一例高致敏尿毒症受者行肾移植联合脾窝异位辅助性肝移植的预后观察  

A case of highly sensitized recipient after combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation in a 28-months follow-up and review

作　　者：马帅军[1] 张更[1] 朱元宏[1] 刘克普[1] 李智斌[1] 阮东丽[1] 吴东娟[1] 杨晓剑[1] 秦卫军[1] 袁建林[1] 

机构地区：[1]第四军医大学附属西京医院泌尿外科,西安710032

出　　处：《中华器官移植杂志》2017年第1期30-33,共4页Chinese Journal of Organ Transplantation

摘　　要：目的 分析1例高致敏尿毒症受者行肾移植联合脾窝异位辅助性肝移植后的随访结果和临床特点.方法 患者10年前诊断为慢性肾功能不全尿毒症期,9年前行肾移植术,8年前移植肾功能丧失,受者群体反应性抗体（PRA）阳性（Ⅰ类31％,Ⅱ类63％）,在全麻下行肾移植联合脾窝异位辅助性肝移植.应用兔抗人胸腺细胞免疫球蛋白（ATG）进行免疫诱导,利妥昔单抗注射液、血浆置换预防急性排斥反应.出院后规律随访.结果 术后第1天丙氨酸转氨酶（ALT）为256 IU/L,天冬氨酸转氨酶（AST）为342 IU/L,血肌酐为502μmol/L;术后第6d血肌酐降至141 μmol/L,ALT、AST正常.术后第7d肌酐升至202μmol/L,尿量减少,B型超声显示,移植肾体积略增大,实质回声增强,段动脉血流阻力指数（RI）升至0.8,考虑发生急性排斥反应,给予单剂利妥昔单抗（Rituximab）、静脉注射用人免疫球蛋白（IⅥG）、血浆置换治疗.至术后60 d血肌酐降至131 μmol/L.至今已随访28个月,免疫抑制方案为他克莫司＋吗替麦考酚酯（MMF）＋泼尼松（Pred）,血他克莫司浓度谷值维持在6～8μg/L,移植肾、肝功能均正常,一般情况良好.结论 肾移植联合脾窝异位辅助性肝移植的技术安全,个体化用药及规律随访是受者获得长期存活的重要因素.Objective To analyze the follow-up results and clinical characteristics of one case of highly sensitized recipient after combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation.Methods This patient was diagnosed as having chronic renal insufficiency in the uremia period 10 years ago,subjected to kidney transplantation 9 years ago,and got renal allograft loss 8 years ago.The recipient was positive for PRA （for class Ⅰ,31％,and for class Ⅱ,63％）.Under the general anesthesia,the patient was given combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation.The ATG was used for immune induction.Rituximab and plasma exchange were applied to prevent acute rejection.Regular follow-up was done after discharge.Results On the postoperative day （POD） one,ALT was 256 IU/L,AST was 342 IU/L and serum creatinine was 502 μmol/L.On the POD 6,ALT and AST levels were normal and serum creatinine was 141 μmol/L.Serum creatinine increased to 202 μmol/L and the volume of urine reduced on the POD 7.The ultrasound displayed graft size increased slightly,substantial echogenicity enhanced,artery blood flow RI increased to 0.8,suggesting the occurrence of acute rejection.A single dose of Rituximab,intravenous IG,and plasma exchange were given.On the POD 60,serum creatinine was reduced to 131 μmol/L.During a follow-up period of 28 months,imrnunosuppresants were given：Tac ＋ MMF ＋ Pred.FK506 valley concentration was maintained at 6-8 μg/L.The function of the transplanted kidney and liver was normal,and the general conditions were good.Conclusion Combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation is safe.Individualized medication and regular follow-up are the important factors for long-term survival of recipients.

关 键 词：肾移植 辅助性肝移植 高致敏 尿毒症 

分 类 号：R657.3[医药卫生—外科学]