Surveillance renal transplant biopsies and subclinical rejection at three months post-transplant in pediatric recipients
Surveillance renal transplant biopsies and subclinical rejection at three months post-transplant in pediatric recipients
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DOI：
10.1111/j.1399-3046.2007.00705.x
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发表时间：
2007-08-01
影响因子：
1.3
通讯作者：
Warshaw, Barry L.
中科院分区：
文献类型：
--
作者：
Hymes, Leonard C.;Greenbaum, Laurence;Warshaw, Barry L.
随着监测活检的出现，亚临床急性排斥反应（SCR）在成人肾移植受者中越来越被认识到。然而，在儿童中，大多数中心并不常规进行监测活检。因此，儿童SCR的发病率、诱发因素、治疗和临床结局仍不清楚。从2004年8月到2005年12月，我们在移植后三个月进行了36次活检。所有患者均接受巴利昔单抗诱导治疗，并维持泼尼松、霉酚酸酯和他克莫司。16例（44%）经活检检出SCR。年龄，性别，种族，供体来源，或血清肌酐没有区分与SCR和那些正常活检的儿童。所有病例均采用大剂量甲基强的松龙治疗。在移植后1年，SCR儿童的肾功能与正常监测活检的儿童相似（p = 0.62）。由于SCR的高发病率，2005年12月后移植的20名儿童中，MMF的维持剂量增加了50%。这导致SCR的发生率从44%显著下降至15%（p < 0.05）。然而，在这些儿童中，多瘤病毒（BK）病毒血症的发生率也显著增加（p < 0.005）。结论：移植后三个月的监测活检发现SCR的发生率很高，并且无法通过年龄、性别、种族、供体来源或血清肌酸酐来预测。随着MMF剂量的增加，SCR的发生率显著下降，但BK病毒血症的发生率增加。我们的结论是，监测活检提供了宝贵的信息，在儿童肾移植受者的管理。增加免疫抑制以避免SCR应与感染风险进行权衡。
Subclinical acute rejection (SCR) has been increasingly recognized in adult renal transplant recipients with the advent of surveillance biopsies. However, in children, surveillance biopsies are not routinely performed at most centers. Therefore, the incidence, predisposing factors, treatment, and clinical outcomes of SCR remain unclear in children. From August 2004 to December 2005, we performed 36 protocol biopsies at three months post-transplantation. All patients had received induction therapy with basiliximab and were maintained on prednisone, MMF, and tacrolimus. Sixteen cases of SCR were detected by biopsy (44%). Age, gender, race, donor source, or serum creatinine did not discriminate between children with SCR and those with normal biopsies. All cases of SCR were treated with high doses of methylprednisolone. At one yr post-transplant, renal function was similar in children with SCR to those with normal surveillance biopsies (p = 0.62). Because of the high incidence of SCR, the maintenance dose of MMF was increased by 50% in 20 children transplanted after December 2005. This resulted in a significant decline in the incidence of SCR from 44 to 15% (p < 0.05). However, the incidence of polyomavirus (BK) viremia also increased significantly in these children (p < 0.005). Conclusion: A high incidence of SCR was found on surveillance biopsies at three months post-transplant and could not be predicted by age, gender, race, donor source, or serum creatinine. The occurrence of SCR declined significantly by increasing the dose of MMF, but resulted in an increase in BK viremia. We conclude that surveillance biopsies provide valuable information in the management of pediatric renal transplant recipients. Increasing immunosuppression to avoid SCR should be weighed against the risk for infection.