血小板与肾移植术后早期移植肾功能延迟性恢复的关联研究

发布时间：2018-06-04 21:10

本文选题：血小板功能 + 肾移植　；参考：《南方医科大学》2014年硕士论文

【摘要】：肾移植是根治终末期肾功能衰竭最佳的治疗手段,随着肾移植成功率逐步提高使得越来越多的患者获得新生。但是,肾移植术后早期移植肾功能延迟恢复(delay graft function, DGF)是导致移植物长期存活率下降的重要原因。临床上观察到,肾移植术后受者一旦发生DGF,会伴有不同程度的移植肾肾单位出血倾向,表现为血尿和炎症反应,病理表现为移植物血管内皮下炎性细胞浸润。血小板不仅具有凝血功能,还参与炎症反应过程。我们在临床工作中发现许多受者在肾移植术后早期外周血中血小板的数量变化非常明显,DGF发病时外周血中普遍出现炎性细胞升高。低温保存后供肾局部缺血和移植后开放血液循环出现缺血-再灌注损伤激活了一系列反应,使移植肾持续受损,在DGF发展中起主导作用。相关研究证实,减轻脂质过氧化反应和减少氧自由基,进行扩张血管、抗氧化、抗炎治疗可减轻DGF相关性肾损伤。这些现象表明血小板性炎症反应可能在DGF的发病中起一定作用。2012年1月,Park等最新报道在肾移植术后检测血小板分泌的某些抗氧化剂水平在早期恢复顺利的受者和出现DGF的受者体内具有统计学差异。移植肾早期不可避免存在缺血-再灌注损伤(Ischemia-reperfusion injury, IRI),它可引起移植肾原发性无功能、移植肾功能延迟恢复,同时还与免疫因素协同作用引起急性排斥反应,严重者可导致移植肾功能丧失,对移植肾的早期恢复和远期预后都产生重要影响。IRI是指缺血组织或器官重新获得血液灌注或氧供后损伤反而加重,甚至发生不可逆性损伤。缺血-再灌注不但损伤肾小管上皮细胞,还导致肾间质炎症和微血管病变,而微血管病变是缺血-再灌注损伤引起肾功能障碍的关键因素,缺血后微血管病变以内皮细胞肿胀和随之而来的微血管闭塞为特征,导致移植肾再灌注不能顺利进行。肾移植术后早期移植肾功能延迟恢复(delayed graft function, DGF)和急性排斥反应(acute rejection. AR),是导致移植肾长期存活率下降的重要原因。临床上观察到,肾移植术后无论是因先发生DGF引起急性排斥,还是因先发生急性排斥而诱发DGF,这两种移植后不良反应就像一对孪生并发症,而且受者一旦发生DGF或急性排斥反应时,会伴有不同程度的移植肾肾单位出血倾向,临床表现为血尿和炎症反应,病理表现为移植肾血管内皮下炎性细胞浸润,严重影响肾移植术后人／肾成活时间,延长住院时间。移植肾功能延迟性恢复的诊断标准为肾移植术后少尿(24h1200ml)或无尿,血肌酐水平无明显下降甚至升高或术后第7天血肌酐仍大于400umol/L,须行血液透析治疗者。引起DGF的主要因素包括肾前性、肾性及肾后性3种,肾移植术中及移植后早期低血容量、低血压、肾动静脉吻合口狭窄为肾前性因素。环孢素A肾毒性、肾小管坏死、排斥反应及供肾原有疾病(如高血压肾病、糖尿病肾病等)为肾性因素。移植肾尿路梗阻如外界血肿压迫、结石或血块梗死、吻合口狭窄、输尿管过长导致扭曲为肾后性因素。目前尽管现在联合应用免疫抑制剂使移植肾存活率显著升高,但急性排斥反应仍然是肾移植后DGF最常见的原因之一。血小板是一种重要的炎症细胞。有研究表明,在溃疡性结肠炎、克罗恩病、类风湿性关节炎和强直性脊柱炎等疾病中血小板平均体积(MPV)参数降低；MPV升高是早期动脉粥样硬化的预测因子,平均血小板体积反映了血小板的大小,血小板活化时,血小板体积增加,体积大的血小板含有更多的颗粒和更高的活性,活化的血小板分泌一系列的炎症物质,如趋化因子、细胞因子等,以促进血小板的聚集、粘附和血栓形成。此外血小板分泌的炎症物质还通过血小板的P-选择素募集中性粒细胞、单核细胞、嗜酸性粒细胞等进入炎症部位,促进炎症反应的发生。研究证实,血小板对移植物的功能有重要影响。我们在临床工作中发现,肾移植后DGF发病时血小板数量发生明显变化,由此推断血小板可能是DGF发病的危险因子之一。血小板膜上有大量磷脂酶,在炎症因子刺激下通过信号转导机制可生成大量生物活性物质,如白三烯(leukotrienes, LT)、脂氧素(lipoxins, LXS)、血栓烷和前列腺素(prostaglandin, PG)等,这些生物活性物质对血管内皮细胞功能、白细胞功能和血小板激活等具有重要的调节作用。目前已经有研究证实,血小板引起的炎症反应在动脉粥样硬化、脑梗塞、心绞痛、缺血性脑病、缺血性心脏病以及由于免疫系统功能异常导致的自身免疫性疾病和各型肾病等疾病中起重要作用。关于血小板数量(platelet number, PLT)、血小板比容测定(platelet hematocrit,PCT)、平均血小板体积(average platelet volume,MPV)、血小板体积分布宽度(platelet volume distribution width, PDW)和大型血小板比值(large platelet ratio, P-LCR)五项参数是否与DGF相关,目前尚无相关报道,本课题拟通过对肾移植术后2个月内受者外周血血小板五项参数变化的统计学分析,探讨血小板在DGF发生中的作用。第一部分肾移植受者血小板相关指标检测结果的统计学分析目的检测肾移植术后早期受者外周血血小板相关指标变化规律,探讨血小板相关指标对肾移植术后受者的作用。方法对我院2009年1月至2013年9月的232例肾移植受者术前至术后2个月内临床资料进行回顾性分析,其中男162例,女70例,年龄14～80岁,平均40.9岁。