儿童逝世后器官捐献肾移植58例早期临床疗效观察

Renal transplantation from pediatric donation after citizens death donors： a preliminary clinical report of 58 cases

目的 研究儿童逝世后器官捐献肾移植的预后及其影响因素.方法 回顾性分析2012年10月至2015年10月郑州大学第一附属医院儿童逝世后器官捐献32例供者及58例肾移植受者（其中单供肾肾移植52例,双供肾整块肾移植6例）的临床资料.单供肾肾移植供者26例,年龄为（7.0±3.9）岁（11个月至17岁）,体质量为（27.1±13.8）kg（8～67 kg）,身高为（119.7±32.2）cm（55～173cm）.单供肾肾移植受者52例,年龄为（20.7±13.3）岁（4～52岁）,体质量为（40.8±15.7）kg（11～77 kg）,身高为（147.3±22.2）cm（84～175 cm）.单供肾肾移植供、受者体表面积比值为0.75±0.24（0.32～1.44）.双供肾整块移植供者6例,年龄为（2.9±4.0）个月（28 d至9个月）,体质量为（7.6±2.5）kg（3.2～10.0 kg）,身高为（66.7±15.6）cm（50～90 cm）.双供肾整块移植受者6例,年龄为（34.0±18.9）岁（8～51岁）,体质量为（35.9±11.9）kg（24～52 kg）,身高为（146.0±15.2）cm（120～155 cm）,供、受者体表面积比值为0.31±0.11 （0.14～0.44）.统计两组受者急性排斥反应发生率、移植肾功能恢复延迟（DGF）发生率、外科并发症发生率,术后1周、2周、1个月、3个月、6个月、12个月及2年肾功能变化、1年及2年受者和移植肾存活率.结果 单供肾肾移植52例受者中,2例发生急性排斥反应,给予皮质激素冲击治疗后肾功能恢复至正常;DGF3例,2例受者肾功能分别在术后3周、4周恢复正常,1例儿童受者透析过程中死于重症肺部感染;术后2个月、3个月发生移植肾动脉狭窄各1例,均行介入支架治疗,分别随访12个月及15个月,均无移植肾动脉狭窄复发;尿瘘4例,延长尿管及引流管留置时间,尿瘘自行愈合;膀胱输尿管吻合口狭窄1例,给予二次手术,随访14个月无狭窄复发.双供肾整块移植6例受者中,发生DGF1例,3周后肾功能逐渐恢复至正常;移植肾动脉血栓形成1例,2周后行移植肾切除术;术后4个月供者腹主动脉狭窄1例,行介入支架治疗,随访1年无狭窄复发.所有受者中随访满2年的16例受者术后1周、2周、1个月、3个月、6个月、12个月及2年时的血肌酐分别为（132.5±104.6）μmol/L、（117.8±62.8）μmol/L、（101.7±54.0）μmol/L、（84.1±27.9）μmol/L、（69.6±22.6）μmol/L、（74.3±30.8）μmol/L、（113.8±90.3）μmol/L.随访满1年不满2年的3例受者术后1周、2周、1个月、3个月、6个月、12个月时的血肌酐分别为（212.8±248.0）μmol/L、（113.4±58.8）μmol/L、（70.3±11.4）μmol/L、（56.0±12.7）μmol/L、（50.5±12.0）μmol/L、（65.2±15.4）μmol/L.结论 注意器官获取前动脉灌注准备及血管吻合细节的改进,同时选择年龄小、体重轻、透析时间短的受者,儿童逝世后器官捐献肾移植可以取得良好的移植效果,可在临床推广.

Objective To investigate the clinical prognosis and influencing factors of kidney transplantation from donation after citizens death （DCD） of pediatric donors.Method We retrospectively analyzed the clinical data of kidney transplantation from DCD pediatric donors from October 2012 to October 2015 in the First Affiliated Hospital of Zhengzhou University.We totally obtained 64 kidneys from 32 pediatric donors and performed 58 kidney transplantation containing 52 single kidney transplantations and 6 en-bloc kidney transplantations.Thirty-two donors included 26 single kidney transplantation donors and 6 en-bloc kidney transplantation donors,who were 6.5 ± 4.9 years old （ranging from 28 days to 17 years） on average,with the mean weight of 25.1 ± 14.4 kg （ranging from 2.5 to 67.0 kg） and the mean height of 114.0 ± 33.8 cm （ranging from 50 to 173 cm）.Fifty-eight recipients were 22.1 ± 14.3 years old （ranging from 4 years to 52 years） on average,with the mean weight of 40.7± 15.8 kg （ranging from 11 to 77 kg） and the mean height of 147.2 ± 21.6 cm （ranging from 84 to 175 cm）.Donor/recipient （D/R） body surface area （BSA） ratio ranged from 0.14 to 1.44,and the average ratio was 0.71 ± 0.26.Through retrospective case analysis and regular follow-up,we calculated the incidence of acute rejection,delayed graft function （DGF） and surgical complications of two groups after operation.Meanwhile,we estimated renal function at 1 st week,2nd week,1st month,3rd month,6th month,12th month and 24th month postoperatively.In addition,human and graft survival rate was also calculated.Result In single kidney transplantation group,2 recipients underwent acute rejection and resumed to normal after treatment with steroid shock therapy.Three recipients experienced with DGF.Among them,renal function of two recipients resumed to normal after 2 and 3 weeks post-operation respectively,and one pediatric recipient died from severe pulmonary infection.Graft artery stenosis occurred in 2 recipients at 2nd and 3rd month,and these 2 recipients underwent graft artery angioplasty and stent implantation respectively.There was no recurrence of graft artery stenosis during the follow-up at 12th month and 15th month respectively.Four recipients had urinary fistula.After prolongation of indwelling catheter and drainage tube,the urinary fistula was self-healed.One case of ureteral stricture of bladder was given second operation and no recurrence of stricture happened during the follow-up period of 14 months.In en-bloc kidney transplantation group,DGF occurred in 1 recipient and renal function resumed to normal after 3 weeks.Graft thrombosis occurred in 1 recipient and graft nephrectomy was performed 2 weeks postoperation.One recipient experienced with donor abdominal aorta stenosis at 4th month after transplantation,subsequently he received stent implantation and no stenosis recurred during the follow-up period of 12 months.The serum creatinine in 16 recipients during the follow-up period of over 2 years was 132.5 ± 104.6,117.8 ± 62.8,101.7 ± 54.0,84.1 ± 27.9,69.6 ± 22.6,74.3 ± 30.8 and 113.8 ± 90.3 μmol/L,and the urea nitrogen was 12.91 ± 8.48,11.15 ± 5.21,8.46 ± 3.01,8.27 ± 2.04,7.21 ± 1.58,7.40 ± 1.88 and 11.30 ± 7.38 mmol/L at post-operative 1st week,2nd week,1st month,3rd month,6th month,12th month,and 24th month respectively.Conclusion The arterial infusion tube preparation before organ procurement should be noticed,vascular anastomosis details be improved,and meanwhile,recipients who are relatively younger,or have smaller weight and shorter maintenance dialysis time be selected.Kidney transplantation from pediatric DCD donors is feasible and applicable and can achieve relatively favorable preliminary clinical effects.