非清髓性外周造血干细胞移植后早期急性肾损伤的多中心临床研究

A multicenter prospective study of early acute kidney injury in adult patients with nonmyeloablative hematopoietic stem cell transplantation

目的观察白血病患者非清髓性外周造血干细胞移植后早期急性肾损伤（AKI）的患病率、危险因素及对生存的影响。方法对象为2002年1月至2007年5月，在东南大学附属中大医院、南京医科大学附属淮安医院、江苏大学附属镇江第一人民医院3个移植中心接受非清髓性外周造血干细胞移植的白血病患者。观察移植前、移植后100d内肾功能改变情况及并发症，并随访观察1年。AKI分为3期：1期，Scr升高≥26．5μmol／L，或升高50％～200％；2期，Scr升高〉200％～300％；3期，Scr升高〉300％，或升高〉353．6μmol／L（急性升高≥44．2μmol／L）。结果62例患者移植后造血均顺利恢复。18例（29％）患者出现不同程度的AKI，其中1期11例，2期6例，3期1例。Logistic多因素回归分析表明，人类白细胞抗原（HLA）不完全匹配、移植后并发症（感染、肝静脉闭塞病、急性移植物抗宿主病）是AKI的独立危险因素，其优势比OR（95％C1）分别为3．6（1．1～13．0）、12．1（2．4～62．4）。移植后1年患者总的病死率为27．4％，且病死率随着AKI的严重程度逐渐增加（log—rank检验，P〈0．01）。结论AKI是非清髓性外周造血干细胞移植后的常见并发症之一。HLA不完全匹配、移植后并发症是发生AKI的独立危险因素。AKI对患者移植后1年生存率有重要影响。

Objective To elucidate the prevalence and risk factors of acute kidney injury （AKI） within the post-operative 100 days in adult patients with nonmyeloablative hematopoietic stern cell transplantation （HSCT）, and whether AKI influences patients＇ survival. Methods Sixty-two adult leukemia patients from three transplant centers in Jiangsu province were treated with similar protocols of nonmyeloablative HSCT. AKI was classified as follows： Grade 0, no AKI; Grade 1, renal dysfunction, Scr increased ≥26.5 μmol/L or increased by 50% to 200% （0.5- to 2-fold） from baseline; Grade 2, Scr increased by 200% to 300% （2- to 3-fold） from baseline; Grade 3, Ser increased 〉300% （〉3-fold） from baseline, or Scr ≥353.6 μmol/L with an acute increase of at least 44.2 μmol/L. Results 29% （18/62） of the patients developed AKI within 100 days after nonmyeloablative HSCT. Risk factors of AKI were incomplete HLA-matched transplantation [odds ratio （OR） 3.6, 95% confidence interval （CI） 1.1-13.0]. The complications, including sepsis, veno-occlusive disease of liver and acute graft-versus-host, were also associated with the development of AKI （OR 12.1, 95% CI 2.4-62.4）. The overall one-year mortality of the patients was 27.4%. AKI was significantly associated with the mortality （log-rank test, P〈0.01）. Conclusions AKI is a very common complication in the patients with nonmyeloablative HSCT. It is associated with the incomplete HLA-matched transplantation and complications and has an important impact on the patients＇ first year survival.