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摘要:
目的 探讨儿童逝世后器官捐献供肾双肾整块肾移植的临床效果。 方法 回顾性分析9例儿童供肾双肾移植供、受者临床资料。计算受者的1年人、肾存活率, 观察术后1年受者肾功能恢复情况, 移植肾长度变化及术后不良事件发生情况。 结果 9例受者术后1年的人、肾存活率分别为8/9、72%。随访1年, 血清肌酐（Scr）水平由术前（747±170）μmol/L下降至（83±27）μmol/L, 血尿素氮由术前（24.5±4.9）mmol/L下降至（6.8±2.0）mmol/L, 移植肾长度由术前（61.1±9.8）mm增长至（100.3±1.7）mm。术后发生移植物功能延迟恢复（DGF）2例, 行血液透析过渡后恢复移植肾功能; 发生急性排斥反应2例, 予甲泼尼龙冲击治疗后逆转; 1例于术后2周发生肺部真菌感染, 停用免疫抑制剂, 予抗真菌治疗, 但效果不佳, 于术后3个月死亡; 1例术后7 d发生移植肾动脉血栓形成, 术后10 d行移植肾切除术, 恢复血液透析; 1例术后1个月发生1个移植肾动脉栓塞, 剩余移植肾功能正常, 术后6个月生长明显。此外, 发生移植肾输尿管狭窄2例、蛋白尿2例、腹主动脉狭窄1例、尿瘘1例, 经相应处理后均治愈或好转。 结论 儿童逝世后器官捐献供肾双肾整块肾移植围手术期并发症较多, 但随着经验逐步积累, 儿童双供肾肾移植的移植效果在逐步改善。 Abstract:Objective To evaluate the clinical efficacy of en-bloc kidney transplantation from pediatric organ donation after death. Methods Clinical data of donors and recipients undergoing en-bloc kidney transplantation from pediatric donor kidneys were retrospectively analyzed. The 1-year survival rates of the recipient and grafted kidney were calculated. The recovery of renal function at postoperative 1 year was observed. The changes in the length of grafted kidney and incidence of postoperative adverse events were monitored. Results The 1-year survival rate of the recipients was 8/9, and 72% for the grafted kidney. During 1-year follow-up, the serum creatinine (Scr) level was down-regulated from (747±170) μmol/L before transplantation to (83±27) μmol/L post-transplantation, the blood urea nitrogen concentration was decreased from (24.5±4.9) mmol/L to (6.8±2.0) mmol/L, and the length of transplanted kidney was increased from (61.1±9.8) mm to (100.3±1.7) mm. Two recipients suffered from delayed graft function(DGF) and restored after hemodialysis. Two cases developed acute rejection and healed after methylprednisolone shock therapy. One recipient presented with lung fungal infection at postoperative 2 weeks after transplantation, and was treated by the withdrawal of immunosuppressive agents and antibacterial treatment with poor clinical efficacy. Then the recipient died at 3rd month. One case had renal arterial thrombosis at postoperative 7 d, underwent nephrectomy at postoperative 10 d and returned to hemodialysis. At postoperative 1st month, one recipient suffered from thrombosis of unilateral renal artery. The grafted kidney in other side normally functioned and significantly grew in size at postoperative 6 months. In addition, two cases had ureterostenosis of the transplanted kidney, albuminuria in 2, abdominal aortic stenosis in 1 and urinary fistula in 1. All these symptoms were cured or alleviated after corresponding treatment. Conclusions The incidence of perioperative complications is relatively high in en-bloc kidney transplantation from pediatric organ donation after death, whereas the clinical efficacy of such kidney transplantation can be gradually increased along with the accumulation of clinical experience. -
