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肾移植术后血管并发症的诊疗策略

张江伟, 丁小明. 肾移植术后血管并发症的诊疗策略[J]. 器官移植, 2024, 15(1): 1-9. doi: 10.3969/j.issn.1674-7445.2023168
引用本文: 张江伟, 丁小明. 肾移植术后血管并发症的诊疗策略[J]. 器官移植, 2024, 15(1): 1-9. doi: 10.3969/j.issn.1674-7445.2023168
Zhang Jiangwei, Ding Xiaoming. Diagnosis and treatment strategies for vascular complications after kidney transplantation[J]. ORGAN TRANSPLANTATION, 2024, 15(1): 1-9. doi: 10.3969/j.issn.1674-7445.2023168
Citation: Zhang Jiangwei, Ding Xiaoming. Diagnosis and treatment strategies for vascular complications after kidney transplantation[J]. ORGAN TRANSPLANTATION, 2024, 15(1): 1-9. doi: 10.3969/j.issn.1674-7445.2023168

肾移植术后血管并发症的诊疗策略

doi: 10.3969/j.issn.1674-7445.2023168
基金项目: 国家自然科学基金(81970670)
详细信息
    作者简介:
    通讯作者:

    丁小明(ORCID 0000-0002-9082-9191),Email:xmding@xjtu.edu.cn

  • 中图分类号: R617, R543

Diagnosis and treatment strategies for vascular complications after kidney transplantation

More Information
  • 摘要: 随着肾移植供受者评估标准、器官获取保存方案、手术技术等不断进步,肾移植术后血管并发症的发生率有所下降,但仍是肾移植较为严重的手术并发症之一,可导致移植物丢失及受者死亡,严重影响肾移植效果。因此,本文就肾移植术后常见血管并发症,包括血管狭窄、动脉夹层、假性动脉瘤、血管破裂、血栓等的发生概况、临床表现、诊断和治疗策略进行综述,并结合西安交通大学第一附属医院肾移植术后血管并发症发生和诊治情况,总结肾移植术后常见血管并发症的诊疗策略,以期为肾移植术后血管并发症的临床诊断和治疗提供参考,降低血管并发症的发生率,提高肾移植疗效和受者生存率。

     

  • 图  1  不同类型移植肾动脉狭窄的治疗方式

    注:A、B图为1例38岁男性患者,肾移植术后8个月,DSA示移植肾动脉主干全段狭窄,呈条索状,放置动脉支架移植肾功能恢复正常;C、D图为1例43岁男性患者,肾移植术后6个月,血清肌酐201 μmol/L,DSA示移植肾动脉分支重度狭窄,球囊扩张后放置动脉支架,术后血清肌酐降至120 μmol/L;E、F图为1例39岁女性患者,肾移植术后1年8个月,尿量减少,血清肌酐360 μmol/L,DSA示移植肾髂外动脉吻合处狭窄80%以上,放置动脉支架,移植肾血供正常化,血清肌酐降至155 μmol/L。

    Figure  1.  Treatment for different types of artery stenosis in renal allograft

    图  2  肾移植术中髂外动脉夹层的治疗

    注:1例33岁男性患者,术中发生髂外动脉夹层,切除血管夹层部分,行髂外动脉人工血管置换术,直径8 mm(白色箭头),移植肾动脉改与髂内动脉吻合(白色虚线箭头),肾功能恢复正常;术后3个月复查髂动脉CT血管造影,见置换部分的血管走行自然,近心端吻合口轻度狭窄。

    Figure  2.  Treatment of external iliac artery dissection during kidney transplantation

    图  3  移植肾动脉和静脉血栓的治疗

    注:A图为1例男性患者,肾移植术后少尿,移植肾超声示血流灌注差,移植肾动脉舒张期反向,考虑动脉血栓,行移植肾探查术,提示移植肾质软色苍白,动脉搏动消失;切除移植肾,剖开移植肾动脉可见条索状血栓形成(白色箭头)。B、C图为1例男性患者,肾移植术后7 d,DGF,尿量减少,移植肾超声示血流灌注差,血管树稀疏,皮质无血流,行移植肾探查术,移植肾色暗紫,提示移植肾静脉血栓,切除移植肾,剖开可见微血管血栓形成。

