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Management der Immunsuppression nach Nierentransplantation

Management of immunosuppression after kidney transplantation

  • Leitthema
  • Published:
Der Nephrologe Aims and scope

Zusammenfassung

Durch die Immunsuppression mit Calcineurininhibitoren (CNI) zusammen mit Glukokortikoiden konnte das Auftreten akuter Abstoßungen nach Nierentransplantation deutlich reduziert werden. Allerdings trägt die Nephrotoxizität der CNI zum chronischen Transplantatversagen bei und die Nebenwirkungen der Glukokortikoide zu einer Verschlechterung des kardiovaskulären Risikoprofils. Beim Absetzen von CNI oder Glukokortikoiden und Fortführen mit DNA-Synthesehemmern bzw. bei der Konversion muss individuell im Hinblick auf das Risiko einer akuten Abstoßung, die Transplantatfunktion und das Nebenwirkungsprofil der Präparate entschieden werden. In Kombination mit Mycophenolatmofetil können CNI sicher reduziert werden, allerdings können diese CNI nicht ersetzen. Eine Konversion von CNI auf mTOR-Inhibitoren ist möglich bei Patienten mit einer GFR >40 ml/min, einem Urin-Protein/Kreatinin-Quotienten ≤0,11 und unter engmaschiger Kontrolle der Transplantatfunktion sowie des Patienten im Hinblick auf mögliche Nebenwirkungen. Eine Vermeidung von CNI- oder Glukokortikoid-basierten Regimen mit Hilfe neuerer Immunsuppressiva ist möglich, allerdings fehlen noch ausreichende Daten für den Langzeitverlauf.

Abstract

The introduction of calcineurin inhibitors (CNIs) and their combination with steroids has led to a decreased incidence of acute rejection episodes in patients after kidney transplantation. However, the nephrotoxicity of CNIs contributes to chronic allograft injury, and the side effects of steroids contribute to a deterioration of the cardiovascular risk profile. The decision to withdraw CNIs or steroids and continue with, or change to, DNA synthesis inhibitors needs to be made individually on the basis of the risk of acute rejection, the function of the graft, and side effects of the applied drugs. Conversion from CNIs to mTOR inhibitors is feasible in patients with a baseline glomerular filtration rate >40 ml/min and a urine protein/creatinine ratio ≤0.11 and with close monitoring of side effects. CNIs or steroid-free immunosuppression may be successful with new immunosuppressants, yet more data are required with respect to long-term results.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung/en hin: Forschungsunterstützung von Astellas, Roche, Novartis, Wyeth.

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  1. Klinik für Nephrologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland

    S. Becker &  O. Witzke

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  1. S. Becker
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  2. O. Witzke
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Correspondence to O. Witzke.

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Becker, S., Witzke, O. Management der Immunsuppression nach Nierentransplantation. Nephrologe 4, 221–229 (2009). https://doi.org/10.1007/s11560-008-0274-4

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