儿童供肾移植后肾动脉狭窄的处理经验  

Renal graft artery stenosis associated with pediatric kidney

作　　者：付嘉钊 赵闻雨 隋明星 陆瀚澜 宋焰鑫 朱有华 曾力 张雷 Fu Jiazhao;Zhao Wenyu;Sui Mingxing;Lu Hanlan;Song Yanxin;Zhu Youhua;Zeng Li;Zhang Lei(Organ Transplantation Center,Affiliated Changhai Hospital,Naval Military Medical University,Shanghai 200433,China;Medical Imaging Center,Municipal Chest Hospital,Harbin 150056,China)

机构地区：[1]海军军医大学附属长海医院器官移植中心,上海200433 [2]哈尔滨市胸科医院医学影像中心,哈尔滨150056

出　　处：《中华器官移植杂志》2022年第1期14-19,共6页Chinese Journal of Organ Transplantation

基　　金：上海长海医院"234学科攀峰计划" (2019YXK002)。

摘　　要：目的回顾性分析儿童供肾移植后肾动脉狭窄的诊疗经验。方法收集2018年1月至2021年10月海军军医大学附属长海医院的儿童(供、受者年龄≤18周岁)肾移植114例。根据受者彩色多普勒超声结果分为正常组80例和流速增快组34例。根据是否存在血压升高、肾功能不稳定等移植肾动脉狭窄(transplant renal artery stenosis,TRAS)的相关临床表现,将流速增快组患者分为有症状组(13例)和无症状组(21例),分析总结可能引起儿童移植肾动脉狭窄的风险因素。结果114例儿童肾移植受者中男性65例,女性49例,男女受者出现移植肾动脉流速增快比例明显不同(38.5%和18.4%,P=0.02)。各组受者月龄、体重差异无统计学意义(P>0.05)。有症状组供者的平均年龄10.4个月、体重9 kg明显低于正常组(平均年龄65.3个月,体重21.0 kg)和无症状组(平均年龄64.4个月,体重21.2 kg),P值均小于0.01。有症状组动脉最快流速363.5 cm/s明显高于无症状组的228.8 cm/s(P<0.001)。有症状组中6例采用药物治疗,治疗后临床表现均完全缓解;另外7例接受有创治疗:2例接受1次,2例接受2次,1例接受3次经皮腔内血管成形(percutaneous transluminal angioplasty,PTA)后临床症状缓解,肾功能稳定;1例接受PTA治疗时穿刺点出血,治疗失败,移植肾功能逐渐丧失;1例接受PTA后未缓解,随后置入血管内支架,此后由于血管支架内再狭窄进行多次支架内扩张无效。最后手术探查,取出血管支架,行移植肾动脉修剪后,临床症状缓解。结论男性受者、低体重或低月龄供者可能是儿童供肾移植发生TRAS的风险因素。彩色多普勒超声提示移植肾动脉流速增快不一定伴随相应临床表现,但动脉流速明显增快往往提示TRAS可能性大,需药物或有创治疗干预。在PTA效果不明显时,可多次治疗,尽量避免置入血管支架,以防止形成血管内再狭窄。Objective To retrospectively summarize the clinical experiences of managing renal artery stenosis after donor kidney transplantation in children.Methods From January 2018 to October 2021,114 pediatric kidney transplants(donor/recipient aged<18 years)were performed.According to the findings of color Doppler ultrasonography,they were divided into two groups of normal(n=80)and rapid flow(n=34).Rapid flow group were assigned into symptomatic(n=13)and asymptomatic(n=21)sub-groups based upon clinical features of hypertension and renal instability.Results Among them,there were 65 males and 49 females.A significant inter-gender difference existed in the proportion of higher arterial flow rate of transplanted kidney(38.5%and 18.4%,P=0.02).No significant difference existed in age or body weight of transplant recipients among all groups(P>0.05).The mean age(10.4 months)and body weight(9 kg)of donors were significantly lower in symptomatic group than those in normal group(65.3 months,21 kg)and asymptomatic group(64.4 months,21.2 kg).The mean velocity of symptomatic group was significantly higher than that of asymptomatic group(363.5 vs 228.8 cm/s)(P<0.001).In symptomatic group,6 cases received medications and their clinical manifestations were completely relieved.Among 7 patients invasively treated,one percutaneous transluminal angioplasty(PTA)was offer once(n=2),twice(n=2)and triple(n=1)with clinical relief and stable renal function.One case of bleeding at puncture site during PTA had treatment failure with a gradual loss of graft function.One ineffective case of PTA was subsequently placed with an endovascular stent.However,repeated stent dilation failed due to restenosis.After surgical exploration,vascular stent removal and transplantation of renal artery clipping,clinical symptoms were relieved.Conclusions Male recipient,low body weight or young donor may be risk factors for transplant renal artery stenosis(TRAS)during pediatric donor renal transplantation.A higher flow rate of transplanted renal artery on ultrasonograph

关 键 词：肾移植 移植肾动脉狭窄 经皮腔内血管成形 

分 类 号：R726.9[医药卫生—儿科]