    Figure  3.  Treatment of artery and vein thrombosis in renal allograft

    图  4  移植肾动脉破裂的治疗

    注:1例男性患者,39岁,伤口泛耐药铜绿假单胞菌感染,肾移植术后2周出现伤口疼痛和引流量增多(血性液体),行移植肾探查,术中见移植肾动脉吻合口破裂,创面有感染征象,考虑为“感染性动脉炎”致破裂。切除移植肾和部分髂外动脉,结扎髂外动脉残端,行股动脉(白色虚线箭头)-人工血管(白色箭头+黑色虚线)-对侧股动脉转流术,术后监测双下肢血流及皮温基本正常。

    Figure  4.  Treatment of artery rupture in renal allograft

    图  5  肾外型假性动脉瘤的治疗

    注:1例男性患者,33岁,肾移植术后6个月,尿少伴肾功异常。A图为移植肾超声检查示灌注良好,右髂外动脉可见大小约25 mm×22 mm的囊性包块,与肾动脉相连,通道开口宽度约7 mm,彩色多普勒血流显像可见动脉血流,呈涡流状。B图为DSA示右髂外动脉假性动脉瘤。C、D图为放置一个Viabahn 直径10~50 mm覆膜支架,再次造影可见假性动脉瘤覆盖完全。

