移植肾功能丧失受者的临床管理策略

杨昊; 林俊; 张健

doi:10.3969/j.issn.1674-7445.2023149

移植肾功能丧失受者的临床管理策略

doi: 10.3969/j.issn.1674-7445.2023149

100050　北京，首都医科大学附属北京友谊医院泌尿外科

基金项目: 国家自然科学基金（82000712）

详细信息

作者简介:

通讯作者:
林俊（ORCID 0000-0002-68847-7150），博士，主任医师，研究方向为泌尿外科，Email：bfhlinjun@hotmail.com

中图分类号: R617, R692
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出版历程
- 收稿日期: 2023-07-31
- 网络出版日期: 2023-09-27
- 刊出日期: 2024-01-11

Clinical management strategies for recipients with renal graft loss

Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China

More Information

Corresponding author: Lin Jun, Email: bfhlinjun@hotmail.com

摘要

摘要: 随着肾移植手术技术的成熟和新型免疫抑制药的引入以及免疫抑制方案的改进，肾移植受者的短期生存率已显著提高，但长期生存并未得到显著改善。肾移植受者通常可能面临移植肾功能丧失。移植肾功能丧失后的医疗管理较为复杂，包括免疫抑制药的调整、移植肾的处理以及后续肾脏替代治疗方式的选择。这些医疗管理直接影响移植肾功能丧失患者的预后，但目前仍缺少相关指南或共识，往往根据临床医师的自身经验决定。本文对目前移植肾功能丧失后免疫抑制药的调整、移植肾的处理和后续肾脏替代治疗方式的选择等进行综述，旨在为延长患者的生存期和提高生活质量提供参考。
- 肾移植 /
- 移植肾功能丧失 /
- 群体反应性抗体 /
- 免疫抑制药 /
- 肾脏替代治疗 /
- 致敏 /
- 移植肾切除术 /
- 经导管血管栓塞术
Abstract: With the maturity of kidney transplantation, introduction of new immunosuppressive drugs and improvement of immunosuppressive regimen, the short-term survival rate of kidney transplant recipients has been significantly improved, whereas the long-term survival rate has not been significantly elevated. Kidney transplant recipients may have the risk of renal graft loss. Clinical management after renal graft loss is complicated, including the adjustment of immunosuppressive drugs, management of renal graft and selection of subsequent renal replacement therapy. These management procedures directly affect clinical prognosis of patients with renal graft loss. Nevertheless, relevant guidelines or consensuses are still lacking. Clinical management of patients after renal graft loss highly depend upon clinicians’ experience. In this article, the adjustment of immunosuppressive drugs, management of renal graft and selection of subsequent renal replacement therapy were reviewed, aiming to provide reference for prolonging the survival and improving the quality of life of these patients.
- Kidney transplantation /
- Renal graft loss /
- Panel reactive antibody /
- Immunosuppressive drugs /
- Renal replacement therapy /
- Sensitization /
- Allograft nephrectomy /
- Transcatheter vascular embolization

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参考文献(65)

