儿童肾移植9例

Pediatric kidney transplantation: a report of 9 cases

目的探讨儿童肾移植的指征、手术特点，以提高手术成功率。方法1993年1月-2004年5月完成12—17岁9例儿童肾移植，原发病7例为慢性肾小球肾炎、1例为药物性（丁胺卡那霉素）肾脏损害、1例为Alport综合征。供肾获取均采用腹部多器官联合切取技术，供肾热缺血时间3—8min，平均4．5min，冷缺血时间5—14h，平均8．5h，以保证供肾质量；除1例患者经腹部供肾动脉与受者髂总动脉行端-侧吻合外，其余患者均与成人肾移植手术方式相同；围手术期甲基泼尼松（MP）用量为2g，采用三联用药方案：环孢素A（CsA）或普乐可复（FK506）加硫唑嘌呤（AzA）或霉酚酸酯（MMF）加泼尼松（Pred）。结果所有患者肾功能均在3—12d恢复正常（血肌酐为77—131μmol·L^-1）；除第1例患者肾移植术后出现供体输尿管末端缺血坏死、经再次手术后痊愈，余无其他外科并发症；2例次出现急性排斥反应，经应用MP0．5g·d^-1，3d后逆转；Alport综合征患者1年2个月后出现蛋白尿，经治疗无明显好转，但血肌酐维持在116—172μmol·L^-1之间；所有移植肾存活至少1年以上，最长存活12年。结论良好的组织配型和供体质量、恰当的手术方式及个体化的免疫抑制方案，以及术后严密监测是提高儿童肾移植手术成功率的关键。

Objective To investigate the application and surgical technology in pediatric renal transplantation. Methods Nine pediatric recipients（less than 18 years） received cadaveric renal allograft between 1993 and 2005. The 9 cases were retrospectively analyzed. All patients were operated like as adults except one case being performed with the cadaver artery and the chief iliac artery of recipient by end-to-side. Warm ischemic time of donor kidney was 3 - 8 min with the average was 4.5 min, whereas cold ischemic time was 5 - 14 h with the average was 8.5 h. The dose of MP was under 2.0 g during the period of operation and the immunosuppressisive regimen was CsA or FK506 ＋ Aza or MMF ＋ Pred. Results The kidney function of all the patients return to the normal level within 3 - 12 days after transplantation. The end of ureter occurred ischemic necrosis in case who recoverd after the repeated operation. Two cases rejection were reversed after antirejection with MP（0.5 g· d^-1 × 3 d）. The alport syndrome （AS） child developed recurrent albuminuria, which kidney function was approach to normal（116～172 μmol·L^-1） after therapy. All grafts survived more than one year and the longest was 12 years. Conclusion Renal transplantation is effective to pediatric end-stage renal disease. Good tissue matching, good quantities of allografts, appropriate technique of operations, immunosuppressants are keys to success.