338.4 📋 章末速蚘 Summary

338.4.1 🔑 䞀句話瞜結

Renal transplant = ESKD 最䜳治療 (vs dialysis) — better survival + QOL + cost-effective long-term台灣 ~ 250 䟋/幎 (vs 85,000 dialysis — severe shortage)donor types(1) living donor (LD) preferred (related/unrelated/paired exchange/altruistic); (2) deceased donor (DD) — DBD or DCD (expanding); HLA matching importance DR > B > A + crossmatch + DSA + ABO compatibilityimmunosuppression(1) induction = basiliximab (low-risk) or rATG (high-risk, sensitized, DCD); (2) maintenance triple = tacrolimus (CNI) + MMF + prednisone (standard); mTOR inhibitor (sirolimus, everolimus) for select; belatacept (CTLA-4 Ig CNI-sparing, BENEFIT trials, EBV+ only) alternativecomplications(1) early (DGF — delayed graft function, surgical, vascular, urological)(2) acute rejection — ACR (cellular, Banff 1A-3, pulse methylprednisolone) + AMR (antibody-mediated, C4d + DSA, plasmapheresis + IVIG + rituximab + bortezomib); (3) chronic allograft injury (IFTA, chronic AMR); (4) infections — CMV (D+/R- highest, valganciclovir prophylaxis 6-12 mo) + BK virus nephropathy (PCR + reduce IS) + PCP (TMP-SMX) + fungal; (5) malignancy — skin cancer SCC > BCC (voriconazole ↑ risk) + PTLD EBV-driven (rituximab + reduce IS) + Kaposi; (6) CV risk + NODAT (new-onset DM 10-30%) + recurrence of original disease (FSGS 20-30%, MN, MPGN, IgA, aHUS, DKD); outcomes1-yr graft 95%+, 5-yr 80-85%, 10-yr 60-70%; emerging 2024xenotransplantation (pig kidney 2023-2024 first humans, gene-edited), dd-cfDNA (AlloSure, Prospera) non-invasive rejection monitoring, organoid + iPS-derived nephron research。

338.4.2 💊 治療粟芁

  • maintenance tripletacrolimus 5-10 ng/mL trough + MMF 1-2 g daily divided + prednisone tapered
  • inductionbasiliximab (IL-2R, low-risk) OR rATG / Thymoglobulin (high-risk, sensitized, DCD)
  • CNI-sparingbelatacept (Nulojix) CTLA-4 Ig, monthly IV, EBV+ only (PTLD risk in EBV-naive)
  • mTOR alternativesirolimus, everolimus (CNI nephrotoxicity, malignancy reduction, CAV)
  • acute cellular rejectionpulse methylprednisolone 500-1000 mg × 3 d; rATG for refractory
  • acute AMRplasmapheresis + IVIG + rituximab + bortezomib + IS optimization
  • CMVvalganciclovir prophylaxis 6-12 mo (D+/R- highest); tissue invasive ganciclovir IV + supportive
  • BK nephropathyplasma BK > 10,000 copies → reduce IS first-line
  • PCP prophylaxisTMP-SMX (also for toxoplasma); pentamidine, dapsone, atovaquone alternatives
  • vaccinationspre-transplant include live; post-transplant avoid live; flu/pneumococcal/COVID/hepatitis B (high-dose); RSV ≥ 60
  • PTLDreduce IS + rituximab (CD20+) + chemo for high-grade
  • NODATmetformin first + minimize steroids + standard DM management

338.4.3 🎯 盧醫垫的考前提醒

  1. renal transplant > dialysis for survival + QOLpreemptive transplant ideal台灣 severe organ shortage (250 transplants/yr vs 85,000 dialysis patients)
  2. donor typesliving donor (LD) preferred > deceased donor (DD)DCD (donation after circulatory death) 擎倧 donor poolECD (expanded criteria) for older recipients
  3. HLA matching importanceDR > B > A in classical viewClass II more critical (DR + DQ + DP)
  4. crossmatch typesT-cell crossmatch (Class I + II), B-cell crossmatch (Class II)positive = pre-formed antibodies = contraindication (hyperacute rejection)
  5. DSA (donor-specific antibodies) + PRA (panel reactive antibodies) monitoring criticalsensitized patients (prior transplant, pregnancy, transfusions) need desensitization (plasmapheresis + IVIG + rituximab + IdeS imlifidase)
  6. maintenance triple SOCtacrolimus (5-10 ng/mL trough early, 4-7 long-term) + MMF (1-2 g daily) + prednisone (tapered) — most centers
  7. belatacept (CTLA-4 Ig) CNI-sparingEBV-positive only (PTLD risk in EBV-naive)BENEFIT trials better long-term GFR
  8. acute rejection differentiationACR = T-cell mediated → pulse steroidsAMR = donor-specific antibodies + C4d on biopsy → plasmapheresis + IVIG + rituximab + bortezomib (more refractory)
  9. post-transplant infectionsCMV (D+/R- highest, valganciclovir prophylaxis 6-12 mo) + BK nephropathy (PCR monitoring, reduce IS) + PCP (TMP-SMX) + fungal + PTLD (EBV-driven, rituximab + reduce IS)
  10. xenotransplantation breakthrough 2023-2024first human pig kidney transplants (David Bennett-era pioneering); multiple gene edits (alpha-Gal, GHR, CMAH, etc.); limited duration so far; future direction