[1]	TANTISATTAMO E, MAGGIORE U. Returning to dialysis after kidney allograft loss: conflicting survival benefit beyond transplant-naïve maintenance dialysis patients[J]. J Nephrol, 2022, 35(1): 91-94. DOI: 10.1007/s40620-021-01084-0.
[2]	LENTINE KL, PASTAN S, MOHAN S, et al. A roadmap for innovation to advance transplant access and outcomes: a position statement from the national kidney foundation[J]. Am J Kidney Dis, 2021, 78(3): 319-332. DOI: 10.1053/j.ajkd.2021.05.007.
[3]	BURGAN CM, SUMMERLIN D, LOCKHART ME. Renal transplantation: pretransplant workup, surgical techniques, and surgical anatomy[J]. Radiol Clin North Am, 2023, 61(5): 797-808. DOI: 10.1016/j.rcl.2023.04.003.
[4]	魏健超, 何凯鸣, 孙启全. 2022年中国肾移植研究年度盘点[J]. 器官移植, 2023, 14(3): 336-342. DOI: 10.3969/j.issn.1674-7445.2023.03.003. WEI JC, HE KM, SUN QQ. Research highlights on kidney transplantation in 2022 from China[J]. Organ Transplant, 2023, 14(3): 336-342. DOI: 10.3969/j.issn.1674-7445.2023.03.003.
[5]	LA PORTA E, CONVERSANO E, ZUGNA D, et al. Returning to dialysis after kidney allograft failure: the experience of the Italian Registry of Paediatric Chronic Dialysis[J]. Pediatr Nephrol, 2021, 36(12): 3961-3969. DOI: 10.1007/s00467-021-05140-6.
[6]	谢振华, 张曙伟, 唐莉, 等. 肾移植发展史的回顾与思考[J]. 现代实用医学, 2022, 34(11): 1401-1403. DOI: 10.3969/j.issn.1671-0800.2022.11.001. XIE ZH, ZHANG SW, TANG L, et al. Review and reflection on the development history of kidney transplantation[J]. Mod Pract Med, 2022, 34(11): 1401-1403. DOI: 10.3969/j.issn.1671-0800.2022.11.001.
[7]	邬莉萍, 张曙伟. 老年活体供肾移植现状与研究进展[J]. 现代实用医学, 2022, 34(11): 1403-1405. DOI: 10.3969/j.issn.1671-0800.2022.11.002. WU LP, ZHANG SW. Current status and research progress of living donor kidney transplantation in the elderly[J]. Mod Pract Med, 2022, 34(11): 1403-1405. DOI: 10.3969/j.issn.1671-0800.2022.11.002.
[8]	SCHREZENMEIER E, LEHNER LJ, MERKEL M, et al. What happens after graft loss? a large, long-term, single-center observation[J]. Transpl Int, 2021, 34(4): 732-742. DOI: 10.1111/tri.13834.
[9]	GARG N, VINEY K, BURGER J, et al. Factors affecting sensitization following kidney allograft failure[J]. Clin Transplant, 2022, 36(3): e14558. DOI: 10.1111/ctr.14558.
[10]	KNOLL G, CAMPBELL P, CHASSÉ M, et al. Immunosuppressant medication use in patients with kidney allograft failure: a prospective multicenter Canadian cohort study[J]. J Am Soc Nephrol, 2022, 33(6): 1182-1192. DOI: 10.1681/ASN.2021121642.
[11]	PHAM PT, EVERLY M, FARAVARDEH A, et al. Management of patients with a failed kidney transplant: dialysis reinitiation, immunosuppression weaning, and transplantectomy[J]. World J Nephrol, 2015, 4(2): 148-159. DOI: 10.5527/wjn.v4.i2.148.
[12]	GÓMEZ-DOS-SANTOS V, LORCA-ÁLVARO J, HEVIA-PALACIOS V, et al. The failing kidney transplant allograft. transplant nephrectomy: current state-of-the-art[J]. Curr Urol Rep, 2020, 21(1): 4. DOI: 10.1007/s11934-020-0957-6.
[13]	RYU H, KIM YC, MOON JJ, et al. Weaning immunosuppressant in patients with failing kidney grafts and the outcomes: a single-center retrospective cohort study[J]. Sci Rep, 2020, 10(1): 6425. DOI: 10.1038/s41598-020-63266-3.
[14]	FREIST M, BERTRAND D, BAILLY E, et al. Management of immunosuppression after kidney transplant failure: effect on patient sensitization[J]. Transplant Proc, 2021, 53(3): 962-969. DOI: 10.1016/j.transproceed.2020.10.009.
[15]	MARTIN K, CANTWELL L, BARRACLOUGH KA, et al. Prolonged immunosuppression does not improve risk of sensitization or likelihood of retransplantation after kidney transplant graft failure[J]. Transpl Int, 2021, 34(11): 2353-2362. DOI: 10.1111/tri.13998.
[16]	STRINGER D, GARDNER L, SHAW O, et al. Optimized immunosuppression to prevent graft failure in renal transplant recipients with HLA antibodies (OuTSMART): a randomised controlled trial[J]. EClinicalMedicine, 2023, 56: 101819. DOI: 10.1016/j.eclinm.2022.101819.
