肾移植后11年及18年发生膀胱癌及自体肾肾盂癌撤除环孢素A1例:停药12周移植肾功能稳定

Cyclosporin A withdrawal following respective development of bladder carcinoma and autologous renal pelvic carcinoma at 11 and 18 years after renal transplantation in one case:Stability of renal function at 12 weeks following drug withdrawal

背景：器官移植后远期反复发生肿瘤患者免疫抑制剂的撤除问题一直是学术界争论的热点。为了进一步提高临床效果,人们开始研发新型免疫抑制剂,研究不同免疫抑制剂组合的免疫效果,其目的就是试图尽量减少甚至取消环孢素A的使用。目的：报告1例肾移植后18年患者,移植后11年及18年时分别发生膀胱癌与自体肾肾盂癌后,成功撤除环孢素的临床病例。方法：在诊断明确后,为患者分别实施膀胱肿瘤电切及左肾脏、输尿管全长及膀胱袖套状切除术,术后病理报告膀胱移行细胞癌Ⅰ~Ⅱ级及肾盂低分化尿路上皮乳头状癌,术后采用在12d内逐步减少直至撤除环孢素A的方法对患者的免疫抑制方案进行调整。在12d内,每3d减少5mg环孢素A用量,至12d时完全停用,硫唑嘌呤片及醋酸泼尼松片用量不变,停药期间每3d复查1次血肌酐水平,并密切观察患者血压、尿量、体征及移植肾超声。结果与结论：撤除环孢素A后的3个月内,患者血肌酐水平波动于65~70μmol/L,每日尿量为2500~3000mL,无排斥反应发生,未见肿瘤复发及转移。提示肾移植后远期反复发生自体泌尿系移行细胞癌患者在行膀胱肿瘤电切、膀胱全切或肾脏、输尿管全长及膀胱袖套状切除术后,逐渐减少环孢素A用量直至停用,短期观察患者移植肾功能稳定,肿瘤无复发及转移。

BACKGROUND：Removal of immunosuppressants in patients with recurrent tumor in long-term following organ transplantation is always a hot controversial point in academic circles.To further elevate clinical efficiency,people began to invent new immunosuppressant and studied immune efficiency of various immunosuppressant component.They tried to reduce the application of cyclosporin A（CsA）.OBJECTIVE：To analyze the CsA safe withdrawal of a case of kidney recipients,at 18 years after renal transplantation,who developed bladder carcinoma and renal pelvic carcinoma at 11 years and 18 years after transplantation,respectively.METHODS：After identified diagnosis,we performed transurethral resection of bladder tumor（TURBt）and total nephro-ureterectomy merobladder excision.Pathologic examination revealed grade Ⅰ-Ⅱ of bladder and renal pelvic transitional cell carcinoma.After the operation,patient was treated with immune suppression program of CsA withdrawal gradually in 12 days.Within 12 days,5 mg CsA was decreased every 3 days,and complete withdrawal was done at 12 days.The dosage of azathioprine tablets and prednisone acetate tablets was not changed.Serum creatinine levels were rechecked every 3 days during drug withdrawal,and blood pressure,urine volume,physical symptom of patients and ultrasound of transplanted kidney were observed.RESULTS AND CONCLUSION：During the three months of CsA withdrawal,the blood creatinine levels were from 65 to 70 μmol/L;urinary volume was 2 500-3 000 mL every day.There was no acute rejection or tumor relapse,diversion.These indicated that the CsA gradually withdrawal of a case of kidney recipients after renal transplantation,who developed transitional cell carcinoma and was performed transurethral resection of bladder tumor（TURBt）and total nephro-ureterectomy merobladder excision,was safe.No tumor relapse or diversion was found.