肝移植术后钙调磷酸酶抑制剂相关性肾损伤所致高钾血症的诊断与治疗

The diagnosis and treatment of hyperkalemia caused by calcineurin inhibitor associated nephrotoxicity after liver transplantation

目的研究肝移植受者术后高钾血症的发生情况，探讨钙调磷酸酶抑制剂（CNI）与高钾血症的关系及其诊治方案。方法回顾性分析西安交通大学第一附属医院肝胆外科2010年1月至2015年12月行肝移植术后发生高血钾症的6例患者资料，了解患者性别、年龄、术前诊断等一般情况和首次发生高血钾症时血钾浓度、血钠浓度、肾功能、血气分析、CNI血药浓度等相关情况。结果本中心肝移植受者术后高钾血症的发生率为2．4％（6／254）。6例患者中男性5例，女性1例，年龄45～64岁，供肝均来源于公民逝世后器官捐献；肝移植术后均采用CNI＋吗替麦考酚酯＋泼尼松三联免疫抑制方案，其中4例采用他克莫司，2例采用环孢素。6例患者肝移植术后首次发生高血钾症的时间为术后70～729d，血钾浓度为5．72—6．70mmol／L。血清尿素氮、血清肌酐均升高，5例血气分析提示代谢性酸中毒，CNI血药浓度和血钠浓度在正常范围。治疗给予静脉滴注碳酸氢钠、葡萄糖加胰岛素（按4：1比例）及口服呋塞米、聚苯乙烯磺酸钙，同时尽量减少CNI剂量。其中2例患者将环孢素转换为他克莫司，并增加吗替麦考酚酯剂量。6例患者均长期规律随访，其中1例因多器官功能衰竭死亡，其余5例截至2015年12月仍存活；有2例患者仍反复发作高钾血症，住院次数〉3次。结论肝移植术后采用CNI为基础的免疫抑制方案，需要关注CNI相关性肾小管损伤导致的高钾血症，建议减少CNI剂量或将其更换为西罗莫司。

Objective To study the incidence of hyperkalemia in the postoperative liver transplantation patients and explore the relationship between calcineurin inhibitor （ CNI ） immunosuppressant and hyperkalemia as well as its treatment. Methods A retrospective study was performed on 6 patients with hyperkalemia after liver transplantation in our hospital from January 2010 to December 2015. General conditions of the patients, included gender, age, preoperative diagnosis were collated and analysed, as well as other related conditions like time of the first occurrence of hyperkalemia, serum concentration of potassium, sodium, and CNI. Results The occurrence rate of hyperkalemia after liver transplantation in this study was 2.4%. The 6 cases （5 males and 1 female） aged 45 to 64 years, grafts were deprived from the donation after citizens death. All patients adopted CNI ＋ mycophenolate mofetil ＋ prednisone, 4 cases of which took tacrolimus while the other 2 cases took cyclosporine. Time of the first occurrence of hyperkalemia ranged from 70 days to 729 days after surgery. The serum sodium and CNI concentrations were not abnormal. The serum potassium level was 5.72 to 6.70 mmol/L. Combine with the significantly increased in urea nitrogen and creatinine, blood gas assay showed metabolic acidosis. Patients were treated with intravenous sodium bicarbonate, glucose plus insulin （4 ： 1 ratio） and oral furosemide, calcium polystyrene sulfonate, minimized the dose of CNI at the same time. Two patients replaced cyclosporine with tacrolimus and increased mycophenolate mofetil to 1 500 mg/d. Conclusions Hyperkalemia caused by CNI-related renal tubular lesion should be concerned when CNI-based immunosuppressive regimen was routinely employed. Reduced the dose of CNI or replace with sirolimus maybe a better choice.