[17]	AUGUSTINE JJ, WOODSIDE KJ, PADIYAR A, et al. Independent of nephrectomy, weaning immunosuppression leads to late sensitization after kidney transplant failure[J]. Transplantation, 2012, 94(7): 738-743. DOI: 10.1097/TP.0b013e3182612921.
[18]	BADELL IR, BRAY RA, ELBEIN R, et al. Belatacept in kidney transplant recipients with failed allografts for the prevention of humoral sensitization: a pilot randomized controlled trial[J]. Transplantation, 2021, 105(12): e395-e396. DOI: 10.1097/TP.0000000000003852.
[19]	EL HENNAWY H, SAFAR O, AL FAIFI AS, et al. Belatacept rescue therapy of CNI-induced nephrotoxicity, meta-analysis[J]. Transplant Rev (Orlando), 2021, 35(4): 100653. DOI: 10.1016/j.trre.2021.100653.
[20]	GARCIA-PADILLA PK, AFANADOR D, GONZALEZ CG, et al. Renal graft embolization as a treatment for graft intolerance syndrome[J]. Transplant Proc, 2020, 52(4): 1187-1191. DOI: 10.1016/j.transproceed.2020.01.051.
[21]	WOODSIDE KJ, SCHIRM ZW, NOON KA, et al. Fever, infection, and rejection after kidney transplant failure[J]. Transplantation, 2014, 97(6): 648-653. DOI: 10.1097/01.TP.0000437558.75574.9c.
[22]	ROBINSON C, CHANCHLANI R, KITCHLU A. Malignancies after pediatric solid organ transplantation[J]. Pediatr Nephrol, 2021, 36(8): 2279-2291. DOI: 10.1007/s00467-020-04790-2.
[23]	FIORENTINO M, GALLO P, GILIBERTI M, et al. Management of patients with a failed kidney transplant: what should we do?[J]. Clin Kidney J, 2020, 14(1): 98-106. DOI: 10.1093/ckj/sfaa094.
[24]	ALHAMAD T, LUBETZKY M, LENTINE KL, et al. Kidney recipients with allograft failure, transition of kidney care (KRAFT): a survey of contemporary practices of transplant providers[J]. Am J Transplant, 2021, 21(9): 3034-3042. DOI: 10.1111/ajt.16523.
[25]	ANDREWS PA, Standards Committee of the British Transplantation Society. Summary of the British Transplantation Society guidelines for management of the failing kidney transplant[J]. Transplantation, 2014, 98(11): 1130-1133. DOI: 10.1097/TP.0000000000000426.
[26]	LUBETZKY M, TANTISATTAMO E, MOLNAR MZ, et al. The failing kidney allograft: a review and recommendations for the care and management of a complex group of patients[J]. Am J Transplant, 2021, 21(9): 2937-2949. DOI: 10.1111/ajt.16717.
[27]	DAVIS S, MOHAN S. Managing patients with failing kidney allograft: many questions remain[J]. Clin J Am Soc Nephrol, 2022, 17(3): 444-451. DOI: 10.2215/CJN.14620920.
[28]	BUNTHOF KLW, VERHOEKS CM, VAN DEN BRAND JAJG, et al. Graft intolerance syndrome requiring graft nephrectomy after late kidney graft failure: can it be predicted? a retrospective cohort study[J]. Transpl Int, 2018, 31(2): 220-229. DOI: 10.1111/tri.13088.
[29]	SENER A, KHAKHAR AK, NGUAN CY, et al. Early but not late allograft nephrectomy reduces allosensitization after transplant failure[J]. Can Urol Assoc J, 2011, 5(6): E142-E147. DOI: 10.5489/cuaj.10032.
[30]	BUDHIRAJA P, NGUYEN M, HEILMAN R, et al. The role of allograft nephrectomy in the failing kidney transplant[J]. Transplantation, 2023, 107(12): 2486-2496. DOI: 10.1097/TP0000000000004625.
[31]	ZGOURA P, DOEVELAAR A, ROHN B, et al. Effect of nephrectomy after allograft failure on inflammation, erythropoiesis, donor-specific antibodies, and outcome of re-transplantation[J]. Ann Transplant, 2022, 27: e935625. DOI: 10.12659/AOT.935625.
[32]	AYUS JC, ACHINGER SG, LEE S, et al. Transplant nephrectomy improves survival following a failed renal allograft[J]. J Am Soc Nephrol, 2010, 21(2): 374-380. DOI: 10.1681/ASN.2009050480.
[33]	LANGEWISCH E, MANNON RB. Chronic allograft injury[J]. Clin J Am Soc Nephrol, 2021, 16(11): 1723-1729. DOI: 10.2215/CJN.15590920.
