胰肾联合移植术后的免疫抑制治疗

Immunosuppressive regimen after simultaneous pancreas and kidney transplantation

目的探讨胰肾一期联合移植(SPK)术后免疫抑制药物的合理应用。方法 2005年1月至2009年6月我中心完成9例SPK,其中男5例,女4例,均采用空肠引流方式。术后采用IL-2单克隆抗体诱导的四联免疫抑制方案:IL-2单克隆抗体(舒莱或赛尼哌)+他克莫司(FK506)+霉酚酸酯(MMF)+激素,并逐渐过渡至单用FK506维持治疗。回顾性分析以上9例患者围术期及长期随访情况。结果 9例手术均获得成功。除1例早期死亡外,其余8例患者术后1周内肌酐降至正常水平,术后停用胰岛素时间为(11.5±3.5)d,空腹血糖恢复至正常时间为(15.4±6.3)d。8例患者随访4～50个月,共发生移植肾急性排斥4例,1例患者在接受床边血液透析过程中并发心脑血管意外后家属放弃治疗,其余3例患者经抗胸腺细胞球蛋白(ATG)或激素冲击治疗后移植肾功能均逆转恢复,随访过程中未发现移植胰腺排斥。结论胰肾联合移植是治疗糖尿病合并终末期糖尿病肾病的有效方法,术后早期采用IL-2单克隆抗体诱导的四联免疫抑制方案并逐渐过渡至单用FK506维持治疗是安全的。

Objective To investigate the feasible immunosuppressive regimen after simultaneous pan-creas and kidney transplantation （SPK）.Methods From January 2005 to June 2009,9 patients with diabetic nephropathy and end stage uremia received SPK.The pancreatic allograft exocrine secretion was drained into the proximal jejunum via a side-to-side duodenojujunostomy.Quadruple immunosuppressive regime including IL-2 receptor monoclonal antibody induction,tacrolimus,mycophenolate mofetil （MMF） and steroid were used,then converted to tacrolimus monotherapy.The clinical data of the 9 patients were analyzed retrospectively.Results SPK was successfully applied to all patients without serious surgical complications such as pancreatitis,graft and pancreatic fistula.One patient died of cardiovascular accident in the early stage after SPK.The other 8 patients were followed up for 4-50 months.Serum creatinine decreased to normal range within 1 week after the opera-tion.The 8 patients achieved euglycemia with insulin independence about 10 days after the operation.Acute re-jection of the renal graft occurred in 4 patients,1 patient died due to cardiovascular accident and the other 3 re-covered after ATG or steroids bolus treatment.No rejection was noted in pancreatic grafts.Conclusions SPK is an effective treatment for patients with DM related uremia.Quadruple immunosuppressive regime including IL-2 receptor monoclonal antibody induction is feasible after SPK,and such regimen can be safely converted to tacrolimus monotherapy.