羟苯磺酸钙治疗慢性移植肾功能不全的临床观察

doi:10.3969/j.issn.2095-4344.2014.49.019

摘要/Abstract

摘要：

背景：羟苯磺酸钙作为一种血管保护剂被广泛用于治疗慢性静脉功能不全和糖尿病肾病，尤其大量临床研究表明它可以减轻糖尿病肾病的肾损害，但很少有关于羟苯磺酸钙用于治疗肾移植后慢性移植肾功能不全的文献报道。

目的：观察羟苯磺酸钙治疗慢性移植肾功能不全的有效性和安全性。

方法：收集解放军第二军医大学附属长征医院全军器官移植研究所收治的152例肾移植后出现慢性移植肾功能不全的患者，分为治疗组(n=78)和对照组(n=74)。治疗组患者口服羟苯磺酸钙500 mg 3次/d，连续服用8周。所有患者均接受钙调磷酸酶抑制剂为基础的免疫抑制方案和综合治疗。

结果与结论：对于服用羟苯磺酸钙治疗的患者，其血肌酐、尿素氮和尿酸在治疗第2周时均较治疗前明显下降并维持稳定(P < 0.05)，但血肌酐和尿素氮在停药后立即回复到原基线水平。而两组患者的血常规、肝功能、血脂、电解质、血压及24 h尿量在治疗前后差异均无显著性意义(P > 0.05)。服用羟苯磺酸钙并不会对肾功能不全患者的一般情况和免疫抑制剂的血药浓度产生影响。羟苯磺酸钙可能通过自身与血肌酐结合、减轻微循环损伤及其抗氧化的特性延缓慢性移植肾功能不全的进展。同时，服药后血肌酐下降有助于缓解患者的焦虑和担忧。然而，羟苯磺酸钙对血肌酐检测的负性干扰需引起重视，以免对患者病情产生误判。

中国组织工程研究杂志出版内容重点：肾移植；肝移植；移植；心脏移植；组织移植；皮肤移植；皮瓣移植；血管移植；器官移植；组织工程

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关键词: 移植, 组织工程, 肾移植, 羟苯磺酸钙, 慢性移植肾功能不全, 血肌酐, 钙调磷酸酶抑制剂, 微循环, 抗氧化

Abstract:

BACKGROUND: Calcium dobesilate (calcium dihydroxy-2, 5-benzenesulfonate) has been widely used to treat chronic venous insufficiency and diabetic retinopathy, especially many clinical studies showed that calcium dobesilate as vasoprotective compound ameliorates renal lesions in diabetic nephropathy. However, there are few literatures reported calcium dobesilate in the treatment of chronic renal allograft dysfunction after renal transplantation.

OBJECTIVE: To observe the efficacy and safety of calcium dobesilate on chronic renal dysfunction after renal transplantation.

METHODS: A total of 152 patients with chronic renal allograft dysfunction after renal transplantation were enrolled from the Military Institute of Organ Transplantation, Changzheng Hospital, Second Military Medical University of Chinese PLA. They were randomly divided into the treatment group (n=78) and the control group (n=74). Patients in the treatment group received 500 mg of calcium dobesilate three times daily for eight weeks. All patients were treated with calcineurin inhibitor-based triple immunosuppressive protocols and comprehensive therapies.

RESULTS AND CONCLUSION: For patients receiving calcium dobesilate, serum creatinine, blood urea nitrogen and uric acid decreased significantly at two weeks after treatment and maintained a stable level (P < 0.05). However, serum creatinine and blood urea nitrogen returned to the original level soon after drug withdrawal. No significant difference was observed in blood cell count, liver function, blood lipids, electrolytes, blood pressure and 24-hour urine output between the two groups before and after therapy (P > 0.05). Administration of calcium dobesilate did not change the general condition of patients with renal insufficiency, nor did it affect blood concentrations of the immunosuppressive agents. Calcium dobesilate may help to delay the progress of graft injury in patients with chronic renal graft dysfunction by conjugating with creatinine, ameliorating the impaired microcirculation and its antioxidant property. The decline in serum creatinine alleviates patients’ anxiety and concern arising from the elevation of creatinine. However, the negative interference with serum creatinine caused by calcium dobesilate should be cautious in order to avoid misjudgment of patients’ condition.

中国组织工程研究杂志出版内容重点：肾移植；肝移植；移植；心脏移植；组织移植；皮肤移植；皮瓣移植；血管移植；器官移植；组织工程

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Key words: calcium dobesilate, renal insufficiency, chronic, microcirculation, kidney transplantation

中图分类号:

R318

郑鳕洋，韩澍，周梅生，傅尚希，王立明. 羟苯磺酸钙治疗慢性移植肾功能不全的临床观察[J]. 中国组织工程研究, 2014, 18(49): 7979-7984.

