Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA.
Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland.
Pediatr Nephrol. 2022 Sep;37(9):2091-2098. doi: 10.1007/s00467-021-05407-y. Epub 2022 Jan 10.
Currently, there is no consensus among pediatric kidney transplant centers regarding the use and regimen for immunosuppressive induction therapy.
In this single center, retrospective cohort study, pediatric kidney transplant recipients transplanted between 1 May 2013 and 1 May 2018 with rabbit antithymocyte globulin (rATG) induction were included. We stratified patients based on immunological risk, with high risk defined as those with repeat transplant, preformed donor specific antibody, current panel-reactive antibodies > 20%, 0 antigen match and/or African-American heritage. Outcome of interest was the incidence of biopsy proven acute rejection by 1 year.
A total of 166 patients met inclusion criteria. Age of patients was 12 years (11 mo-21 y), (median, range), 21.5% received a living donor transplant and 50.6% were female. Low-immunologic-risk patients were divided into 2 groups, those who received the lower cumulative rATG dose of ≤ 3.5 mg/kg (n = 52) versus the higher cumulative dose of > 3.5 mg/kg (n = 47). The median total dose in the lower dose group was 3.1 (IQR 0.3) and 4.4 (IQR 0.8) in the higher dose group, P < 0.001. Rejection rate did not differ significantly between the 2 treatment groups (7/52 vs. 6/47). None in the lower dose group developed BK nephropathy versus 3 in the higher dose group. Graft loss due to BK nephropathy occurred in 1 patient in the higher dose group. Graft loss in the whole cohort at 12 months was a rare event (n = 1) with 99.5% graft survival and 100% patient survival.
Reduced rATG dosing (≤ 3.5 mg/kg) when compared to higher dosing (> 3.5 mg/kg) is safe and effective in low-risk pediatric kidney transplant recipients without increasing risk of rejection. A higher resolution version of the Graphical abstract is available as Supplementary information.
目前，儿科肾移植中心在免疫抑制诱导治疗的应用和方案方面尚未达成共识。
在这项单中心回顾性队列研究中，纳入了 2013 年 5 月 1 日至 2018 年 5 月 1 日期间接受兔抗胸腺细胞球蛋白（rATG）诱导的儿科肾移植受者。我们根据免疫风险进行了患者分层，高风险定义为重复移植、预先形成的供体特异性抗体、当前面板反应性抗体>20%、0 抗原匹配和/或非裔美国人血统。研究的主要转归是 1 年内活检证实的急性排斥反应发生率。
共有 166 名患者符合纳入标准。患者年龄为 12 岁（11 个月至 21 岁），中位数（范围），21.5%接受活体供者移植，50.6%为女性。低免疫风险患者分为 2 组，一组接受累积 rATG 剂量≤3.5mg/kg（n=52），另一组接受累积剂量>3.5mg/kg（n=47）。低剂量组的中位总剂量为 3.1（IQR 0.3），高剂量组为 4.4（IQR 0.8），P<0.001。两组治疗组的排斥反应率无显著差异（52 例中有 7 例 vs. 47 例中有 6 例）。低剂量组无一例发生 BK 肾病，而高剂量组有 3 例。高剂量组有 1 例因 BK 肾病导致移植物丢失。在整个队列中，12 个月时移植物丢失是一种罕见事件（n=1），移植物存活率为 99.5%，患者存活率为 100%。
与高剂量（>3.5mg/kg）相比，低剂量（≤3.5mg/kg）rATG 给药减少是安全有效的，不会增加排斥反应的风险。可提供图形摘要的高分辨率版本作为补充信息。
