crónica <strong>de</strong>l injerto, es imprescindible el control y tratamiento<strong>de</strong> los mismos para evitar su posible efecto<strong>de</strong>letéreo. Por su alta prevalencia y <strong>de</strong>mostrada asociacióncon el <strong>de</strong>sarrollo <strong>de</strong> la nefropatía crónica <strong>de</strong>linjerto, la presión arterial y el nivel sérico <strong>de</strong> lípidos<strong>de</strong>ben ser objetivos a tratar <strong>de</strong> forma prioritaria.Tanto en mo<strong>de</strong>los experimentales en animales comoen humanos se ha <strong>de</strong>mostrado que el tratamiento con antihipertensivos,IECAs y antagonistas <strong>de</strong> los receptores<strong>de</strong> la angiotensina II disminuye la proteinuria y enlentecela progresión <strong>de</strong> la nefropatía crónica <strong>de</strong>l injerto (47-53). Algunos autores han propuesto que un a<strong>de</strong>cuadocontrol <strong>de</strong> la HTA podría prevenir o enlentecer la disfunciónprogresiva <strong>de</strong>l injerto (46). Las observacionespublicadas con losartan son prometedoras, aunque es necesariorealizar estudios prospectivos y aleatorizados alargo plazo para confirmar la capacidad preventiva <strong>de</strong>dicho fármaco en la nefropatía crónica <strong>de</strong>l injerto.Otras modalida<strong>de</strong>s terapéuticas consi<strong>de</strong>radas, aunqueno está probada su efectividad en ensayos clínicoshumanos, incluyen: antiagregantes plaquetarios, antagonistas<strong>de</strong>l tromboxano, aceite <strong>de</strong> pescado, dieta hipoproteica,análogos <strong>de</strong> la somastatina, antagonistas<strong>de</strong> los factores <strong>de</strong> crecimiento, heparinoi<strong>de</strong>s, etc.BIBLIOGRAFÍA1. L.C. Paul . Chronic allograft nephropaty: An update. KidneyInternational 1999, 56: 783-793.2. K Solez, LC Racusen, ME Billingham: Solid organ transplantrejection. New York: Marcel Dekker 1966.3. Meyer MM, Norman DJ, Danovitch GM. Long-term post-transplantmanagement and complications. Handbook of kidneytransplantation 2nd edition. Boston: Little, Brown and Company,1996, p. 154.4. Racusen LC, Solez K, Colvin RB, et al. The Banff 97 workingclassification of renal allograft pathology. Kidney Int 1999; 55:713.5. Monaco AP, Burke JF, Ferguson RM, et al. Current thinking onchronic renal allograft rejection: Issues, concerns, and recommendationsfrom a 1997 roundtable discussion. Am J KidneyDis 1999; 33: 150.6. Abrass CK, Berfield AK, Stehman-Breen C, et al. Unique changesin interstitial extracelular matrix composition are associatedwith rejection and cyclosporine toxicity in human renal allograftbiopsies. Am J Kidney Dis 1999; 33: 11.7. C-G Orosz. Endothelial activation and chronic allograft rejection.Clin Transplantation 1994; 8: 299.8. Carpenter CB. Long-term failure of renal transplants: Addinginsult to injury. Kidney Int 1995; 48: 40.9. GP Basadona, AJ Matas, KJ Gillingham, WD Payne, DL Dunn,DER Sutherland, PF Gores, RWG Gruessner, JS Najarian. Earlyversus late acute renal allograft rejection: impact on chronicrejection. Transplantation 1993; 55: 993.10. Z A Massy, C Guijarro, M R Wie<strong>de</strong>rkehr, J Z. Ma, B L Kasiske.Chronic renal allograft rejection: Immunologic and nonimmunologicrisk factors. Kidney Int 1996; 49: 518.11. Humar A, Kerr S, Gillingham KJ, Matas AJ. Features of acuterejection that increase risk for chronic rejection. Transplantation1999; 68: 