Luna E, Cerezo I, Macias R, Villa J, Martinez C, Cubero J, Martinez R, Ferreira F, García C
Nephrology Department, Infanta Cristina Hospital, Badajoz, Spain.
Transplant Proc. 2011 Jul-Aug;43(6):2187-90. doi: 10.1016/j.transproceed.2011.06.055.
The change from calcineurin inhibitors (CNI) to sirolimus (SRL) is a safe alternative in transplant patients with neoplasia (NEO) whereas the results of conversion for chronic allograft nephropathy (CAN) are controversial, depending on the histologic score, degree of proteinuria, and glomerular filtration rate (GFR). Our aim in this study was to compare GFR, proteinuria, albuminuria, blood pressure (BP) effects, and anemia after switching to sirolimus (SRL) among renal transplant recipients with CAN versus NEO.
Fifty-five kidney transplant recipients with conversion from CNI to SRL owing to CAN or NEO were analyzed for the variables at 6 months before, at the time of, and at 6 months and 1, 2, and 3 years after the switch to SRL.
There were no differences between CAN and NEO in the slope of estimated GFR (mL/min/1.73 m(2) by Cockcroft-Gault formula) at 1 year (-5.5 vs 3.7; P = .007) and at 2 years (-3.86 vs -10.3; P = .01). The values of proteinuria (mg/24 h/1.73 m(2)) before (665 ± 136 vs 329 ± 69; P = .036) as well as at 1 (1,122 ± 306 vs 863 ± 190; P = .478) and at 2 years after conversion (1,360 ± 430 vs 457 ± 154; P = .045) showed some significant differences, as did the use of both antiangiotensin agents, angiotensin-converting enzyme inhibitor and angiotensin receptor blocker at the moment of switch (35% vs 0%; P = .005) at 1 year (69% vs. 6% P = .02) and at 2 years (67% vs 28%; P = .047). There were no differences in graft survival (log rank: P = .515). By logistic regression analysis, the best covariate associated with GFR >45 mL/min at 2 years was GFR >60 mL/min at the moment of switch to SRL (odds ratio, 1.33; 95% confidence interval, 1.002-1.74).
The evolution of renal damage was more important in the CAN group requiring greater use of 2 angiotensin antagonists for control of proteinuria. We probably need histologic and serologic biomarkers to show which patients with CAN will show a bad evolution after the change to SRL.
对于患有肿瘤（NEO）的移植患者，从钙调神经磷酸酶抑制剂（CNI）转换为西罗莫司（SRL）是一种安全的替代方案，而对于慢性移植肾肾病（CAN）患者进行转换的结果存在争议，这取决于组织学评分、蛋白尿程度和肾小球滤过率（GFR）。我们这项研究的目的是比较CAN患者与NEO患者转换为西罗莫司（SRL）后在GFR、蛋白尿、白蛋白尿、血压（BP）影响以及贫血方面的情况。
对55例因CAN或NEO从CNI转换为SRL的肾移植受者，在转换为SRL前6个月、转换时、转换后6个月以及1、2和3年时的各项变量进行分析。
CAN组和NEO组在转换后1年（-5.5对3.7；P = 0.007）和2年（-3.86对-10.3；P = 0.01）时，估算GFR（根据Cockcroft - Gault公式计算的mL/min/1.73 m²）的斜率没有差异。转换前蛋白尿（mg/24 h/1.73 m²）的值（665 ± 136对329 ± 69；P = 0.036）以及转换后1年（1,122 ± 306对863 ± 190；P = 0.478）和2年（1,360 ± 430对457 ± 154；P = 0.045）显示出一些显著差异，转换时同时使用抗血管紧张素药物（血管紧张素转换酶抑制剂和血管紧张素受体阻滞剂）的情况也是如此（1年时35%对0%；P = 0.005，2年时69%对6%，P = 0.02，2年时67%对28%；P = 0.047）。移植肾存活率没有差异（对数秩检验：P = 0.515）。通过逻辑回归分析，与转换为SRL后2年时GFR > 45 mL/min相关的最佳协变量是转换时GFR > 60 mL/min（比值比，1.33；95%置信区间，1.002 - 1.74）。
在CAN组中，肾脏损害的进展更为明显，需要更多地使用两种血管紧张素拮抗剂来控制蛋白尿。我们可能需要组织学和血清学生物标志物来表明哪些CAN患者在转换为SRL后会出现不良进展。
