Katznelson S, Cecka J M
University of California at Davis, USA.
Clin Transpl. 1996:361-71.
The distribution and effectiveness of different immunosuppression protocols among recipients of first cadaver donor renal transplants reported to the UNOS Scientific Renal Transplant Registry whose graft survived at least 14 days after transplantation were analyzed. The results showed that between 1988-1993, 50-60% of recipients received triple therapy regimens including cyclosporine, azathioprine and prednisone (CAP). An additional 20% received CAP with antibody induction therapy (OKT3 or ALG). After 1993, there was an increase in the use of other drug combinations which include FK506 and, more recently, Neoral and mycophenylate mofetil. Patient survival was 90% at 3 years regardless of the immunosuppressive protocol. The 3-year graft survival rate was 75% under cyclosporine-based protocols, but was 79% for more recent recipients treated with FK506 (p = 0.015). Antibody induction protocols were not used more frequently for high-risk patients, including those with broadly reactive anti-HLA antibodies, pediatric recipients, transplants with delayed graft function and those with prolonged cold ischemia times. When induction therapies were reported for these higher risk transplants, there was no noticeable improvement in graft survival rates after excluding failures within the first 2 weeks. Any benefit of antibody induction must therefore be manifest with the first 2 weeks after transplantation. Induction protocols significantly reduced the incidence of rejection episodes (prior to hospital discharge) from 31% for those treated with CAP to 12% for those with antibody induction (p < 0.01), however, 24% of those given induction had at least one rejection between discharge and 6 months compared with only 18% of those treated with CAP without induction (p < 0.01). Although graft outcomes might be significantly influenced by the dosing and timing of immunosuppressive drugs, among the different combinations of drugs analyzed, only FK506 resulted in improved graft survival and half life. With the rapid proliferation of newer drugs and immunosuppressive strategies during 1996, it will be interesting to follow the course of these very recent transplants with regard to the effectiveness of changing immunosuppression.
对向美国器官共享联合网络（UNOS）科学肾脏移植登记处报告的首次尸体供肾移植受者中不同免疫抑制方案的分布情况及有效性进行了分析，这些受者的移植肾在移植后至少存活了14天。结果显示，在1988年至1993年期间，50%至60%的受者接受了包括环孢素、硫唑嘌呤和泼尼松（CAP）在内的三联疗法方案。另外20%的受者接受了CAP联合抗体诱导治疗（OKT3或抗淋巴细胞球蛋白）。1993年之后，其他药物组合的使用有所增加，这些组合包括FK506，以及最近的新山地明和霉酚酸酯。无论免疫抑制方案如何，患者3年生存率均为90%。基于环孢素的方案下3年移植肾生存率为75%，但接受FK506治疗的近期受者的3年移植肾生存率为79%（p = 0.015）。抗体诱导方案在高危患者中使用并不更频繁，这些高危患者包括具有广泛反应性抗HLA抗体的患者、儿科受者、移植肾功能延迟的患者以及冷缺血时间延长的患者。当报告对这些高风险移植进行诱导治疗时，在排除前2周内的移植失败病例后，移植肾生存率没有明显改善。因此，抗体诱导的任何益处必须在移植后的前2周内显现出来。诱导方案显著降低了（出院前）排斥反应的发生率，接受CAP治疗的患者排斥反应发生率为31%，接受抗体诱导治疗的患者为12%（p < 0.01），然而，接受诱导治疗的患者中有24%在出院至6个月期间至少发生了一次排斥反应，而未接受诱导治疗的CAP治疗患者中这一比例仅为18%（p < 0.01）。尽管移植肾的结局可能会受到免疫抑制药物剂量和给药时间的显著影响，但在所分析的不同药物组合中，只有FK506提高了移植肾生存率和半衰期。随着1996年新型药物和免疫抑制策略的迅速增加，关注这些最新移植在改变免疫抑制有效性方面的进展将很有意思。
