老年肾移植受者的临床分析与管理

Clinical characteristics and nmnagement of kidney transplantation in the older adults： monocentric retrospective analysis

目的分析老年肾移植受者的临床特点及移植效果，提出临床管理策略。方法2009年1月至2012年12月接受肾移植的40例老年（≥60岁）及777例中青年（18~59岁）终末期肾病（ESRD）患者，对术前情况、移植效果及治疗策略进行回顾性分析。结果老年组术前合并糖尿病和冠状动脉粥样硬化性心脏病的发生率（25％和32．50％）明显高于中青年组（4．9％和11．38％）。老年组7例（17．5％）受者死亡，均发生于术后半年内，其中4例死于重症肺部感染，2例死于心力衰竭，1例死于肺栓塞。中青年组36例（4．6％）死亡，其中31例死于术后半年内，死因包括肺部感染21例，脑血管意外5例，心力衰竭4例，急性排斥反应4例，肺栓塞2例，老年组死亡率明显高于中青年组（P=0．003）。老年组术后半年、3年受者存活率分别为81．56％和81．56％，均明显低于中青年组的95．35％和94．5％（P=0．03），术后半年、3年移植肾存活率（78．75％和68．82％）均明显低于中青年组（92．02％和85．40％）。术后1、2年时两组受者血肌酐水平接近，术后第3年老年组血肌酐水平则显著低于中青年组（P=0．0373）。结论老年ESRD患者术前合并症较多，机体状态较差，临床特点复杂。严格把握肾移植手术适应证、充分的术前准备、良好的组织配型及供肾质量是老年肾移植成功的关键，合理应用免疫抑制剂、精细的围手术期管理、预防和及时处理并发症是提高受者和移植肾长期存活的有力措施。

Objective To explore the clinical characteristics and management of kidney transplantation in the older adults. Method Forty older kidney recipients （≥60 years old） and 777 younger （18- 59 years old） recipients from June 2009 to December 2012 were retrospectively reviewed to evaluate the clinical characteristics and managements. Result Of 40 older recipients, the co- morbidities of diabetes and coronary artery disease in older group were higher than in the younger （25% vs. 4. 9%, and 32. 50% vs. 11.38%）. During the first 6 months, 7 older patients died, among which 4 died from severe pneumonia, 2 from heart failure and I from pulmonary embolism. There were 31 deaths in younger group, among which 21 died from severe pneumonia, 4 from heart failure, 5 from cerebrovascular accident and 2 from pulmonary embolism. The mortality in the older group was higher than in the younger group （17. 5% vs. 4. 6%）. Six-month and 3-year survival rate in the older recipients was lower than the younger recipients （81.56% vs. 95.35%, and 81.56% vs. 94. 5%, respectively）. Six-month graft survival rate and 3-year survival rate in the older group were also lower than in the younger group （78. 75% vs. 92. 02%, and 68. 82% vs. 85.40%）. At the 1st and 2nd year during follow-up, the serum creatinines in the older group were close to those in the younger group, while lower level was observed 3 years after transplantation in the older patients （89. 38 ± 11.34 （mol/ L vs. 116. 57 ± 48. 68 （mol/L）. Conclusion The patients with ESRD older than 60 years have more preoperative concomitant diseases and worse health status, which contribute to the complex clinical characteristics. More aggressive indication selection, sufficient pre-operative preparation, well- matched histocompatibility and high quality of donor kidney are the key factors of successful transplantation. Optimized immunosuppressant therapy, delicate perioperative management, preventve and effective treatment of related complications are necessary to promote the survival of recipients and graft in long term.