Ogawa Lauren, Beaird Omer E, Schaenman Joanna M
Division of Infectious Diseases, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, United States.
Front Nephrol. 2023 Aug 21;3:1149116. doi: 10.3389/fneph.2023.1149116. eCollection 2023.
Patients with a failing kidney allograft are often continued on immunosuppression (IS) to preserve residual kidney function and prevent allosensitization. It has been previously accepted that maintaining patients on immunosuppressive therapy results in an increased risk of infection, hospitalization, and mortality. However, as the management of IS in patients with a failed kidney allograft continues to evolve, it is important to review the data regarding associations between infection and specific immunosuppression regimens. We present a review of the literature of failed kidney allograft management and infection risk, and discuss practices for infection prevention. Fifteen studies, published from 1995 to 2022, which investigated the experience of patients with failed allograft and infection, were identified. Infection was most commonly documented as a general event, but when specified, included infections caused by , , and In addition, the definition of reduced "IS" varied from decreased doses of a triple drug regimen to monotherapy, whereas others did not specify which medications patients were receiving. Despite attempts at lowering net immunosuppression, patients with failed allografts remain at risk of acquiring opportunistic and non-opportunistic infections. Although opportunistic infections secondary to IS are expected, somewhat surprisingly, it appears that the greatest risk of infection may be related to complications of dialysis. Therefore, mitigating strategies, such as planning for an arteriovenous (AV) fistula over a hemodialysis catheter placement, may reduce infection risk. Additional studies are needed to provide more information regarding the types and timing of infection in the setting of a failed kidney allograft. In addition, more data are needed regarding specific medications, doses, and timing of taper of IS to guide future patient management and inform strategies for infection surveillance and prophylaxis.
移植肾功能衰竭的患者通常会继续接受免疫抑制治疗（IS），以保留残余肾功能并防止致敏。此前人们普遍认为，让患者持续接受免疫抑制治疗会增加感染、住院和死亡风险。然而，随着移植肾功能衰竭患者免疫抑制治疗的管理不断发展，回顾有关感染与特定免疫抑制方案之间关联的数据非常重要。我们对移植肾功能衰竭管理和感染风险的文献进行了综述，并讨论了感染预防措施。我们检索到了1995年至2022年发表的15项研究，这些研究调查了移植失败患者与感染相关的情况。感染最常被记录为一般事件，但具体来说，包括由 、 和 引起的感染。此外，“免疫抑制降低”的定义各不相同，从三联药物方案剂量减少到单一疗法，而其他研究则未明确患者接受的是哪些药物。尽管试图降低净免疫抑制水平，但移植失败的患者仍有获得机会性和非机会性感染的风险。虽然免疫抑制继发的机会性感染是预期中的，但有点令人惊讶的是，似乎最大的感染风险可能与透析并发症有关。因此，采取缓解策略，如优先计划动静脉（AV）内瘘而非放置血液透析导管，可能会降低感染风险。需要更多研究来提供有关移植肾功能衰竭情况下感染类型和时间的更多信息。此外，还需要更多有关特定药物、剂量以及免疫抑制治疗减量时间的数据，以指导未来的患者管理，并为感染监测和预防策略提供依据。
