CAJ | 학술논문

目的研究肝移植术后暂停及转换钙调磷酸酶抑制剂(CNI)对控制感染和改善受损肾功能的作用.方法回顾性分析单中心施行的947例原位肝移植的资料,分为2个阶段,第1阶段(2002年1月至2007年12月)有234例肝移植术后发生感染的患者,第2阶段(2008年1月至2010年12月)有101例.2个阶段共有329例受者因CNI肾毒性而造成肾功能损害,其中将CNI转换为SRL者40例(转换组),其余289例采取CNI减量+吗替麦考酚酯(MMF)加量方案(减量组).结果肝移植术后存活超过1、3和5年者CNI的应用率分别为95.8%、95.3%和97.5%.第2阶段共有17例受者短期停用免疫抑制剂,停药的主要原因是细菌(部分合并真菌)感染(88.2%);2个阶段共有48例患者将CNI转换为SRL,换药主要原因是肾功能损害(83.3%).第2阶段感染患者中短期暂停CNI者15例,占14.9%(15/101),CNI暂停后感染控制的有效率为73.3%(11/15),排斥反应发生率为6.7%(1/15).第2阶段感染患者的累积存活率明显高于第1阶段(P＜0.05).转换组CNI转换前肾小球滤过率为(0.82±0.24)ml/s,CNI转换后6周时为(1.28±0.31)ml/s,6个月时为(1.36±0.32)ml/s,转换后6周和6个月时高于转换前(P＜0.05).CNI调整后6个月时,转换组患者存活率为85.0%,减量组为83.7%(P＞0.05).结论肝移植术后患者发生感染及肾功能损害时可采取CNI减量甚至短时间停用CNI,或转换使用SRL,此方案是安全、有效的.
목적 연구간이식술후잠정급전환개조린산매억제제(CNI)대공제감염화개선수손신공능적작용.방법 회고성분석단중심시행적947례원위간이식적자료,분위2개계단,제1계단(2002년1월지2007년12월)유234례간이식술후발생감염적환자,제2계단(2008년1월지2010년12월)유101례.2개계단공유329례수자인CNI신독성이조성신공능손해,기중장CNI전환위SRL자40례(전환조),기여289례채취CNI감량+마체맥고분지(MMF)가량방안(감량조).결과 간이식술후존활초과1、3화5년자CNI적응용솔분별위95.8%、95.3%화97.5%.제2계단공유17례수자단기정용면역억제제,정약적주요원인시세균(부분합병진균)감염(88.2%);2개계단공유48례환자장CNI전환위SRL,환약주요원인시신공능손해(83.3%).제2계단감염환자중단기잠정CNI자15례,점14.9%(15/101),CNI잠정후감염공제적유효솔위73.3%(11/15),배척반응발생솔위6.7%(1/15).제2계단감염환자적루적존활솔명현고우제1계단(P＜0.05).전환조CNI전환전신소구려과솔위(0.82±0.24)ml/s,CNI전환후6주시위(1.28±0.31)ml/s,6개월시위(1.36±0.32)ml/s,전환후6주화6개월시고우전환전(P＜0.05).CNI조정후6개월시,전환조환자존활솔위85.0%,감량조위83.7%(P＞0.05).결론 간이식술후환자발생감염급신공능손해시가채취CNI감량심지단시간정용CNI,혹전환사용SRL,차방안시안전、유효적.
Objective To report the results of a single-center, retrospective study on the effect of calcineurin inhibitors (CNI) withdraw for controlling infections and conversion to sirolimus (SRL)for ameliorating renal dysfunction. Methods A total of 947 liver transplant cases from 2002 to 2010were divided into two eras (Jan. 2002 to Dec. 2007 and Jan. 2008 to Dec. 2010). There were 234cases of infections after liver transplantation (LT) in the first era and 101 cases in the second era. And of 329 cases of CNI-related renal dysfunction after LT in two eras, 40 cases (converting group) had converted CNI to SRL, while 289 cases (reducing group) adopted protocol of CNI reducing and mycophenolate mofetil (MMF) raising. Results CNI-based IS took up 95.8 %, 95. 3 %, 97. 5 % of the IS protocols with recipient survival time longer than 1, 3, and 5 years. The primary cause for CNI withdraw was infection (88. 2 %, 15/17) in the second era, and renal dysfunction for conversion to SRL in the two eras (83. 3 %, 40/48). In the second era, 14. 9% (15/101) of the cases of infections after LT experienced CNI withdraw. Of the 15 patients, 11 had effectively controlled the infection (77. 3 %) while rejection rate was 6. 7 % (1/15). The cumulative survival rate of the second era was significantly higher than the first era (P＜0. 05). The glomerular filtration rate (GFR) of converting group at 6th week and 6th month was statistically elevated as compared with that before conversion,respectively (1.28 ± 0. 31, 1.36 ± 0. 32 mL/s vs. 0. 82 ± 0. 24 mL/s, P＜0. 05). Six months after CNI adjustments, survival rate of converting group and reducing group was 85. 0% and 83. 7 %,respectively (P＞0. 05). Conclusion Reducing or even short-term withdraw of CNI may allow the better control of infections after LT, and the conversion from CNI to SRL can ameliorate the CNIrelated nephrotoxicity. These individually tailored IS protocols will benefit the long term survival for LT.