析的受者仍然是一个有争议的问题。目前，将择期分配限制于接受边缘已故供体双肾移植的老年候选人是最可行的选择。然而，如果有活体供体，择期移植是必须的，其实施主要取决于透析开始前肾脏科咨询的效果。
