移植肾自发性破裂(附15例报告)

目的：总结移植肾自发性破裂的病因，临床表现，诊治及预防，方法：15例患者中，手术探查12例（9例保留移植肾，用明胶海绵填压或医用粘合胶粘贴联合减压，引流处理，3例切除移植肾），3例保守治疗。结果：移植肾切除3例患者行血液透析维持，手术保留移植肾9例和3例保守治疗患者痊愈出院，其中2例手术保留移植肾患者分别于出院98d和6个月因肺部感染，心衰死亡，其他病例随访3－31个月，平均19个月，肾功能均良好，结论：移植肾自发性破裂发生的确切原因尚未清楚，结合临床症状行B超检查对确诊此症价值较高，及时发现，尽早行内，外科联合处理对于移植肾破裂的治疗是重要的，明胶海绵或医用粘合胶粘贴联合减压，引流是一种有效的治疗方法，另外，预防也是一重要环节。     

移植肾自发性破裂的诊治

目的：探讨移植肾自发性破裂的原因及防治措施。方法：回顾分析本院３９２例同种肾移植术后发生移植肾自发性破裂２０例临床资料。结果：发生率为５．１％。１４例保留肾脏功能，其中２例经保守治疗痊愈。６例肾切除者中有４例为急性排斥反应引起。结论：肾破裂的发生与排斥反应、肾缺血性损害、肾静脉引流不畅及尿路梗阻有关。对于出血量少、肾功能好者，可采用保守治疗。预防要从肾脏摘取与灌洗、植肾手术、合理应用免疫抑制剂、及     

移植肾自发性破裂的处理与随访

本文报道在302例324次同种肾移植术后发生移植肾自发性破裂19例22次。破裂时间为术后3周内,11例发生在CsA减量的交替期。15例破裂前出现典型的急性排斥反应。裂口1～4处不等。5例行移植肾切除;14例行保肾手术,术后3周内尿量及肾功能恢复正常。随访1～5年,保肾患者的人/肾长期存活率与同期移植肾未破裂者比较无显著性差异。     

肾错构瘤自发破裂出血3例报告

目的提高肾错构瘤自发破裂出血的诊治水平。方法回顾分析3例肾错构瘤自发破裂出血临床资料。结果2例经手术及病理证实诊断,行肾切除1例,肾动脉栓塞后肾切除1例;保守治疗1例。鲒论B超和CT是诊断肾错构瘤自发破裂出血的重要方法,肾动脉栓塞、保留肾单位肾部分切除、肾切除术为可选治疗手段。     

单纯捆扎法治疗移植肾自发性实质破裂

目的 介绍一种移植肾白发性实质破裂的实用手术治疗方法.方法 移植肾自发性实质破裂14例.移植肾破裂时肾功能正常1例,急性排斥8例,急性肾小管坏死5例.术中证实14例均为肾实质破裂.破裂伤口1个者10例,2个裂12者4例.14例均以受者组织填塞伤口后,以可吸收肠线单纯捆扎加压止血.结果 14例破裂移植肾均治疗成功.术后伤口感染2例,其中1例因合并严重的粒细胞减少症和肺部感染在术后3周死亡.其余13例肾功能恢复满意,术后4～8周出院.随访0.5～5年,人肾存活良好11例,发生慢性移植物肾病2例.结论 单纯捆扎法是快捷、安全、可靠的移植肾自发性实质破裂的治疗方法.     

器官捐献移植肾动脉细菌感染破裂的诊疗对策

目的探讨移植肾动脉细菌感染破裂的诊疗方案。方法回顾性研究4例肾移植术后因细菌感染导致移植肾动脉破裂患者的临床资料,并检索相关文献进行综合分析。结果患者临床表现为突然出现的移植肾区肿胀,不同程度疼痛,引流管引流出鲜红色血液或沿切口缝合线渗出鲜红色血液,移植肾彩色多普勒超声检查提示移植肾周血肿。4例患者均行手术探查,同期切除移植肾,标本进行细菌培养,4例均为细菌感染,均行髂外动脉感染破裂修补术。1例术后恢复血液透析,等待再次移植;1例因术后并发腹腔严重感染死亡;2例因失血性休克死亡。结论移植肾动脉感染导致动脉破裂出血的病情凶险,需要急诊手术治疗,病死率较高。应严格执行器官供体选择标准,供体器官灌注液进行细菌培养,围手术期加强抗感染,预防术后感染性移植肾动脉破裂的发生。     

