心脏死亡器官捐献供肾ABO血型不相容肾移植八例临床分析

ABO blood group incompatible donation after cardiac death donor kidney transplantation: a report of 8 cases

目的探讨心脏死亡器官捐献(DCD)供肾ABO血型不相合肾移植临床疗效和安全性。方法回顾性分析中国人民解放军联勤保障部队第九二四医院移植科2016年12月至2018年6月实施的8例DCD供肾ABO血型不相容肾移植受者临床资料,其中男性6例,女性2例,年龄26～54岁,群体反应性抗体(PRA)阳性4例,二次肾移植2例,供受者Rh(D)血型均为阴性。根据受者初始血型抗体效价及术前PRA抗体水平制定个体化预处理方案。术后常规监测受者免疫抑制剂血药浓度,重点监测尿量、肾功能、凝血状态和血型抗体水平,PRA阳性受者注意监测供者特异性抗体水平。结果 8例受者经个体化预处理后肾移植手术当天血型抗体Ig G效价水平均≤1∶16。术后2周内7例受者血型抗体无反弹。截至2018年6月,8例受者平均随访时间6～18个月。病例1于术后第2周发生体液性排斥反应,采用蛋白A免疫吸附及大剂量丙种球蛋白冲击治疗后恢复。病例2术后2 h出现膀胱出血,持续膀胱冲洗保守治疗后止血,移植肾功能恢复正常。病例3术后第5个月并发严重肺部真菌感染,抗真菌治疗失败后并发呼吸衰竭死亡。病例6术后出现移植肾功能延迟恢复,予血液透析处理后恢复。病例7术后尿量少,术后第4天出现右下肢深静脉血栓(移植肾侧),行下腔静脉滤网植入及溶栓抗凝治疗,效果欠佳,移植肾失功后恢复血液透析治疗。病例8术后第2个月并发药物性糖尿病,目前血糖控制较好。其余2例受者移植肾功能恢复良好。结论根据受者初始血型抗体效价及PRA水平进行个体化预处理,可安全、有效地实施DCD供肾ABO血型不相容肾移植。

Objective To investigate the clinical efficacy and safety of ABO incompatible donation after cardiac death(DCD)donor kidney transplantation.Methods Retrospective analysis of clinical data of 8 patients with ABO incompatible DCD donor kidney transplantation performed from December 2016 to June 2018 in the department of transplantation of Guilin NO.924 Hospital of People′Liberation Army of China.Among them,6 were male and 2 were female,aged 26-54,4 were positive for panel reactive antibodies(PRA)and 2 were for secondary renal transplantation.The Rh(D)blood type of donors and recipients were all negative.The individualized preconditioning protocol was established according to the initial blood group antibody titer and the preoperative PRA antibody level.Postoperative routine monitoring of blood concentration of immunosuppressive agents,urine volume,renal function,coagulation status and blood group antibody level,and the change of donor specific antibody level were observed in PRA positive recipients.Results Blood group antibody titers were all≤1∶16 on the day of renal transplantation in 8 recipients after individualized preconditioning.There was no rebound of blood group antibody in 7 patients within 2 weeks after transplantation.Eight recipients had been followed up for an average of 6 to 18 months up to June 2018.Case 1 developed humoral rejection at the second week after transplantation and recovered after immunosorbent assay with protein A and high dose immunoglobulin shock therapy.Case 2 developed bladder bleeding 2 h after transplantation,hemostasis was got after continuous bladder washing and the function of transplant kidney returned to normal.Case 3 was complicated with severe pulmonary fungal infection at the 5th month after transplantation and died of respiratory failure after failure of antifungal treatment.Case 6 was complicated with delayed graft function and recovered after hemodialysis.Case 7 showed less urine volume,right lower extremity deep vein thrombosis(graft side),inferior vena cava mesh implantation and thrombolytic anticoagulant therapy were ineffective and hemodialysis treatment was recovered.Case 8 complicated with drug-induced diabetes 2 months after operation.The renal graft function of the remaining recipients maintained well.Conclusions ABO incompatible DCD donor kidney transplantation was safe and effective with individualized preconditioning according to the initial blood group antibody titer and PRA level of the recipient.