儿童肾移植术后急性排斥反应的危险因素分析

Analysis of risk factors related to acute rejection after pediatric kidney transplantation

目的探讨儿童肾移植术后急性排斥反应(acute rejection,AR)发生的相关危险因素及其对预后的影响。方法回顾性分析海军军医大学第一附属医院2011年9月至2022年8月189例儿童肾移植受者的临床资料。根据是否发生AR,将受者分为AR组和无AR组,采用单因素分析及多因素Logistic回归分析儿童肾移植术后AR的相关危险因素,并进一步明确AR对移植肾功能和长期存活的影响。结果随访期间共有33例(17.5%,AR组)儿童受者发生了AR,术后1年内AR发生率为16.9%(32/189);另156例未发生AR儿童受者为无AR组。单因素分析发现AR组受者的中位透析时间为19个月,大于无AR组的11个月;AR组供者中位年龄为12月龄,小于无AR组的24月龄;AR组供者中位体重为9.5 kg,低于无AR组的12 kg;AR组中位供/受体体重比为0.36,小于无AR组的0.50;AR组他克莫司(tacrolimus,TAC)浓度未达标的比例为45.5%(15/33),高于无AR组的21.2%(33/156),上述参数两组间比较,差异均有统计学意义(P=0.034、0.033、0.025、0.005、0.004)。多因素分析显示,TAC浓度未达标是儿童肾移植术后发生AR的独立危险因素(OR=2.977,95%CI:1.314~6.743,P=0.009)。AR组和无AR组受者末次随访血肌酐分别为(78.4±24.3)μmol/L和(74.6±24.7)μmol/L,估算的肾小球滤过率分别为(85.3±26.3)ml·min^(-1)·1.73 m^(-2)和(89.5±24.2)ml·min^(-1)·1.73 m^(-2),组间比较,差异均无统计学意义(均P>0.05)。AR组受者术后1年和5年的存活率均为97.0%,无AR组均为99.4%,组间比较,差异无统计学意义(P>0.05)。AR组术后1年和5年的移植肾存活率均为90.9%,无AR组分别为98.1%和97.4%,组间比较,差异亦无统计学意义(P>0.05)。结论儿童肾移植术后早期AR发生率较高,虽不影响移植预后,但仍应注意其早期预防、及时诊断和合理治疗。

Objective To explore the risk factors related to acute rejection(AR)after pediatric kidney transplantation(KT).Methods Retrospective analysis was performed for 189 pediatric KT recipients from September 2011 to August 2022.They were divided into two groups of AR(n=33)and non-AR(n=156).Univariate and multivariate Logistic regression analyses were performed for identifying potential risk factors of AR.And the effects of AR on graft function and survival were also examined.Results During follow-ups,a total of 33(17.5%)patients developed AR with a 1-year cumulative incidence of AR of 16.9%(32/189).Univariate analysis revealed that median time on dialysis was longer in AR group than that in non-AR group(19 vs.11 months,P=0.034).Median age of donors(12 vs.24 months,P=0.033),median weight of donors(9.5 vs.12 kg,P=0.025)and median donor/recipient body weight ratio(0.36 vs.0.50,P=0.005)were lower in AR group than those in non-AR group.And the proportion of subtherapeutic tacrolimus(TAC)trough level was higher in AR group than that in non-AR group(45.5%vs.21.2%,P=0.004).Multivariate regression analysis indicated that subtherapeutic TAC trough level was an independent risk factor for AR(OR=2.977,95%CI:1.314-6.743,P=0.009).At the last follow-up,serum creatinine and eGFR were(78.4±24.3)vs.(74.6±24.7)μmol/L and(85.3±26.3)vs.(89.5±24.2)ml·min^(-1)·1.73 m^(-2)in AR and non-AR groups respectively.There were no significant differences.1/5-year patient survival rate was both 97%in AR group and both 99.4%in non-AR group;1/5-year graft survival rate both 90.9%in AR group and was 98.1%and 97.4%in non-AR group.No significant inter-group differences existed in patient and graft survival.Conclusions Although an occurrence of early AR does not negatively impact graft outcomes,the incidence of AR remains high after pediatric KT.Therefore prompt diagnosis and treatment of AR should be strengthened.