DCD肾移植术热缺血评估方式的探讨

发布时间：2018-03-21 17:27

本文选题：肾移植　切入点：心脏死亡供体　出处：《浙江大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:结合心脏死亡供体(Donor after cardiac death,DCD)肾移植受体术后随访情况探寻肾移植合理的热缺血评估方式。方法:回顾性分析本院肾脏病中心自2011年5月至2015年6月获取的194例DCD供体,共367例接收肾移植手术的受体。根据受体术后是否发生DGF分为DGF组和非DGF组;术后1月及术后1年的随访中eGFR水平是否大于等于60 ml/min/1.73m2分为高肾功能组及低肾功能组,比较不同分组其供体基本情况及血氧、收缩压变化情况。Logistic回归分析DGF发生影响因素,多因素分析影响DCD受体术后1年eGFR影响因素。结果:DGF组供体捐献时肌酐高于非DGF组(129.04±84.07 vs 92.22±73.70μmol/Lmp=0.002),DGF 组供体捐献时 eGFR 显著低于非 DGF 组(80.58±41.40 vs 107.87±43.80 ml/min/1.73m2,p0.001)。DGF 组受体体表面积显著大于非DGF组(1.74±0.18 vs 1.70±0.17 m2m,p0.042)。DGF组供受体体表面积比值显著低于非DGF组(1.03±0.17 vs 0.98±0.21,p=0.033)。根据撤除呼吸后不同时间点供体收缩压以及血氧进行的热缺血评估均未发现DGF组及非DGF组间存在显著性差异。进行Logistic回归分析发现:供体捐献时eGFR、供受体BSA比值是DCD肾移植受体术后DGF的独立预测因子。术后1月高肾功能组的捐献时平均eGFR、平均供受体体表面积比值均显著高于低肾功能组(捐献时 eGFR:112.43±42.59 vs 88.71±43.74 ml/min/1.73m2,p0.001、供受体体表面积比值:1.04±0.17vs1.00±0.19.p=0.011)。高肾功能组的平均供体年龄、平均受体年龄、捐献时平均肌酐、受体平均BMI、受体平均体表面积、平均小球病理评分、术后DGF发生率均显著低于低肾功能组(供体年龄:33.50±13.54vs38.28±15.20 岁,p=0.002、受体年龄:39.87±10.97vs 42.46±11.31 岁,p=0.031、捐献时肌酐:89.55±80.66 vs 112.58±68.55μmol/L,p=0.005、受体 BMI:20.63±2.72vs21.79±3.54kg/m2,p=0.001、受体体表面积：·1.68±0.17 vs 1.73±0.18 m2,p=0.005、小球病理评分:0.30±0.59 vs 0.48±0.71,p=0.032、DGF 发生率:11/211(5.21%)vs 50/91(54.95%),p0.001)。高肾功能组供体撤除生命支持装置至血氧测不出的时间显著长于低肾功能组(7.99±5.29 vs 6.66±4.35min,p=0.016),高肾功能组初始血氧下降至90%、80%、70%、60%的平均时间显著长于低肾功能组。在速率比较中也发现,高肾功能高肾功能组撤除生命支持装置后,初始血氧下降至90%、,70%、60%的平均下降速率,显著低于低肾功能组。但高肾功能组供体血氧饱和度低于70%至灌注开始的时间显著短于低肾功能组(15.33±4.39 vs 17.08±6.24 min,p=0.026)。在远期预后中:术后一年随访情况,高肾功能组供体捐献时平均eGFR、供体男性百分比显著高于低肾功能组(供体捐献时eGFR:110.02±45.20 vs 86.73±38.28 ml/min/1.73m2,p0.001、供体男性百分比:86.49%vs 74.07%,p=0.009)。高肾功能组供受体平均年龄、供体平均BMI、供肾小球病理及小管病理评分显著低于低肾功能组(供体年龄:32.62±13.80vs43.53±12.34岁,p0.001、受体年龄:40.00±10.98 vs 43.88±10.74 岁,p=0.006、供体 BMI:21.77±2.83 vs 22.49±2.52kg/m2,P=0.04、供肾小球病理评分:0.30±0.59vs0.48±0.71,p=0.011、供肾小管病理评分:0.37±0.64vs0.43±0.52,p=0.006)。高肾功能组供体从撤除生命支持装置至血氧测不出的时间显著长于低肾功能组(8.00±5.19 vs 6.10±4.35 min,p=0.006)。高肾功能组供体分别从血氧90%、80%、70%、60%下降至血氧饱和度测不出的时间均显著长于低肾功能组,且高肾功能组血氧从撤除生命支持装置至血氧无法测及这段时间的平均血氧下降速率显著慢于低肾功能组(19.60±17.49vs25.80±22.85%/min,p=0.038)。将DCD 肾移植预后影响因素单因素分析后,筛选纳入p值小于等于0.05且剔除筛选存在共线性的因素后,进行多元线性回归分析发现:供体年龄、受体年龄、受体BSA与受体术后1年时eGFR呈负相关,供体男性、血氧存续时间(定义为从撤除生命支持装置至血氧饱和度无法测及)与受体术后1年时eGFR呈正相关。结论:DCD肾移植预后受供受体年龄、供体性别及供体基础肾功能等影响,供肾零点肾穿结果对于中远期预后具有一定的提示作用。在供肾热缺血评估中,将热缺血评估分为两个时期更为精准,即高血氧时期(撤除生命支持装置-血氧饱和度70%)以及低血氧时期(血氧饱和度低于70%-灌注)两阶段,高血氧时期一定范围内较长的血氧下降时间以及较慢血氧下降速度对于供肾预后也许具有保护作用,低血氧时期过长可能导致器官损伤,定义为供体血氧低于70%-灌注开始的热缺血时间,可更有效评估术后1月肾功能预后,并且应在考虑预后时将供体的一般情况考虑在内。考虑到目前严峻的器官短缺形式,在保证术后患者生存质量的同时,探究各影响因素的安全临界值,尽量扩大供体范围,将是未来发展肾脏移植的关键。
[Abstract]:Objective: combined with cardiac death donor (Donor after cardiac death, DCD) in renal transplantation recipient follow-up to explore reasonable assessment of renal transplantation ischemia. Methods: a retrospective analysis of 194 cases of DCD kidney disease center of our hospital from May 2011 to June 2015 for the donor, a total of 367 patients receiving renal transplantation according to the receptor receptor. After the occurrence of DGF was divided into DGF group and non DGF group; eGFR level after 1 years in January and postoperative follow-up is greater than or equal to 