Yoo Min C, Vanatta Jason M, Modanlou Kian A, Campos Luis, Nezakatgoo Nosratollah, Nair Satheesh, Eason James D
1 Transplantation, University of Tennessee/Methodist University Hospital Transplant Institute, Memphis, TN.
Transplantation. 2015 Jun;99(6):1231-5. doi: 10.1097/TP.0000000000000477.
We have previously documented the efficacy of a steroid-free immunosuppression protocol using rabbit antithymocyte globulin (RATG) induction in orthotopic liver transplantation (OLT) with tacrolimus minimization. The purpose of this report is to demonstrate the benefits of this protocol in a large cohort of patients.
We evaluated outcomes of 500 consecutive OLT recipients who received RATG induction and a single dose of solumedrol given before the first dose of RATG. Mycophenolate mofetil was initiated postoperatively with delayed initiation of tacrolimus. Sirolimus replaced tacrolimus if serum creatinine remained above 2.0 mg/dL by day 7. Patients were weaned to tacrolimus or sirolimus monotherapy at 3 months. Mean model for end-stage liver disease (MELD) at transplantation was 22 ± 6.
Forty-four percent of patients had hepatitis C. Posttransplant creatinine was highest at 1 month (1.43 ± 0.95 mg/dL) and improved to 1.26 ± 0.60 mg/dL (P < 0.05) at 2.5 years. Glomerular filtration rate was lowest at 1 month (65.6 ± 30.0) and improved by 1 year (72.7 ± 28.2, P < 0.01). Tacrolimus was initiated at 4.79 ± 13.3 days with a level of 4.95 ± 2.45 ng/mL at 1 year. One-year patient and graft survival were 92.8% and 89.6%, respectively, with a 3-year patient survival of 82.9%. Rejection occurred in 114 (22.8%) patients, 33 (6.6%) patients requiring steroids. Univariate and multivariate Cox proportional hazard analyses were performed to evaluate the effects of donor and recipient characteristics on patient and graft survivals. Pretransplant creatinine was consistently a statistically significant predictor for patient and graft survival.
This is the largest reported series of OLT recipients using a steroid-free protocol with RATG induction demonstrating excellent outcomes, low complication rates, and preservation of renal function.
我们之前记录了一种无类固醇免疫抑制方案在原位肝移植（OLT）中使用兔抗胸腺细胞球蛋白（RATG）诱导并尽量减少他克莫司用量的疗效。本报告的目的是在一大群患者中证明该方案的益处。
我们评估了500例连续接受RATG诱导以及在首剂RATG之前给予单剂量甲泼尼龙的OLT受者的结局。术后开始使用霉酚酸酯，他克莫司延迟开始使用。如果到第7天血清肌酐仍高于2.0mg/dL，则用西罗莫司替代他克莫司。患者在3个月时逐渐停用药物，改为他克莫司或西罗莫司单药治疗。移植时终末期肝病模型（MELD）的平均值为22±6。
44%的患者患有丙型肝炎。移植后肌酐在1个月时最高（1.43±0.95mg/dL），在2.5年时改善至1.26±0.60mg/dL（P<0.05）。肾小球滤过率在1个月时最低（65.6±30.0），到1年时有所改善（72.7±28.2，P<0.01）。他克莫司在4.79±13.3天开始使用，1年时血药浓度为4.95±2.45ng/mL。1年时患者和移植物存活率分别为92.8%和89.6%，3年患者存活率为82.9%。114例（22.8%）患者发生排斥反应，33例（6.6%）患者需要使用类固醇。进行单因素和多因素Cox比例风险分析以评估供体和受体特征对患者和移植物存活的影响。移植前肌酐始终是患者和移植物存活的统计学显著预测因素。
这是报告的使用RATG诱导的无类固醇方案的OLT受者的最大系列，显示出优异的结局、低并发症发生率以及肾功能的保留。