    Figure  5.  Treatment of extrarenal pseudoaneurysm

    表  1  肾移植术后血管并发症概况

    Table  1.   Overview of vascular complications after kidney transplantation

    血管并发症类型 n 术后发生时间 治疗方案 发生率(%)
    移植肾动脉狭窄 36 0.5~7.0个月 PTA:球囊扩张术(3例),血管内支架植入术(33例) 1.56
    髂外动脉夹层 5 <1 d(4例),
    3个月(1例)
    人工血管置换术(3例),供者髂动脉搭桥术(1例),PTA(1例) 0.22
    肾动脉破裂 4 2~18 d 肾切除术(3例),动脉修补术(1例) 0.17
    肾静脉血栓 3 7~15 d 肾切除术(3例) 0.13
    肾动脉血栓 2 7 d 肾切除术(1例),PTA(1例) 0.09
    假性动脉瘤 2 4.5个月 PTA(2例) 0.09
    肾动脉夹层 1 3 d PTA 0.04
    肾动脉扭结 1 2 d 肾切除术 0.04
    下载: 导出CSV
  • [1] JALALI F, HAKEMI M, NASSIRI A. Awareness and knowledge about kidney transplantation: a reflection on the current state among iranian patients with end-stage renal disease (ESRD) treated by dialysis[J]. Iran J Kidney Dis, 2021, 15(6): 433-440.
    [2] BESSEDE T, DROUPY S, HAMMOUDI Y, et al. Surgical prevention and management of vascular complications of kidney transplantation[J]. Transpl Int, 2012, 25(9): 994-1001. DOI: 10.1111/j.1432-2277.2012.01533.x.
    [3] SALAMIN P, DESLARZES-DUBUIS C, LONGCHAMP A, et al. Predictive factors of surgical complications in the first year following kidney transplantation[J]. Ann Vasc Surg, 2022, 83: 142-151. DOI: 10.1016/j.avsg.2021.08.031.
    [4] GUNAWARDENA T. Update on vascular complications after renal transplantation[J]. Exp Clin Transplant, 2022, 20(4): 333-341. DOI: 10.6002/ect.2021.0303.
    [5] VAN DER MOLEN AJ, REIMER P, DEKKERS IA, et al. Post-contrast acute kidney injury - part 1: definition, clinical features, incidence, role of contrast medium and risk factors : recommendations for updated ESUR Contrast Medium Safety Committee guidelines[J]. Eur Radiol, 2018, 28(7): 2845-2855. DOI: 10.1007/s00330-017-5246-5.
    [6] VAN DER MOLEN AJ, REIMER P, DEKKERS IA, et al. Post-contrast acute kidney injury. part 2: risk stratification, role of hydration and other prophylactic measures, patients taking metformin and chronic dialysis patients : recommendations for updated ESUR Contrast Medium Safety Committee guidelines[J]. Eur Radiol, 2018, 28(7): 2856-2869. DOI: 10.1007/s00330-017-5247-4.
    [7] DE LAFORCADE L, BOBOT M, BELLIN MF, et al. Kidney and contrast media: common viewpoint of the French Nephrology Societies (SFNDT, FIRN, CJN) and the French Radiological Society (SFR) following ESUR guidelines[J]. Diagn Interv Imaging, 2021, 102(3): 131-139. DOI: 10.1016/j.diii.2021.01.007.
    [8] RAVN EJ, HASIFIC S, THOMASSEN M, et al. Intravenous versus oral hydration to reduce the risk of postcontrast acute kidney injury after intravenous contrast-enhanced CT in patients with severe chronic kidney disease (ENRICH): a study protocol for a single-centre, parallel-group, open-labelled non-inferiority randomised controlled trial in Denmark[J]. BMJ Open, 2023, 13(9): e074057. DOI: 10.1136/bmjopen-2023-074057.
    [9] GHEITH OA, NAGIB AM, HALIM MA, et al Contrast-induced nephropathy in kidney transplant recipients: a single-center experience[J]. Iran J Kidney Dis, 2023, 1(1): 47-53.
    [10] KULU Y, FATHI P, GOLRIZ M, et al. Impact of surgeon's experience on vascular and haemorrhagic complications after kidney transplantation[J]. Eur J Vasc Endovasc Surg, 2019, 57(1): 139-149. DOI: 10.1016/j.ejvs.2018.07.041.
    [11] TAVAKKOLI M, ZAFARGHANDI RM, TAGHAVI R, et al. Immediate vascular complications after kidney transplant: experience from 2100 recipients[J]. Exp Clin Transplant, 2017, 15(5): 504-508. DOI: 10.6002/ect.2016.0057.
    [12] DE FREITAS RAP, DE LIMA ML, MAZZALI M. Early vascular thrombosis after kidney transplantation: can we predict patients at risk?[J]. Transplant Proc, 2017, 49(4): 817-820. DOI: 10.1016/j.transproceed.2017.03.004.
    [13] TIWARI B, PANDEY P, G V, et al. Various techniques and outcomes of arterial anastomosis in live renal transplant: an institutional experience[J]. Cureus, 2022, 14(5): e25262. DOI: 10.7759/cureus.25262.
    [14] HUANG JF, WANG HB, ZHENG SS, et al. Advances in China's organ transplantation achieved with the guidance of law[J]. Chin Med J (Engl), 2015, 128(2): 143-146. DOI: 10.4103/0366-6999.149183.
    [15] NOBLE J, JOUVE T, MALVEZZI P, et al. Transplantation of marginal organs: immunological aspects and therapeutic perspectives in kidney transplantation[J]. Front Immunol, 2020, 10: 3142. DOI: 10.3389/fimmu.2019.03142.
    [16] ZHANG X, SHAN H, ZHANG M, et al. Donor-derived infection's prevention and control in kidney transplantation[J]. Transplant Proc, 2023, 55(1): 22-29. DOI: 10.1016/j.transproceed.2022.12.009.
    [17] PONTICELLI C, REGGIANI F, MORONI G. Delayed graft function in kidney transplant: risk factors, consequences and prevention strategies[J]. J Pers Med, 2022, 12(10): 1557. DOI: 10.3390/jpm12101557.
    [18] LONG J, FENG Z, LIU J, et al. Endovascular treatment of transplant renal artery stenosis: a single-center retrospective cohort study[J]. Exp Clin Transplant, 2023, 21(3): 220-228. DOI: 10.6002/ect.2022.0400.
    [19] CALZAS MONTALVO C, MEDINA-POLO J, MIRANDA UTRERA NR, et al. Transplant renal artery stenosis: study of incidence using doppler ultrasound, risk factors and analysis is effect in graft outcomes[J]. Actas Urol Esp (Engl Ed), 2023,DOI: 10.1016/j.acuroe.2023.08.004[Epub ahead of print
    [20] BARTECZKO MLM, ORELLANA HC, SANTOS GRF, et al. Long-term clinical outcomes of patients with nonsignificant transplanted renal artery stenosis[J]. BMC Nephrol, 2022, 23(1): 61. DOI: 10.1186/s12882-022-02691-0.
    [21] LACOMBE M. Arterial stenosis complicating renal allotransplantation in man: a study of 38 cases[J]. Ann Surg, 1975, 181(3): 283-288. DOI: 10.1097/00000658-197503000-00007.
    [22] DIMITROULIS D, BOKOS J, ZAVOS G, et al. Vascular complications in renal transplantation: a single-center experience in 1367 renal transplantations and review of the literature[J]. Transplant Proc, 2009, 41(5): 1609-1614. DOI: 10.1016/j.transproceed.2009.02.077.
    [23] GUNAWARDENA T, SHARMA H. Transplant renal artery stenosis: current concepts[J]. Exp Clin Transplant, 2022, 20(12): 1049-1057. DOI: 10.6002/ect.2022.0334.
    [24] PINI A, FAGGIOLI G, PINI R, et al. Assessment and management of transplant renal artery stenosis. a literature review[J]. Ann Vasc Surg, 2022, 82: 13-29. DOI: 10.1016/j.avsg.2022.01.011.
    [25] PATEL U, KUMAR S, JOHNSON OW, et al. Long-term graft and patient survival after percutaneous angioplasty or arterial stent placement for transplant renal artery stenosis: a 21-year matched cohort study[J]. Radiology, 2019, 290(2): 555-563. DOI: 10.1148/radiol.2018181320.
    [26] LEERTOUWER TC, GUSSENHOVEN EJ, BOSCH JL, et al. Stent placement for renal arterial stenosis: where do we stand? a meta-analysis[J]. Radiology, 2000, 216(1): 78-85. DOI: 10.1148/radiology.216.1.r00jl0778.
    [27] BENOIT G, MOUKARZEL M, HIESSE C, et al. Transplant renal artery stenosis: experience and comparative results between surgery and angioplasty[J]. Transpl Int, 1990, 3(3): 137-140. DOI: 10.1007/BF00355459.
    [28] RENGEL M, GOMES-DA-SILVA G, INCHÁUSTEGUI L, et al. Renal artery stenosis after kidney transplantation: diagnostic and therapeutic approach[J]. Kidney Int Suppl, 1998, 68: S99-S106. DOI: 10.1038/sj.ki.4490573.
    [29] ULUER MC, BRAZIO PS, WOODALL JD, et al. Vascularized composite allotransplantation: medical complications[J]. Curr Transplant Rep, 2016, 3(4): 395-403. DOI: 10.1007/s40472-016-0113-x.
    [30] 谢恩泽华, 丘俊涛, 吴进林, 等. 主动脉夹层发病机制研究进展[J]. 中国胸心血管外科临床杂志, 2020, 27(9): 1081-1086. DOI: 10.7507/1007-4848.202002112.

