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Vojnosanitetski pregled
2013, vol. 70, br. 9, str. 848-853
jezik rada: engleski
vrsta rada: izvorni naučni članak
doi:10.2298/VSP1309848I


Konverzija sa kalcineurinskih inhibitora na sirolimus kod primalaca sa hroničnom insuficijencijom bubrežnog grafta trećeg stepena u periodu 2003-2011.
aVojnomedicinska akademija
bMilitary Medical Academy, Clinic of Nephrology, Belgrade + University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade
cUniversity of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade + Military Medical Academy, Clinic of Vascular Surgery, Belgrade
dUniversity of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade + Military Medical Academy, Clinic of Urology, Belgrade
eUniversity of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade + Military Medical Academy, Institute for Medical Research, Belgrade

e-adresa: ignjatovicl957@gmail.com

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

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