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肾移植失败后免疫抑制剂的停药

Authors
Brent W Miller, MD
Daniel C Brennan, MD, FACP
Section Editor
Barbara Murphy, MB, BAO, BCh, FRCPI
Deputy Editor
Alice M Sheridan, MD
Translators
王梁, 副主任医师，副教授

引言

过去数十年间，同种异体肾移植的长期存活率已明显升高。尽管如此，仍有大量的同种异体肾移植受者最终因异体移植失败而需长期进行反复的肾脏替代疗法[1]。例如，约13%于2006年接受同种异体肾移植的患者既往曾接受过一次肾脏移植[1]。此外，于2002年开始透析的100,000多名患者中，有4%的患者出现同种异体肾移植失败[2,3]。

这类透析患者的生存率似乎相对较差[4-7]。例如，加拿大一项纳入4743例肾移植受者的研究中，异体移植失败患者相比移植物功能继续存在的受者，死亡风险明显更高(校正HR 3.4，95%CI 2.75-4.2)[6]。

肾移植失败后重新开始透析使临床医生进退两难：是否停用免疫抑制药物；若开始停药，免疫抑制剂逐渐减量至停药的最佳方法又是什么。肾移植失败后必须采用停止免疫抑制来解决的问题总结在此。

停药原因

肾移植失败的透析患者停用免疫抑制剂最主要的原因是感染、恶性肿瘤的风险增加，以及长期使用皮质类固醇药物进行免疫抑制引起的相关并发症风险增加。这种情况下，感染是死亡的第二大原因[8]。另一个问题则是，在肾衰竭患者中难以确定某些免疫抑制剂的给药剂量。

感染风险增加 — 在移植受者(由于免疫抑制药物的直接作用)和透析患者(由于尿毒症引发的免疫系统紊乱及血管通路相关问题)中均可观察到严重感染的风险增加。这些因素导致在同种异体肾移植失败后继续接受免疫抑制药物的透析患者中，感染的发生率非常高[9-11]：

            

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Literature review current through: 2017-06 . | This topic last updated: 2017-02-24.
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