供受者ABO血型相符,淋巴毒实验均阴性,HLA配型检测A、B、DR三个位点,所有受者均采用口服他克莫司(FK506)或环孢素A (CsA)+霉酚酸酯(MMF)+醋酸泼尼松(Pred)三联抗排斥药物方案,取受试者术前及术后第1天、第2天、第3天、第4天、第5天、第6天、第7天、第8天、第9天、第10天、第15天、第30天、第45天、第60天外周静脉血各2mL,乙二胺四乙酸二钾抗凝,采用Sysmex XE2100型全自动血液分析仪及配套进口试剂对血小板参数进行测定,所有检测数据用均数±标准差(±s)表示,采用SPSS19.0统计软件,两组间比较采用独立样本t检验,以P0.05有统计学意义。结果通过对术后2个月内232例肾移植受者血小板相关指标检验发现,与术前相比,肾移植受者术后第1天PLT、PCT迅速降低,于术后第5天降至最低且明显低于术前水平(p0.05),后又开始升高,于术后第15天升至最高并明显高于术前水平(p0.05),然后又缓慢降低,术后第30-60天接近术前水平(p0.05)。PLT、PCT在术后第1至第15天与术前相比差异有统计学意义(p0.05),在术后第30天、45天、60天降至接近术前水平,与术前相比差异无统计学意义(p0.05)。术后第1天MPV、PDW、P-LCR均迅速升高,于术后第7天升至最高且明显高于术前水平(p0.05),之后缓慢降低并于术后第15天降至接近术前水平(p0.05),后又缓慢升高,MPV、P-LCR至术后30-60天明显高于术前水平(p0.05),PDW至术后45-60天明显高于术前水平(p0.05)。结论所有232例肾移植受者血小板相关指标呈规律性变化,提示临床上血小板相关指标作为肾移植术后骨髓功能恢复情况的监测指标有一定的临床价值。第二部分肾移植术后是否发生DGF的受者血小板相关指标检测结果的统计学分析目的探讨血小板参数变化与肾移植术后早期移植肾功能延迟恢复(DGF)的关系。方法对我院2009年1月至2013年9月的232例肾移植受者进行回顾性分析,以术后第1周内需要行血液透析治疗,或者虽未经过血液透析治疗,但在术后第7天血肌酐水平仍大于400umol/L作为DGF的诊断标准,供受者ABO血型相符,淋巴毒实验均阴性,HLA配型检测A、B、DR三个位点,所有受者均采用口服他克莫司(FK506)或环孢素A (CsA)+霉酚酸酯(MMF)+醋酸泼尼松(Pred)三联抗排斥药物方案。其中肾移植术后发生DGF患者29例,发生率为12.5%(29/232),未发生DGF203例。同样取受试者术前及术后第1天、第2天、第3天、第4天、第5天、第6天、第7天、第8天、第9天、第10天、第15天、第30天、第45天、第60天外周静脉血各2mL,乙二胺四乙酸二钾抗凝,采用Sysmex XE2100型全自动血液分析仪及配套进口试剂对血小板参数进行测定,所有检测数据用均数±标准差(±s)表示,采用SPSS19.0统计软件,两两比较采用配对样本t检验,以P0.05有统计学意义。结果肾移植术后29例DGF受者与203例非DGF受者血小板相关指标检测发现,非DGF组受者PLT在术后第5天降至最低,后开始升高并于术后第15天升至最高且明显高于术前水平,术后30-60天降至接近术前水平；DGF组受者PLT于术后第6天降至最低,术后第15天升至最高且明显高于术前水平,术后30天又降至低于术前水平,术后45-60天恢复至接近术前水平。非DGF组受者MPV、PDW、P-LCR在术后第7天升至最高,于术后第15天降至接近术前水平,后又缓慢升高；DGF组患者MPV、PDW、P-LCR在术后第7天升至最高,于术后30天降至最低但仍高于术前水平,二组受者术后血小板数量变化有一定规律性,即移植早期血小板数明显降低,之后逐渐升高且明显高于术前水平,术后第2天起DGF组受者血小板数量始终低于非DGF组受者,其中第7-10天二组受者血小板计数差异有统计学意义(p0.05)；PCT二者无明显统计学意义(p0.05);DGF组患者MPV、PDW. P-LCR始终高于非DGF组患者,其中术后第7、10、15天二组MPV、PDW、P-LCR的差异均有统计学意义(p0.05)。结论 232例肾移植受者PLT、PCT在术后第5天降至最低,术后第15天升至最高且明显高于术前水平(p0.05), MPV、PDW、P-LCR在肾移植术后均有所增高,其中第6天、第7天升至最高(p0.05),术后15天降至最低(p0.05),肾移植属于有创手术,早期PLT降低可能因血小板参与创伤的止血和凝血过程,防止创伤后的血液丢失,血小板破坏增多。接受肾移植患者MPV增加的机理可能是肾移植术后能有效清除尿毒症毒素,尿毒症潴留产物对骨髓的抑制作用逐渐解除,骨髓造血微环境逐渐恢复正常,造血干细胞可正常分化成熟,巨核系细胞正常增值,血小板是由骨髓中成熟巨核细胞的胞浆脱落而成,使循环血中出现较多年轻的大血小板,同时也使PLT数量逐渐增多(5-15天)。PLT与MPV相关,血小板生成减少时,MPV降低；血小板破坏增多时,MPV增大；血小板分布异常导致血小板减少时,MPV变化不大,由此可见,MPV、PDW、P-LCR可作为肾移植术后骨髓功能恢复情况的动态监测指标。本研究还发现,肾移植术后发生DGF患者PLT始终低于未发生DGF患者,其中DGF组患者与非DGF组患者相比术后第7d-10d有统计学意义(p0.05)：同样,发生DGF患者MPV、PDW、P-LCR始终高于未发生DGF患者,其中DGF组患者与非DGF组患者相比术后第7d、10d、15d有统计学意义(p0.05),说明在骨髓造血干细胞分化成熟过程中,在DGF患者中出现血小板活化过程,血小板破坏增多,消耗增加,血小板参与移植肾炎症反应和损伤再修复过程。对肾移植术后早期受者外周血血小板计数(PLT)、血小板比容测定(PCT)、平均血小板体积(MPV)、血小板体积分布宽度(PDW)、大型血小板比值(P-LCR)五项参数变化的监测,可为肾移植术后DGF的发生和逆转提供新的疾病监测标志物、药物靶标和新的治疗方法,这将有利于减少DGF的发生率,并借此提高肾移植患者的长期存活率。
