Konverzija sa kalcineurinskih inhibitora na sirolimus kod primalaca sa hroničnom insuficijencijom bubrežnog grafta trećeg stepena u periodu 2003–2011.

  • Ljiljana Bozidar Ignjatovic*, Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
  • Rajko Hrvačevic Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
  • Dragan Jovanović Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
  • Zoran Kovačević Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
  • Neven Vavić Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
  • Violeta Rabrenović Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
  • Aleksandar Tomić Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
  • Predrag Aleksić Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
  • Biljana Draškovć-Pavlović Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
  • Aleksandar Dujić†. Institute for Medical Research, Military Medical Academy, Belgrade, Serbia
  • Željiko Karan Center for Hospital Information System, Military Medical Academy, Belgrade, Serbia
  • Djoko Maksić Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
DOI: https://doi.org/10.2298/1383

Sažetak


Uvod/Cilj. Značajan prodor u transplantaciji solidnih organa postignut je uvođenjem kalcineurinskih inhibitora (KNI). Istovremeno, njihovi potencijalno nefrotoksični efekti mogu da doprinesu nastanku i progresiji insuficijencije bubrežnog grafta. Cilj ispitivanja bio je da se utvrdi ishod konverzije sa imunosupresivnih protokola baziranih na KNI na sirolimus (SRL) kod primalaca sa trećim stepenom hronične bubrežne slabosti grafta i proteinurijom manjom od 500 mg/dan. Metode. U periodu od 2003. do 2011. 24 bolesnika (6 žena i 18 muškaraca), prosečne starosti 41 ± 12,2 godine, na trostrukoj imunosupresivnoj terapiji: steroidi, antiproliferativni lek [mekofenolat mofetil (MMF)/ azatioprin (AZA)] i KNI prevedeno je sa KNI na SRL i praćeno 76 ± 13 meseci. Devet bolesnika (I grupa) prevedeno je rano, tokom prve postransplantacione godine (4 ± 3 meseca) i 15 kasno, nakon prve godine (46 ± 29 meseci). Tokom redovnih ambulantnih kontrola pratili smo funkciju grafta praćenjem vrednosti serumskog kreatinina,  jačine glomerulske filtarcije (JGF), proteinurije i lipidemije. Rezultati. Tridesetog dana nakon konverzije kod svih bolesnika vrednosti JGF, proteinurije i lipidemije bile su neznato povećane. Tokom prva dva meseca svi bolesnici imali su makar jednu urinarnu ili respiratornu infekciju, a kod 10 bolesnika se reaktivirala citomegalovirusna infekcija/bolest, Bolesnici su uspešno izlečeni standardnom terapijom. U preriodu od 21 ± 11 meseci kod 15 bolesnika iz obe grupe obustavljena je terapija SRL zbog: rekonverzije na KNI (10 bolesnika) ili dvostruke imunosupresivne terapije (3 bolesnika), vraćanja na hemodijalizu (1 bolesnik) i smrti (1 bolesnik). Devet bolesnika bilo je i dalje na terapiji SRL. Do kraja praćenja oni su znatno popravili JGF (sa 53,2 ± 12,7 na 69 ± 15 mL/min), a neznatno povećali proteinuriju (sa 265 ± 239 na 530,6 ± 416,7 mg/dan) i lipidemiju (holesterol sa 4,71 ± 0,98 na 5,61 ± 1,6 mmol/L i trigliceride sa 2,04 ± 1,18 na 2,1 ± 0,72 mmol/L). Svi su bili stabilni tokom praćenja. Deset bolesnika vraćeno je na KNI zbog naglog povećanja proteinurije, sa 298 ± 232 na 1639 ± 1641 mg/dan (7 bolesnika), brzog rasta multiplih ovarijalnih cista (2 bolesnika) i operativnog lečenja perzistentnog hematoma (1 bolesnik). Od rekonverzije do kraja praćenja bili su stabilni, ali sa neznatnim sniženjem JGF (sa 56,10 ± 28,09 na 47 ± 21 mL/min) i značajno nižom proteinurijom (sa 1639 ± 1641 na 529 ± 688 mg/dan). Do kraja praćenja kod njih se neznatno povećala vrednost serumskog kreatinina (sa 172 ± 88 na 202 ± 91 mmol/L), smanjila vrednost JGF (sa 56,10 ± 28,09 na 47 ± 21 mL/min) i povećala proteinurija (sa 528,9 ± 688 na 850 ± 1083 mg/dan). Zaključak. U ovom malom deskriptivnom ispitivanju prevođenje sa KNI na SRL bilo je praćeno većom incidencijom infektivnih komplikacija, što je uslovilo sniženje doze drugog antiproliferativnog leka (AZA ili MMF) za 25–50% i moguće imalo uticaj na pojavu glomerulopatije, koja je bila razlog za prekid terapije sirolimusom kod sedam (29%) bolesnika. Najveću korist od konverzije sa CNI na SRL imalo je devet (37,5%) bolesnika koji nisu ispoljili značajne komplikacije nakon konverzije.

 

Ključne reči:

transplantacija bubrega; graft, preživljavanje; bubreg, hronična insuficijencija; kalcineurin; sirolimus; bolest, progresija.

Biografije autora

Ljiljana Bozidar Ignjatovic*,, Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia

Clinic Of Nephrologu I

nephrologyst

Aleksandar Dujić†., Institute for Medical Research, Military Medical Academy, Belgrade, Serbia
retired

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Objavljeno
2017/01/20
Broj časopisa
Vol. 70 Br. 9 (2013)
Rubrika
Originalni članak