200.12. Hariharan S, Jonson CP, Bresnahan BA, Taranto SE, McIntoshMJ, Stablein DS. Improved graft survival after renal transplantationin the United States, 1988 to 1966. N Engl J Med2000; 342: 605-12.13. Keown, Paul. Niese, Detlef. On behalf of the International SandimmunNeoral Study Group. Cyclosporine microemulsion increasesdrug exposure and reduces acute rejection without incrementaltoxicity in <strong>de</strong> novo renal transplantation. Kidney International1998; 54: 938-94414. Pirsch JD, Miller J, Dejerhoi MH, Vincenti F, Filo RS. FK-506Kidney Transplant study group. A comparison of tacrolimus(FK-506) and cyclosporine for immunosuppression after cadavericrenal transplantation. Transplantation 1997; 63: 977-983.15. Sollinger HW. Mycophenolate Mofetil for the prevention ofacute rejection in primary cadaveric renal allograft recipients.Transplantation 1995; 60: 225-232.17. The European Mycophenolate Mofetil Cooperative Study Group:Placebo controlled study of Mycophenolate Mofetilcombinedwith cyclosporin and corticosteroids for prevention of acute rejection.Lancet 1995; 345: 1321-1326.18. Tricontinental Mycophenolate Mofetil Study Group: A blin<strong>de</strong>d,randomized clinical trial of Mycophenolate Mofetil for the preventionof acute rejection in cadaveric renal transplantation.Transplantation 1996; 61: 1029-1037.19. Ojo. Al, Meier-Kriesche HU, Hanson JA, Leichtman AB, CibrikD, Magee JC, Wolfe RA, Agodoa LY, Kaplan B. Mycofe-142
Tratamiento y Prevención - Ponenciasnolate Mofetil reduces late renal allograft loss in<strong>de</strong>pen<strong>de</strong>nt ofacute rejection. Transplantation 2000, 69: 2405-2409.18. M. Gonzalez Molina, D. Seron, R. Garcia <strong>de</strong>l. Moral, M. Carreras,E. Sola, P. Gomez Ullate, L. Cap<strong>de</strong>vila, M. A. Gentil.Protective effect of mycophenolate mofetil (MMF) against graftloss in patients with chronic allograft nephropathy (CAN). XCongress of the European Society for Organ Transplantation,ESOT 2001: pp 30 Abs 130.19. Skahan, B, Julian BA, Yves Vanrenterghem P, Neylan JN. Sirolimusreduces the inci<strong>de</strong>nce of acute rejection episo<strong>de</strong>s <strong>de</strong>spitelower cyclosporine doses in caucasian recipients of mismatchedprimary renal allografts: a phase II trial. Transplantation1999: 68: 10: 1526-1532.20. Opelz G. Influence of treatment with cyclosporine, azathioprineand steroids on chronic allograft failure . Kidney Int 1992;48(Suppl 52): S89-S92.21. Grinyo JM, Gil-Vernet S, Seron D, Cruzado JM, Moreso F, FulladosaX, Castelao AM, Torras J, Hooftman L, Alsina J. Steroidwithdrawal in mycophenolate mofetil- treated renal allograftrecipients. Transplantation 1997, 63: 1688-1690.22. Gjerstson DW. Survival trends in long.term first cadáver-donorkidney transplants, in Clinical Transplants 1991, edited byTerasaki PI, Cecka JM, Los Angeles, UCLA Tissue typing Laboratory,1991, p 225.23. Throgood J, van Houwelingen HC, van Rood JJ, Zantvoort FA,Schreu<strong>de</strong>r GMT, Persijn GG: Long term results of kidney transplantationin Eurotransplant, in Organ Transplantation: LongTerm Results, edited by Paul LC, Solez K, New York, Basel,Hong Kong, Marcel Dekker, 1992, pp 33.24. Mayer AD, Dmitrewski J Squifflet JP, Besse et al. EuropeanTacrolimus multicenter renal study group. Multicenter randomizedtrial comparing tacrolimus (FK-506) and cyclosporinein the prevention of renal allograft rejection. Transplantation1997; 64: 