Infektionen unter Immunsuppression nach Nierentransplantation

Stephan Kemmner; Ulf Schönermarck

doi:10.1055/a-1176-6416

Dialyse aktuell, Inhaltsverzeichnis

Dialyse aktuell 2020; 24(08): 309-318
DOI: 10.1055/a-1176-6416

Schwerpunkt

Transplantation

Infektionen unter Immunsuppression nach Nierentransplantation

Eine aktuelle Übersicht

Stephan Kemmner

¹Transplantationszentrum, Klinikum der Universität München, LMU München

,

Ulf Schönermarck

²Nephrologisches Zentrum, Medizinische Klinik IV, Klinikum der Universität München, LMU München

› Institutsangaben

Abstract

ZUSAMMENFASSUNG

Unter immunsuppressiver Therapie besteht ein deutlich erhöhtes Infektionsrisiko nach Nierentransplantation (NTx), insbesondere für virale Infektionen. Bereits vor einer geplanten NTx sollte auf einen aktuellen Impfstatus geachtet werden, da nach einer Transplantation unter immunsuppressiver Therapie einerseits Lebendimpfstoffe nicht mehr gegeben werden dürfen und andererseits eine adäquate Impfantwort schwieriger zu erreichen ist. Die saisonale Influenzaimpfung kann bereits einen Monat nach Transplantation gegeben werden, für alle anderen Impfungen wird ein Abwarten von 3–6 Monaten empfohlen. Eine prophylaktische Therapie kann das Auftreten bestimmter Infektionen effektiv verhindern. Nach NTx sollte für die ersten 6 Monate eine PjP-Prophylaxe (PjP: Pneumocystis-jirovecii-Pneumonie) mit Trimethoprim/Sulfamethoxazol verabreicht werden. Eine CMV-Prophylaxe (CMV: Zytomegalievirus) mit Valganciclovir erfolgt in Abhängigkeit vom Sero-Status von Empfänger und Spender i. d. R. für 3 bzw. 6 Monate. Im Falle einer Infektion kann in Abhängigkeit vom Schweregrad der Antimetabolit (meist MMF: Mycophenolatmofetil) dosishalbiert oder pausiert werden, jedoch ist dies mit einem erhöhten Rejektionsrisiko verbunden. Insbesondere bei Infektionen mit CMV und BKV (Polyomavirus BK) kann anstelle von MMF ein mTOR-Inhibitor (mTOR: „mechanistic target of rapamycin“) eingesetzt werden in Kombination mit einem niedrigdosierten Calcineurininhibitor (CNI). Bei einer COVID-19-Erkrankung (COVID-19: Coronavirus Disease 2019) nach NTx sollte wie bei anderen Infektionen in einer Kombinationstherapie zunächst der Antimetabolit bzw. der mTOR-Inhibitor dosisreduziert oder pausiert werden. Ein Absetzen des CNIs bei COVID-19 erscheint aus unserer Sicht nicht regelhaft indiziert, sondern bleibt schweren Verläufen im Einzelfall vorbehalten. Im Falle einer antiviralen Therapie bei COVID-19 muss immer an mögliche Interaktionen mit den Immunsuppressiva (v. a. mit CNI und mTOR-Inhibitoren) gedacht werden.

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Referenzen

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