University of Alabama at Birmingham, Birmingham, AL, USA.
University of Minnesota, Minneapolis, MN, USA.
Am J Transplant. 2018 May;18(5):1158-1167. doi: 10.1111/ajt.14590. Epub 2017 Dec 5.
Beyond the first posttransplant year, 3% of kidney transplants fail annually. In a prospective, multicenter cohort study, we tested the relative impact of early versus late events on risk of long-term death-censored graft failure (DCGF). In grafts surviving at least 90 days, early events (acute rejection [AR] and delayed graft function [DGF] before day 90) were recorded; serum creatinine (Cr) at day 90 was defined as baseline. Thereafter, a 25% rise in serum Cr or new-onset proteinuria triggered graft biopsy (index biopsy, IBx), allowing comparison of risk of DCGF associated with early events (AR, DGF, baseline serum Cr >2.0 mg/dL) to that associated with later events (IBx). Among 3678 patients followed for 4.7 ± 1.9 years, 753 (20%) had IBx at a median of 15.3 months posttransplant. Early AR (HR = 1.77, P < .001) and elevated Cr at Day 90 (HR = 2.56, P < .0001) were associated with increased risk of DCGF; however, later-onset dysfunction requiring IBx had far greater impact (HR = 13.8, P < .0001). At 90 days, neither clinical characteristics nor early events distinguished those who subsequently did or did not undergo IBx or suffer DCGF. To improve long-term kidney allograft survival, management paradigms should promote prompt diagnosis and treatment of both early and later events.
在移植后的第一年之后，每年有 3%的肾脏移植失败。在一项前瞻性、多中心队列研究中，我们测试了早期和晚期事件对长期死亡风险的相对影响-无细胞性移植物衰竭（DCGF）。在至少存活 90 天的移植物中，记录了早期事件（急性排斥反应[AR]和 90 天前的延迟移植物功能[DGF]）；第 90 天的血清肌酐（Cr）定义为基线。此后，血清 Cr 升高 25%或出现新发性蛋白尿触发移植物活检（指数活检，IBx），允许比较与早期事件（AR、DGF、基线血清 Cr >2.0mg/dL）相关的 DCGF 风险与与晚期事件（IBx）相关的风险。在随访 4.7±1.9 年的 3678 例患者中，753 例（20%）在移植后中位数 15.3 个月时进行了 IBx。早期 AR（HR=1.77，P<0.001）和第 90 天升高的 Cr（HR=2.56，P<0.0001）与 DCGF 风险增加相关；然而，后期需要 IBx 的功能障碍的影响要大得多（HR=13.8，P<0.0001）。在第 90 天，临床特征和早期事件都无法区分随后是否进行了 IBx 或是否发生了 DCGF 的患者。为了提高长期肾脏移植物存活率，管理模式应促进早期和晚期事件的及时诊断和治疗。
