ABO血型不相容活体肾移植中的预处理疗法：一项系统评价与荟萃分析
Preconditioning Therapy in ABO-Incompatible Living Kidney Transplantation: A Systematic Review and Meta-Analysis.
作者信息
Lo Phillip, Sharma Ankit, Craig Jonathan C, Wyburn Kate, Lim Wai, Chapman Jeremy R, Palmer Suetonia C, Strippoli Giovanni F M, Wong Germaine
机构信息
1 University of New South Wales Medical School, Sydney, NSW, Australia. 2 Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia. 3 Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia. 4 Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia. 5 Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia. 6 Department of Renal Medicine, Sir Charles Gairdner Hospital, Nedlands, Australia. 7 Department of Medicine, University of Otago Christchurch, New Zealand. 8 Cochrane Renal Group, Sydney, Australia. 9 Department of Emergency and Organ Transplantation, University of Bari, Italy. 10 Diaverum Medical Scientific Office and Diaverum Academy, Lund, Sweden.
出版信息
Transplantation. 2016 Apr;100(4):933-42. doi: 10.1097/TP.0000000000000933.
BACKGROUND
ABO-incompatible (ABOi) kidney transplantation is now an established form of renal replacement therapy, but the efficacy and safety of the different types of preconditioning therapies are unclear. We aimed to synthesize the totality of the published evidence about the effects of any form of preconditioning therapies in living donor ABOi kidney transplantation on graft and patient outcomes.
METHODS
We searched MEDLINE, Embase, and Clinicaltrial.gov databases (inception through June 2015) to identify all studies that described the outcomes of adult living donor ABOi kidney transplantations using any form of preconditioning therapies. Two independent reviewers identified studies, extracted data, and assessed the risk of bias. Data were summarized using the random effects model, and heterogeneity was explored using subgroup analyses. We assessed confidence in the evidence using the Grading of Recommendations Assessment, Development, and Evaluation framework.
RESULTS
Eighty-three studies (54 case reports and case series, 25 cohort, 2 case-control, and 2 registry studies) involving 4810 ABOi transplant recipients were identified. Overall, confidence in the available evidence was low. During a mean follow-up time of 28 (standard deviation [SD], 26.6) months, the overall graft survival for recipients who received immunoadsorption or apheresis was 94.1% (95% confidence interval [95%CI], 88.2%-97.1%) and 88.0% (95% CI, 82.6%-91.8%), respectively. For those who received rituximab or underwent splenectomy, the overall graft survival was 94.5% (95% CI, 91.6%-96.5%) and 79.7% (95% CI, 72.9%-85.1%), respectively. Data on other longer-term outcomes, including malignancy, were sparse.
CONCLUSIONS
Rituximab or immunoadsorption appeared to be promising preconditioning strategies before ABOi kidney transplantation. However, the overall quality of evidence and the confidence in the observed treatment effects are low. The increased use of ABOi kidney transplantation needs to be matched with randomized trials of different types, dosing, and frequency of preconditioning therapies so that this scarce resource can be used most effectively and efficiently.
背景
ABO血型不相容（ABOi）肾移植目前是一种既定的肾脏替代治疗方式，但不同类型预处理疗法的疗效和安全性尚不清楚。我们旨在综合已发表的关于任何形式的预处理疗法对活体供体ABOi肾移植中移植物和患者结局影响的全部证据。
方法
我们检索了MEDLINE、Embase和Clinicaltrial.gov数据库（从创建至2015年6月），以识别所有描述使用任何形式预处理疗法的成年活体供体ABOi肾移植结局的研究。两名独立的评审员识别研究、提取数据并评估偏倚风险。使用随机效应模型汇总数据，并通过亚组分析探讨异质性。我们使用推荐分级评估、制定和评价框架评估证据的可信度。
结果
共识别出83项研究（54例病例报告和病例系列、25项队列研究、2项病例对照研究和2项登记研究），涉及4810例ABOi移植受者。总体而言，对现有证据的可信度较低。在平均28（标准差[SD]，26.6）个月的随访期内，接受免疫吸附或血液成分单采术的受者的总体移植物存活率分别为94.1%（95%置信区间[95%CI]，88.2%-97.1%）和88.0%（95%CI，82.6%-91.8%）。对于接受利妥昔单抗或脾切除术的受者，总体移植物存活率分别为94.5%（95%CI，91.6%-96.5%）和79.7%（95%CI，72.9%-85.1%）。关于其他长期结局的数据，包括恶性肿瘤，较为稀少。
结论
利妥昔单抗或免疫吸附似乎是ABOi肾移植前有前景的预处理策略。然而，证据的总体质量以及对观察到的治疗效果的可信度较低。ABOi肾移植使用的增加需要与不同类型、剂量和频率的预处理疗法的随机试验相匹配，以便能最有效和高效地利用这一稀缺资源。
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