[Abstract]:Renal transplantation is the best cure for end-stage renal failure. With the gradual improvement of renal transplantation success rate, more and more patients get new life. However, early renal transplantation after renal transplantation (delay graft function, DGF) is an important cause of the decrease of the long term graft survival rate. Once the recipients have DGF, they will be accompanied by a different degree of renal allograft bleeding tendency, characterized by hematuria and inflammatory reaction, and the pathological manifestation is infiltration of inflammatory cells under the graft vascular endothelium. Platelet not only has coagulation function, but also participates in the process of inflammatory reaction. In clinical work, we found that many recipients were transplanted in kidney transplantation. The changes in the number of platelets in the early peripheral blood are very obvious, and inflammatory cells are generally elevated in the peripheral blood of DGF. After cryopreservation, a series of reactions are activated by ischemia and reperfusion injury in the donor kidney and the open blood circulation after transplantation, which leads to the continued damage of the transplanted kidney and plays a leading role in the development of DGF. It is confirmed that the reduction of lipid peroxidation and oxygen free radicals, dilated blood vessels, antioxidation, and anti-inflammatory treatment can reduce DGF related renal damage. These phenomena suggest that the platelet inflammatory response may play a role in the pathogenesis of DGF in January, Park and other recent reports on the detection of some antioxidation of platelet secretions after renal transplantation. There was a significant difference in the level of the drug in the early recovery of the successful recipients and those with DGF.
The inevitable existence of ischemia-reperfusion injury (Ischemia-reperfusion injury, IRI) early in the transplant kidney, which can cause the primary transplantation of renal function, the delayed restoration of renal function, and the synergistic effect of the immune factors to the acute rejection, which can lead to the loss of transplanted kidney function, the early recovery of the transplanted kidney and the long term preconditioning. The subsequent important effect of.IRI is that the ischemic tissue or organ is re obtained after blood