Recurrent and de novo glomerular disease after renal transplantation: A report from Renal Allograft Disease Registry
Recurrent and de novo glomerular disease after renal transplantation: A report from Renal Allograft Disease Registry
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DOI：
10.1016/s0041-1345(98)01511-5
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发表时间：
1999-02-01
影响因子：
0.9
通讯作者：
George, V
中科院分区：
文献类型：
--
作者：
Hariharan, S;Adams, MB;George, V
材料和方法从1987年10月至1996年12月，威斯康星医学院、辛辛那提大学、加州大学旧金山分校、路易斯维尔大学、西雅图华盛顿大学和华盛顿大学医学院共为成年人进行了4913例肾脏移植手术。对患者进行至少1年的随访。经肾活检确诊167例(3.4%)为复发性和复发性疾病。将这些患者与其他没有复发和新发疾病的患者(n=4746)进行比较。在复发和新发疾病组中，男性更多(67.7%比59.8%，P<；0.035)，再次移植的次数更多(17%比11.5%，P<；0.005)。不同的移植类型(活体亲属供者与身体，P=NS)的复发率和新发疾病的发生率没有差异。其他人口统计学研究结果并没有显著不同。常见的肾小球肾炎包括局灶性节段性肾小球硬化(FSGS)57例；免疫球蛋白A肾炎22例；膜增生性肾小球肾炎(GN)18例；膜性肾病16例。其他诊断包括：糖尿病肾病19例；免疫复合体GN 12例；新月体肾炎(血管炎)6例；溶血性尿毒症综合征-血栓性血小板减少性紫癜(HUS/TTP)8例；系统性红斑狼疮3例；抗肾小球基底膜疾病2例；牛津病2例；以及其他2例。在随访期内，复发性疾病组的移植物失败率显著增加，分别为55%和25%，P<；0.001。复发和新发疾病患者的1、2、3、4和5年肾脏存活率分别为86.5%、78.5%、65%、47.7%和39.8%。无复发和新发病例的相应生存率分别为85.2%、81.2%、76.5%、72%和67.6%(对数等级检验，P<；0.0001)。有无复发和新发疾病的患者肾脏存活率的中位数分别为1360天和3382天(P<；0.0001)。使用COX比例风险模型对移植失败进行多变量分析，以确定各种危险因素。身体移植、冷缺血时间延长、群体反应性抗体升高和疾病复发被确定为同种异体移植失败的危险因素。因复发和新发疾病导致移植失败的相对风险(95%可信区间)为1.9%(1.57-2.40%)，P<；0.0001。膜增生性肾小球肾炎移植失败的相对危险度为0.0001，膜增生性肾小球肾炎移植失败的相对危险度为0.003，HUS/TTP为5.36(2.2-12.9)，P<；0.0002。复发的FSGS患者移植物失败率较高(64.9%)，半衰期较短(1244天)。总而言之，复发和新发疾病与较差的长期存活率有关，而同种异体移植物丢失的相对风险是前者的两倍。复发和复发的FSGS、膜增生性肾小球肾炎和HUS/TTP对移植物存活率有显著影响。
Materials and Methods. From October 1987 to December 1996, a total of 4913 renal transplants were performed on adults at the Medical College of Wisconsin, University of Cincinnati, University of California at San Francisco, University of Louisville, University of Washington, Seattle, and Washington University School of Medicine. The patients were followed for a minimum of 1 year. A total of 167 (3.4%) cases of recurrent and de novo disease were diagnosed by renal biopsy. These patients were compared with other patients who did not have recurrent and de novo disease (n= 4746). There were more men (67.7% vs. 59.8%, P< 0.035) and a higher number of re-transplants (17% vs. 11.5%, P< 0.005) in the recurrent and de novo disease group. There was no difference in the rate of recurrent and de novo disease according to the transplant type (living related donor vs. cadaver, P= NS). Other demographic findings were not significantly different. Common forms of glomerulonephritis seen were focal segmental glomerulosclerosis (FSGS), 57; immunoglobulin A nephritis, 22; membranoproliferative glomerulonephritis (GN), 18; and membranous nephropathy, 16. Other diagnoses include: diabetic nephropathy, 19; immune complex GN, 12; crescentic GN (vasculitis), 6; hemolytic uremic syndrome-thrombotic thrombocytopenic purpura (HUS/TTP), 8; systemic lupus erythematosus, 3; Anti-glomerular basement membrane disease, 2; oxalosis, 2; and miscellaneous, 2.The diagnosis of recurrent and de novo disease was made after a mean period of 678 days after the transplant. During the follow-up period, there were significantly more graft failures in the recurrent disease group, 55% vs. 25%, P< 0.001. The actuarial 1-, 2-, 3-, 4, and 5-year kidney survival rates for patients with recurrent and de novo disease was 86.5%, 78.5%, 65%, 47.7%, and 39.8%. The corresponding survival rates for patients without recurrent and de novo disease were 85.2%, 81.2%, 76.5%, 72%, and 67.6%, respectively (Log-rank test, P< 0.0001). The median kidney survival rate for patients with and without recurrent and de novo disease was 1360 vs. 3382 days (P< 0.0001). Multivariate analysis using the Cox proportional hazard model for graft failure was performed to identify various risk factors. Cadaveric transplants, prolonged cold ischemia time, elevated panel reactive antibody, and recurrent disease were identified as risk factors for allograft failure. The relative risk (95% confidence interval) for graft failure because of recurrent and de novo disease was 1.9 (1.57-2.40), P< 0.0001. The relative risk for graft failure because of posttransplant FSGS was 2.25 (1.6-3.1), P< 0.0001, for membranoproliferative glomerulonephritis was 2.37 (1.3-4.2), P< 0.003, and for HUS/TTP was 5.36 (2.2-12.9), P< 0.0002. There was higher graft failure (64.9%) and shorter half-life (1244 days) in patients with recurrent FSGS.Conclusion. In conclusion, recurrent and de novo disease are associated with poorer long-term survival, and the relative risk of allograft loss is double. Significant impact on graft survival was seen with recurrent and de novo FSGS, membranoproliferative glomerulonephritis, and HUS/TTP.