慢性移植物肾病患者免疫抑制剂的调整

Immunosuppressive adjustment in patients with chronic allograft nephropathy

目的 探讨调整免疫抑制剂的使用方案能否改善肾移植后慢性移植物肾病患者的肾功能。方法 对病理诊断为慢性移植物肾病早期肾功能不全的 3 8例 (A组 )患者在 1～ 2周内将其神经钙蛋白阻滞剂 (环孢素A或FK 5 0 6)减少至原剂量的 1 3或完全停用 ,同时适当增加硫唑嘌呤或骁悉的用量 ,与同期内环孢素A或他克莫司未作大幅度减量、仅适当增加硫唑嘌呤或骁悉用量的 2 7例 (B组 )慢性移植物肾病患者进行对比 ,随访比较两组的移植肾功能 ,观察急性排斥反应的发生情况。结果 2年后A组有 2 6例 ( 68.4% )患者移植肾功能得以好转或不再继续恶化 ,而B组除 4例 ( 14 .8% )移植肾功能维持在原有水平外 ,其他患者肾功能均进行性恶化。两组急性排斥反应发生率无显著差异。结论 快速减少甚至停用神经钙蛋白阻滞剂可使部分肾移植后慢性移植物肾病患者的肾功能得以改善或者防止其进行性恶化。

Objective To observe the roles of reduced or discontinued calcineurin inhibitor (CNI) in improving the renal function of renal transplant recipients with chronic allograft nephropathy (CAN). Methods A total of 65 renal transplant recipients with declining graft function and biopsy-proven CAN were studied. Within 1-2 weeks, 38 recipients (group A) had CNI (cyclosporine A or tacrolimus) discontinued or reduced to one third of their original doses with properly increased azathioprine (Aza) or mycophenolate mofetil (MMF). The doses of CNI in another 27 recipients (group B) were not changed obviously only with properly increased Aza or MMF. All patients were followed up for at least one year. Renal functions were compared in the two groups. The incidence rates of acute renal graft rejection were calculated in both groups. Results One year later, there were 26 patients (68.4%) with stabilized or improved graft function in group A, but 4 patients (14.8%) in group B. The difference was significant. The incidences of acute rejection in both groups were not significantly different. Conclusion For some renal transplant recipients with declining graft function and biopsy proven CAN, remarkably reduced or discontinued CNI can stabilize or improve their renal functions. Adjustment of the doses of immunosuppressive agents does not increase the risk of acute rejection and any other side effects.