肾移植术后再次手术的临床分析

Clinical study of unplanned re-operation after renal transplantation

目的分析肾移植受者围手术期再次手术的原因、结局,总结对应策略。方法回顾性分析2014年1月至2017年9月实施的435例肾移植术后再次手术病例20例22次的临床资料。所有受者均采用抗体诱导的四联免疫抑制方案(吗替麦考酚酯+他克莫司+泼尼松)。分析再次手术原因、发生时间、手术效果及移植肾功能恢复情况,评价术后受者和移植物的短期存活率,并追踪移植物功能恢复延迟(DGF)、急性排斥反应、肺部感染等并发症发生率。结果截至2017年9月,对所有受者随访1~36个月。再次手术整体发生率4.6%,三次手术2例,再次手术原因中,出血18例(创面渗血13例,排斥反应肾实质裂伤3例,肾动脉感染破裂出血2例),移植肾动脉血栓2例,漏尿修补2例。两次手术间隔1d 9例,2~5d 5例,6~10d 3例,>10d 5例;围手术期无死亡,1例术后3月动脉瘤破裂死亡,1例术后半年脑溢血死亡,去除死亡患者移植肾存活率为72.2%(13/18),DGF发生率为55%。结论。肾移植术后再次手术案例发生多与各种原因引起的出血相关,术后DGF发生率高,二次手术有效治疗后患者肾功能恢复良好。

Objective To analyze the reasons and outcomes of the unplanned re-operation in renal transplant recipients during perioperative period,and to summarize the corresponding strategies.Methods From January 2014 to September 2017,the clinical data of 20 cases of kidney transplantation which had a total of 22 unplanned re-operations were retrospectively analyzed.All patients were given quadruple immunosuppression with antibody induction and tacrolimus (TAC) and mycophenolate mofetil (MMF) plus prednisone (Pred).We analyzed the reasons,occurrence time,effect of re-operation and the renal function,as well as survival rate of all graft and recipient.The delayed graft function (DGF),acute rejection (AR) and incidence of pulmonary infection were monitored as well.Results Up to September 2017,during the follow-up of 1-36 months,the overall rate of unplanned re-operation was 4.6%,and 2 patients underwent 3 operations.For the reasons of re-operation,there were 18 cases of bleeding (13 cases of blood oozing from the wound surface,3 cases of renal parenchyma rupture because of rejection,and 2 cases of rupture of renal artery infection),2 cases of renal artery thrombosis and 2 cases of the repair of leakage of urine.Two operations were performed within 1 days for 9 cases,2-5 days for 5 cases,6-10 days for 3 cases,above 10 days for 45 cases.There was no deaths during the perioperative period.One patient died of rupture of exiliac aneurysm 3 months after the operation.One patient died of cerebral hemorrhage 6 months postoperation.The death censored graft survival rate was 72.2% (13/18) and the incidence of DGF was 55 %.Conclusion The major reason of unplanned re-operation for renal transplantation is associated with bleeding of various causes.And the incidence of DGF is high.If the secondary operation was performed with the correct decision,the kidney allograft recovers well.