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儿童肾移植并发症

Author
Ruth A McDonald, MD
Section Editor
Patrick Niaudet, MD
Deputy Editor
Melanie S Kim, MD

引言

一旦估计肾小球滤过率(glomerular filtration rate, GFR)降至不足30mL/(min·1.73m2)[4期慢性肾脏病(chronic kidney disease, CKD)]，即可以开始让儿童和家属准备接受肾脏替代疗法[1]。虽然在保守性肾脏替代治疗上已取得许多进步，但肾移植仍是终末期肾病(end-stage renal disease, ESRD)儿童的最佳治疗方法[2]。澳大利亚和新西兰的一项研究说明了这一点；在这项研究中，接受透析治疗的ESRD儿童的死亡风险是接受肾移植治疗的ESRD儿童的4倍以上[2]。对年轻患者术后护理的改善和免疫抑制治疗的进步，也增加了同种异体移植肾和患者的存活率。特别是，随着急性排斥反应(acute rejection, AR)发生频率和严重程度的降低，同种异体移植肾的存活率已得以提高[3]。

本专题将概述儿童肾移植的并发症。肾移植的部分并发症是儿童特有的，而其他并发症可见于所有移植受者。关于儿童移植的其他问题以及儿童和成人共有的肾移植问题参见其他专题。 (参见“儿童肾移植的一般原则”和“儿童肾移植的结局”)

移植肾功能丧失

同种异体移植肾功能丧失的病因随移植后的时间而变化。这些时期通常被分为：即刻(术后0-1周)、早期(术后1-12周)、晚期急性期(术后3个月后)和晚期慢性期(数年)。 (参见“Evaluation and diagnosis of the patient with renal allograft dysfunction”)

  • 移植肾功能延迟恢复[(delayed graft function, DGF)，在肾移植后即刻发生的肾衰竭持续存在]的病因包括缺血后急性肾损伤、肾动脉或静脉的血管血栓形成、泌尿系并发症(即尿漏或尿路梗阻)，以及极少数时候原因为超急性排斥反应。
  • 在移植肾初期有功能但发生早期(即移植后1-12周)肾功能不全的患者中，移植肾功能丧失的主要原因是移植肾急性排斥反应、钙调磷酸酶抑制剂毒性、尿路梗阻、感染、血容量不足和复发性疾病。
  • 在移植后3个月以上急性发作的同种异体移植肾功能丧失，最常见由移植肾急性排斥反应、钙调磷酸酶抑制剂毒性、尿路梗阻、血容量不足、肾盂肾炎和复发性或新发肾脏病引起。
  • 在肾移植后数年间发生的缓慢进展性肾脏病，最常见的原因为慢性移植肾损伤、钙调磷酸酶抑制剂肾毒性(calcineurin inhibitor nephrotoxicity, CIN)、高血压性肾硬化、病毒感染和复发性或新发肾脏病。

移植肾功能延迟恢复 — 在移植后肾衰竭持续存在的情况被称为移植肾功能延迟恢复(DGF)。在不同的研究中DGF的定义不同，但一般是指在移植后头1周少尿或需要透析。以前，DGF患者的移植肾存活率比无DGF患者的移植肾存活率低15%-25%。越来越多的移植肾来自于心脏死亡器官捐献(donation after cardiac death, DCD)。虽然DCD移植肾具有较高的DGF发病率，但这些移植肾的短期存活率与没有DGF的移植肾的短期存活率相近[4]。

                           

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Literature review current through: 2017-06 . | This topic last updated: 2017-01-24.
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