儿童移植肾动脉狭窄的处理及临床疗效分析

Treatment and mid/long-term outcomes of transplantation renal artery stenosis in children

目的探讨血管介入治疗在儿童移植肾动脉狭窄(transplantation renal artery stenosis,TRAS)中应用的临床疗效。方法回顾性分析2013年1月至2021年9月在郑州大学第一附属医院肾移植科诊断为移植肾动脉狭窄的儿童受者的临床资料,比较血管介入治疗前后及末次随访时的血肌酐水平及移植肾动脉收缩期峰值(peak systolic velocity,PSV)、叶间动脉PSV和峰值流速后比值变化。结果238例儿童肾移植受者中6例诊断为TRAS,发生率2.5%,手术时的中位年龄为12岁(9~17岁),确诊TRAS时的中位时间为术后4个月(1.7~18.0个月),随访中位时间6.6年(2.5~8.0年)。6例TRAS的儿童受者均经血管介入治疗,其中经皮腔内血管成形(percutaneous transluminal angioplasty,PTA)治疗5例,经皮血管内支架成形(PTAS)治疗1例。肌酐基础值为(75.2±27.9)μmol/L,确诊TRAS时为(200.8±88.5)μmol/L,较基础值显著升高(P=0.025),而经血管介入治疗后1个月时的肌酐下降为(103.8±44.7)μmol/L,至末次随访时肌酐为(98.7±30.2)μmol/L,与基础值比较差异有统计学意义(P=0.196,P=0.115)。与血管介入治疗前移植肾动脉吻合口内径(2.6±0.6)mm相比,治疗后24 h时吻合口内径(3.8±0.5)mm和末次随访时的吻合口内径(4.1±0.8)mm均明显增加(P=0.027)。此外,处理后24 h和末次随访时移植肾动脉PSV为(163±45.0)cm/s和(184.7±80.8)cm/s,峰值流速比为6.5±2.2和5.4±2.0,均较血管介入处理前的(356.5±77.9)cm/s和18.0±5.8明显降低,而叶间叶间动脉PSV均较处理前明显升高(P=0.024,P=0.032)。在随访期内,6例TRAS儿童受者的移植肾动脉未再次出现狭窄或血栓等并发症。结论PTA或血管支架置入术治疗儿童TRAS在技术上是可行的,经治疗后再狭窄率低,可获得较为满意的中长期临床疗效。

Objective To explore the clinical efficacy of vascular interventional therapy in children with transplantation renal artery stenosis(TRAS).Methods From January 2013 to September 2021,retrospective analysis was performed for clinical data of 238 TRAS children.Peak systolic velocity(PSV)of transplant renal artery,interlobular artery PSV,transplant renal artery PSV/interlobular artery PSV(post PSV ratio)and serum creatinine level before and after vascular interventional therapy and at the last follow-up were compared.Results Six pediatric kidney transplantation recipients were diagnosed as TRAS.The median operative age was 12(9-17)years,the median postoperative time to diagnosing TRAS 4(1.7-18.0)months and the median follow-up period 6.6(2.5-8.0)years.All of them received vascular interventional therapy of percutaneous transluminal angioplasty(PTA,n=5)and stent angioplasty(n=1).The serum creatinine pre-treatment with vascular interventional therapy was significantly higher than baseline serum creatinine level at discharge(200.8±88.5)vs(75.2±27.9)μmol/L,P=0.025 and decreased to(103.8±44.7)μmol/L at Month 1 post-treatment(P=0.196)and(98.7±30.2)μmol/L at the last follow-up(P=0.115).Comparing with internal diameter of grafted renal artery anastomosis site(2.6±0.6 mm)pre-treatment with vascular interventional therapy,significant changes occurred at 24 h post-treatment(3.8±0.5 mm)and at the last follow-up(4.1±0.8 mm)(all P=0.027).In addition,PSV and post PSV ratio of transplanted renal artery at 24 h post-treatment(163±45.0 cm/s,6.5±2.2)and at the last follow-up(184.7±80.8 cm/s,5.4±2.0)were significantly lower than that before vascular interventional therapy(356.5±77.9 cm/s,18.0±5.8)and interlobular artery PSV was significantly higher than that before vascular interventional therapy(P=0.024,P=0.032,respectively).During follow-ups,no restenosis or thrombosis occurred in transplanted renal arteries.Conclusions PTA or stent angioplasty for TRAS children is technically feasible with low restenosis rate and relatively satisfactory mid/long-term outcomes.