心脏移植术后肾功能不全患者不同免疫抑制方案的临床研究  

The analysis of immunosuppression adjusting strategies for renal dysfunction following human heart transplantation

作　　者：贾一新[1,2] 孟旭[1,2] 李岩[1,2] 韩杰[1,2] 张海波[1,2] 罗天戈[1,2] 程虹[1,3] 孙丽君[1,3] 

机构地区：[1]首都医科大学附属北京安贞医院 [2]北京市心肺血管疾病研究所心外科,北京100029 [3]北京市心肺血管疾病研究所肾内科,北京100029

出　　处：《心肺血管病杂志》2013年第3期316-320,共5页Journal of Cardiovascular and Pulmonary Diseases

摘　　要：目的:回顾性分析心脏移植后出现肾功能不全的患者,进行不同的免疫制方案调整策略的结果。方法:34例在心脏移植1年后随访期出现肾功能不全的患者,以诊断标准分类,进行3种不同的免疫抑制方案调整:①、降低环孢素A剂量,记为Lo-C组;②、转换为低剂量他克莫司,记为Lo-F组;③、转换为西罗莫司,记为S组。观察各组方案调整后的血肌酐(Scr)及肾小球滤过率(GFR)变化趋势、血压、血脂、血糖变化情况及全部随访期的排斥反应发生情况。结果:33例患者存活并完成1年随访,1例死亡。排斥反应发生率分别为16.7%(2/12)vs.5.9%(1/17)vs.20%(1/5)。各组Scr及GFR在免疫抑制方案替换后均有所改善,其中Lo-C组在替换后6个月和12个月时,Scr值比较替换前差异有统计学意义(P<0.05);Lo-F组在替换后3个月、6个月和12个月时Scr及GFR比较替换前差异均有统计学意义(P<0.05);S组在替换后3个月、6个月和12个月时Scr及GFR比较替换前差异均有统计学意义(P<0.05)。各组患者高血压、糖尿病及高脂血症罹患情况,Lo-C组在替换前后无变化;Lo-F组在替换后6个月较替换前糖尿病明显增多,而高脂血症减少;S组在替换后6个月较替换前高脂血症明显增多。结论:心脏移植术后出现肾功能不全的患者,低剂量的钙调素抑制剂(CNI)或替换为西罗莫司(SLR)可改善肾功能,但相应排斥反应和代谢并发症的风险会加大,免疫抑制方案的调整仍须谨慎,并考虑个体情况和加强监测。Objective：To evaluate the result of immunosuppressive agents adjusting in patients with renal function impairment after heart transplantation.Methods： Heart graft recipients with nephropathy were assigned into 3 group with different strategies of immunosuppressive agents adjusting： low-dose cyclosporine,low-dose tacrolimus,or low-dose sirolimus in combination with standard dose of mycophenolate mofetil and corticosteroids.Serum creatine（Scr） and glomerular filtration rate（GFR） were observed,so as the rejection,survival and metabolic syndrome.Results： There wre 34 patients included in this trial,12 in low-dose cyclosporine group（Lo-C）,17 in low-dose tacrolimus group（Lo-F）,and 5 in low-dose sirolimus group（S）.One death occurred in S group caused of rejection and renal failure.Renal function improved in all groups apparently after 12 months compared to the beginning.The occurrence rate of rejection in 3 groups were Lo-C：16.7%（2/12）;Lo-F：5.9%（1/17）;S：20%（1/5）,metabolic syndrome remains no change in Lo-C,yet the diabetes mellitus morbidity in Lo-F is highly increased so that hyperlipidemia in S.Conclusion： CNI-reduced or conversion to sirolimus immunosuppression can both improve the renal function in heart transplantation patients with renal dysfunction caused by drugs nephrotoxicity.On the other hand,the risk of rejection and complications was also increased.

关 键 词：心脏移植 肾功能 肾毒性 钙调素抑制剂 西罗莫司 

分 类 号：R54[医药卫生—心血管疾病]