利妥昔单抗或血浆置换预防肾移植后局灶节段性肾小球硬化复发:一项系统回顾和荟萃分析。

Boonphiphop Boonpheng, Panupong Hansrivijit, Charat Thongprayoon, Shennen A Mao, Pradeep K Vaitla, Tarun Bathini, Avishek Choudhury, Wisit Kaewput, Michael A Mao, Wisit Cheungpasitporn
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引用次数: 8

摘要

背景:局灶节段性肾小球硬化(FSGS)是导致肾功能衰竭最常见的肾小球疾病之一。肾移植后FSGS复发风险高。使用利妥昔单抗和/或血浆置换预防FSGS复发已在多个小型研究中进行了评估,结果相互矛盾。目的:评价预防性利妥昔单抗联合或不联合血浆置换、单独血浆置换与不加预防治疗的标准治疗组比较FSGS移植术后复发的风险。方法:首先对MEDLINE、EMBASE和Cochrane数据库进行文献检索,从建立到2021年3月,进行meta分析和系统评价;搜索词包括“FSGS”、“类固醇抵抗性肾病综合征”、“利妥昔单抗”和“血浆置换”。我们确定了评估移植后FSGS风险的研究,这些研究是在使用利妥昔单抗联合或不联合血浆置换或单独血浆置换后进行的。纳入标准为:原始的、已发表的、随机对照试验或队列研究(前瞻性或回顾性)、病例对照或横断面研究;纳入95%置信区间(CI)的优势比、相对风险和标准化发病率,或足够的原始数据来计算这些比率;在队列和横断面研究中,没有干预的受试者(对照)被用作比较者。从个别研究中提取效果估计,并使用随机效应模型进行组合。结果:11项研究,共399例FSGS肾移植受者,评估了利妥昔单抗伴或不伴血浆置换的使用;13项研究共纳入571例FSGS肾移植受者,单独评估血浆置换。移植后FSGS复发较早。接受利妥昔单抗组(伴或不伴血浆置换)与标准治疗组的复发率无显著差异,合并风险比为0.82 (95%CI: 0.47-1.45, i2 = 65%)。同样,单独血浆置换与不进行血浆置换相比,FSGS复发无显著差异;合并风险比为0.85 (95%CI: 0.60 ~ 1.21, i2 = 23%)。在儿童和成人组的亚组分析中,复发风险没有显著差异。我们还回顾和分析了移植后的结果,包括复发时间和移植物存活。结论:总体而言,使用利妥昔单抗联合或不联合血浆置换,或单独使用血浆置换,与肾移植后FSGS复发风险降低无关。未来的研究需要评估利妥昔单抗联合或不联合血浆置换在FSGS复发高风险的特定亚组患者中的有效性。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Rituximab or plasmapheresis for prevention of recurrent focal segmental glomerulosclerosis after kidney transplantation: A systematic review and meta-analysis.

Rituximab or plasmapheresis for prevention of recurrent focal segmental glomerulosclerosis after kidney transplantation: A systematic review and meta-analysis.

Rituximab or plasmapheresis for prevention of recurrent focal segmental glomerulosclerosis after kidney transplantation: A systematic review and meta-analysis.

Rituximab or plasmapheresis for prevention of recurrent focal segmental glomerulosclerosis after kidney transplantation: A systematic review and meta-analysis.

Background: Focal segmental glomerulosclerosis (FSGS) is one of the most common glomerular diseases leading to renal failure. FSGS has a high risk of recurrence after kidney transplantation. Prevention of recurrent FSGS using rituximab and/or plasmapheresis has been evaluated in multiple small studies with conflicting results.

Aim: To assess the risk of recurrence of FSGS after transplantation using prophylactic rituximab with or without plasmapheresis, and plasmapheresis alone compared to the standard treatment group without preventive therapy.

Methods: This meta-analysis and systematic review were performed by first conducting a literature search of the MEDLINE, EMBASE, and Cochrane databases, from inception through March 2021; search terms included 'FSGS,' 'steroid-resistant nephrotic syndrome', 'rituximab,' and 'plasmapheresis,'. We identified studies that assessed the risk of post-transplant FSGS after use of rituximab with or without plasmapheresis, or plasmapheresis alone. Inclusion criteria were: Original, published, randomized controlled trials or cohort studies (either prospective or retrospective), case-control, or cross-sectional studies; inclusion of odds ratio, relative risk, and standardized incidence ratio with 95% confidence intervals (CI), or sufficient raw data to calculate these ratios; and subjects without interventions (controls) being used as comparators in cohort and cross-sectional studies. Effect estimates from individual studies were extracted and combined using a random effects model.

Results: Eleven studies, with a total of 399 kidney transplant recipients with FSGS, evaluated the use of rituximab with or without plasmapheresis; thirteen studies, with a total of 571 kidney transplant recipients with FSGS, evaluated plasmapheresis alone. Post-transplant FSGS recurred relatively early. There was no significant difference in recurrence between the group that received rituximab (with or without plasmapheresis) and the standard treatment group, with a pooled risk ratio of 0.82 (95%CI: 0.47-1.45, I 2 = 65%). Similarly, plasmapheresis alone was not associated with any significant difference in FSGS recurrence when compared with no plasmapheresis; the pooled risk ratio was 0.85 (95%CI: 0.60-1.21, I 2 = 23%). Subgroup analyses in the pediatric and adult groups did not yield a significant difference in recurrence risk. We also reviewed and analyzed post-transplant outcomes including timing of recurrence and graft survival.

Conclusion: Overall, the use of rituximab with or without plasmapheresis, or plasmapheresis alone, is not associated with a lower risk of FSGS recurrence after kidney transplantation. Future studies are required to assess the effectiveness of rituximab with or without plasmapheresis among specific patient subgroups with high-risk for FSGS recurrence.

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