Factors affecting kidney-transplant outcome in recipients with lupus nephritis
Factors affecting kidney-transplant outcome in recipients with lupus nephritis
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DOI：
10.1111/j.1399-0012.2007.00781.x
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发表时间：
2008-05-01
影响因子：
2.1
通讯作者：
Goldfarb-Rumyantzev, Alexander S.
中科院分区：
文献类型：
--
作者：
Tang, Hongying;Chelamcharla, Madhukar;Goldfarb-Rumyantzev, Alexander S.
背景：与狼疮性肾炎肾移植受者结局相关的因素尚未进行研究。方法：利用美国肾脏数据系统中1995年1月1日至2002年12月31日期间（并随访至2003年12月31日）移植患者的数据（n = 2882），我们对与长期死亡审查移植物存活和受者存活相关的因素进行了回顾性分析。结果：在整个女性亚组和 25-35 岁受者亚组中，移植前妊娠的数量逐渐增加移植失败的风险 [风险比 (HR) 1.54，p < 0.05]。受者和供者年龄与移植失败风险（HR 0.96，p < 0.001；HR 1.01，p < 0.005）和受者死亡风险（HR 1.04，p < 0.001；HR 1.01，p < 0.05）相关。移植失败风险随受者体重增加而增加（HR 1.01，p < 0.001）；非裔美国人与白人相比（HR 1.55，p < 0.001）；更大的查尔森合并症指数（HR 1.17，p < 0.05）；和更高的反应性抗体 (PRA) 水平（HR 1.06，p < 0.001）。与血液透析 (HD) 相比，移植前腹膜透析作为主要方式与移植失败风险降低相关（HR 0.49，p < 0.001），而移植前与移植失败和受者死亡风险较高相关（分别为 HR 2.29，p < 0.001；HR 3.59，p < 0.001）。匹配的人类白细胞抗原 (HLA) 抗原和活体供体的数量（分别为 HR 0.92，p < 0.05；HR 0.64，p < 0.001）与移植失败风险降低相关。移植失败和受者死亡风险增加与不使用钙调神经磷酸酶抑制剂（HR 1.89，p < 0.005；HR 1.80，p < 0.005）和麦考酚酸（MPA）（包括吗替麦考酚酯和 MPA）或硫唑嘌呤（HR 1.41，p < 0.05；HR 1.66，p < 0.01）相关。同时使用环孢素和他克莫司会增加移植失败的风险（HR 2.09，p < 0.05）。与硫唑嘌呤相比，使用 MPA 与受者死亡风险较高相关（HR 1.47，p < 0.05）。结论：在患有狼疮性肾炎的肾移植受者中，多次妊娠、多次输血、较高的合并症指数、较高的体重、供者或受者的年龄和非裔美国人种族、既往移植史、较高的 PRA 水平、较低的 HLA 匹配水平、已故供者以及移植前的 HD与移植失败风险增加有关。同样，较高的受者和供者年龄、既往移植史以及较高的移植前输血率与较高的受者死亡风险相关。既不使用环孢素也不使用他克莫司或同时使用两者（与他克莫司相比）并且既不使用 MPA 也不使用硫唑嘌呤（与硫唑嘌呤相比）与移植失败和受体死亡风险增加相关。与硫唑嘌呤相比，使用 MPA 会增加受者死亡的风险。在前瞻性研究中测试这些结果可能为临床实践提供重要信息。
Background: Factors associated with outcome in renal transplant recipients with lupus nephritis have not been studied.Methods: Using the data from the United States Renal Data System of patients transplanted between January 1, 1995 through December 31, 2002 (and followed through December 31, 2003) (n = 2882), we performed a retrospective analysis of factors associated with long-term death-censored graft survival and recipient survival.Results: The number of pretransplant pregnancies incrementally increased the risk of graft failure [hazard ratio (HR) 1.54, p < 0.05] in the entire subgroup of females and in the subgroup of recipients aged 25-35 yr. Recipient and donor age had an association with both the risk of graft failure (HR 0.96, p < 0.001; HR 1.01, p < 0.005) and recipient death (HR 1.04, p < 0.001; HR 1.01, p < 0.05). Greater graft-failure risk accompanied increased recipient weight (HR 1.01, p < 0.001); African Americans compared with whites (HR 1.55, p < 0.001); greater Charlson comorbidity index (HR 1.17, p < 0.05); and greater panel reactive antibody (PRA) levels (HR 1.06, p < 0.001). Pretransplant peritoneal dialysis as the predominant modality had an association with decreased risk of graft failure (HR 0.49, p < 0.001), while prior transplantation was associated with greater risk of graft failure and recipient death (HR 2.29, p < 0.001; HR 3.59, p < 0.001, respectively) compared with hemodialysis (HD). The number of matched human leukocyte antigens (HLA) antigens and living donors (HR 0.92, p < 0.05; HR 0.64, p < 0.001, respectively) was associated with decreased risk of graft failure. Increased risk of graft failure and recipient death was associated with nonuse of calcineurin inhibitors (HR 1.89, p < 0.005; HR 1.80, p < 0.005) and mycophenolic acid (MPA) (including mycophenolate mofetil and MPA) or azathioprine (HR 1.41, p < 0.05; HR 1.66, p < 0.01). Using both cyclosporine and tacrolimus was associated with increased risk of graft failure (HR 2.09, p < 0.05). Using MPA is associated with greater risk of recipient death compared with azathioprine (HR 1.47, p < 0.05).Conclusion: In renal transplant recipients with lupus nephritis, multiple pregnancies, multiple blood transfusions, greater comorbidity index, higher body weight, age and African American race of the donor or recipient, prior history of transplantation, greater PRA levels, lower level of HLA matching, deceased donors, and HD in pretransplant period have an association with increased risk of graft failure. Similarly, higher recipient and donor age, prior transplantations, and higher rate of pretransplant transfusions are associated with greater risk of recipient mortality. Using neither cyclosporine nor tacrolimus or using both (compared with tacrolimus) and neither MPA nor azathioprine (compared with azathioprine) was associated with increased risk of graft failure and recipient death. Using MPA is associated with greater risk of recipient death compared with azathioprine. Testing these results in a prospective study might provide important information for clinical practice.