perfusion or oxygen supply and even aggravated, even irreversible damage. Ischemia-reperfusion not only damage the renal tubular epithelial cells, but also lead to renal interstitial inflammation and microvascular lesions, and microvascular disease is ischemia reperfusion injury causing renal dysfunction. The key factor is microvascular lesion after ischemia. It is characterized by swelling of endothelial cells and consequent microvascular occlusion, leading to the failure of renal graft reperfusion.
Early renal transplantation (delayed graft function, DGF) and acute rejection (acute rejection. AR) after renal transplantation is an important cause of the decline in the long-term survival rate of renal allograft. It is clinically observed that after renal transplantation, acute rejection is caused by first DGF, and DGF is induced by acute rejection. The two kinds of adverse reactions are like a pair of twin complications, and when the recipients have DGF or acute rejection, they will be accompanied by different degrees of renal allograft bleeding tendency. The clinical manifestation is hematuria and inflammatory reaction. The pathological manifestation is inflammatory cell infiltration under the vascular endothelium of the transplanted kidney, which seriously affects human and renal survival after renal transplantation. The diagnostic criteria for delayed restoration of renal function were oliguria (24h1200ml) or no urine after renal transplantation, no significant decrease in serum creatinine level or even higher serum creatinine or more than 400umol/L after seventh days of operation. Hemodialysis patients must be treated with hemodialysis. The main factors that cause DGF include 3 types of pre renal, renal and postrenal, renal migration. Early low blood volume, hypotension, and narrowing of renal arteriovenous anastomosis are the prerenal factors during and after transplantation. Cyclosporine A nephrotoxicity, renal tubular necrosis, rejection and kidney disease (such as hypertensive nephropathy, diabetic nephropathy, etc.) are renal factors. Renal allograft obstruction such as external hematoma oppression, stone or clot infarction, anastomotic narrow Narrow ureteral distortion is a factor of post renal disease. Although immunosuppressive agents are now associated with a significant increase in renal graft survival, acute rejection is still one of the most common causes of DGF after renal transplantation.
