心脏移植后采用他克莫司替代环孢素A治疗的体会

目的 探讨心脏移植后因排斥反应或环孢素A(CsA)不良反应而将CsA替换为他克莫司(FK506)的临床效果.方法 6例原位心脏移植患者中,5例因发生严重排斥反应或排斥反应不能控制、1例因CsA的肝毒性,而将CsA替换为FK506,其它免疫抑制剂不变,转换时间为术后(167.8±166.7)d,FK506的用量为(6.0±1.4)mg/d,维持其血药浓度在(14.7±5.6) μg/L.心内膜心肌活检(EMB)联合超声心动图监测排斥反应.结果 随访(17.1±6.0)个月,6例患者全部存活,2例心功能下降者在换用FK506后心功能恢复正常.换用FK506前,排斥反应评分为(2.50±0.42)分,换用FK506后,排斥反应评分降至(0.60±0.39)分(P＜0.01).1例患者转换为FK506后3周,出现发热及胸腔积液,经抗结核治疗1周后好转,半年后停止抗结核治疗,患者至今存活1年;转换为FK506后,4例患者因血糖升高(其中2例转换前血糖即升高)需用胰岛素治疗;换用FK506后,CsA所致的多毛消失,牙龈增生减轻.结论 心脏移植后采用CsA进行免疫抑制治疗者,若反复发生排斥反应或出现不能耐受的CsA不良反应,可将CsA替换为FK506,临床效果明显.

Tacrolimus as a rescue immunosuppressant after heart transplantation

Objective To review our experience with tacrolimns as a rescue immunosuppressant for heart transplant recipients with refractory rejection or cyclosporine intolerance. Methods From June 2004 to May 2007, 6 out of 64 cardiac transplant recipients were converted from our standard cyclosporine-based immunosuppressive regimen to a tacrolimus-based treatment. Each recipient had been treated with cyelosporine, mycophenolate mofetil and steroids. Five were switched to tacrolimus for rejection and one for severe debilitating side-effects attributed to cyclosporine. All 5 converted to tacrolimus because of rejection had been treated with high-dose methylprednisolone intravenously.Results The time between transplantation and conversion to tacrolimus ranged from 50 to 480 (average 167. 8 ± 166. 7) days. The 6 recipients are alive with a follow-up period of 17. 1 ± 6. 0 months. The average score of acute rejection was decreased from 2. 50 ± 0. 42 on the cyclosporine regimen to 0. 60 ± 0. 39 on the tacrolimus regimen (P＜0. 01). The intolerant and rejection recipients resolved in all patients who were converted to tacrolimus. During tacrolimus-based immunosuppression two recipients developed diabetes mellitus and required insulin therapy. Three recipients had reduced gingiral hyperplasia and hirsute attributed to cyclosporine side effects. Conclusion In our experience, conversion from a cyclosporine-based to a tacrolimus-based maintenance immunosuppression has been shown to be an effective and safe approach to the management of patients with persistent or recurrent cardiac allograft rejection or those with cyclosporine intolerance.