Lorenz Elizabeth C, Smith Byron H, Cosio Fernando G, Schinstock Carrie A, Shah Nilay D, Groehler Paul N, Verdick Jayson S, Park Walter D, Stegall Mark D
William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.
Health Sciences Research, Mayo Clinic, Rochester, MN.
Transplant Direct. 2018 Sep 7;4(10):e392. doi: 10.1097/TXD.0000000000000824. eCollection 2018 Oct.
Nonadherence to immunosuppression after kidney transplant is an important contributor to graft failure. Little is known about how nonadherence changes 3 years posttransplant when Medicare coverage of immunosuppression ends and how that nonadherence impacts allograft histology. The goal of this study was to compare rates of nonadherence during posttransplant years 1 to 3 to years 3 to 5 and examine the relationship between nonadherence during years 3 to 5 and 5-year allograft histology.
We retrospectively analyzed 552 conventional kidney allografts in patients transplanted at our center between January 1, 1999, and June 1, 2010, who used the Mayo Clinic Specialty Pharmacy for the first 5 years posttransplant. Nonadherence was defined as less than 80% proportion of days covered. Overall adherence to immunosuppression appeared to be higher during years 3 and 5 compared to between years 1 and 3 (89.4% vs 82.9%, respectively; < 0.0001 [paired test]).
Overall nonadherence during posttransplant years 3 to 5 appeared to be associated with fibrosis and inflammation on 5-year allograft biopsy but not with transplant glomerulopathy (16.9% vs 5.9%, = 0.004; 10.4% vs 8.5%, = 0.61, respectively). After adjusting for nonadherence to calcineurin inhibitor and prednisone therapy, only nonadherence to antimetabolite therapy remained significantly associated with 5-year fibrosis and inflammation (odds ratio, 10.6; 95% confidence interval, 1.5-76.1; = 0.02).
Efforts to improve long-term adherence, possibly through the use of specialty pharmacies and increased adherence to antimetabolite therapy, may improve long-term allograft histology and survival, although further studies are needed to confirm these findings.
肾移植后免疫抑制治疗的不依从是导致移植肾失功的重要因素。对于免疫抑制医保覆盖结束后3年时不依从情况的变化以及这种不依从如何影响移植肾组织学，我们知之甚少。本研究的目的是比较移植后1至3年与3至5年的不依从率，并探讨3至5年的不依从与5年移植肾组织学之间的关系。
我们回顾性分析了1999年1月1日至2010年6月1日在本中心接受移植的552例接受常规肾移植的患者，这些患者在移植后的前5年使用梅奥诊所专科药房。不依从定义为覆盖天数比例低于80%。与1至3年相比，3年和5年时免疫抑制的总体依从性似乎更高（分别为89.4%和82.9%；配对检验，P<0.0001）。
移植后3至5年的总体不依从似乎与5年移植肾活检时的纤维化和炎症相关，但与移植性肾小球病无关（分别为16.9%对5.9%，P = 0.004；10.4%对8.5%，P = 0.61）。在对钙调神经磷酸酶抑制剂和泼尼松治疗的不依从进行校正后，仅抗代谢物治疗的不依从仍与5年时的纤维化和炎症显著相关（比值比，10.6；95%置信区间，1.5 - 76.1；P = 0.02）。
尽管需要进一步研究来证实这些发现，但通过使用专科药房和提高抗代谢物治疗的依从性等努力来改善长期依从性，可能会改善移植肾的长期组织学和存活率。