Key words:
- Child /
- Donor /
- Marginal kidney donor /
- Kidney transplantation /
- En-bloc kidney transplantation /
- Perioperative period /
- Complication /
- Hemodialysis
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图 1 1例肾移植受者移植肾生长情况
A图为术前供肾照片, 左肾长径55 mm, 右肾长径58 mm; B图为术后3个月磁共振成像图片, 左肾长径72 mm, 右侧长径74 mm; C图为术后6个月磁共振成像图片, 左肾长径88 mm, 右肾长径89 mm
Figure 1. Renal allograft growth of one renal transplant recipient
表 1 9例双供肾肾移植供、受者的基线资料
Table 1. Baseline data of 9 pairs of donors and recipients for en bloc kidney transplantation
例序 受者资料 供者资料 热缺血时间（min） 冷缺血时间（h） HLA错配数 性别 年龄（岁） 身高（cm） 体质量（kg） 透析方式 透析时间（月） 性别 月龄（月） 身高（cm） 体质量（kg） 死亡原因 1 女 16 147 40 血液透析 2.5 男 14.0 53 8 脑外伤 7 6 1 2 男 15 150 29 血液透析 13 女 13.0 75 10 脑外伤 5 8 2 3 女 9 115 20 腹膜透析 24 男 15.0 94 12 脑外伤 8 6 2 4 女 32 155 45 腹膜透析+血液透析+ 24+12 男 2.0 55 5 低氧性脑损伤 5 8 2 5 女 52 150 50 血液透析 36 男 0.9 50 3 脑外伤 6 6 2 6 女 51 153 48 腹膜透析 60 男 8.5 70 7 颅内感染 5 5 1 7 女 46 152 50 血液透析 84 男 13.0 90 10 脑外伤 6 8 1 8 女 32 150 32 血液透析 1 男 9.0 80 7 脑外伤 5 7 1 9 女 50 153 59 未透析 0 男 0.9 50 4 脑肿瘤 8 6 2 HLA为人类白细胞抗原 
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表 2 肾移植受者术前和术后各时间点肾功能和移植肾长度的变化
Table 2. Changes of renal function and length of transplant kidney of recipients at each time point before and after renal transplantation(x±s)
时间 n 血清肌酐（μmol/L） 血尿素氮（mmol/L） 移植肾长度（mm） 术前 9 747±170 24.5±4.9 61.1±9.8 术后1周 9 309±154 21.7±8.1 065.2±11.1 术后1个月 8 148±550 16.2±5.1 73.8±7.1 术后3个月 7 121±430 11.1±4.4 82.6±9.2 术后6个月 7 83±32 09.4±3.2 92.1±6.3 术后1年 7 83±27 06.8±2.0 100.3±1.70
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表 3 9例肾移植受者术后不良事件的发生情况
Table 3. Adverse events in 9 cases of renal transplant recipients
例序 不良事件 发生时间 治疗经过 结局 1 单侧移植肾动脉栓塞DGF 术后1个月术后1周内 未予特殊处理透析过渡治疗 剩余移植肾功能正常、生长明显术后20 d恢复移植肾功能 2 急性排斥反应移植肾动脉轻度狭窄 术后2周术后2个月 甲泼尼龙冲击治疗未予特殊处理 逆转稳定 3 急性排斥反应尿瘘 术后3周术后8 d 甲泼尼龙冲击治疗充分引流、延长尿管留置时间 逆转治愈 4 蛋白尿 术后2周 严格控制血压, 雷公藤多苷 术后3个月尿蛋白转阴 5 移植肾输尿管狭窄尿路感染DGF 术后20 d术后3个月术后1周内 行经皮肾盂造瘘术, 后行球囊扩张术致病菌为大肠埃希菌, 予抗菌治疗透析过渡治疗 术后6个月拔除造瘘管尿路感染治愈术后26 d恢复移植肾功能 6 移植肾动脉血栓形成 术后7 d 行移植肾切除术 恢复血液透析 7 肺部真菌感染 术后2周 停用免疫抑制剂, 抗真菌治疗 死亡 8 腹主动脉狭窄蛋白尿 术后4个月术后2周 经介入放置支架处理严格控制血压, 雷公藤多苷 好转术后3个月尿蛋白转阴 9 移植肾输尿管狭窄尿路感染 术后2周术后3个月 行经皮肾盂造瘘术致病菌为近平滑假丝酵母, 予抗菌治疗 仍带有外引流造瘘管尿路感染治愈
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