Platelets are an important inflammatory cell. Studies have shown that the mean platelet volume (MPV) parameters in ulcerative colitis, Crohn's disease, rheumatoid arthritis and ankylosing spondylitis are reduced, and the increase of MPV is a predictor of early atherosclerosis, and the flat average platelet volume reflects the size of platelets and platelet activity. Platelet volume increases and large platelets contain more particles and higher activity. Activated platelets secrete a series of inflammatory substances, such as chemokines, cytokines, etc., to promote platelet aggregation, adhesion and thrombosis. In addition, the inflammatory substances secreted by platelets are also collected through the P- selectin of platelets. Granulocytes, monocytes and eosinophils enter the site of inflammation and promote the occurrence of inflammatory reactions. Studies have shown that platelets have an important impact on the function of the graft. We found in clinical work that the number of platelets in DGF after renal transplantation is significantly altered, and it is concluded that platelets may be a risk factor for the pathogenesis of DGF. 1. There are a large number of phospholipases on the membrane of the platelets, which can produce a large number of bioactive substances, such as leukotrienes (LT), lipoxins (LXS), thromboxane and prostaglandin (prostaglandin, PG), through the signal transduction mechanism under the stimulation of inflammatory factors. These bioactive substances have the function of vascular endothelial cells, leukocyte function and blood. Platelets have been shown to play an important regulatory role. Studies have shown that the inflammatory reactions caused by platelets play an important role in atherosclerosis, cerebral infarction, angina, ischemic encephalopathy, ischemic heart disease, and autoimmune diseases and various types of kidney disease caused by abnormal immune system function. Number (platelet number, PLT), platelet specific volume assay (platelet hematocrit, PCT), average platelet volume (average platelet volume, MPV), platelet volume distribution width (platelet volume) and large platelet ratio are related to the five, there is no correlation at present. The purpose of this study is to explore the role of platelets in the occurrence of DGF by statistical analysis of the changes in the five parameters of the peripheral blood platelets within 2 months after renal transplantation.
Part one statistical analysis of platelet related indicators in renal transplant recipients
objective
Objective to detect the changes of platelet related indexes in the peripheral blood of recipients in early stage after renal transplantation, and to explore the effects of platelet related indexes on recipients after renal transplantation.
Method
The clinical data of 232 renal transplant recipients from January 2009 to September 2013 were retrospectively analyzed, including 162 men, 70 women, 14~80 years old and 40.9 years old. The donor ABO blood group was matched, the lymphatic test was negative, and the HLA matching was used to detect A, B, DR, and all the recipients were taken oral tacrolimus (FK). 506) or cyclosporin A (CsA) + mycophenolate mofetil (MMF) + prednisone acetate (Pred) triple anti rejection drug regimen, taking first days, second days, fourth days, fifth days, sixth days, seventh days, eighth days, Ninth days, Ninth days, Ninth days, Ninth days, tenth days, fifteenth, thirtieth days, and forty-fifth days, and Sysmex, potassium anticoagulant of ethylene diamine tetra acetic acid, using Sysmex. Platelet parameters were measured by XE2100 automatic hematology analyzer and matching imported reagents. All the measured data were expressed with mean standard deviation (+ s), and SPSS19.0 statistical software was used. The two groups were compared with independent sample t test, and P0.05 had statistical significance.
