Pediatric Nephrology and Transplant Immunology, Cedars-Sinai Medical Center, Los Angeles, California, United States.
Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Pediatr Transplant. 2020 May;24(3):e13685. doi: 10.1111/petr.13685. Epub 2020 Feb 29.
Steroid avoidance in pediatric kidney transplants was found effective with extended daclizumab induction. Upon discontinuation of daclizumab, lymphocyte-depleting agents became used, with little comparative data. We assessed outcomes in children undergoing low immunologic-risk deceased donor (DD) kidney transplants using induction with antithymocyte globulin (ATG) compared to alemtuzumab. We reviewed consecutive DD kidney transplants from January 2015 to September 2017 at two pediatric centers that used different lymphocyte-depleting agents in steroid-avoidance protocols: ATG (Center A) and alemtuzumab (Center B), with tacrolimus and MMF as maintenance immunosuppression. Anti-infective prophylaxis was based on center protocol. Over the first year post-tx, there were similar rates of infections. EBV and BK viremia were comparable though Center A manifested more low-grade CMV viremia (A 46% vs B 0%; P = .0009) at median onset 1.8 months, followed by early seroconversion. Reduction of immunosuppression did not differ between groups. DSA at 1 year was similar (A 8% vs 13%) with low rates of BPAR. Need for steroid-based conversion was low. There were no graft losses and no differences in median eGFR at 30, 90, 180, and 365 days. (a) 1-year graft outcomes are excellent in steroid-avoidance regimens using ATG or alemtuzumab induction; (b) conversion to steroid-based therapy is low; (c) alemtuzumab/high-dose MMF is associated with lower WBC and more GCSF use; (d) alemtuzumab/higher dose MMF results in more diarrhea and azathioprine conversion than ATG/lower dose MMF; (e) CMV viremia is seen more often with ATG use with infection prophylaxis reduction; however, seroconversion occurs promptly.
在儿科肾移植中，使用延长的达利珠单抗诱导可有效避免使用类固醇。停用达利珠单抗后，开始使用淋巴细胞耗竭剂，但比较数据较少。我们评估了在两个儿科中心接受低免疫风险的已故供体（DD）肾移植的儿童的结果，这些中心在类固醇避免方案中使用抗胸腺细胞球蛋白（ATG）与阿仑单抗进行诱导。我们回顾了 2015 年 1 月至 2017 年 9 月期间在两个儿科中心进行的连续 DD 肾移植，这些中心在类固醇避免方案中使用不同的淋巴细胞耗竭剂：ATG（中心 A）和阿仑单抗（中心 B），并使用他克莫司和霉酚酸酯作为维持免疫抑制。抗感染预防基于中心方案。在移植后的第一年，感染率相似。EBV 和 BK 病毒血症相似，尽管中心 A 表现出更多的低级别 CMV 病毒血症（A 为 46%，B 为 0%；P=0.0009），中位发病时间为 1.8 个月，随后出现早期血清转换。两组之间免疫抑制的减少没有差异。1 年时的 DSA 相似（A 为 8%，B 为 13%），BPAR 的发生率较低。需要基于类固醇的转换的情况较低。没有移植物丢失，在 30、90、180 和 365 天的中位 eGFR 也没有差异。（a）使用 ATG 或阿仑单抗诱导的类固醇避免方案 1 年的移植物结果非常好；（b）转换为基于类固醇的治疗的情况较低；（c）阿仑单抗/高剂量霉酚酸酯与白细胞计数较低和更多 GCSF 使用相关；（d）阿仑单抗/较高剂量霉酚酸酯导致更多腹泻和硫唑嘌呤转换，而不是 ATG/较低剂量霉酚酸酯；（e）ATG 使用率较高时，CMV 病毒血症更常见，感染预防减少，但血清转换迅速发生。