    XIE EZH, QIU JT, WU JL, et al. Advances in the pathogenesis of aortic dissection[J]. Chin J Clin Thorac Cardiovasc Surg, 2020, 27(9): 1081-1086. DOI: 10.7507/1007-4848.202002112.
    [31] 唐前辉, 张显岚. 主动脉夹层破裂4例并文献复习[J]. 血管与腔内血管外科杂志, 2021, 7(7): 881-884. DOI: 10.19418/j.cnki.issn2096-0646.2021.07.25.

    TANG QH, ZHANG XL. Rupture of aortic dissection: a report of 4 cases and literature review[J]. J Vasc Endovasc Surg, 2021, 7(7): 881-884. DOI: 10.19418/j.cnki.issn2096-0646.2021.07.25.
    [32] BAYRAKTAR N. Repair experience of external iliac artery dissection using internal iliac artery transposition during renal transplantation[J]. Ulus Travma Acil Cerrahi Derg, 2023, 29(8): 944-947. DOI: 10.14744/tjtes.2023.97284.
    [33] MALIK MS, AKOH JA, HOULBERG K, et al. Iliofemoral polytetrafluoroethylene graft interposition: a rescue procedure in external iliac artery dissection to restore lower limb revascularization and salvage kidney transplant[J]. Exp Clin Transplant, 2023, 21(5): 467-470. DOI: 10.6002/ect.2023.0062.
    [34] 张江伟, 李杨, 田普训, 等. 基于人工血管置换术治疗肾移植术中髂外动脉夹层的临床效果研究[J]. 中华器官移植杂志, 2022, 43(4): 211-214. DOI: 10.3760/cma.j.cn421203-20211121-00290.

