Technical specification for diagnosis and treatment of chronic renal allograft dysfunction (2019 edition)
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摘要: 为了进一步规范慢性移植肾功能不全的诊断和治疗,中华医学会器官移植学分会组织器官移植学专家从慢性移植肾功能不全的诊断思路和治疗原则、移植肾复发肾小球疾病、钙神经蛋白抑制剂(CNI)肾损伤等方面,制订本规范。
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关键词:
- 器官移植 /
- 肾移植 /
- 慢性移植肾功能不全 /
- IgA肾病 /
- 局灶性节段性肾小球硬化 /
- 膜性肾病 /
- C3肾小球病 /
- 增生性肾小球肾炎合并单克隆IgG沉积 /
- 钙神经蛋白抑制剂 /
- 肾损伤
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表 1 慢性移植肾功能不全的常见病因、临床表现和诊断要点
Table 1. Common causes, clinical manifestations and diagnostic points of chronic renal allograft dysfunction
病因 主要临床表现 诊断要点 新发或复发肾小球疾病 Scr升高、蛋白尿、血尿 临床缺乏特异性,需行移植肾活检以明确诊断 慢性细胞性排斥反应 Scr升高 移植肾活检明确诊断 慢性体液性排斥反应 早期出现单纯蛋白尿,晚期出现Scr升高合并蛋白尿 DSA阳性可辅助诊断,移植肾活检可明确诊断 CNI移植肾毒性 Scr升高,蛋白尿少见 长期CNI血药浓度高,移植肾活检可明确诊断 BKVN Scr升高,蛋白尿少见 血、尿BK病毒升高,尿Decoy细胞阳性,移植肾活检可明确诊断 复发的肾盂肾炎 反复发作的高热、移植肾区疼痛、Scr升高、尿白细胞阳性 中段尿细菌培养阳性 移植肾动脉狭窄 血压升高,Scr逐渐升高 移植肾动脉超声、MRI或CT血管成像、数字减影血管造影可明确诊断 尿路梗阻 尿量减少,Scr升高,部分伴有移植肾胀痛 移植肾超声、移植肾MRI尿路成像、肾盂输尿管顺行造影可明确诊断 CNI为钙神经蛋白抑制剂;BKVN为BK病毒性肾病;Scr为血清肌酐;DSA为供体特异性抗体;活检为活组织检查 表 2 导致慢性移植肾功能不全的常见病治疗原则
Table 2. Treatment principles of common diseases leading to chronic renal allograft dysfunction
病因 治疗原则 新发或复发肾小球疾病 针对不同复发疾病采用不同的办法 慢性细胞性排斥反应 增强免疫抑制强度,加大免疫抑制剂剂量,转换免疫抑制较强的免疫抑制剂方案 慢性体液性排斥反应 增强免疫抑制强度,加大免疫抑制剂剂量,转换免疫抑制较强的免疫抑制剂方案去除抗体治疗:免疫吸附、血浆置换;大剂量丙种球蛋白;利妥昔单抗、硼替佐米、卡非佐米等 CNI肾损伤 减少CNI药物剂量,调低血药浓度将CNI换为西罗莫司(或依维莫司)、贝拉西普等药物 BKVN 降低免疫抑制强度,调整免疫抑制剂方案抗病毒治疗 复发的肾盂肾炎 明确病原体,药物试验敏感的抗生素足疗程治疗排除梗阻因素,调整免疫抑制剂方案 移植肾动脉狭窄 介入治疗:球囊扩张,血管支架植入移植肾动脉狭窄段再次成型术 尿路梗阻 移植肾输尿管支架置入;输尿管狭窄段扩张;输尿管狭窄段切除再次成型术 -
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