可預測捐腎者長期併發症的風險因子


  July 31, 2006 (波士頓) — 一項新研究顯示,器官捐贈時若屬年長者和腎絲球過濾速率(GFR)降低者,可能在捐贈後有顯著風險發生腎功能不佳;此外,肥胖、男性捐贈者之捐贈後高血壓風險也可能增加;Andrew Posselt醫師於此間舉行的世界人體器官移植大會發表此研究發現,Posselt醫師是加州大學的移植外科醫師。
  
  Posselt醫師向與會聽眾表示,最近數年來,對活體腎臟捐贈者的需求漸增,於是,活體捐贈者排除規範被鬆綁,使得以納入年長捐贈者、肥胖捐贈者、單側腎動脈疾病病患和高血壓病患,短期來說,這看似微不足道,但長期之後遺症則尚未被充分了解。
  
  Posselt醫師和共同研究者,欲確定是否有任何可以預測捐贈者最終發生腎功能不全、蛋白尿和高血壓的病患特徵或捐贈前檢測方法。
  
  Posselt醫師在訪談中向Medscape表示,因為大多認為捐贈者在腎臟摘除後仍有好的腎功能而無人研究此領域,所以我們對此加以研究。
  
  研究者在其服務之醫學中心於1969和2002年間進行活體捐贈腎臟摘除的超過2000位的捐贈者中,找到127位捐贈者參與研究,對這些參與者之醫療紀錄身體檢查和抽取血液樣本加以回顧。
  
  此外,這些參與者接受24小時尿液蒐集以分析肌酸酐清除率、蛋白尿和GFR,研究者定義低GFR為 60 mL/min/1.73 m2 ,和定義蛋白尿為24小時總蛋白尿分泌超過150 mg/天。
  
  這些參與者都是捐贈後已3年以上者,平均追蹤期為 8 年。
  
  研究發現,較年長的捐贈者比年輕捐贈者在捐贈後較可能有低GFR (P < .001),男性和身體質量指數(BMI) 則無法預測捐贈後低GFR。
  
  Posselt醫師表示,捐贈前GFR小於等於80之捐贈者較可能在追蹤期出現GFR小於等於60,當使用多變項分析校正年紀因素後,研究者發現捐贈前GFR可強烈預測捐贈後GFRs (P < .0008)。
  
  Posselt醫師指出,有趣的是,常用來篩選捐贈者的肌酸酐清除率一點也無法預測追蹤期的GFR或者肌酸酐清除率。
  
  常見於高血壓病患的蛋白尿,則顯著和男性相關(P < .01),也和捐贈時體重相關(P < .01)。
  
  可以顯著預測發生高血壓的風險因子是男性(P < .01)和捐贈前BMI > 30 kg/m2 (P < .05)。
  
  Posselt醫師建議,有潛在風險的捐贈者應接受適當的術前諮商和頻繁的追蹤。
  
  Posselt醫師向Medscape表示,捐贈者應接受每年定期追蹤和腎功能檢測,以及進行固定的血壓監測,捐贈者若完全健康且無掛慮之處自然不必接受治療,我們所需要的是在(捐贈)之後確保有加以監測。
  
  哥倫比亞大學醫學中心腎臟胰臟移植主任、Lloyd Ratner醫師向Medscape提出建議,目前對捐贈者的長期追蹤極少,移植委員會直截了當地表達感謝之意,而我們現在要找出的是捐贈者的可能長期風險,我想,我們可以說有風險,但不管怎樣,對一般族群的風險增加或者減少則尚屬未定。
  
  Posselt醫師認為此議題是明確的,一般族群的GFR隨年紀增加而減少,但我認為在有風險者的GFR減少會加劇;但因捐贈者只剩下一顆腎臟,因此無法對捐贈者和一般族群進行實際比較。
  
  此研究之資金獨立。作者無相關財金關係。
  
  世界人體器官移植大會2006:摘要 976。發表於July 26, 2006。

Risk Factors May Predict Long-

By Katherine Kahn, DVM
Medscape Medical News

July 31, 2006 (Boston) — Older age and reduced glomerular filtration rate (GFR) at organ donation may be significant risk factors for developing renal dysfunction after donation, a new study shows. In addition, obese, male donors may be at increased risk for postdonation hypertension. Andrew Posselt, MD, PhD, presented the findings here at the World Transplant Congress. Dr. Posselt is a transplant surgeon at the University of California in San Francisco.

"Over the last several years demand for living donor kidneys has increased," Dr. Posselt told meeting attendees. "As a result, live donor exclusion criteria have been liberalized to include older donors, obese donors, patients with unilateral renal artery disease, and patients with hypertension. In the short term, the consequences of this seem to be negligible, but long-term sequelae are not well-understood."

Dr. Posselt and coinvestigators wanted to determine if there were any patient characteristics or predonation tests that could predict the eventual development of renal insufficiency, proteinuria, and hypertension in donors.

"We wanted to look at this because it seemed like it was almost accepted that donors have good renal function after nephrectomy, and no one was looking into that," Dr. Posselt told Medscape in an interview.

From more than 2000 donors that had undergone living donor nephrectomies between 1969 and 2002 at their center, the researchers recruited 127 donors. Participating donors had their medical records reviewed, and they received a physical examination and had blood samples taken.

In addition, donors underwent 24-hour urine collection for creatinine clearance, proteinuria, and GFR analysis. The researchers defined a low GFR as 60 mL/min/1.73 m2 and proteinuria as a total protein urine excretion over 24 hours as more than 150 mg/day.

All participants were more than 3 years postdonation, with a mean follow-up of 8 years.

The study found that older donors were more likely to have a low GFR after donation than younger donors (P < .001). Male sex and body mass index (BMI) at donation or follow-up did not predict a low postdonation GFR.

"Donors who had a predonation GFR of 80 or less were more likely to have a GFR of 60 or less on follow-up," Dr. Posselt said. When adjusting for age using multivariate analysis, the researchers found that predonation GFR was strongly predictive of postdonation GFRs (P < .0008).

"Interestingly, corrected creatinine clearance, which is very often used in donor screening, was not predictive at all of eventual GFR or follow-up creatinine clearance," Dr. Posselt noted.

Proteinuria, which was mostly seen in the hypertensive patients, correlated significantly with male sex (P < .01) and weight at donation (P < .01).

Risk factors significantly predicting the development of hypertension were male sex (P < .01) and a predonation BMI > 30 kg/m2 (P < .05).

Donors with potential risk factors should receive appropriate preoperative counseling and frequent follow-up, Dr. Posselt advised.

Dr. Posselt told Medscape that donors should receive regular annual follow-ups and renal function tests, and they should have their blood pressure monitored. "Donors shouldn't be treated as if they are completely healthy and have nothing to worry about. We need to make sure we watch them afterwards."

Lloyd Ratner, MD, director of renal and pancreatic transplantation at Columbia University Medical Center in New York, City, commented to Medscape, "The long-term follow-up of donors has been very slim. The transplant community has come to the point where we appreciate that there are probably long-term risks to at least some of the donors, and now we are trying to sort all that out. I think we can say there is risk, but whether or not that has increased above and beyond [the risks] to the general population, the jury is still out."

Dr. Posselt felt the issue is more clear-cut. "There is a decline in GFR in the general population as it ages, but I think you see an accelerated decline in some of these at-risk patients. You can't really compare donors to the general population because the donors now have only one kidney, so it's tricky."

The study was independently funded. The authors report no relevant financial relationships.

World Transplant Congress 2006: Abstract 976. Presented July 26, 2006.

    
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