University of Ottawa, Department of Medicine (Nephrology) and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada.
J Am Soc Nephrol. 2022 Jun;33(6):1182-1192. doi: 10.1681/ASN.2021121642. Epub 2022 Mar 23.
Patients with kidney transplant failure have a high risk of hospitalization and death due to infection. The optimal use of immunosuppressants after transplant failure remains uncertain and clinical practice varies widely.
This prospective cohort study enrolled patients within 21 days of starting dialysis after transplant failure in 16 Canadian centers. Immunosuppressant medication use, death, hospitalized infection, rejection of the failed allograft, and anti-HLA panel reactive antibodies were determined at 1, 3, 6, and 12 months and and then twice yearly until death, repeat transplantation, or loss to follow-up.
The 269 study patients were followed for a median of 558 days. There were 33 deaths, 143 patients hospitalized for infection, and 21 rejections. Most patients (65%) continued immunosuppressants, 20% continued prednisone only, and 15% discontinued all immunosuppressants. In multivariable models, patients who continued immunosuppressants had a lower risk of death (hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.17 to 0.93) and were not at increased risk of hospitalized infection (HR, 1.81; 95% CI, 0.82 to 4.0) compared with patients who discontinued all immunosuppressants or continued prednisone only. The mean class I and class II panel reactive antibodies increased from 11% to 27% and from 25% to 47%, respectively, but did not differ by immunosuppressant use. Continuation of immunosuppressants was not protective of rejection of the failed allograft (HR, 0.81; 95% CI, 0.22 to 2.94).
Prolonged use of immunosuppressants >1 year after transplant failure was not associated with a higher risk of death or hospitalized infection but was insufficient to prevent higher anti-HLA antibodies or rejection of the failed allograft.
移植失败的肾病患者因感染而住院和死亡的风险很高。移植失败后免疫抑制剂的最佳使用方法仍不确定，临床实践差异很大。
这项前瞻性队列研究纳入了 16 个加拿大中心的 269 名患者，这些患者在移植失败后开始透析的 21 天内。在 1、3、6 和 12 个月以及随后的每两年，评估免疫抑制剂的使用情况、死亡、住院感染、移植失败的移植物排斥、抗 HLA 面板反应性抗体。
中位随访 558 天，研究患者中发生 33 例死亡、143 例感染住院和 21 例排斥。大多数患者（65%）继续使用免疫抑制剂，20%仅继续使用泼尼松，15%停止使用所有免疫抑制剂。多变量模型显示，与停止所有免疫抑制剂或仅继续使用泼尼松的患者相比，继续使用免疫抑制剂的患者死亡风险较低（风险比[HR]，0.40；95%置信区间[CI]，0.17 至 0.93），且住院感染风险并未增加（HR，1.81；95%CI，0.82 至 4.0）。类 I 和类 II 面板反应性抗体的平均值分别从 11%增加到 27%和从 25%增加到 47%，但与免疫抑制剂的使用无关。继续使用免疫抑制剂并不能预防移植失败的移植物排斥（HR，0.81；95%CI，0.22 至 2.94）。
移植失败后 >1 年继续使用免疫抑制剂与死亡或住院感染风险增加无关，但不足以预防更高的 HLA 抗体或移植失败的移植物排斥。
