急性肾损伤可能并不妨碍移植


  【24drs.com】根据在线发表于3月11日美国移植期刊的一篇多中心研究,监于合理之6个月的移植肾功能,医师可考虑从急性肾脏损伤(acute kidney injury,AKI)死亡的器捐者摘取肾脏,不过,仍有肾脏无法使用或者延迟发挥移植物功能(DGF)的风险;DGF的定义是,在移植后第一周,仍需要继续透析支持。
  
  资深作者、耶鲁大学医学院移植应用研究计画主任Chirag R. Parikh医师在大学新闻稿中表示,这些急性肾脏损伤的肾脏似乎仍有更多的移植运用空间,而不是直接把它们丢掉。
  
  Parikh医师表示,等候移植名单已经超过10万名病患,因为每年等候移植的病患数都比实际进行移植者多数千人。此外,美国成人等到进行移植的时间,在1998-2008年间已经从平均2.7年增加到4.2年,每年有超过5000人因为等不到肾脏移植而死亡。
  
  耶鲁大学医学院医学系移植应用研究计画的Isaac E. Hall医师等人,使用1,632名捐赠者的资料,检视急性肾脏损伤的关联,定义是,因为末端血清中肌酸酐增加住院、肾脏弃用、延迟发挥移植物功能、以及6个月时的估计肾丝球过滤速率(eGFR)。
  
  相较于没有急性肾脏损伤的捐赠者,「AKI Network」分期1、2、3者的肾脏弃用风险增加,校正相关风险为分别是1.28 (95%信赖区间 [CI]为1.08 - 1.52)、1.82 (95% CI,1.45 - 2.30)与 2.74 (95% CI,2.00 - 3.75)。
  
  捐赠者的急性肾脏损伤分期也和延迟发挥移植物功能的风险有关,校正相关风险为分别是:第1期为1.27 (95% CI,1.09 - 1.49)、第2期为1.70 (95% CI,1.37 - 2.12)、第3期为2.25 (95% CI,1.74 - 2.91)。
  
  不过,令人惊讶的是,急性肾脏损伤和6个月后的肾脏移植功能不佳无关,急性肾脏损伤分期并未显著影响6个月时的eGFR,但是,延迟发挥移植物功能之受赠者6个月时的eGFR (48 mL/minute/1.73 m2;四分位范围为31 - 61 mL/minute/1.73 m2)显著低于没有发生延迟发挥移植物功能者(58 mL/minute/ 1.73 m2;四分位范围为45 - 75 mL/minute/1.73 m2;P < .001)。
  
  捐赠者的急性肾脏损伤分期与延迟发挥移植物功能之间有显著的良性互动,随著捐赠者的急性肾脏损伤分期增加,延迟发挥移植物功能肾脏的6个月eGFR也增加(互动P值= 0.05)。
  
  Hall医师在新闻稿中表示,我们看到的是,随著捐赠者的急性肾脏损伤恶化,6个月时的结果实际上优于发生延迟发挥移植物功能的受赠者。
  
  Hall医师提出一个可能的解释,捐赠者的肾脏急性损伤可能会发生一些缺血性的先决条件,而使器官免于后续的损伤,或者,校正捐赠者的年龄、合并症、以及其它临床因素后,被成功移植之急性损伤肾脏的质量可能比较好,否则,就会是被排斥的急性损伤肾脏。
  
  作者们指出几个研究限制,包括观察型研究设计的可能干扰因素,以及缺乏6个月之后的追踪资料,不过,研究作者建议,对于扩大急性肾脏损伤之已故者的器捐要谨慎考量。
  
  Parikh医师在新闻稿中表示,就算这样只代表每年都出几十个可移植的肾脏,受赠者可以在移植后脱离等候名单,生活质量也会比等待著不知道何时才会有的较高质量肾脏而继续透析者还要好。
  
  资料来源:http://www.24drs.com/

Acute Kidney Injury May Not Preclude Transplant

By Laurie Barclay, MD
Medscape Medical News

In light of reasonable 6-month graft function, clinicians should consider kidney transplant from deceased donors with acute kidney injury (AKI), according to a multicenter study published online March 11 in the American Journal of Transplantation. However, there are risks for kidney discard and delayed graft function (DGF), defined as the need for continued dialysis support in the first week after transplantation.

"There appears to be room to attempt more transplants using these AKI kidneys rather than throwing them away," senior author Chirag R. Parikh, MD, director of the Program of Applied Translational Research at Yale University School of Medicine, New Haven, Connecticut, said in a university news release.

"The waiting list has grown to over 100,000 patients as thousands more people are wait-listed each year than actually receive a transplant. In addition, the median time it takes for an adult to receive a transplant in the United States increased from 2.7 to 4.2 years between 1998 and 2008, and more than 5,000 people die each year while waiting for a kidney," Dr Parikh continued.

Using a sample of 1632 donors, Isaac E. Hall, MD, from the Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, and colleagues examined associations of AKI, defined as increasing admission-to-terminal serum creatinine, with kidney discard, DGF, and 6-month estimated glomerular filtration rate (eGFR).

Compared with donor kidneys with no AKI, kidneys with AKI Network stages 1, 2, and 3 had increased kidney discard risk. Adjusted relative risks were 1.28 (95% confidence interval [CI], 1.08 - 1.52), 1.82 (95% CI, 1.45 - 2.30), and 2.74 (95% CI, 2.00 - 3.75), respectively.

Donor AKI stage was also linked to risk for DGF, with adjusted relative risks of 1.27 (95% CI, 1.09 - 1.49) for stage 1, 1.70 (95% CI, 1.37 - 2.12) for stage 2, and 2.25 (95% CI, 1.74 - 2.91) for stage 3.

Surprisingly, however, AKI was not linked to poor kidney transplant function 6 months later, and AKI stages did not differ significantly in terms of 6-month eGFR. However, recipients with DGF had significantly lower 6-month eGFR (48 mL/minute per 1.73 m2; interquartile range, 31 - 61 mL/minute per 1.73 m2) than those without DGF (58 mL/minute per 1.73 m2; interquartile range, 45 - 75 mL/minute per 1.73 m2; P < .001).

There was a significant, favorable interaction between donor AKI stage and DGF. Six-month eGFR increased in tandem for DGF kidneys with increasing donor AKI (P for interaction = .05).

"What we saw was, with worsening AKI in the donor, the six-month outcome was actually better for recipients who experienced DGF," Dr Hall said in the news release.

A possible explanation offered by Dr Hall was that kidneys acutely injured in the donor may develop ischemic preconditioning, which could protect the organs from later injury. Alternatively, the successfully transplanted kidneys with AKI may have been of better quality otherwise than the rejected kidneys with AKI, despite adjustment for donor age, comorbidity, and other clinical factors.

The authors note several study limitations, including its observational design with possible residual confounding and lack of complete follow-up data beyond 6 months. Nonetheless, the study authors suggest considering cautious expansion of the donor pool to deceased donors with AKI.

"Even if it only means a few dozen more kidney transplants each year, those are patients who would come off of the waiting list for transplants sooner and have much better survival than continuing on dialysis in hopes of seemingly higher-quality kidney offers, which may never come in time," Dr Parikh said in the release.

The American Heart Association and the National Institutes of Health supported this study. Dr Parikh received a Roche Organ Transplantation Research Foundation Award. The other authors have disclosed no relevant financial relationships.

Am J Transplant. Published online March 11, 2015.

    
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