Infections Following Kidney Transplantation After Exposure to Immunosuppression for Treatment of Glomerulonephritis.
Infections Following Kidney Transplantation After Exposure to Immunosuppression for Treatment of Glomerulonephritis.
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肾移植后暴露于免疫抑制治疗肾小球肾炎后的感染。
DOI：
10.1053/j.ajkd.2023.10.016
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发表时间：
2023
期刊：
影响因子：
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通讯作者：
Derebail,VimalK
中科院分区：
文献类型：
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作者：
Massicotte-Azarniouch,David;Detwiler,RandalK;Hu,Yichun;Falk,RonaldJ;Saha,ManishK;vanDuin,David;Hogan,SusanL;Derebail,VimalK
基本原理和目的以肾小球肾炎（GN）为原发病的肾移植患者通常接受移植前免疫抑制（PTI）。这可能会导致免疫抑制负担增加，从而可能增加移植后感染的风险。研究设计单中心、回顾性队列研究。设置和参与者从 2005 年 1 月至 2020 年 5 月在三级保健大学教学医院接受肾移植的接受者。暴露将 GN 为自身肾脏疾病并接受 PTI 治疗 GN 的患者 (n = 184) 与非糖尿病肾移植受者进行比较未接受 PTI 的患者 (n = 579)。 结果 移植后首次出现病毒性感染（BK 或巨细胞病毒 [CMV] 感染）或细菌性感染结果。分析方法 根据移植时年龄、性别、种族、供者类型、移植手术年份、透析年份、接受 T 细胞耗竭诱导和 CMV 移植状态进行调整的 Cox 回归分析。结果在中位随访期 5.7 年中，肾小球肾炎患者与对照组相比，PTI 发生首次病毒感染的风险并未增加（调整后 HR [AHR] 0.69 [95% CI，0.52-0.91]），特定病毒感染的风险也没有增加：BK 感染 19.6% vs 26.3%（AHR 0.72 [95% CI，0.50-1.05]）或 CMV 感染，24.5% vs 29.0% （AHR，0.76 [95% CI，0.54-1.07]）。首次细菌感染的风险也没有增加：54.5% vs 57.5% (AHR, 0.90 [95% CI, 0.71-1.13])。这些感染风险没有增加的发现与所使用的 PTI 类型（环磷酰胺、利妥昔单抗、吗替麦考酚酯或钙调神经磷酸酶抑制剂）或 T 细胞消耗诱导治疗（阿仑单抗或抗胸腺细胞球蛋白）的类型无关。 局限性 单中心研究，没有甲基泼尼松用于 PTI 的数据，未测量的混杂因素。 结论 使用 PTI 治疗 GN与移植后病毒（BK 或 CMV）或细菌感染风险增加无关。对于接受 PTI 的患者，可能不需要在移植后进行额外的感染监测。通俗易懂的总结许多肾移植患者因肾小球疾病而导致肾衰竭。这些患者在移植前可能会受到免疫抑制，这可能会增加接受移植肾后感染的风险。我们在一所大学教学医院确定了肾移植受者，他们在移植前接受了免疫抑制治疗肾小球肾病。我们通过与移植前未接触免疫抑制的移植患者的风险进行比较，检查了移植后感染的风险。我们观察到，在暴露于先前的免疫抑制后，感染风险并未增加。因此，移植前暴露于大量免疫抑制的患者可能不需要特殊监测或药物调整，因为担心接受肾移植后感染。
Rationale & ObjectiveKidney transplant patients with glomerulonephritis (GN) as their native disease commonly have received pretransplant immunosuppression (PTI). This may contribute to the immunosuppression burden potentially increasing the risk for infections after transplantation.Study DesignSingle-center, retrospective cohort study.Setting & ParticipantsRecipients of a kidney transplant from January 2005 until May 2020 at a tertiary care university teaching hospital.ExposurePatients with GN as their native kidney disease who received PTI for treatment of GN (n = 184) were compared with nondiabetic recipients of kidney transplants who did not receive PTI (n = 579).OutcomeFirst occurrence after transplantation of an infection outcome, either viral (BK or cytomegalovirus [CMV] infection) or bacterial.Analytical ApproachCox regression analysis adjusted for age at transplant, sex, race, donor type, year of transplant surgery, dialysis vintage, receipt of T-cell depleting induction, and CMV transplant status.ResultsOver a median follow-up period of 5.7 years, patients with GN PTI were not at an increased risk for developing any first viral infection compared with controls (adjusted HR [AHR] 0.69 [95% CI, 0.52-0.91]) nor at increased risk for specific viral infections: BK infection 19.6% vs 26.3% (AHR 0.72 [95% CI, 0.50-1.05]) or CMV infection, 24.5% vs 29.0% (AHR, 0.76 [95% CI, 0.54-1.07]), respectively. There was also no increased risk of developing a first bacterial infection: 54.5% vs 57.5% (AHR, 0.90 [95% CI, 0.71-1.13]). These findings of no increased risk for infection were independent of the type of PTI used (cyclophosphamide, rituximab, mycophenolate mofetil, or calcineurin inhibitor) or the type of T-cell depleting induction therapy (alemtuzumab or antithymocyte globulin) administered.LimitationsSingle-center study, no data on methylprednisone use for PTI, unmeasured confounding.ConclusionsUse of PTI for the treatment of GN was not associated with an increased risk of viral (BK or CMV) or bacterial infection after transplantation. Additional surveillance for infection after transplantation for patients who received PTI may not be necessary.Plain-Language SummaryMany kidney transplant patients have glomerular disease as the cause of kidney failure. These patients may be exposed to immunosuppression before transplantation, which could increase the risk for infections after receipt of a transplanted kidney. We identified kidney transplant recipients at a university teaching hospital who received immunosuppression before transplant for the treatment of glomerular kidney disease. We examined their risk for infection after transplantation by comparing it with the risk among transplant patients who were not exposed to immunosuppression before transplant. We observed no increased risk for infection after exposure to prior immunosuppression. Therefore, patients exposed to significant amounts of immunosuppression before transplantation may not require special surveillance or medication adjustment for fear of infection after their receipt of a kidney transplant.