儿童肾移植多学科管理模式的探讨

Multi-disciplinary management of pediatric renal transplantation

目的:本研究旨在探讨改善儿童肾移植长期预后的管理模式,尤其是术前、术后多学科管理在儿童肾移植中的意义。方法:2011年1月至2019年5月,复旦大学附属儿科医院肾脏科与海军军医大学附属长海医院及复旦大学附属中山医院合作开展器官捐献供肾-儿童肾移植,对肾移植患儿采用术前-术中-术后闭环管理模式。本研究通过临床资料分析,探讨该模式的特点和效果,重点讨论术前、术后管理在儿童肾移植中发挥的作用。结果:(1)一般资料:129例终末期肾衰竭患儿接受器官捐献供肾移植,肾移植受者年龄10.6±3.8岁,其中最小移植年龄21月龄,最小移植体重9 kg。供体中104例(80%)为儿童供体,儿童供体中位年龄1.5岁(11月~3岁)。(2)术前管理:原发病诊断方面,儿童肾脏科与泌尿外科、分子诊断中心等多学科合作,使得86%患儿原发病诊断明确,先天性肾脏和尿路畸形(CAKUT)及遗传性肾病为其主要病因,占28.6%和27.9%;移植前肾替代治疗方面:96%患儿移植前接受透析治疗,中位透析时间1.3(0.7~2.0)年;移植前慢性肾脏病相关并发症纠正情况:肾性贫血控制率70%,血钙控制率77%,血磷控制率65%,全段甲状旁腺激素(iPTH)控制率66%,严重左心室肥厚(LVH)控制率80%。(3)术后管理:129例肾移植患儿中位随访时间2.0(1.1~4.8)年。随访期间感染情况:63例(48%)肾移植受者发生感染,病原菌中以细菌感染最多见(54%),其次为病毒感染(42%),病毒感染中半数以上为巨细胞病毒(CMV);排斥情况:14例(10.8%)肾移植术后发生排斥反应;原发病复发情况:1例(0.8%)局灶节段性肾小球硬化原发病复发。(4)肾移植预后:受者1年、3年、5年、7年存活率均为96.6%,移植肾1年、3年、5年、7年存活率均为87%。末次随访时估算肾小球滤过率为81.2±29.8(ml/min/1.73 m^2)。16例移植肾失功,其中13例(81%)移植肾丢失发生在移植后1月内,移植肾血管栓塞是主要失功原因。结论:多学科闭环管理下的儿童肾移植受者预后良好,该模式值得推广。

Objective:To explore the effect of multi-disciplinary management on pediatric renal transplantation,especially the role of preoperative and postoperative management in improving prognosis of pediatric renal transplantation. Methodology:Clinical data of children who underwent renal transplantation using organ donations between January 2011 to May 2019 were retrospectively analyzed.All of the recipients underwent multi-disciplinary preoperative and postoperative management.Multi-disciplinary management program includes:pre-transplantation evaluation,management and preparation were performed at our institution;perioperative treatments were performed at organ transplant centers cooperated with us;and both pediatric nephrologist and transplant surgeon are responsible for the post-transplantation manage ment of the recipients. Results:①One hundred and twenty nine pediatric patients underwent renal transplantation in our unit.The mean age of recipients was 10.6±3.8 years,the minimum recipient age was 21 month,and the minimum recipient weight was 9 kg.②86% of recipients were ascertained definite diagnosis of primary disease of ESRD,and among them,congenital anomalies of the kidney and urinary tract and inherited renal disease were the major causes of ESRD.Prior to the transplantation,the majority of the recipients were on dialysis(96%),and the median dialysis time was 1.3(0.7-2.0) years.Anemia control rate was 70%,serum calcium control rate was 77%,phosphorus control rate was 65%,iPTH control rate was 66% and severe LVH control rate was 80%.③Postoperative management:The median duration of follow-up was 2.0(1.1-4.8) years.During the follow-up period,the infection rate was 48%, bacteria was the most frequent causative organisms;the incidence of rejection was 10.8%.④The mean eGFR was 81.2±29.8(ml/min/1.73 m^2) at the last follow up.Patient survival at 1,3,5 and 7 years was 96.6%.Graft survival at 1,3,5 and 7 years was 87%.Sixteen cases experienced graft loss,and most of them were occurred in the first month after transplantation. Conclusion:The long-term outcome of pediatric renal transplantation was very well based on the multi-disciplinary management approach.This approach is a well-established experience and worthy promoting.