肾移植术后西罗莫司的应用方案选择

Immunosuppressive regimens for sirolimus-treated renal transplant recipients: which one is the best?

本综述总结西罗莫司用于预防肾移植术后排斥反应的各种用药方案,从急性排斥发生率、肾功能、人/肾存活率4个方面综合比较各种用药方案同其他传统免疫抑制方案的优劣。综合比较显示,肾移植术后转换使用西罗莫司是最值得推荐的用药方案。在环孢素与西罗莫司联用(CsA+SRL)过程中减、停环孢素也是可以考虑的方案,但要注意控制西罗莫司浓度。西罗莫司可以替换麦考酚酸酯,此时钙调神经蛋白抑制剂(CNI)应适当减量。起始低剂量西罗莫司与CNI联用(CNI+SRL),以及起始足量CNI+SRL并维持、起始不含CNI以及术后移植肾功能延迟恢复(DGF)过渡期使用西罗莫司均应当避免。西罗莫司支持术后撤停激素,此种情况下推荐西罗莫司与他克莫司联用。需定期监测西罗莫司谷浓度,并多数情形下推荐使用首剂负荷剂量。

Sirolimus and its immunosuppressive regimens have been used for preventing rejection after kidney transplantation. This review analyzes their merits and demerits comparing with other conventional regimens from the aspects of acute rejection rate, graft function, as well as graft survival rates. As conclusion, sirolimus is mostly recommended to be used as conversion therapy after kidney transplantation. Minimization or withdrawal of cyclosporine A（CsA） could also be considered when they were combined with SRL, while SRL concentration should be controlled. SRL can replace mycophenolate mofetil（MMF）, and the calcineurin inhibitors（CNIs） should be reduced appropriately in this setting. Initiated low dose of CNI combined with SRL has no apparent merits and thus is not recommended. Initiated then maintained standard dose of CNI combined with SRL, initiated non-CNI regimens as well as SRL use in DGF patients should be avoided. Sirolimus can support steroids withdrawal after kidney transplantation, and SRL combined with tacrolimus is recommended in this setting. Loading dose is recommended when initiating SRL treatment and its trough blood level should be routinely monitored.