[34]	LÓPEZ-GÓMEZ JM, PÉREZ-FLORES I, JOFRÉ R, et al. Presence of a failed kidney transplant in patients who are on hemodialysis is associated with chronic inflammatory state and erythropoietin resistance[J]. J Am Soc Nephrol, 2004, 15(9): 2494-2501. DOI: 10.1097/01.ASN.0000137879.97445.6E.
[35]	张志宏, 管德林, 张凯, 等. 慢性移植肾失功后的移植肾切除手术分析[J]. 临床泌尿外科杂志, 2015, 30(2): 156-159. DOI: 10.13201/j.issn.1001-1420.2015.02.018. ZHANG ZH, GUAN DL, ZHANG K, et al. Analysis of removal of transplanted kidney after chronic renal allograft dysfunction[J]. J Clin Urology, 2015, 30(2): 156-159. DOI: 10.13201/j.issn.1001-1420.2015.02.018.
[36]	GAVRIILIDIS P, O'CALLAGHAN JM, HUNTER J, et al. Allograft nephrectomy versus nonallograft nephrectomy after failed renal transplantation: a systematic review by updated meta-analysis[J]. Transpl Int, 2021, 34(8): 1374-1385. DOI: 10.1111/tri.13901.
[37]	REQUIÃO-MOURA LR, ALBINO CRM, BICALHO PR, et al. Long-term outcomes after kidney transplant failure and variables related to risk of death and probability of retransplant: results from a single-center cohort study in Brazil[J]. PLoS One, 2021, 16(1): e0245628. DOI: 10.1371/journal.pone.0245628.
[38]	VLACHOPANOS G, EL KOSSI M, AZIZ D, et al. Association of nephrectomy of the failed renal allograft with outcome of the future transplant: a systematic review[J]. Exp Clin Transplant, 2022, 20(1): 1-11. DOI: 10.6002/ect.2021.0133.
[39]	RUBINZ R, ANDAÇOĞLU OM, ANDERSON E, et al. Transplant nephrectomy with peritoneal window: Georgetown University experience[J]. Turk J Surg, 2019, 35(3): 191-195. DOI: 10.5578/turkjsurg.4122.
[40]	FANTONI M, MARCATO C, CIUNI A, et al. Renal artery embolization of non-functioning graft: an effective treatment for graft intolerance syndrome[J]. Radiol Med, 2021, 126(3): 494-497. DOI: 10.1007/s11547-020-01294-9.
[41]	HINDI H, HARB A. Role of failed renal allograft embolization in the treatment of graft intolerance syndrome[J]. J Clin Imaging Sci, 2023, 13: 3. DOI: 10.25259/JCIS_109_2022.
[42]	TAKASE HM, CONTTI MM, NGA HS, et al. Nephrectomy versus embolization of non-functioning renal graft: a systematic review with a proportional meta-analysis[J]. Ann Transplant, 2018, 23: 207-217. DOI: 10.12659/AOT.907700.
[43]	JACOBS ML, STRATTA RJ, MILLER MJ JR, et al. Improving outcomes after allograft nephrectomy through use of preoperative angiographic kidney embolization[J]. J Am Coll Surg, 2022, 234(4): 493-503. DOI: 10.1097/XCS.0000000000000079.
[44]	PANARESE A, D'ANSELMI F, DE LEONARDIS M, et al. Embolization of the renal artery before graft nephrectomy: a comparing study to evaluate the possible benefits[J]. Updates Surg, 2021, 73(6): 2375-2380. DOI: 10.1007/s13304-021-01018-2.
[45]	CHAN MR, OZA-GAJERA B, CHAPLA K, et al. Initial vascular access type in patients with a failed renal transplant[J]. Clin J Am Soc Nephrol, 2014, 9(7): 1225-1231. DOI: 10.2215/CJN.12461213.
[46]	ANIORT J, KAYSI S, GARROUSTE C, et al. CKD complications in kidney-transplanted patients going back to dialysis: impact on patients outcomes[J]. J Nephrol, 2018, 31(1): 147-155. DOI: 10.1007/s40620-017-0449-z.
[47]	PERL J, ZHANG J, GILLESPIE B, et al. Reduced survival and quality of life following return to dialysis after transplant failure: the dialysis outcomes and practice patterns study[J]. Nephrol Dial Transplant, 2012, 27(12): 4464-4472. DOI: 10.1093/ndt/gfs386.
[48]	SLEIMAN J, GARRIGUE V, VETROMILE F, et al. Return to dialysis after renal allograft loss: is dialysis treatment initiated too late?[J]. Transplant Proc, 2007, 39(8): 2597-2598. DOI: 10.1016/j.transproceed.2007.08.030.
[49]	MOURAD G, MINGUET J, PERNIN V, et al. Similar patient survival following kidney allograft failure compared with non-transplanted patients[J]. Kidney Int, 2014, 86(1): 191-198. DOI: 10.1038/ki.2014.6.
