急性腎損傷可能並不妨礙移植


  【24drs.com】根據線上發表於3月11日美國移植期刊的一篇多中心研究,鑑於合理之6個月的移植腎功能,醫師可考慮從急性腎臟損傷(acute kidney injury,AKI)死亡的器捐者摘取腎臟,不過,仍有腎臟無法使用或者延遲發揮移植物功能(DGF)的風險;DGF的定義是,在移植後第一週,仍需要繼續透析支持。
  
  資深作者、耶魯大學醫學院移植應用研究計畫主任Chirag R. Parikh醫師在大學新聞稿中表示,這些急性腎臟損傷的腎臟似乎仍有更多的移植運用空間,而不是直接把它們丟掉。
  
  Parikh醫師表示,等候移植名單已經超過10萬名病患,因為每年等候移植的病患數都比實際進行移植者多數千人。此外,美國成人等到進行移植的時間,在1998-2008年間已經從平均2.7年增加到4.2年,每年有超過5000人因為等不到腎臟移植而死亡。
  
  耶魯大學醫學院醫學系移植應用研究計畫的Isaac E. Hall醫師等人,使用1,632名捐贈者的資料,檢視急性腎臟損傷的關聯,定義是,因為末端血清中肌酸酐增加住院、腎臟棄用、延遲發揮移植物功能、以及6個月時的估計腎絲球過濾速率(eGFR)。
  
  相較於沒有急性腎臟損傷的捐贈者,「AKI Network」分期1、2、3者的腎臟棄用風險增加,校正相關風險為分別是1.28 (95%信賴區間 [CI]為1.08 - 1.52)、1.82 (95% CI,1.45 - 2.30)與 2.74 (95% CI,2.00 - 3.75)。
  
  捐贈者的急性腎臟損傷分期也和延遲發揮移植物功能的風險有關,校正相關風險為分別是:第1期為1.27 (95% CI,1.09 - 1.49)、第2期為1.70 (95% CI,1.37 - 2.12)、第3期為2.25 (95% CI,1.74 - 2.91)。
  
  不過,令人驚訝的是,急性腎臟損傷和6個月後的腎臟移植功能不佳無關,急性腎臟損傷分期並未顯著影響6個月時的eGFR,但是,延遲發揮移植物功能之受贈者6個月時的eGFR (48 mL/minute/1.73 m2;四分位範圍為31 - 61 mL/minute/1.73 m2)顯著低於沒有發生延遲發揮移植物功能者(58 mL/minute/ 1.73 m2;四分位範圍為45 - 75 mL/minute/1.73 m2;P < .001)。
  
  捐贈者的急性腎臟損傷分期與延遲發揮移植物功能之間有顯著的良性互動,隨著捐贈者的急性腎臟損傷分期增加,延遲發揮移植物功能腎臟的6個月eGFR也增加(互動P值= 0.05)。
  
  Hall醫師在新聞稿中表示,我們看到的是,隨著捐贈者的急性腎臟損傷惡化,6個月時的結果實際上優於發生延遲發揮移植物功能的受贈者。
  
  Hall醫師提出一個可能的解釋,捐贈者的腎臟急性損傷可能會發生一些缺血性的先決條件,而使器官免於後續的損傷,或者,校正捐贈者的年齡、合併症、以及其他臨床因素後,被成功移植之急性損傷腎臟的品質可能比較好,否則,就會是被排斥的急性損傷腎臟。
  
  作者們指出幾個研究限制,包括觀察型研究設計的可能干擾因素,以及缺乏6個月之後的追蹤資料,不過,研究作者建議,對於擴大急性腎臟損傷之已故者的器捐要謹慎考量。
  
  Parikh醫師在新聞稿中表示,就算這樣只代表每年都出幾十個可移植的腎臟,受贈者可以在移植後脫離等候名單,生活品質也會比等待著不知道何時才會有的較高品質腎臟而繼續透析者還要好。
  
  資料來源:http://www.24drs.com/

Acute Kidney Injury May Not Preclude Transplant

By Laurie Barclay, MD
Medscape Medical News

In light of reasonable 6-month graft function, clinicians should consider kidney transplant from deceased donors with acute kidney injury (AKI), according to a multicenter study published online March 11 in the American Journal of Transplantation. However, there are risks for kidney discard and delayed graft function (DGF), defined as the need for continued dialysis support in the first week after transplantation.

"There appears to be room to attempt more transplants using these AKI kidneys rather than throwing them away," senior author Chirag R. Parikh, MD, director of the Program of Applied Translational Research at Yale University School of Medicine, New Haven, Connecticut, said in a university news release.

"The waiting list has grown to over 100,000 patients as thousands more people are wait-listed each year than actually receive a transplant. In addition, the median time it takes for an adult to receive a transplant in the United States increased from 2.7 to 4.2 years between 1998 and 2008, and more than 5,000 people die each year while waiting for a kidney," Dr Parikh continued.

Using a sample of 1632 donors, Isaac E. Hall, MD, from the Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, and colleagues examined associations of AKI, defined as increasing admission-to-terminal serum creatinine, with kidney discard, DGF, and 6-month estimated glomerular filtration rate (eGFR).

Compared with donor kidneys with no AKI, kidneys with AKI Network stages 1, 2, and 3 had increased kidney discard risk. Adjusted relative risks were 1.28 (95% confidence interval [CI], 1.08 - 1.52), 1.82 (95% CI, 1.45 - 2.30), and 2.74 (95% CI, 2.00 - 3.75), respectively.

Donor AKI stage was also linked to risk for DGF, with adjusted relative risks of 1.27 (95% CI, 1.09 - 1.49) for stage 1, 1.70 (95% CI, 1.37 - 2.12) for stage 2, and 2.25 (95% CI, 1.74 - 2.91) for stage 3.

Surprisingly, however, AKI was not linked to poor kidney transplant function 6 months later, and AKI stages did not differ significantly in terms of 6-month eGFR. However, recipients with DGF had significantly lower 6-month eGFR (48 mL/minute per 1.73 m2; interquartile range, 31 - 61 mL/minute per 1.73 m2) than those without DGF (58 mL/minute per 1.73 m2; interquartile range, 45 - 75 mL/minute per 1.73 m2; P < .001).

There was a significant, favorable interaction between donor AKI stage and DGF. Six-month eGFR increased in tandem for DGF kidneys with increasing donor AKI (P for interaction = .05).

"What we saw was, with worsening AKI in the donor, the six-month outcome was actually better for recipients who experienced DGF," Dr Hall said in the news release.

A possible explanation offered by Dr Hall was that kidneys acutely injured in the donor may develop ischemic preconditioning, which could protect the organs from later injury. Alternatively, the successfully transplanted kidneys with AKI may have been of better quality otherwise than the rejected kidneys with AKI, despite adjustment for donor age, comorbidity, and other clinical factors.

The authors note several study limitations, including its observational design with possible residual confounding and lack of complete follow-up data beyond 6 months. Nonetheless, the study authors suggest considering cautious expansion of the donor pool to deceased donors with AKI.

"Even if it only means a few dozen more kidney transplants each year, those are patients who would come off of the waiting list for transplants sooner and have much better survival than continuing on dialysis in hopes of seemingly higher-quality kidney offers, which may never come in time," Dr Parikh said in the release.

The American Heart Association and the National Institutes of Health supported this study. Dr Parikh received a Roche Organ Transplantation Research Foundation Award. The other authors have disclosed no relevant financial relationships.

Am J Transplant. Published online March 11, 2015.

    
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