Zheng Xue-yang, Han Shu, Zhou Mei-sheng, Fu Shang-xi, Wang Li-ming. Clinical observation of calcium dobesilate in the treatment of chronic renal allograft dysfunction[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(49): 7979-7984.

图/表（结果） 2

Quantitative analysis and clinical information of subjects

A total of 152 chronic renal allograft dysfunction patients entered the final analysis. The general information and baseline data were shown in Table 1. There were no significant differences in demographic, disease duration, original renal function, and immunosuppressant administration between the two groups prior to treatment (P > 0.05).

Effect of calcium dobesilate on renal function

For patients receiving calcium dobesilate, serum creatinine, blood urea nitrogen and uric acid decreased obviously at the time of two weeks after treatment and maintained at a stable level (P < 0.05). The 24-hour urinary protein did not change much compared with the control group (P > 0.05; Table 2). However, serum creatinine and blood urea nitrogen in patients receiving calcium dobesilate returned to the original level quickly after discontinuation of the drugs (Table 2).

Effect of calcium dobesilate on the other indicators

According to blood routine, biochemical and other indicators were detected with the venous blood. No significant difference was observed in blood cell count, liver function, blood lipids and electrolytes between the two groups, or pre- and post-therapy in each group (P > 0.05; Table 3). Salt restriction, combination of antihypertensive drugs made the patients’ blood pressure under control, which had no significant difference in both groups (P > 0.05). The same situation was observed in the 24-hour urine output no matter calcium dobesilate use or not (P > 0.05; Table 3). Administration of calcium dobesilate did not change the general condition of patients with renal insufficiency, nor did it affect blood concentrations of the immunosuppressive agents (P > 0.05; Table 3).

Adverse reactions of calcium dobesilate in chronic renal allograft dysfunction patients

No adverse reactions were identified in the control group, but were observed in four (5%) of 78 patients in the treatment group, including a patient who had facial hot flush, which relieved spontaneously; three patients whose serum alanine transaminase elevated slightly, but returned to normal after administration of hepatoprotective drugs.

