Fabrega A J, Lopez-Boado M, Gonzalez S
University of Minnesota Hospital and Clinic, Minneapolis, Minnesota.
Crit Care Clin. 1990 Oct;6(4):979-1005.
Despite great improvement in patient and graft survival, the long-term morbidity and mortality in renal transplant recipients are still significant. Cardiovascular disease accounts for much of the mortality in long-term survivors; screening before the transplant procedure and adequate control of hypertension should help improve patient survival. Many of the gastrointestinal complications are due to overimmunosuppression and sepsis. Adequate management must include withdrawal of all immunosuppressive medications in order to save the patient's life. Liver disease is usually of viral origin; patients with chronic active hepatitis or cirrhosis should remain on dialysis. Chronic rejection is the major cause of graft loss in long-term survivors; it is unresponsive to antirejection treatment and its progression may be mediated by nonimmunologic mechanisms. Correctable problems such as renal artery stenosis and ureteral obstruction should be ruled out before a late deterioration in graft function is disregarded as chronic rejection. Post-transplant diabetes, osteonecrosis, cataracts, and nephrotoxicity are directly related to the various immunosuppressive drugs currently used. The lowest dose compatible with graft acceptance should help reduce the incidence of these nonfatal but significant complications. Recurrence of disease is a common histologic finding in many transplant recipients but, except for a few diseases such as HUS, FSGS, and oxalosis, it usually does not lead to graft failure. Successful transplantation restores fertility in many uremic patients. Adequate counseling on contraception is imperative in order to avoid unwanted pregnancies and to delay parenthood for at least 1 year. Current immunosuppressive agents are not teratogenic, no dose adjustments are necessary, and an ill-advised decrease in medication may precipitate a rejection episode. Premature delivery is the major problem in these patients and can be avoided by maintaining adequate graft function and controlling hypertension and infections. It is evident from this review that most of the long-term morbidity and mortality seen in renal allograft recipients are due to overimmunosuppression with sepsis or to side effects of the individual drugs, steroids being a common denominator in almost all cases. New immunosuppressive protocols must aim not only to improve patient and graft survival but also to avoid the many complications that limit the full rehabilitation of these patients.
尽管患者和移植物存活率有了很大提高，但肾移植受者的长期发病率和死亡率仍然很高。心血管疾病是长期存活者死亡的主要原因；移植前进行筛查和充分控制高血压有助于提高患者存活率。许多胃肠道并发症是由于免疫抑制过度和败血症所致。充分的处理必须包括停用所有免疫抑制药物以挽救患者生命。肝病通常源于病毒感染；患有慢性活动性肝炎或肝硬化的患者应继续接受透析治疗。慢性排斥是长期存活者移植物丢失的主要原因；它对抗排斥治疗无反应，其进展可能由非免疫机制介导。在将移植肾功能晚期恶化视为慢性排斥之前，应排除诸如肾动脉狭窄和输尿管梗阻等可纠正问题。移植后糖尿病、骨坏死、白内障和肾毒性与目前使用的各种免疫抑制药物直接相关。与移植物接受相容的最低剂量应有助于降低这些非致命但严重并发症的发生率。疾病复发是许多移植受者常见的组织学表现，但除了少数疾病如溶血尿毒综合征、局灶节段性肾小球硬化和草酸盐中毒外，通常不会导致移植物失败。成功的移植可恢复许多尿毒症患者的生育能力。必须提供充分的避孕咨询，以避免意外怀孕并将生育推迟至少1年。目前的免疫抑制药物不会致畸，无需调整剂量，不适当减少药物剂量可能会引发排斥反应。早产是这些患者的主要问题，通过维持足够的移植肾功能、控制高血压和感染可以避免。从这篇综述中可以明显看出，肾移植受者中出现的大多数长期发病率和死亡率是由于免疫抑制过度伴发败血症或个别药物的副作用，几乎所有病例中类固醇都是共同因素。新的免疫抑制方案不仅要旨在提高患者和移植物存活率，还要避免许多限制这些患者完全康复的并发症。
