Immunosuppressive treatment in dialysis patients.

Renal Department, Ospedale San Michele, Cagliari, Italy.
Nephrology Dialysis Transplantation (Impact Factor: 3.49). 08/2002; 17 Suppl 8:2-9.
Source: PubMed

ABSTRACT Immunosuppressive treatment is a critical procedure in dialysis patients, in whom an increased risk of infection is already present. Haemodialytic treatment increases the patient's susceptibility to bacterial infection, mainly by impairing polymorphonuclear leukocyte phagocytosis, but it can also restore the patient's immunological defences by improving the T-cell function, which is reduced by pre-dialysis uraemia. Patients on dialysis usually continue the immunosuppressive treatment that had been established for the illness that caused their renal failure [e.g. systemic lupus erythematosus (SLE) or renal vasculitis]. Less frequently, patients on dialysis need immunosuppression for immunological or inflammatory diseases that appear 'de novo' after initiation of dialysis. SLE and antineutrophil cytoplasmic antibody (ANCA)-related vasculitides are immunological illnesses that frequently cause end-stage renal failure (ESRF). A reduction in serological and/or clinical activity is usually observed in SLE patients after they reach ESRF, but a similar or increased frequency of extrarenal relapse episodes in lupus patients after the beginning of the dialysis, compared with the pre-dialysis period, has also been described. Frequency of relapse episodes in patients on dialysis treatment for ANCA-related vasculitides varies from 10 to 30% per patient/year in different reports, and it is higher than the frequency of relapses after renal transplantation; anti-rejection therapy seems to be the most likely protective factor in these conditions. The treatment of relapse episodes in SLE or ANCA vasculitis in dialysis-dependent patients is usually not different from treatment of relapses in patients with dialysis-independent renal function. However, the risk of severe infection caused by immunosuppressive treatment is relevantly higher in dialysis patients. Furthermore, there is a lack of prospective controlled studies indicating the optimal management of immunosuppressive protocols in dialysis patients. A particularly careful assessment of the patient's risks and benefits is necessary in deciding how long immunosuppressive treatment should last after acute or rapidly progressive renal damage, that should require dialysis treatment, in patients with SLE or ANCA vasculitis. In the above conditions, the risks of prolonging immunosuppressive treatment must be balanced against the relatively good prognosis offered to these patients by dialysis and renal transplantation. In a retrospective review of 24 patients receiving long-term steroid therapy (>3 months) in our dialysis unit in the past 5 years, we found relevant clinical differences in the patients receiving steroid treatment compared with 24 controls. Steroid-treated patients showed less favourable nutritional conditions, with lower serum albumin and body mass index vs non-steroid-treated patients; moreover, C-reactive protein values were persistently higher in the steroid-treated group. Steroid treatment in these patients was usually performed at the beginning of regular dialysis, as a continuation of the treatment that started before the initiation of dialysis. Only two patients, who needed a prolonged low-dose steroidal treatment to control a malnutrition-inflammation-atherosclerosis (MIA) syndrome, started steroids many years after beginning dialysis. Steroid treatment was effective in improving the nutritional condition and inflammatory symptoms in these two patients after all conventional measures had failed.

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    ABSTRACT: Although prognosis of lupus nephritis has improved over time, a substantial amount of lupus patients still reach end-stage renal disease and require dialysis. Treatment of these patients can be challenging, since the disease poses a number of problems that can portend a poor prognosis, such as infections, lupus reactivations, vascular access thrombosis and cardiovascular complications. Consensus is lacking among investigators about the real incidence of these complications and related diagnosis and treatment. Moreover, the choice of the type of dialysis treatment and the overall prognosis are still a matter of debate. In this paper, we have reviewed the currently available literature in an attempt to answer the most controversial issues about the topic.
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    ABSTRACT: It is well known that the existence of residual renal function (RRF) in peritoneal dialysis (PD) is related, amongst others, to im-proved results in nutrition, cardiovascular morbidity, and techni-que and patient survival. It appears natural to think that this fact, obvious in the population who starts replacement therapy, should also occur in dialysis patients in whom RRF depends on a transplant, which could justify maintenance of immunosuppres-sive treatment (IST). However, there are currently no studies sho-wing a correlation between RRF of the graft and survival on dialysis. At the same time, IST maintenance in an attempt to pre-serve glomerular filtration rate would involve risks (cardiovascu-lar morbidity, infections, etc.) that could counteract the theoreti-cal beneficial effect on RRF or even worsen prognosis. The available literature analyzing this controversy is scarce and is mostly based on small and retrospective series providing conflic-ting results. The decision about what to do with IST and how to do it in patients with chronic kidney transplant dysfunction arri-ving to dialysis should be based on opinions. When faced with this situation, and because of the significant negative effects of IST at cardiovascular and infectious level, the main causes of morbidity and mortality in uremic patients, we advocate discon-tinuation of IST when PD is started until future studies on the subject are available. Key words: Peritoneal dialysis. Renal transplantation. Immunosu-pression. Residual renal function. RESUMEN Es bien sabido que la existencia de función renal residual (FRR) en diálisis peritoneal (DP) se relaciona, entre otros, con mejores resultados en nutrición, morbilidad cardiovas-cular y supervivencia de técnica y paciente. Parece lógico pensar que este hecho, evidente en la población que inicia tratamiento sustitutivo, debería también producirse en enfermos dializados en los que la FRR dependa de un tras-plante, lo que podría justificar el mantenimiento del trata-miento inmunosupresor (TIS). No obstante, en el momento actual no hay trabajos que hayan demostrado una correla-ción entre FRR del injerto y supervivencia en diálisis. Al mismo tiempo, el mantenimiento del TIS para intentar conservar el filtrado glomerular conllevaría unos riesgos (morbilidad cardiovascular, infecciones, etc.) que podrían contrarrestar el teórico efecto beneficioso sobre la FRR o incluso empeorar el pronóstico. A día de hoy, la literatura dedicada a analizar esta controversia es escasa y se basa, en la mayoría de casos, en series cortas y retrospectivas con resultados contrapuestos, por lo que la decisión sobre qué hacer y cómo con el TIS del paciente con disfunción crónica de trasplante renal que llega a diálisis debe basar-se en opiniones. Ante esta situación, y dados los impor-tantes efectos negativos que el TIS tiene a nivel cardiovas-cular e infeccioso, principales causas de morbi-mortalidad del enfermo urémico, nos mostramos partidarios de sus-pender su administración al iniciar DP hasta disponer de futuros estudios al respecto. Palabras clave: Diálisis peritoneal. Trasplante renal. Inmunosupre-sión. Función renal residual.

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