肾移植排斥反应管理中的范式转变：从基于方案的治疗向精准医疗时代演进。
Changing Paradigms in the Management of Rejection in Kidney Transplantation: Evolving From Protocol-Based Care to the Era of P4 Medicine.
作者信息
Maier Mirela, Takano Tomoko, Sapir-Pichhadze Ruth
机构信息
Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Metabolic Disorders and Complications, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.
Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Metabolic Disorders and Complications, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada; Multi-Organ Transplant Program, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada.
出版信息
Can J Kidney Health Dis. 2017 Jan 23;4:2054358116688227. doi: 10.1177/2054358116688227. eCollection 2017.
PURPOSE OF REVIEW
P4 medicine denotes an evolving field of medicine encompassing predictive, preventive, personalized, and participatory medicine. Using the example of kidney allograft rejection because of donor-recipient incompatibility in human leukocyte antigens, this review outlines P4 medicine's relevance to the various stages of the kidney transplant cycle.
SOURCES OF INFORMATION
A search for English articles was conducted in Medline via OvidSP (up to August 18, 2016) using a combination of subject headings (MeSH) and free text in titles, abstracts, and author keywords for the concepts kidney transplantation and P4 medicine. The electronic database search was expanded further on particular subject headings.
FINDINGS
Available histocompatibility methods exemplify current applications of the predictive and preventive domains of P4 medicine in kidney transplant recipients' care. Pharmacogenomics are discussed as means to facilitate personalized immunosuppression regimens and promotion of active patient participation as a means to improve adherence.
LIMITATIONS
For simplicity, this review focuses on rejection. P4 medicine, however, should more broadly address health concerns in kidney transplant recipients, including competing outcomes such as infections, malignancies, and cardiovascular disease. This review highlights how biomarkers to evaluate these competing outcomes warrant validation and standardization prior to their incorporation into clinical practice.
IMPLICATIONS
Consideration of all 4 domains of the P4 medicine framework when caring for and/or studying kidney transplant recipients has the potential of increasing therapeutic efficiency, minimizing adverse effects, decreasing health care costs, and maximizing wellness. Technologies to gauge immune competency, immunosuppression requirements, and early/reversible immune-mediated injuries are required to optimize kidney transplant care.
综述目的
“P4医学”代表着一个不断发展的医学领域，涵盖预测性、预防性、个性化和参与性医学。本文以人类白细胞抗原中供体 - 受体不相容导致的肾移植排斥反应为例，概述了P4医学与肾移植周期各阶段的相关性。
信息来源
通过OvidSP在Medline中检索英文文章（截至2016年8月18日），使用主题词（医学主题词）与标题、摘要及作者关键词中的自由文本相结合的方式，检索肾移植和P4医学相关概念。针对特定主题词进一步扩大了电子数据库搜索范围。
研究结果
现有的组织相容性方法体现了P4医学预测性和预防性领域在肾移植受者护理中的当前应用。讨论了药物基因组学作为促进个性化免疫抑制方案的手段，以及促进患者积极参与作为改善依从性的手段。
局限性
为简化起见，本综述重点关注排斥反应。然而，P4医学应更广泛地解决肾移植受者的健康问题，包括感染、恶性肿瘤和心血管疾病等相互竞争的结果。本综述强调，在将评估这些相互竞争结果的生物标志物纳入临床实践之前，需要对其进行验证和标准化。
启示
在护理和/或研究肾移植受者时考虑P4医学框架的所有四个领域，有可能提高治疗效率、将不良反应降至最低、降低医疗成本并使健康状况最大化。需要评估免疫能力、免疫抑制需求以及早期/可逆性免疫介导损伤的技术，以优化肾移植护理。
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