1 University of Wisconsin Hospital and Clinics, Madison WI, USA.
2 University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Ann Pharmacother. 2019 Mar;53(3):268-275. doi: 10.1177/1060028018802814. Epub 2018 Sep 20.
Biologic agents inhibiting the tumor necrosis factor α pathway (TNFα-Is) are used to treat systemic inflammatory diseases. The best management of these agents after renal transplantation is unknown.
Evaluate peritransplant use of TNFα-Is and associated outcomes.
Retrospective, single-center study of adult renal-transplant-recipients (RTRs) transplanted between 1/1/1998-12/31/2017, who received TNFα-Is for inflammatory disease prior to transplant. Qualifying patients were divided into 2 cohorts: patients who resumed TNFα-Is after transplant and those who did not. Outcomes were evaluated.
A total of 5256 renal transplants occurred in the study window; 14 patients met inclusion criteria. Primary indication for TNFα-I was Crohn's-disease (CD; 57.1%). Infliximab was utilized most frequently (50%). Seven RTRs resumed TNFα-I posttransplant; mean time to resumption of 10.6±4.35 months (median=6 months), 85.7% for CD. Immunosuppression was modified in 2 patients (28.6%) in response to restarting TNFα-I therapy. Seven RTRs did not resume TNFα-Is following transplant; the majority of these had rheumatic diseases. There was no significant difference in time to first bacterial or fungal infection, rejection, or patient survival between the 2 groups. Last measured estimated glomerular-filtration-rate was similar between groups (TNFα-I: 41 ± 14.2 vs 48.6 ± 8.6, P = 0.25). No patient had cytomegalovirus infection; however, 42.8% of each cohort had documented BK virus infection. Malignancy occurred more frequently in the cohort that resumed TNFα-Is (42.8% vs 14.3%, P = 0.24); however, this was not statistically significant. Conclusion and Relevance: TNFα-I therapy prior to renal-transplant is relatively uncommon. The decision to continue therapy after transplant must balance risks of infection and malignancy against inflammatory disease recurrence. A multidisciplinary treatment approach is necessary as use of TNFα-I affects immunosuppressive management and appears to affect transplant outcomes. Future studies are needed to further clarify the role of TNFα-I therapy use in RTRs with inflammatory disorders focusing on its correlation with both BK and malignancy.
抑制肿瘤坏死因子 α 通路的生物制剂（TNFα-Is）用于治疗全身性炎症性疾病。肾移植后这些药物的最佳管理方法尚不清楚。
评估肾移植前使用 TNFα-Is 及其相关结果。
这是一项回顾性、单中心研究，纳入 1998 年 1 月 1 日至 2017 年 12 月 31 日期间接受肾移植的成年肾移植受者（RTR），这些患者在移植前因炎症性疾病接受 TNFα-Is 治疗。符合条件的患者分为两组：移植后继续使用 TNFα-Is 的患者和未继续使用 TNFα-Is 的患者。评估结局。
在研究期间共发生 5256 例肾移植，14 例患者符合纳入标准。TNFα-I 的主要适应证是克罗恩病（CD；57.1%）。最常使用英夫利昔单抗（50%）。7 例 RTR 在移植后恢复使用 TNFα-I；恢复时间的平均值为 10.6±4.35 个月（中位数为 6 个月），85.7%为 CD。2 例（28.6%）患者因重启 TNFα-I 治疗而改变了免疫抑制方案。7 例 RTR 移植后未恢复使用 TNFα-Is；这些患者多数患有风湿性疾病。两组之间首次细菌或真菌感染、排斥反应或患者生存率无显著差异。两组间最后一次测量的估算肾小球滤过率相似（TNFα-I：41±14.2 与 48.6±8.6，P=0.25）。无患者发生巨细胞病毒感染；然而，每个队列中有 42.8%的患者有 BK 病毒感染的记录。在恢复使用 TNFα-I 的队列中，恶性肿瘤的发生率更高（42.8%比 14.3%，P=0.24）；然而，这并没有统计学意义。结论和相关性：肾移植前使用 TNFα-I 治疗相对少见。是否继续在移植后使用该药物，必须权衡感染和恶性肿瘤复发的风险与炎症性疾病复发的风险。需要采用多学科治疗方法，因为 TNFα-I 的使用会影响免疫抑制治疗，并可能影响移植结局。未来的研究需要进一步阐明 TNFα-I 治疗在炎症性疾病 RTR 中的作用，重点关注其与 BK 病毒和恶性肿瘤的相关性。
