Sureshkumar K K, Hussain S M, Thai N L, Marcus R J
Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.
Transplant Proc. 2013 Jan-Feb;45(1):99-101. doi: 10.1016/j.transproceed.2012.07.148.
Pre-transplant dialysis duration exerts a graded negative influence on outcomes after kidney transplantation. Higher immune reactivity associated with prolonged dialysis with consequent increased acute rejection could be contributory.
Using the Organ Procurement and Transplant Network/United Network of Organ Sharing database, we identified patients ≥ 18 years of age who received deceased-donor kidney (DDK) transplants from 2000 to 2008 after being on maintenance dialysis for ≥ 4 years. Patients received induction therapy with rabbit antithymocyte globulin (r-ATG), alemtuzumab, or an interleukin-2 receptor blocker (IL-2B) and were discharged on calcineurin inhibitor (CNI)/mycophenolate mofetil (MMF)-based immunosuppression with or without steroid. Unadjusted and adjusted graft/patient survivals were compared in steroid versus no-steroid groups by induction type.
A total of 14,459 patients were identified, of which 7,684 received r-ATG (steroid, 6,098; no-steroid, 1,586), 1,292 alemtuzumab (steroid, 362; no-steroid, 930), and 5,483 an IL-2B agent (steroid, 5,107; no-steroid, 376). Adjusted graft survivals were similar for steroid versus no-steroid groups in r-ATG (hazard ratio [HR] 1.10, 95% confidence interval (CI) 0.96-1.26, P = .16), alemtuzumab (HR 0.88, 95% CI 0.65-1.19; P = .40), and IL-2B (HR 0.91, 95% CI 0.73-1.13; P = .38) groups. Adjusted patient survival for steroid versus no-steroid groups was inferior in r-ATG (HR 1.41, 95% CI 1.17-1.71; P < .001) but similar in alemtuzumab (HR 1.05, 95% CI 0.70-1.59; P = .80) and IL-2B (HR 1.17, 95% CI 0.86-1.58; P = .32) groups.
Our analysis failed to show a graft survival benefit for the addition of steroid to a CNI/MMF-based immunosuppression after induction with r-ATG, alemtuzumab, or an IL-2B agent in DDK recipients exposed to prolonged pretransplantation dialysis.
肾移植前透析时间对肾移植后的结局有分级负面影响。与长期透析相关的较高免疫反应性以及随之增加的急性排斥反应可能是其原因。
利用器官获取与移植网络/器官共享联合网络数据库，我们确定了年龄≥18岁、在接受维持性透析≥4年后于2000年至2008年接受尸体供肾（DDK）移植的患者。患者接受兔抗胸腺细胞球蛋白（r-ATG）、阿仑单抗或白细胞介素-2受体阻滞剂（IL-2B）诱导治疗，并在使用或不使用类固醇的基于钙调神经磷酸酶抑制剂（CNI）/霉酚酸酯（MMF）的免疫抑制方案下出院。根据诱导类型比较类固醇组与非类固醇组的未调整和调整后的移植物/患者生存率。
共确定了14459例患者，其中7684例接受r-ATG（类固醇组6098例，非类固醇组1586例），1292例接受阿仑单抗（类固醇组362例，非类固醇组930例），5483例接受IL-2B制剂（类固醇组5107例，非类固醇组376例）。在r-ATG组（风险比[HR]1.10，95%置信区间[CI]0.96-1.26，P = 0.16）、阿仑单抗组（HR 0.88，95%CI 0.65-1.19；P = 0.40）和IL-2B组（HR 0.91，95%CI 0.73-1.13；P = 0.38）中，类固醇组与非类固醇组的调整后移植物生存率相似。在r-ATG组中，类固醇组与非类固醇组的调整后患者生存率较差（HR 1.41，95%CI 1.17-1.71；P < 0.001），但在阿仑单抗组（HR 1.05，95%CI 0.70-1.59；P = 0.80）和IL-2B组（HR 1.17，95%CI 0.86-1.58；P = 0.32）中相似。
我们的分析未能显示在接受长期移植前透析的DDK受者中，在用r-ATG、阿仑单抗或IL-2B制剂诱导后，在基于CNI/MMF的免疫抑制方案中添加类固醇对移植物生存有益。
