肾移植术中肾缺血事件的诊断及治疗(附27例报告)

Diagnosis and treatment of the crisis events of renal ischemia in kidney transplant operation(report of 27 cases)

目的探讨肾移植术中急性移植肾缺血的诊断和治疗。方法总结27例肾移植术中急性移植肾缺血患者的临床资料。结果27例肾移植术中肾缺血事件病因:血管痉挛11例,其中肾外动脉痉挛5例,肾内血管痉挛6例;肾血流灌注不足6例,肾动脉狭窄1例,肾动脉血栓2例,肾静脉血栓1例,肾动/静脉扭转3例;肾动脉内膜损伤2例,超急性排斥反应1例。2例肾动/静脉血栓溶栓治疗成功。4例(肾动脉狭窄1例、肾动脉血栓1例、肾动脉内膜损伤2例)术中切取移植肾二次灌注再吻合成功。1例超急性排斥反应,切除术后病理证实。其余病例经抗凝、解痉、升压、调整移植肾位置等治疗缓解。1例术后因急性排斥并移植肾破裂手术切除。余25例中22例人肾存活良好,3例移植肾因慢性移植物肾病而失功。8例发生肾小管坏死。急性排斥4例,用甲泼尼龙或抗胸腺细胞球蛋白(ATG)治疗后3例逆转。结论肾移植术中发生移植肾缺血,及时准确判断原因和及时恢复血供,与移植肾的存活率密切相关。

Objective To investigate the causes, diagnosis and treatment of renal crisis ischemia incidentally found in the kidney transplant operation. Methods The clinical data of 27 recipients who experienced severe renal ischemia during kidney transplant operation was analyzed retrospectively. Results Of 27 cases 11 were vasospasm of transplant kidney（5 were extrarenal artery spasm, 6 were intrarenal artery spasm）. 6 were inadequate blood supply because of low blood pressure. For these grafts, enhancing blood pressure, anti renal artery spasm and keeping warm treatment were effective. Among other 10 cases, one was diagnosised as renal artery stenosis, two were renal artery embolism, one was renal vein embolism, three were renal artery and/or vein angulation, two were artery inner membrane damaged, one was hyperacute rejection. 2 cases with artery and vein embolism were successfully treated with heparin and anti artery spasm drugs via external iliac artery. 4 renal grafts （one renal artery stenosis, one renal artery embolism, two artery inner membrane damaged） were reperfused and underwent revascularization successfully. 2 renal grafts were discarded because of hyperacute rejection and acute rejection complicated by rupture respectively. By now 22 of 25 remainder renal grafts survived with satisfactory function and the other three suffered from chronic allograft nephropathy. Conclusions Diagnosis of graft kidney ishemia and to restore blood flow as fast as we can are essential for the survival of graft kidney in the kidney transplant operation.