[50]	MOLNAR MZ, STREJA E, KOVESDY CP, et al. Estimated glomerular filtration rate at reinitiation of dialysis and mortality in failed kidney transplant recipients[J]. Nephrol Dial Transplant, 2012, 27(7): 2913-2921. DOI: 10.1093/ndt/gfs004.
[51]	AIKPOKPO NV, SHARMA A, HALAWA A. Management of the failing kidney transplant: challenges and solutions[J]. Exp Clin Transplant, 2022, 20(5): 443-455. DOI: 10.6002/ect.2021.0229.
[52]	CHAN MR, DALL AT, FLETCHER KE, et al. Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis[J]. Am J Med, 2007, 120(12): 1063-1070. DOI: 10.1016/j.amjmed.2007.04.024.
[53]	ASTOR BC, EUSTACE JA, POWE NR, et al. Timing of nephrologist referral and arteriovenous access use: the CHOICE Study[J]. Am J Kidney Dis, 2001, 38(3): 494-501. DOI: 10.1053/ajkd.2001.26833.
[54]	COUCEIRO C, RAMA I, COMAS J, et al. Effect of kidney replacement therapy modality after first kidney graft failure on second kidney transplantation outcomes[J]. Clin Kidney J, 2022, 15(11): 2046-2055. DOI: 10.1093/ckj/sfac155.
[55]	PERL J, DONG J, ROSE C, et al. Is dialysis modality a factor in the survival of patients initiating dialysis after kidney transplant failure?[J]. Perit Dial Int, 2013, 33(6): 618-628. DOI: 10.3747/pdi.2012.00280.
[56]	MELO AGJT, BARBOSA GSB, V R CORTES DDP, et al. Returning to PD after kidney transplant failure is a valuable option[J]. Int Urol Nephrol, 2022, 54(5): 1123-1126. DOI: 10.1007/s11255-021-02980-x.
[57]	MENG X, WU W, XU S, et al. Comparison of outcomes of peritoneal dialysis between patients after failed kidney transplant and transplant-naïve patients: a meta-analysis of observational studies[J]. Ren Fail, 2021, 43(1): 698-708. DOI: 10.1080/0886022X.2021.1914659.
[58]	宋小炜, 张凌. 移植肾失功后转归肾脏替代治疗的特点[J]. 西南国防医药, 2020, 30(8): 782-784. DOI: 10.3969/j.issn.1004-0188.2020.08.026. SONG XW, ZHANG L. Characteristics of renal replacement therapy after renal graft failure[J]. Med J Natl Defending Forces Southwest China, 2020, 30(8): 782-784. DOI: 10.3969/j.issn.1004-0188.2020.08.026.
[59]	MALIK J, LOMONTE C, ROTMANS J, et al. Hemodialysis vascular access affects heart function and outcomes: tips for choosing the right access for the individual patient[J]. J Vasc Access, 2021, 22(1_suppl): 32-41. DOI: 10.1177/1129729820969314.
[60]	ASSFALG V, HÜSER N. Repeated kidney re-transplantation in times of organ shortage - a critical review[J]. Curr Opin Organ Transplant, 2021, 26(1): 106-111. DOI: 10.1097/MOT.0000000000000831.
[61]	CLARK S, KADATZ M, GILL J, et al. Access to kidney transplantation after a failed first kidney transplant and associations with patient and allograft survival: an analysis of national data to inform allocation policy[J]. Clin J Am Soc Nephrol, 2019, 14(8): 1228-1237. DOI: 10.2215/CJN.01530219.
[62]	LEAL R, PARDINHAS C, MARTINHO A, et al. Strategies to overcome HLA sensitization and improve access to retransplantation after kidney graft loss[J]. J Clin Med, 2022, 11(19): 5753. DOI: 10.3390/jcm11195753.
[63]	LLOVERAS J, ARCOS E, COMAS J, et al. A paired survival analysis comparing hemodialysis and kidney transplantation from deceased elderly donors older than 65 years[J]. Transplantation, 2015, 99(5): 991-996. DOI: 10.1097/TP.0000000000000474.
[64]	PÉREZ-SÁEZ MJ, ARCOS E, COMAS J, et al. Survival benefit from kidney transplantation using kidneys from deceased donors aged ≥75 years: a time-dependent analysis[J]. Am J Transplant, 2016, 16(9): 2724-2733. DOI: 10.1111/ajt.13800.
[65]	EHRSAM J, RÖSSLER F, HORISBERGER K, et al. Kidney retransplantation after graft failure: variables influencing long-term survival[J]. J Transplant, 2022: 3397751. DOI: 10.1155/2022/3397751.