参考文献

[1] Meier-Kriesche HU, Schold JD, Kaplan B. Long-term renal allograft survival: have we made significant progress or is it time to rethink our analytic and therapeutic strategies? Am J Transplant. 2004;4(8):1289-1295.
[2] Kaplan B. Overcoming barriers to long-term graft survival. Am J Kidney Dis. 2006;47(4 Suppl 2):S52-64.
[3] Schweitzer EJ, Matas AJ, Gillingham KJ, et al. Causes of renal allograft loss. Progress in the 1980s, challenges for the 1990s. Ann Surg. 1991;214(6):679-688.
[4] Chapman JR, O'Connell PJ, Nankivell BJ. Chronic renal allograft dysfunction. J Am Soc Nephrol. 2005;16(10):3015- 3026.
[5] Arceo A, Berber A, Trevi?o C. Clinical evaluation of the efficacy and safety of calcium dobesilate in patients with chronic venous insufficiency of the lower limbs. Angiology. 2002;53(5):539-544.
[6] Michal M, Gotti C. Effect of calcium dobesilate on platelet function. Thromb Res. 1988;51(6):593-605.
[7] Fernández IS, Cuevas P, Angulo J, et al. Gentisic acid, a compound associated with plant defense and a metabolite of aspirin, heads a new class of in vivo fibroblast growth factor inhibitors. J Biol Chem. 2010;285(15):11714-11729.
[8] Ribeiro ML, Seres AI, Carneiro AM, et al. Effect of calcium dobesilate on progression of early diabetic retinopathy: a randomised double-blind study. Graefes Arch Clin Exp Ophthalmol. 2006;244(12):1591-1600.
[9] Einarsdóttir AB, Stefánsson E. Prevention of diabetic retinopathy. Lancet. 2009;373(9672):1316-1318.
[10] Agus GB. Medical treatment of chronic venous disease: evolution or involution? Minerva Cardioangiol. 2011;59(3): 285-298.
[11] Scolari MP, Cappuccilli ML, Lanci N, et al. Predictive factors in chronic allograft nephropathy. Transplant Proc. 2005;37(6): 2482-2484.
[12] Hong LQ, Huang ZY, Luo Y, et al. The outcomes in renal allograft recipients after conversion from cyclosporine A to sirolimus for chronic renal allograft dysfunction. Zhonghua Qiguan Yizhi Zazhi. 2009;30(3):167-171.
[13] Ramanathan V, Suki WN, Rosen D, et al. Chronic allograft nephropathy and nephrotic range proteinuria. Clin Transplant. 2005;19(3):413-417.
[14] Zhang X. Therapeutic effects of calcium dobesilate on diabetic nephropathy mediated through reduction of expression of PAI-1. Exp Ther Med. 2013;5(1):295-299.
[15] Gao MJ, Liu M, Li B, et al. Protective effect of calcium dobesilate against early diabetic nephropathy of rat kidney. Yao Xue Xue Bao. 2009;44(2):126-133.
[16] Beyer J, Meissner KO, Happ J, et al. Effect of calcium dobesilate on permeation of plasma proteins in diabetic patients. Dtsch Med Wochenschr. 1980;105(46):1604-1608.
[17] Anderson S, Diamond JR, Karnovsky MJ, et al. Mechanisms underlying transition from acute glomerular injury to late glomerular sclerosis in a rat model of nephrotic syndrome. J Clin Invest. 1988;82(5):1757-1768.
[18] Takahashi T, Huynh-Do U, Daniel TO. Renal microvascular assembly and repair: power and promise of molecular definition. Kidney Int. 1998;53(4):826-835.
[19] Nankivell BJ, Borrows RJ, Fung CL, et al. Evolution and pathophysiology of renal-transplant glomerulosclerosis. Transplantation. 2004;78(3):461-468.
[20] Berthet P, Farine JC, Barras JP. Calcium dobesilate: pharmacological profile related to its use in diabetic retinopathy. Int J Clin Pract. 1999;53(8):631-636.
[21] Tejerina T, Ruiz E. Calcium dobesilate: pharmacology and future approaches. Gen Pharmacol. 1998;31(3):357-360.
[22] Purkerson ML, Joist JH, Yates J, et al. Inhibition of thromboxane synthesis ameliorates the progressive kidney disease of rats with subtotal renal ablation. Proc Natl Acad Sci U S A. 1985;82(1):193-197.
[23] Schmidt M, Michal M. Inhibition of sorbitol formation in human erythrocytes by calcium dobesilate. Arzneimittelforschung. 1989;39(4):493-495.
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[25] Suschek C, Kolb H, Kolb-Bachofen V. Dobesilate enhances endothelial nitric oxide synthase-activity in macro- and microvascular endothelial cells. Br J Pharmacol. 1997; 122(7): 1502-1508.
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引言

With the progress in surgical and preservation techniques and the improvement in immunosuppressant and tissue typing, short-term allograft survival has a tremendous improvement after renal transplantation. Unfortunately, the overall gain in long-term kidney graft survival rate has not been consistent^[1-2]. Chronic renal allograft dysfunction, which is clinically characterized by a gradual worsening of renal function in the presence of arterial hypertension and low-grade proteinuria, remains the leading cause of late allograft failure among kidney transplant recipients and positively associated with long-term graft and patient survival^[3-5]. The etiology and pathogenesis of chronic renal allograft dysfunction are complex and multifactorial. Both immunological and non-immunological mechanisms are likely involved. In addition, the histological changes of chronic renal allograft dysfunction, which is characterized by interstitial fibrosis/tubular atrophy accompanied by vascular changes and glomerulosclerosis, usually precede the functional deterioration. The graft function deterioration can be partially attributed to the impairment of renal microcirculation and changes in blood rheology. The effective prevention and treatment of chronic renal allograft dysfunction are undoubtedly the key point to prolong the long-term survival rate, and one therapeutic strategy is to improve renal microcirculation.

Calcium dobesilate (calcium dihydroxy-2, 5-benzenesulfonate) is not only avascular protective agent that improves microcirculation by reducing platelet adhesion and blood viscosity^[6], but also the most effective member of a new family of efficient fibroblast growth

factor inhibitors^[7]. Calcium dobesilate has been used in the treatment of diabetic retinopathy and vascular diseases such as chronic venous insufficiency for decades^[8-10]. A recent study^[11] has revealed that calcium dobesilate could reduce urinary albumin excretion in patients with diabetic nephropathy. Whether calcium dobesilate could delay the deterioration of graft renal function on chronic renal allograft dysfunction is not well understood. The purpose of this study is to observe the therapeutic effects of calcium dobesilate on chronic renal allograft dysfunction after renal transplantation.

中国组织工程研究杂志出版内容重点：肾移植；肝移植；移植；心脏移植；组织移植；皮肤移植；皮瓣移植；血管移植；器官移植；组织工程
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材料方法

Design

A retrospective cohort study.

