Tarantino A, Montagnino G, Ponticelli C
Ospedale Maggiore-IRCCS, Divisione Di Nefrologia E Dialisi, Milan, Italy.
Drug Saf. 1995 Sep;13(3):145-56. doi: 10.2165/00002018-199513030-00002.
Corticosteroids have played a key role in the immunosuppression of organ transplantation. Unfortunately, the extensive use of these agents has resulted in disabling and life-threatening adverse effects in many patients. The advent of concomitant corticosteroid/cyclosporin regimens has allowed a reduction in the dosages of steroids administered, yet steroid-induced morbidity is still a major problem in many cyclosporin-treated renal transplant patients. After favourable initial experiences with cyclosporin monotherapy, several attempts at steroid-free immunosuppression in renal transplant patients have been undertaken, either by not starting steroids after transplantation or by stopping steroids in patients with stable graft function. Most controlled and uncontrolled trials showed that with either strategy short term graft survival was similar with or without steroids, but acute rejection was more frequent in patients not taking steroids. The percentage of patients who could be maintained steroid-free ranged from 28 to 94%, and was higher in patients who stopped steroids later than in those never receiving them. Little information is available about long term follow-up of these patients. Some studies reported late attrition of renal function in patients not taking steroids, while others reported a favourable outcome even in the long term. Steroid-free immunosuppression is feasible in renal transplant patients, but it requires careful monitoring of renal function and cyclosporin dosage. This strategy is particularly indicated in patients at high risk of cardiovascular disease or steroid-related complications, and in children. Nevertheless, several issues need to be better elucidated by further studies, namely the long term outcome of steroid-free immunosuppression, the advantages and disadvantages of steroid avoidance versus steroid withdrawal, and the criteria for selecting patients.
皮质类固醇在器官移植的免疫抑制中发挥了关键作用。不幸的是，这些药物的广泛使用已在许多患者中导致了致残和危及生命的不良反应。皮质类固醇与环孢素联合用药方案的出现使得所使用的类固醇剂量得以减少，但类固醇诱导的发病率在许多接受环孢素治疗的肾移植患者中仍然是一个主要问题。在环孢素单一疗法取得良好的初始经验之后，已经对肾移植患者进行了几次无类固醇免疫抑制的尝试，要么在移植后不开始使用类固醇，要么在移植肾功能稳定的患者中停用类固醇。大多数对照和非对照试验表明，无论采用哪种策略，短期移植存活率在使用或不使用类固醇的情况下相似，但在未服用类固醇的患者中急性排斥反应更为频繁。能够维持无类固醇状态的患者百分比在28%至94%之间，在较晚停用类固醇的患者中这一比例高于从未接受过类固醇治疗的患者。关于这些患者的长期随访信息很少。一些研究报告了未服用类固醇患者的肾功能后期减退，而其他研究报告即使从长期来看结果也良好。无类固醇免疫抑制在肾移植患者中是可行的，但需要仔细监测肾功能和环孢素剂量。这种策略特别适用于有心血管疾病或类固醇相关并发症高风险的患者以及儿童。然而，一些问题需要通过进一步研究更好地阐明，即无类固醇免疫抑制的长期结果、避免使用类固醇与停用类固醇的优缺点以及选择患者的标准。
