颅脑损伤尿崩症供者维护策略及其供肾移植疗效分析

The maintenance strategy of brain injury donors with diabetes insipidus and its clinical efficacy on kidney transplantation

目的总结颅脑损伤尿崩症供者维护策略并评价其供肾移植后临床疗效。方法回顾性分析2016年1月至2018年9月武汉大学人民医院器官移植科完成的颅脑损伤尿崩症供者供肾移植供、受者临床资料,总结此类供者临床维护策略、吻合方式及供肾移植术后受者情况。采用配对t检验比较尿崩症供者治疗前后血压、每小时尿量、心率、血钠水平、尿比重、体温、血浆渗透压及血清肌酐等指标。P<0.05为差异有统计学意义。结果经系统性抗尿崩治疗后,12例尿崩症供者血压、每小时尿量、心率、血钠水平、尿比重、体温、血浆渗透压及血清肌酐均明显改善,差异均有统计学意义(P均<0.05)。供肾获取时均灌注良好,颜色和质地佳,无血栓和瘀斑等情况。修整后复灌均采用输血器灌注,灌注良好。24例受者中,19例移植后移植肾立即发挥功能,血清肌酐恢复至133μmol/L以下,平均时间为术后(10±3)d;5例发生移植肾功能延迟恢复(DGF),术后维持血液透析时间为(9±3)d,DGF恢复[eGFR≥30mL·min^-1·(1.73m^2)^-1]平均时间为术后(23±4)d。1例发生DGF受者于术后第2天因移植肾出血,二次手术止血后于术后第19天恢复。术后3个月,24例受者平均血清肌酐为(105±43)μmol/L。2例受者于围手术期发生急性排斥反应,应用兔抗人胸腺细胞球蛋白(rATG)后逆转。截至2018年12月,7例受者出现移植后并发症:4例发生急性排斥反应,其中2例经甲泼尼龙冲击治疗后恢复,2例经甲泼尼龙+rATG治疗后恢复;2例出现肺部感染,经积极抗感染治疗后恢复;1例术后3个月出现移植肾动脉狭窄,行移植肾动脉支架植入术后恢复。结论尿崩症是颅脑损伤供者常见临床综合征,其发生可能会影响供肾质量,对尿崩症进行全面监测和积极治疗后,有助于供肾功能的维护,促进移植肾功能早期恢复。

Objective To summarize the maintenance strategy of brain injury donors with diabetes insipidus and evaluate its clinical efficacy after kidney transplantation.Methods The clinical data of donors with diabetes insipidus and corresponding kidney transplant recipients who got transplantion during January 2016 and September 2018 in the Department of Organ Transplantation,Renmin Hospital of Wuhan University were retrospectively analyzed.The maintenance strategy of diabetes insipidus,anastomotic methods and prognosis conditions of recipients were summarized.The paired-t test was used to compare the blood pressure,hourly urine volume,heart rate,blood sodium level,urine specific gravity,body temperature,plasma osmotic pressure and serum creatinine before and after treatment in donors with diabetes insipidus.P<0.05 was considered statistically significant.Results After systemic anti-diabetes insipidus treatment,blood pressure,hourly urine volume,heart rate,blood sodium level,urine specific gravity,body temperature,plasma osmotic pressure and serum creatinine were significantly improved in donors with diabetes insipidus.The differences was statistically significant(P all<0.05).When the kidney was obtained,it was well perfused with good color and texture and without thrombosis or ecchymoses.After the repairing,the reperfusion was performed by blood transfusion set,and the perfusion was good.Of the 24 recipients,the renal function of 19 recipients recovered immediately(serum creatinine<133μmol/L)and the recover time was(10±3)days after transplantation.Five recipients developed delayed graft function(DGF),the duration of dialysis replacement therapy is(9±3)days,and the recover time was(23±4)days after transplantation.One recipient with DGF underwent secondary surgery because of transplant kidney hemorrhage,and the renal function recovered on the 19th day after transplantation.The average serum creatinine of all recipients was(105±43)μmol/L 3 months after transplantation.Two recipients experienced acute rejection during the perioperative period and were reversed after application of rabbit anti-human thymocyte globulin(rATG).As of December 2018,there were 7 recipients developed post-transplant complications,includeing 4 cases of acute rejection,2 of them were reversed by methylprednisolone therapy,and the other 2 cases were reversed by methylprednisolone+rATG therapy.Two recipients developed lung infections and recovered after anti-infective therapy.One recipient developed renal artery stenosis 3 months after operation and recovered after interventional therapy.Conclusions Diabetes insipidus is a common clinical syndrome of donors with craniocerebral injury.The occurrence of diabetes insipidus may affect the quality of donor kidney.Comprehensive monitoring and active treatment of diabetes insipidus may contribute to the maintenance of renal function and promote early recovery of transplanted kidney.