60 ml/min/1.73m2 divided into high and low group renal renal function group, compare group the basic situation and the oxygen donor, systolic blood pressure changes.Logistic DGF regression analysis of influence multi factor analysis of influence factors, DCD factors affecting eGFR recipients after 1 years. Results: DGF group of donor creatinine was higher than that of DGF group (129.04 + 84.07 vs 92.22 + 73.70 mol/Lmp=0.002), group DGF donors donated eGFR Was significantly lower than that in non DGF group (80.58 + 41.40 vs 107.87 + 43.80 ml/min/1.73m2, p0.001).DGF receptor surface area was significantly higher than that of non DGF group (1.74 + 0.18 vs 1.70 + 0.17 M2M, p0.042).DGF group and donor body surface area was significantly lower than that in non DGF group (1.03 + 0.98 + 0.17 vs 0.21, p= 0.033). According to the assessment of respiratory heat ischemia at different time points after removal of donor blood pressure and the blood oxygen were not found significant difference between DGF group and non DGF group. Logistic regression analysis found that donor eGFR, donor BSA ratio is an independent predictor of DGF DCD in renal transplant recipients after kidney donation high. In January the group after operation, the average eGFR, the average for the receptor surface area ratio were significantly higher than low renal function group (eGFR:112.43 + 42.59 vs donated 88.71 + 43.74 ml/min/1.73m2, p0.001, and surface area ratio: receptor 1.04 + 0.17vs1.00 + 0.19.p=0.01 1). The average age of high donor renal function group, the average donation recipient age, average creatinine, average BMI receptor, receptor average surface area, average glomerular pathology score, the incidence of postoperative DGF was significantly lower than the low renal function group (donor age: 33.50 + 13.54vs38.28 + 15.20, p=0.002 receptor, age: 39.87 42.46 + 10.97vs + 11.31, p=0.031: 89.55, donation creatinine + 80.66 vs 112.58 + 68.55 mol/L, p=0.005, BMI:20.63 + 2.72vs21.79 + 3.54kg/m2 receptor, p=0.001 receptor, surface area: 1.68 + 0.17 vs 1.73 + 0.18 m2, p=0.005, ball pathological score: 0.30 + 0.59 vs 0.48 + 0.71, p=0.032. The incidence rate of DGF: 11/211 (5.21%) vs (54.95%) 50/91, p0.001). The high donor renal function group of withdrawal of life support device to be measured oxygen time significantly longer than the low renal function group (7.99 + 5.29 vs 6.66 + 4.35min, p=0.016), high oxygen group of initial renal function decreased to 90 %, 80%, 70%, 60% of the average time was significantly longer than the low group. Renal function was found in high rate comparison, renal function and renal function were high after withdrawal of life support device, the initial oxygen decreased to 90%, 70%, average decline rate of 60%, significantly lower than that of the low renal function but high renal function group group. The donor oxygen saturation below 70% to the start of perfusion time was significantly shorter than the low renal function group (15.33 + 4.39 vs 17.08 + 6.24 min, p=0.026). In the long term prognosis in follow-up one year after the operation, the high renal donor group average eGFR, male was significantly higher than the low percentage of