Induction Immunosuppression and Clinical Outcomes in Kidney Transplant Recipients Infected With Human Immunodeficiency Virus
Induction Immunosuppression and Clinical Outcomes in Kidney Transplant Recipients Infected With Human Immunodeficiency Virus
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DOI：
10.1111/ajt.13840
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发表时间：
2016-08-01
影响因子：
8.8
通讯作者：
Segev, D. L.
中科院分区：
文献类型：
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作者：
Kucirka, L. M.;Durand, C. M.;Segev, D. L.
人类免疫缺陷病毒阳性（HIV+）肾移植（KT）受者发生急性排斥反应（AR）的风险增加。诱导免疫抑制是AR高风险患者的标准治疗;然而，由于担心感染率增加，在HIV+患者中使用存在争议。我们试图比较接受（i）抗胸腺细胞球蛋白（ATG）、（ii）IL-2受体阻滞剂和（iii）无诱导治疗的HIV+ KT受者的临床结局。我们研究了2000年至2014年期间830名HIV+ KT接受者，如移植接受者科学登记处所记录，并比较了移植物功能延迟（DGF），AR，移植物丢失和死亡的发生率。通过国际疾病分类第九次修订版代码确定了308名医疗保险患者的感染和住院情况。与无诱导相比，两种诱导剂均未增加感染风险（加权风险比[wHR] 0.80，95%置信区间[CI] 0.55-1.18）。接受诱导治疗的艾滋病毒阳性接受者在医院的天数更少（加权相对风险[wRR] 0.70，95% CI 0.52-0.95），DGF发生率较低（wRR 0.66，95%CI 0.51-0.84）、移植物丢失较少（wHR 0.47，95%CI 0.24-0.89）和死亡率降低的趋势（wHR 0.60，95%CI 0.24-1.28）。接受ATG诱导的患者AR发生率较低（wRR 0.59，95% CI 0.35-0.99）。HIV+ KT接受者的诱导与感染增加无关;事实上，接受最有效药物ATG的患者感染率最低。鉴于该人群中AR的高风险，应强烈考虑诱导治疗。一项对830例HIV阳性肾移植受者的国家注册研究表明，使用抗胸腺细胞球蛋白诱导免疫抑制可降低急性排斥反应和移植物丢失的风险，且与感染、住院或死亡率增加无关。
There is an increased risk of acute rejection (AR) in human immunodeficiency virus-positive (HIV+) kidney transplant (KT) recipients. Induction immunosuppression is standard of care for those at high risk of AR; however, use in HIV+ patients is controversial, given fears of increased infection rates. We sought to compare clinical outcomes between HIV+ KT recipients who were treated with (i) anti-thymocyte globulin (ATG), (ii) IL-2 receptor blocker, and (iii) no induction. We studied 830 HIV+ KT recipients between 2000 and 2014, as captured in the Scientific Registry of Transplant Recipients, and compared rates of delayed graft function (DGF), AR, graft loss and death. Infections and hospitalizations were ascertained by International Classification of Diseases, Ninth Revision codes in a subset of 308 patients with Medicare. Compared with no induction, neither induction agent was associated with an increased risk of infection (weighted hazard ratio [wHR] 0.80, 95% confidence interval [CI] 0.55-1.18). HIV+ recipients who received induction spent fewer days in the hospital (weighted relative risk [wRR] 0.70, 95% CI 0.52-0.95), had lower rates of DGF (wRR 0.66, 95% CI 0.51-0.84), less graft loss (wHR 0.47, 95% CI 0.24-0.89) and a trend toward lower mortality (wHR 0.60, 95% CI 0.24-1.28). Those who received induction with ATG had lower rates of AR (wRR 0.59, 95% CI 0.35-0.99). Induction in HIV+ KT recipients was not associated with increased infections; in fact, those receiving ATG, the most potent agent, had the lowest rates. In light of the high risk of AR in this population, induction therapy should be strongly considered.A national registry study of 830 HIV-positive kidney transplant recipients demonstrates that induction immunosuppression use with anti-thymocyte globulin decreases the risk of acute rejection and graft loss and is not associated with increased infection, hospitalization, or mortality.