Time and setting

Investigations were conducted in the Military Institute of Organ Transplantation, Changzheng Hospital, China from January 2010 to December 2012.

Subjects

A total of 152 patients who had transplanted for more than one year and progressed to chronic renal allograft dysfunction were recruited for this study. Kidney transplant patients who developed proteinuria and hypertension, with a simultaneous or delayed rise in serum creatinine level over months were evaluated and treated in the outpatient department. These patients met the following criteria were included in this study. Prior written and informed consent was obtained from each patient and the study was approved by the Ethics Committee of Changzheng Hospital (Shanghai, China).

Inclusion criteria^[12]: (1) Patients whose renal function deteriorated progressively and serum creatinine increased 25% within six months; (2) Patients whose renal function did not improve through adjusting the immunosuppressive therapy; (3) Ruled out the possibility that could lead to chronic renal damage, such as acute rejection, calcineurin inhibitor nephrotoxicity, urinary obstruction, renal artery stenosis and infection; (4) No acute rejection occurred within six months prior to the study.

Exclusion criteria: (1) patients with hepatitis B virus or hepatitis C virus infection and impaired liver function; (2) patients with reversible factors that can cause renal function deterioration, such as insufficient blood volume, acute stress and poor blood pressure control.

The recruited patients were randomly divided into two groups: a treatment group (n=78), including 42 males and 36 females with an average age of (43.79±13.40) years; and a control group (n=74), including 41 males and 33 females with an average age of (45.41±11.99) years. All patients in both groups were treated with calcineurin inhibitor-based triple immunosuppressive protocols. Cyclosporine A, mycophenolatemofetil and prednisone were used in 40 cases of the treatment group and 38 cases of the control group. Tacrolimus, mycophenolatemofetil and prednisone were used in 38 cases of the treatment group and 36 cases of the control group.

Methods

Treatment with calcium dobesilate after renal transplantation

Comprehensive therapies were applied on all patients, including food restriction (low salt, low fat and high-quality protein diet), homeostasis (maintaining the balance of fluid, electrolytes and acid-base, supplement of iron, folic acid and erythropoietin to improve anemia), blood pressure control and removal of intestinal toxins. Patients in the treatment group received 500 mg of calcium dobesilate (Kangya Pharmaceutical Co., Ltd, Ningxia Province, China) three times daily for eight weeks. None of patients received angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker drugs.

Follow-up observation

Medical histories of all patients were recorded in details and they were followed up every two weeks by outpatient clinical visits or telephone calls. Blood pressure, 24-hour urine output, blood cell count, liver and kidney function, 24-hour urinary protein quantity, blood lipids, electrolytes and cyclosporine A/tacrolimus concentrations were all measured prior to and following treatment. (1) Every two weeks during the treatment, venous blood was taken between 7:00 and 8:00 a.m. after fasting for 10 hours and the venous blood serum was separated for the detection of alanine aminotransferase, total bilirubin, blood urea nitrogen, serum creatinine, uric acid, total cholesterol, triglyceride, electrolytes and cyclosporine A/tacrolimus concentrations. (2) The morning resting state blood pressure and average 24-hour urine output were recorded before and eight weeks after the treatment. (3) Adverse reactions were determined and treated symptomatically based on symptoms and laboratory tests.

Main outcome measures

(1) Effect of calcium dobesilate on renal function and 24-hour urinary protein quantity in chronic renal allograft dysfunction patients; (2) influence of calcium dobesilate on blood pressure and the other indicators of blood test in chronic renal allograft dysfunction patients; (3) interaction of calcium dobesilate and immunosuppressant; (4) adverse reactions of calcium dobesilate in chronic renal allograft dysfunction patients.

Statistical analysis

Continuous variables were expressed as mean ± SD. Independent sample t-test was performed to evaluate the data between the treatment group and the control group, and one-way repeated measurements analysis of variance was performed to analyze the data before and after calcium dobesilate treatment in each group. P-value of less than 0.05 was considered statistically significant. All statistical calculations were performed with the SPSS 13.0 software.

中国组织工程研究杂志出版内容重点：肾移植；肝移植；移植；心脏移植；组织移植；皮肤移植；皮瓣移植；血管移植；器官移植；组织工程

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讨论

Due to a variety of immune and non-immune factors, renal graft function gradually diminishes after renal transplantation and eventually results in renal graft dysfunction, which is one of the major impediments to long-term graft survival^[1].