436-443.25. D. Del Castillo. Analysis of primary and recurrent rejectionfollowing renal transplantation in a large, comparative, multicentretrial. Transplantation Proceedings 2001; 33:1259-1261.26 Knoll GA, Bell RC.Tacrolimus versus cyclosporine for immunosuppressionin renal transplantation: meta-analysis of randomizedtrials. BMJ 1999; 318:1104-1107.27. Gjerston DW, Cecka JM ,Terasaki PI: The relative effects ofFK-506 and cyclosporine on short and long term kidney graftsurvival. Transplantation1995; 60: 1384-1388.28. Suren N. Sehgal. Rapamune (RAPA, rapamycin, sirolimus):Mechanism of action Immunosuppressive effect results fromblocka<strong>de</strong> of signal transduction and inhibition of cell cycle progression.1998; Clinical biochemistry, 31: 5: 335-340.29. Sousa JE, Costa MA, Abizaid A, Feres F, Pinto I, Seixas A, StaicoR, Mattos L, Sousa A, Falotico R, Jaeger J, Popma JJ, SerruysP: Lack of neointimal proliferation after implantation ofsirolimus-coated Stents in human coronary arteries. Circulation2001; 103: 192-195.30. Kahan BD, Podbielski J, Napoli KL. Immunosupressive effectsand safety of a sirolimus/cyclosporine combination regimen forrenal transplantation. Tansplantation 2998; 66: 1040-1046.31. Kries H, Cisterne JM, Land W. Sirolimus in association withmycofenolate mofetil induction for the prevention of acute graftrejection in renal allograft recipients. Transplantation 2000;89: 1252-1260.32. Cecka JM, Gjerston D, Teraski PI: Do prophylactic anti-limphocyteglobulins improve renal transplant survival in recipientand donor high-risk groups? Transplant Proc 1993; 25: 548-549.33. Opeltz G. Efficacy of rejection prophylaxis with OKT3 in renaltransplantation. Transplantation 1995, 60:1220-1224.34. Szczech LA, Berlin JA, Feldman HI. Anti-lymphocyte antibodyinduc therapy: The effect of antilymphocyte induction therapyon renal allograft survival: A meta-analysis of individual patientlevel data. Ann Intern Med 1998, 128: 817-826.35. Tran HT, Acharya MK, Mckay DB. Avoidance of cyclosporinein renal transplantation: effects of daclizumab, mycophenolatemofetil, and steroids. J Am Soc Nephrol 2000; 11: 1903-1909.36. Gjerston DW. A multi-factor analysis of kidney graft outcomesat one year and five years post-transplantation : 1996 UNOSupdate, in Clinical Transplants 1996. Edited by Cecka JM, TerasakiPI, Los Angeles UCLA Tissue Typing Laboratory, 1997;343.37. Terasaki PI, Gjerston DW, Cecka JM, Takemoto S, Cho YW.Significance of the donor age effect on kidney transplants. ClinTranspl 1977; 11: 366-372.38. Shoskes D, Cecka JM. Deleterious effects of <strong>de</strong>layed graft functionin cadaveric renal transplantation recipients in<strong>de</strong>pen<strong>de</strong>ntof acute rejection. Transplantation 1998; 55: 1697-1701.39. Yokoyama I, Uchida K, Kobayashi T, et al. Effect of prolonged<strong>de</strong>layed graft function on long-term graft outcome in cadaverickidney transplantation. Clin Transplant 1994; 8: 101.40. Almond PS, Matas A, Gilingham K, et al. Risk factors for chronicrejection in renal allograft recipients. Transplantation 1993;55: 752.41. Brenner BM, Cohen RA, Milford EL. In renal transplantation,one size may not fit all, J Am Soc Nephrol 1992; 3: 162.42. Mackenzie HS, Tulius SG, Heemann UW, et al. Nephron supplyis a major <strong>de</strong>terminant of long-term renal allograft survival inrats, J Clin Invest 1994; 64: 2148.143
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