    ZHANG JW, LI Y, TIAN PX, et al. Clinical efficacy of artificial vascular replacement for external iliac artery dissection during renal transplantation[J]. Chin J Organ Transplant, 2022, 43(4): 211-214. DOI: 10.3760/cma.j.cn421203-20211121-00290.
    [35] 孙蕊, 周梦馨, 刘志丽, 等. 罕见外周动脉夹层诊治经验探讨[J]. 中华老年多器官疾病杂志, 2018, 17(8): 603-605. DOI: 10.11915/j.issn.1671-5403.2018.08.138.

    SUN R, ZHOU MX, LIU ZL, et al. Experience in the diagnosis and treatment of rare peripheral arterial dissection[J]. Chin J Mult Organ Dis Elderly, 2018, 17(8): 603-605. DOI: 10.11915/j.issn.1671-5403.2018.08.138.
    [36] 李光新, 王宾, 王坤, 等. 肾移植相关血管并发症的治疗体会[J]. 血管与腔内血管外科杂志, 2015, 1(Z1): 105-107. DOI: 10.19418/j.cnki.issn2096-0646.2015.z1.007.

    LI GX, WANG B, WANG K, et al. Experience in the treatment of vascular complications related to kidney transplantation[J]. J Vasc Endovasc Surg, 2015, 1(Z1): 105-107. DOI: 10.19418/j.cnki.issn2096-0646.2015.z1.007.
    [37] YOSHIDA T, YANISHI M, NAKAMOTO T, et al. Successful treatment of transplant renal artery thrombosis with systemic infusion of recombinant-tissue-plasminogen activator after renal transplant[J]. Exp Clin Transplant, 2017, 15(5): 571-573. DOI: 10.6002/ect.2015.0099.
    [38] 陈刚. 中国儿童肾移植的现状及对未来发展的思考[J]. 中华器官移植杂志, 2020, 41(1): 1-2. DOI: 10.3760/cma.j.issn.0254-1785.2020.01.001.

    CHEN G. Current situation of renal transplantation in children in China and its future development[J]. Chin J Organ Transplant, 2020, 41(1): 1-2. DOI: 10.3760/cma.j.issn.0254-1785.2020.01.001.
    [39] HARRAZ AM, SHOKEIR AA, SOLIMAN SA, et al. Salvage of grafts with vascular thrombosis during live donor renal allotransplantation: a critical analysis of successful outcome[J]. Int J Urol, 2014, 21(10): 999-1004. DOI: 10.1111/iju.12485.
    [40] LYSAKOWSKI S, DRUCK GARCIA C, WEISHEIMER ROHDE R, et al. Pediatric kidney transplantation: outcomes with under and over 6-year-old donors[J]. J Pediatr (Rio J), 2023,DOI: 10.1016/j.jped.2023.07.005[Epub ahead of print
    [41] PARAJULI S, LOCKRIDGE JB, LANGEWISCH ED, et al. Hypercoagulability in kidney transplant recipients[J]. Transplantation, 2016, 100(4): 719-726. DOI: 10.1097/TP.0000000000000887.
    [42] MELAMED ML, KIM HS, JAAR BG, et al. Combined percutaneous mechanical and chemical thrombectomy for renal vein thrombosis in kidney transplant recipients[J]. Am J Transplant, 2005, 5(3): 621-626. DOI: 10.1111/j.1600-6143.2004.00696.x.
    [43] CAMBOU L, MILLET C, TERRIER N, et al. Management and outcome after early renal transplant vein thrombosis: a french multicentre observational study of real-life practice over 24 years[J]. Transpl Int, 2023, 36: 10556. DOI: 10.3389/ti.2023.10556.
    [44] NATOUR AK, AHMED S, KIM DY, et al. Risk of ipsilateral deep vein thrombosis after kidney transplantation: a retrospective study[J]. Cureus, 2022, 14(4): e24482. DOI: 10.7759/cureus.24482.
    [45] TANG M, XU X, SHEN B, et al. Fifty-one cases of fungal arteritis after kidney transplantation: a case report and review of the literature[J]. Transpl Infect Dis, 2017, 19(6). DOI: 10.1111/tid.12781.
    [46] PATRONO D, VERHELST R, BUEMI A, et al. Renal allograft implantation on prosthetic vascular grafts: short- and long-term results[J]. World J Surg, 2013, 37(7): 1727-1734. DOI: 10.1007/s00268-013-2028-3.
    [47] 张龙, 周江桥, 邱涛, 等. 6例供者来源性感染致肾移植后血管并发症的诊疗经验[J]. 中华器官移植杂志, 2022, 43(6): 340-345. DOI: 10.3760/cma.j.cn421203-20210917-00233.