Nowadays, the biggest challenge for transplant physician is to maximize the potential of kidney graft, delay the time of returning to hemodialysis, and to alleviate the pressure of organ shortage. Many different factors can be responsible for chronic renal allograft dysfunction and its pathogenesis has not been fully understood, so that until now it is still lack of effective treatments except for choosing a better immunosuppression regimen. Proteinuria is an independent risk factor for chronic allograft nephropathy^{[11, 13]}. Through drug intervention to reduce proteinuria, serum creatinine and urea nitrogen in patients with chronic allograft nephropathy may improve the prognosis, and delay the progress of renal allograft insufficiency. Calcium dobesilate, a drug that improves microcirculation, can reduce urinary albumin excretion, lower serum creatinine, and slow down deterioration of renal function in patients with diabetic nephropathy^[14-16]. Therefore, learning from the experience of administration of calcium dobesilate in diabetic nephropathy, we applied this drug to treat chronic renal allograft dysfunction.

It is observed that progressive renal injury is mainly caused by damages in renal microcirculation^[17-18]. It contributes to the occurrence of glomerulosclerosis, which is the major pathological change of chronic renal dysfunction after transplantation, and eventually leads to renal graft failure^[19]. Pharmacological researches^[20-21]have shown that calcium dobesilate can significantly decrease capillary permeability, blood viscosity and platelet activity, and improve abnormal hemorheology and microcirculation. The mechanism has not been well validated, but may be due to the followings: (1) inhibit the synthesis of vasoactive substances such as histamine, bradykinin, prostaglandin and thromboxane A2 by antagonizing their actions, and stop vascular endothelial cell contraction and gap formation^[22]; (2) slow down excessive collagen formation and the thickening of capillary basement membrane, reduce capillary permeability and sorbitol formation in red blood cells, and thus decrease the permeability and dysfunction of red blood cells and endothelial cells^[23]; (3) decrease the synthesis and release of platelet aggregation factors to reduce the platelet activity^[6]; (4) reduce the levels of fibrinogen and globulin, lower the high cohesiveness of red blood cells, increase fiber protease activity and blood fibrinolysis, and thereby decrease blood viscosity^[24]; (5) enhance the activity of nitric oxide synthase in macrovascular and microvascular endothelial cells^[25], antagonize reactive oxygen species, and thus protect blood vessels^[26]. In the present study, our two-month observation showed that serum creatinine, blood urea nitrogen and uric acid decreased significantly in patients receiving calcium dobesilate compared with the control group. Administration of calcium dobesilate did not significantly change patients’ general condition, nor did it have significant impact on the concentration of the immunosuppressive agents. No significant liver toxicity or other adverse reactions were observed in the patients who were treated with calcium dobesilate. Liu et al^[27]reported that calcium dobesilate can decrease serum creatinine through conjugating creatinine, ameliorate the renal pathological structure and thus increase the endogenous creatinine clearance rate. However, it is suspicious whether calcium dobesilate could be a promising drug in the treatment of chronic renal allograft dysfunction. In our study, there was no significant difference in 24-hour urine output before and after treatment, indicating that calcium dobesilate’s effect on decreasing serum creatinine and blood urea nitrogen was not caused by improving glomerular filtration. The serum creatinine lowered in a short time after calcium dobesilate administration and maintained at a stable level until discontinuation, suggesting that the angioprotective drug had no accumulation effect in decreasing serum creatinine. The serum creatinine returned to the original level after discontinuation, which could not be explained explicitly. Yu et al^[28]suggested that the serum creatinine of patients with renal dysfunction varied significantly using different detections when taking calcium dobesilate. Calcium dobesilate had a significant negative interference with serum creatinine detected by the sarcosine oxidase-based assay, which leads to the bias of creatinine in patients with renal insufficiency.

There is still some confusion over the protective effect of calcium dobesilate on renal function. Whether calcium dobesilate really improves renal graft function needs further researches, for creatinine decline does not necessarily mean the fundamental improvement of renal graft function. In clinical practice, transplant physicians could not draw a conclusion blindly that renal graft function has been improved based only on the reduction of serum creatinine when patients receive calcium dobesilate. In our opinion, the drug may help to delay the progress of graft injury in chronic renal allograft dysfunction patients by conjugating with creatinine, ameliorating the impaired microcirculation and its antioxidant property. In addition, decline in serum creatinine offers psychological consolation and comfort to the patients, since it alleviates their anxiety and concern arising from the elevation of creatinine. Positive emotion is conductive to improve quality of life of patients with renal graft insufficiency. However, application of calcium dobesilate could not fundamentally cure chronic renal allograft dysfunction because creatinine would return to the original level soon after discontinuation of the drug. The negative interference with serum creatinine caused by calcium dobesilate should be cautious in order to avoid misjudgment of patients’ condition.