Acute Late Rejectionの治療と予後

Abstract

1)移植後4ヵ月目以降に発症する急性拒絶反応は3ヵ月以内に発症する拒絶反応とは別の概念として扱う方が統計的に妥当であり, しかもその頻度が30%程度と無視できない. 2)ALRの治療法としてのステロイド, DSGは短期的にはある程度の治療成績を示すものの長期における移植腎機能の低下を阻止することは出来ない. 3)長期成績を向上させるために現時点では一般的な腎保護のための保存療法に真剣に取り組むことしか良い方法がない

To examine the acute late rejection episodes (ALR) occurring 4 months after kidney transplantation, 330 cadaver kidney transplant recipients who were operated on between 1982 and 1996 and immunosuppressed by cyclosporine or tacrolimus were analyzed. In 213 recipients who were followed up for 5 years or longer, the frequency of ALR without an acute early rejection (AER) was 14% and ALR with AER was 16%, respectively. ALR was the strongest deteriorating factor for graft survival at the chronic stage. Judging from the renal function 1 month after an ALR episode, the complete and partial response rates were 22% and 62% with steroid treatment and 16% and 58% with DSG treatment, respectively. The 5-year graft survival after the treatment was 20% with steroid treatment and 45% with DSG treatment. Although the intensity of the rejection classified based on the Banff grading system was the strongest factor affecting the graft survival, the multivariate analysis by Cox proportional hazard model for non-pathological factors revealed that urine protein and hypertension 1 month before the episodes may also be important prognostic factors. The body weight of recipient (> 55 kg) and donor age (> 55 y.o) were slightly correlated to the graft prognosis. Due to incomplete immuno-suppressive methods for acute late rejection, the conservative nephron sparing policy after a rejection episode is inevitable to obtain better graft survival at the chronic stage.