尸体供肾结石对肾移植短期疗效的影响

Short-term outcome of kidney transplantation from deceased donors with nephrolithiasis

目的:移植供肾短缺是终末期肾病(end-stage renal disease,ESRD)患者获得肾移植机会的最主要障碍,而目前打破这种障碍的策略主要为扩大供肾来源和充分利用可获得的肾脏。全球肾结石的发病率呈上升态势且影响了约10%的成年人,其中也包括移植肾供者。然而,目前关于利用患有肾结石的尸体器官供者肾进行移植的研究较少。本研究旨在探究尸体器官供者的结石供肾被用于移植的安全性及其对肾移植短期临床疗效的影响。方法:选取于2016年至2020年期间由中南大学湘雅二医院完成尸体器官捐献且年龄至少10岁的520名供者,以及在同一医院接受这些供者供肾移植且为单肾移植的945名成年受者。根据器官捐献前是否存在结石将供者分为无肾结石(D^(-))组和肾结石(D^(+))组;根据供者和供肾是否存在结石将受者分为供者/供肾无结石(D^(-)K^(-))组、供肾无结石/供者肾结石(D^(+)K^(-))组和供者结石/供肾结石(D^(+)K^(+))组。回顾性分析这些供者和受者的基本资料和临床资料。比较不同供者组之间的移植肾弃用情况;比较不同受者组之间术后1年移植肾和受者生存率、移植肾功能以及并发症的发生情况。结果:在520名供者中,9.6%(50名)的供者在器官捐献前患有肾结石。总共获取1040个肾脏,总的供肾弃用率为4.4%(46/1040),而D^(+)组的供肾弃用率约为7%。在D^(+)组供者中,12%的供者肾存在被弃用的现象,比例显著高于D^(-)组(5.1%,P<0.05)。受者的总体移植肾功能延迟恢复(delayed graft function,DGF)发生率为7.5%(71/945),而D^(-)K^(-)组、D^(+)K^(-)组及D^(+)K^(+)组之间的DGF发生率差异无统计学意义(7.5%vs 6.5%vs 8.2%,P>0.05)。在移植肾和受者1年生存率方面,8名受者发生移植肾失功,19名受者发生移植肾带功能死亡,D^(-)K^(-)组、D^(+)K^(-)组及D^(+)K^(+)组之间差异无统计学意义(P>0.05)。然而,与D^(-)K^(-)组相比,术后1年时D^(+)K^(+)组受者的血肌酐水平明显偏高[(139.2±62.46)μmol/L vs(117.19±51.22)μmol/L,P<1218 Short-term outcome of kidney transplantation from deceased donors with nephrolithiasis TAN Liang,et al©Journal of Central South University(Medical Science).All rights reserved.0.05],而估计肾小球滤过率明显偏低[(56.67±23.31)mL/(min·1.73 m^(−2))vs(66.86±21.90)mL/(min·1.73 m^(−2)),P<0.05]。0.4%(4/945)的受者在术后1年内发生移植肾或移植输尿管结石,接受D^(+)组供肾移植受者的泌尿系结石的发生率明显高于接受D^(-)组供肾移植的受者(2.2%vs 0.2%,P<0.05);在术后1年时,接受D^(+)组供肾移植的受者和接受D^(-)组供肾移植的受者之间尿路感染和输尿管狭窄的发生率差异均无统计学意义(均P>0.05)。结论:经过严格评估,来自患有肾结石尸体器官供者的肾脏可被安全用于肾移植,并且可获得较为理想的短期效果。然而,供者患有肾结石会增加供肾被弃用的风险,在降低移植肾功能的同时也增加了受者发生泌尿系结石的风险。此外,对于患有肾结石尸体器官供者供肾移植的长期疗效需要长期随访研究来进一步验证。

Objective:Shortage of kidney allografts is a major barrier to end-stage renal disease patients receiving kidney transplantation,and it is necessary to enlarge the donor pool and find better ways of using available allografts.The global incidence of nephrolithiasis is increasing,nephrolithiasis affects approximately 10%of adults worldwide,and it also affects the kidney donors.However,there is little information about the use of cadaveric kidney allografts with nephrolithiasis.This study aims to evaluate the safety and outcome of kidney transplantation with allografts from the deceased donors with nephrolithiasis.Methods:A total of 520 deceased donors who was at least 10 years old,and 945 adult recipients with single kidney transplantation at the Department of Kidney Transplantation,the Second Xiangya Hospital from 2016 to 2020 were included in this study.The donors were divided into 2 groups according to nephrolithiasis diagnoses:The donors with nephrolithiasis(D^(+))and the donors without nephrolithiasis(D^(-)).The recipients were assigned into 3 groups according to their donors and the allografts they received:The allografts from donors without nephrolithiasis(D^(-)K^(-)),the allografts without nephrolithiasis from donors with nephrolithiasis(D^(+)K^(-)),and the allografts with nephrolithiasis(D^(+)K^(+)).The demographic and clinical data of enrolled subjects were retrospectively analyzed.The allograft discard ratio between different donors were analyzed.The one-year survival of allografts and recipients,as well as the allograft function and the complications of kidney transplantation were compared.Results:Fifty out of 520 donors had nephrolithiasis,and the nephrolithiasis incidence was 9.6%.We recovered 1040 kidneys,and total discard rate was 4.4%(46/1040).The D^(+)group had a rate of 7% discard.The donors with kidney discard accounted for 12% in the D^(+)group,and this was higher than that of donors in the D^(-)group(5.1%,P<0.05).The total incidence of delayed graft function(DGF)was 7.5%,and there were no significant differences in the incidence of DGF in recipients among the D^(-)K^(-),D^(+)K^(-),and D^(+)K^(+)group(7.5%vs 6.5%vs 8.2%,P>0.05).During the one-year follow-up,8 allografts lost function and 19 recipients died with a functional allograft.Recipients in the D^(-)K^(-),D^(+)K^(-),and D^(+)K^(+)groups also had no significant difference between a one-year allograft and patient survival rate(P>0.05).However,recipients in the D^(+)K^(+)group had a higher level of serum creatinine[(139.2±62.46)μmol/L vs(117.19±51.22)μmol/L,P<0.05]and lower estimated glomerular filtration rate[eGFR;(56.67±23.31)mL/(min·1.73 m^(−2))vs(66.86±21.90)mL/(min·1.73 m^(−2)),P<0.05]compared with recipients in the D^(-)K^(-)group at 12 months after transplantation.During the first year after transplantation,4 recipients developed urolithiasis,and recipients who received allografts from the D^(+)group donors had a higher incidence of urolithiasis than those who received allografts from the D^(-)group donors(2.2%vs 0.2%,P<0.05).There were no significant differences in the incidence of urinary tract infections and ureteral strictures at 1 year between recipients of D^(+)and D^(-)donors(both P>0.05).Conclusion:The cadaveric kidney allografts with nephrolithiasis could be safely used for transplantation,and the short-term outcome is acceptable.However,nephrolithiasis in donors may increase the rate of kidney discard,disturb the short-term function of allografts,and increase the risk of urolithiasis in recipients.Further research with a long-term study is needed to verify the long-term outcome of kidney transplantation using cadaveric kidney allografts with nephrolithiasis.