Journal Information
Vol. 29. Issue. S1.March 2009
Pages 1-77
Vol. 29. Issue. S1.March 2009
Pages 1-77
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RETRANSPLANT
Retrasplante
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4369
Roberto Marcéna, Ana Fernándeza, Milagros Fernández Lucasa, José Luis Teruela, Isabel Pérez-Floresb, Ana Sánchez-Fructuosob
a Servicio de Nefrología, Hospital Ramón y Cajal., Madrid, Madrid, España,
b Servicio de Nefrología, Hospital Clínico San Carlos, Madrid, Madrid, España,
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A pesar de los avances en el tratamiento inmunosupresor y en los cuidados del enfermo trasplantado, a los tres años del trasplante el 20-30% de los receptores habrán perdido el injerto y la pérdida continuará a razón de un 2-4% anual. Estos enfermos de nuevo se incluyen en programas de diálisis, y constituyen entre el 4 y 10% de los enfermos admitidos anualmente para tratamiento dialítico. De ellos, el 40-60% según las series se incluyen en lista de espera para un segundo trasplante, lo que origina un aumento del número de enfermos en espera de trasplante y plantea el dilema sobre los derechos a trasplantarse en los programas basados en donantes cadáver. Como característica importante, los enfermos en espera de un segundo o tercer trasplante con frecuencia tienen anticuerpos circulantes frente a los antígenos HLA. El retrasplante constituye la mejor forma de tratamiento de la insuficiencia renal crónica (IRC), y los resultados de la supervivencia del injerto se acercan a los del primer trasplante, a pesar de ser considerados enfermos de alto riesgo. También mejora la supervivencia del enfermo respecto a aquel que permanece en lista de espera. Los grupos más favorecidos por el retrasplante son los enfermos en que la diabetes tipo I fue la causa del fallo renal y el grupo de edad entre 18 y 50 años (evidencia C). A pesar de las ventajas terapéuticas del retrasplante, el porcentaje de enfermos que se somete a un segundo trasplante permanece estacionario, posiblemente por la aplicación de criterios más amplios en cuanto a la aceptación de candidatos a trasplantarse (evidencia B). En el segundo trasplante, se pueden repetir los antígenos HLA-AB no compartidos si el receptor no ha desarrollado anticuerpos específicos. La prueba cruzada reciente e histórica debe ser negativa. Las pautas de inmunosupresión a utilizar son las mismas que en el primer trasplante. Complicaciones asociadas a la inmunosupresión, como la enfermedad linfoproliferativa y la nefropatía por el virus BK, así como las glomerulopatías recidivantes, no son contraindicaciones para el retrasplante (evidencia C).

Despite the advances in immunosuppressive therapy and in patient care, about 20-30% of patients wi l l have lost their grafts after 3 years and this loss will continue by 3-4% per year. These patients are included in maintenance dialysis programmes and account for 4 to 10% of those admitted every year for maintenance dialysis therapy. Among those patients who loss their grafts 40-60% are included in transplant waiting l ists. This increases the number of patients waiting for a graft and raises the di lemma about the rights to be included in deceased donor programmes. A common characteristic of these patients waiting for a second or even third transplant is the presence in the blood of antibodies to HLA antigens. A new transplant is the best therapeutic option for these patients, and the results are quite close to those achieved for the first graft. Moreover, a new transplant improves patient outcome when compared with those remaining in the waiting l ist. The best results are obtained in diabetic patients and in those between 18 to 50 years old (Evidence C). However, the percentage of patients retransplanted has not varied in the last years, possibly due to the wider criteria adopted on candidate selection that increases the waiting l ists (Evidence B). In the second transplant, mismatched HLA-A,B antigens could be repeated if the recipient has not developed specific antibodies to these antigens. Recent cross-match has to be negative. Immunosuppressive therapy is simi lar to that used with first transplants. Lymphoprol iferative diseases, BK virus nephropathy and primary glomerulonephritis do not preclude a second transplant (Evidence C).

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