西罗莫司替代钙调磷酸酶抑制剂方案治疗肾移植后“爬行肌酐”患者的疗效观察（附28例报告）

目的探讨采用西罗莫司替代钙调磷酸酶抑制剂（CNI）方案治疗肾移植后＂爬行肌酐＂患者的临床疗效。方法具有＂爬行肌酐＂表现的28例患者中,术后采用以环孢素（CsA）为主的三联免疫抑制方案20例,采用以他克莫司（FK506）为主的三联免疫抑制方案8例。患者确诊后即停用CsA或FK506,24h后给予西罗莫司,初始剂量6mg,维持剂量为2mg/d,以后根据西罗莫司的血药浓度来调整剂量,使其血药谷浓度维持在5～9μg/L,药物替代前后麦考酚吗乙酯（MMF）及肾上腺皮质激素（激素）的用量不变。随访6个月,定期观察移植物肾功能,记录排斥反应的发生情况,并监测血常规、血糖、血脂、肝功能等指标。结果移植物肾功能明显改善16例,患者的血清肌酐（Scr）由替代前（205±20）μmo1/L降为替代后的（153±18）μmo1/L,内生肌酐清除率（Ccr）由（51±3）ml/min升高为（56±3）ml/min（均为P〈0.05）;移植物肾功能维持稳定8例,移植物肾功能继续恶化2例。治疗中,1例发生急性排斥反应,移植肾失功并恢复血液透析,1例西罗莫司替代后出现明显骨髓抑制而放弃替代治疗,恢复替代前的免疫抑制方案。结论西罗莫司替代CNI治疗肾移植后＂爬行肌酐＂患者是一种比较安全并有效的方法,可明显改善移植物肾功能,但会使患者血脂升高。

Substitution therapy of sirolimus for calcineurin inhibitors in renal transplant recipients with creeping creatinine:clinical analysis of 28 cases

Objective To investigate the effect of sirolimus substitution for calcineurin inhibitors（CNI）in renal transplant recipients with creeping creatinine.Methods A retrospective study was performed in 28 kidney recipients with creeping creatinine.Cyclosporine（CsA）-based immunosuppressive regimen had been used in 20 patients and tacrolimus（FK506）-based in another 8 patients.The substitution of sirolimus for CNI（CsA or FK506）was applied with the same dosage of MMF and prednisone 24 h after CNI withdrawal.The initial dose of sirolimus was 6 mg,then was changed to 2 mg/d,and was adjusted according to its blood trough level.The target blood level of sirolimus was 5～9 μg/L.All patients were followed up for 6 months to evaluate the renal function and monitor parameters such as serum creatinine,creatinine clearance rate of change,blood routine examination,blood glucose,blood lipids,liver function and so on.Results During six months follow-up,the renal function of 16 patients was improved after substitution therapy.The value of serum creatinine was decreased from（205±20）μmol/L to（153±18）μmol/L.The value of clearance of creatinine rate was increased from（51±3）ml/min to（56±3）ml/min（all in P0.05）.The renal function was stable in 8 patients and deteriorated progressively in 2 patients.During the therapeutic process,1 case developed acute rejection and continued with hemodialysis because of transplanted renal failure.One case gave up substitute treatment and continued with the previous immunosuppressive regimen because of myelosuppression.Conclusion Sirolimus substitution for CNI is safe and effective in renal transplant recipients with treating creeping creatinine.The substitution can improve the transplanted renal function but will increase the blood lipid in the recipients.