    ZHANG L, ZHOU JQ, QIU T, et al. Management of vascular complications after kidney transplantation caused by donor derived infection: a report of 6 cases[J]. Chin J Organ Transplant, 2022, 43(6): 340-345. DOI: 10.3760/cma.j.cn421203-20210917-00233.
    [48] GUO YL, LU X, ZHU L, et al. Infective artery rupture of renal allografts: a single-center retrospective study in China[J]. Curr Med Sci, 2022, 42(4): 847-855. DOI: 10.1007/s11596-022-2557-9.
    [49] CAÑO-VELASCO J, POLANCO-PUJOL L, GONZÁLEZ-GARCÍA J, et al. Renal artery infectious (mycotic) pseudoaneurysms in renal transplantation recipients[J]. Actas Urol Esp (Engl Ed), 2021, 45(5): 335-344. DOI: 10.1016/j.acuroe.2021.04.009.
    [50] NEYMARK AI, NEYMARK BA, NOZDRACHEV NA, et al. Spontaneous rupture of kidney tumor. successful surgical treatment[J]. Urologiia, 2022(1): 74-77.
    [51] AKTAS S, BOYVAT F, SEVMIS S, et al. Analysis of vascular complications after renal transplantation[J]. Transplant Proc, 2011, 43(2): 557-561. DOI: 10.1016/j.transproceed.2011.01.007.
    [52] VERLOH N, DOPPLER M, HAGAR MT, et al. Interventional management of vascular complications after renal transplantation[J]. Rofo, 2023, 195(6): 495-504. DOI: 10.1055/a-2007-9649.
    [53] GÓMEZ DOS SANTOS V, HEVIA PALACIOS V, GALEANO ÁLVAREZ C, et al. Renal allograft transplant vascular complications. diagnostic and treatment[J]. Arch Esp Urol, 2021, 74(10): 1013-1028.
    [54] TRIVEDI SB, GABA RC. Transplant renal biopsy complicated by arteriovenous fistula[J]. J Vasc Interv Radiol, 2023, 34(9): 1634-1635. DOI: 10.1016/j.jvir.2023.03.032.
    [55] KOLLI KP, LABERGE JM. Interventional management of vascular renal transplant complications[J]. Tech Vasc Interv Radiol, 2016, 19(3): 228-236. DOI: 10.1053/j.tvir.2016.06.008.
    [56] SERNA-HIGUITA LM, ZULUAGA-QUINTERO M, HIDALGO-OVIEDO JM, et al. Treatment of post-biopsy arteriovenous fistula of a renal graft by selective embolization[J]. Indian J Nephrol, 2021, 31(2): 201-204. DOI: 10.4103/ijn.IJN_351_19.
    [57] ZILINSKA Z, CHRASTINA M, TREBATICKY B, et al. Vascular complications after renal transplantation[J]. Bratisl Lek Listy, 2010, 111(11): 586-589.
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出版历程
  • 收稿日期:  2023-09-04
  • 网络出版日期:  2023-11-29
  • 刊出日期:  2024-01-11

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