Result
By examining the platelet related indexes of 232 renal transplant recipients within 2 months after the operation, it was found that compared with the preoperative PLT, PCT decreased rapidly at first days after the operation, and decreased to the lowest and significantly lower than the preoperative level (P0.05) at fifth days after the operation, and then began to rise again at the highest level at the fifteenth day after the operation and significantly higher than the preoperative level (P0.05), and then again Slow down, 30-60 days after operation was close to preoperative level (P0.05).PLT, and PCT was statistically significant (P0.05) compared with preoperative (P0.05), thirtieth days, 45 days, 60 days after operation, and there was no statistical difference between preoperative and preoperative (P0.05). MPV, PDW, P-LCR increased rapidly on the first day after operation, and reached seventh days after the operation. The highest and significantly higher than preoperative level (P0.05), then slow down and fifteenth days after the operation to close to preoperative level (P0.05), and then slowly increase, MPV, P-LCR to 30-60 days after the operation was significantly higher than the preoperative level (P0.05), PDW to 45-60 days after the operation was significantly higher than the preoperative level (P0.05).
conclusion
The platelet related indexes of all 232 renal transplant recipients showed regular changes, suggesting that the clinical platelet related indexes were of certain clinical value as the monitoring index of the recovery of bone marrow function after renal transplantation.
The second part is a statistical analysis of the results of platelet related indexes in recipients of DGF after renal transplantation.
objective
Objective to investigate the relationship between platelet parameter changes and delayed graft function (DGF) in early stage after renal transplantation.
Method
A retrospective analysis of 232 renal transplant recipients from January 2009 to September 2013 was conducted in our hospital. Hemodialysis was required within first weeks after the operation, or although it was not treated by hemodialysis, but the serum creatinine level was still greater than 400umol/L as a diagnostic criterion for DGF at seventh days after the operation. The donor ABO blood group was matched, the lymphatic experiment was negative, and the HLA was matched. The three loci of A, B, and DR were detected. All the recipients were taken oral administration of tacrolimus (FK506) or cyclosporin A (CsA) + mycophenolate (MMF) and prednisone acetate (Pred). Among them, 29 cases of patients with DGF after renal transplantation were 12.5% (29/232), and no DGF203 cases. The subjects were also taken before and first days, second days after the operation. Third days, fourth days, fifth days, sixth days, eighth days, Ninth days, tenth days, fifteenth days, thirtieth days, thirtieth days, forty-fifth days, every 2mL of peripheral venous blood, ethylene diamine tetra acetic acid two potassium anticoagulant, Sysmex XE2100 automatic blood analyzer and matching import reagent to measure the parameters of the blood small plate, all the test data were measured with mean standard deviation standard deviation (+ s) table SPSS19.0 statistical software was used. 22 paired sample t test was used to compare P0.05 with statistical significance.
Result
After renal transplantation, 29 DGF recipients and 203 non DGF recipient platelet related indexes found that the PLT in non DGF group fell to the lowest fifth days after the operation, and then began to rise to the highest and higher than the preoperative level at fifteenth days after the operation, and to the level close to the preoperative level 30-60 days after the operation; the DGF group received PLT to the lowest postoperative day after the operation, after the operation. Fifteenth days to the highest and significantly higher than the preoperative level, 30 days after the operation to lower than the preoperative level, 45-60 days after the 45-60 day to close to the preoperative level. Non DGF group MPV, PDW, P-LCR reached the highest seventh days after the operation, fifteenth days after the operation to close to the preoperative level, then slowly rise; MPV, PDW, P-LCR in the group of DGF, the seventh day after the operation to the highest level to the most. The number of platelets in the two groups had a certain regularity after 30 days of operation. The number of platelets in the two groups had a certain regularity, that is, the number of platelets in the early stage of transplantation decreased obviously, and then gradually increased and significantly higher than that before the operation. The number of platelets in the DGF group was lower than that of the non DGF group on the second day of the operation, and the two group in the 7-10 day was the two group. The difference of platelet count was statistically significant (P0.05), and there was no significant statistical significance in PCT two (P0.05), and in group DGF, MPV and PDW. P-LCR were always higher than those in non DGF group, and the difference of MPV, PDW and P-LCR was statistically significant in group two after operation.
conclusion
232 cases of renal transplant recipients PLT, PCT to the lowest fifth days after operation, fifteenth days to the highest and significantly higher than preoperative level (P0.05), MPV, PDW, P-LCR increased after renal transplantation, sixth days, seventh days to the highest (P0.05), 15 days to the lowest (P0.05), kidney transplantation is a invasive operation, early PLT reduction may be due to platelets Participate in the process of hemostasis and coagulation, prevent blood loss and platelet damage after trauma.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R699.2

【参考文献】