donor renal function group (donor when eGFR:110.02 + 45.20 vs 86.73 + 38.28 ml/min/1.73m2, p0.001, the donor male percentage: 86.49%vs 74.07%, p=0.009). The average age of donor renal function group, the average BMI for donor, glomerular pathology and pathological scores were significantly lower than the renal tubular function group (donor age: 32 .62 + 13.80vs43.53 + 12.34, p0.001 receptor, age: 40 + 10.98 vs 43.88 + 10.74, p=0.006 + 2.83 vs donor BMI:21.77 22.49 + 2.52kg/m2, P=0.04, and glomerular pathology score: 0.30 + 0.59vs0.48 + 0.71, p=0.011, and renal tubule pathological score: 0.37 + 0.64vs0.43 + 0.52, p=0.006). The high kidney the function of the donor group from the withdrawal of life support device to be measured oxygen time significantly longer than the low renal function group (8 + 5.19 vs 6.10 + 4.35 min, p=0.006). The high donor renal function group respectively from 80%, 70%, 90% oxygen, oxygen saturation decreased from 60% to undetectable time were significantly longer than that of low kidney functional group, renal function and high oxygen group from the withdrawal of life support device to measure the average oxygen to oxygen and this time the decline rate was significantly slower than low renal function group (19.60 + 17.49vs25.80 + 22.85%/min, p=0.038). The factors affecting the prognosis of DCD after renal transplantation single factor analysis Screening, included in the p value is less than or equal to 0.05 and eliminate the multicollinearity screening factors, multivariate linear regression analysis showed that age of donor, recipient age, receptors BSA and eGFR after 1 year was negatively correlated with male donor, oxygen duration (defined as withdrawal of life support from the device to the oxygen saturation can not be measured and after 1 years) and the receptor of eGFR was positively correlated. Conclusion: the prognosis of DCD in renal transplant donor recipient age, donor sex and donor renal function based on donor renal biopsy zero results have some tips for long-term prognosis for renal ischemia. In the evaluation, the evaluation of warm ischemia the two period is more accurate, high oxygen period (withdrawal of life support device - oxygen saturation and low oxygen (70%) during the period of oxygen saturation below 70%- perfusion) two stage, a long period of high oxygen oxygen within a certain range of fall time And the slower rate of decline of oxygen may have protective effect on renal prognosis, low oxygen period is too long can lead to organ damage, defined as the donor oxygen less than 70%- perfusion to warm ischemia time, can be more effective in January to assess the progression of renal function after operation, consider the general situation and should be considered when the donor in the pre, taking into account. At present, the severe shortage of organs, while ensuring the quality of life of patients after operation, to explore the influencing factors of the safety critical value, to expand the scope of the donor, will be key to the future development of kidney transplantation.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699.2

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