心肾联合移植中肾移植临床特点的初步分析

Clinical characters of kidney transplantation in combined heart and kidney transplantation

目的 初步分析我国首例心肾联合移植中肾移植的临床特点。方法 对 1例 5 8岁男性原发性扩张性心肌病伴慢性肾功能衰竭的患者实施同期心肾联合移植术 ,供心和供肾来自同一供体。结果 移植肾立即泌尿 ,但术后第 1天尿量仅 80 0ml,连续性肾脏替代治疗 (CRRT)支持 2 4h后血压逐渐升高 ,尿量显著增加而脱机。术后第 3天移植心、肾功能恢复正常。术后第 15天发生移植心、肾急性排斥反应 ,经处理后移植心肾功能正常至术后 3 8d因肺部感染死亡。结论 不可逆转的心衰合并肾衰是心肾联合移植的适应证 ;移植心功能恢复、循环稳定后开始肾移植 ;心脏移植术中可能发生水、电解质、酸碱平衡紊乱 ,紧急抢救可采用单纯血液超滤 ;移植肾血流开放时短时间升高血压然后维持较低水平 ,以降低移植心负荷 ,肾功能采用CRRT替代 ,术后第 2天 ,可升高血压增多尿量 ,撤除CRRT ;应分别对两个移植器官进行排斥反应监测 ;肺部感染是联合器官移植的重要死亡原因。

Objective To analyze and summarize the clinical characters of kidney transplantation in the first case of combined heart and kidney transplantation in our country. Methods Combined heart and kidney transplantation with allografts from the same donor was performed on a 58 year old male patient with coexisting primary dilated cardiomyopathy and chronic renal failure. Results The transplanted kidney had immediately graft function, but the urine volume was 800 ml/24 h due to lower blood pressure. After continuous renal replacement therapy (CRRT) on post operation day (POD)1, the transplanted heart loaded step up blood pressure, urine volume produced by transplanted kidney increased markedly, and CRRT was removed on POD2. The functions of the transplanted heart and kidney recovered on POD3. However, both of the allografts developed acute rejection on POD15, but the acute rejection was reversed by methylprednisolone and ATG, and reoperation for pericardial sac and perinephric drainage were performed simultaneously. The patient died from pulmonary infection on POD38. Conclusion Combined heart and kidney transplantation with allografts from the same donor is proved to be a feasible approach for selected patients with coexisting end stage cardiomyopathy and renal failure. Kidney transplantation should be performed after functions of transplanted heart have recovered and circulation has stabilized. Disturbance of water, electrolyte and acid base might appear during heart transplantation, but simple hemofiltration is effective in emergency condition. Elevation of systolic pressure to 140 mmHg in a short time at the blood reperfusion of the donor kidney and maintenance at 100～110 mmHg may decrease the heart load as well as guarantee the perfusion pressure kidney. CRRT can replace renal function until urine volume increases. It is necessary to monitor both of the grafts respectively. Pulmonary infection especially fungus infection is the main cause of death in combined organ transplantation.