13例移植肾动脉感染破裂典型病例分析及总结

目的:对13例公民逝世后器官捐献(donation after citizen's death,DCD)移植术后肾动脉破裂案例进行分析总结。方法:回顾性分析郑州人民医院器官移植中心617例DCD供肾移植受者,其中因感染因素导致移植肾动脉破裂13例,通过供受者多种途径查找致病微生物,确定感染来源。结果:受者移植肾动脉破裂时间为术后6～86 d,致病微生物包括曲霉菌、毛霉菌、热带念珠菌、肺炎克雷伯杆菌及粘质沙雷菌等。10例受者切除移植肾,1例通过介入治疗保留移植肾。死亡3例,死因为消化道大出血、重症肺炎、失血性休克。结论:在供肾获取前,应取供者血液、尿液及伤口分泌物等进行病原学监测,阳性者给予敏感药物抗感染治疗,效果不佳者果断弃用。同一供者的一个受者出现移植肾动脉破裂,另一受者也应高度重视,立即抗感染治疗。遵守"先保命再保肾"原则,若感染无法控制,应尽早切除移植肾。对病史长、感染因素不确定的供肾,术后常规应用广谱抗细菌药物联合抗真菌药物预防感染,并根据培养结果和药物敏感试验及时调整治疗方案。     

同种异体尸肾移植术后移植肾血管自发破裂七例

同种异体尸肾移植术后移植肾血管自发破裂七例潘光辉，罗永礼，徐健，于立新，张国良，张依利，马俊杰，汪志伟我院自１９８６年８月至１９９２年８月以来共行肾移植手术４１４例，术后出现移植肾血管自发破裂７例（１．６９％）。现对其发病原因、临床特点及防治探讨如下...     

延迟性脾破裂22例的诊治

目的 探讨延迟性脾破裂的手术方法及临床观察时间。方法 对1985年8月-1994年6月,我院手术治疗的22例延迟性脾破裂进行回顾性总结。结果 病程为2-28d,平均16.3d,行脾切除7例,脾切除自体脾片网膜囊内移植3例,保留脾脏手术12例。结论 延迟性脾破裂的临床观察时间至少4周,应尽可能地采用保留脾脏的术式。     

移植肾假性动脉瘤的诊断和治疗四例报告

目的 总结移植肾假性动脉瘤的诊治体会.方法 首次接受肾移植者4例,其供肾动脉均为单支,肾动脉无损伤,也未行动脉修补成形术.供肾动脉均与受者的髂外动脉行端侧吻合.术中发现受者髂外动脉有粥样斑块或动脉分层者2例.术后4例均未出现移植肾周感染,亦未行移植肾穿刺活检或其他有创检查.依据临床表现、彩色多普勒超声检查、多层螺旋CT血管成像和数字减影血管造影诊断移植肾假性动脉瘤.结果 分别在术后1.5个月、2个月、5个月和7个月诊断移植肾假性动脉瘤,其临床表现缺乏特异性,3例经数字减影血管造影、1例经多层螺旋CT血管成像确诊.1例移植肾假性动脉瘤突发破裂,急诊切除假性动脉瘤和移植肾;1例因瘤体短期迅速增大,行带膜支架置入及栓塞术;2例行移植肾动脉瘤切除及动脉裂口修补术.结论 移植肾假性动脉瘤是肾移植术后的少见并发症,其临床表现缺乏特异性,多层螺旋CT血管成像和数字减影血管造影有助于本病的诊断.对于移植肾假性动脉瘤的治疗,可选择手术切除或介入栓塞术,关键在于是否保留移植肾,并需考虑移植肾血管重建方式.     

Spontaneous kidney allograft rupture

Spontaneous renal allograft rupture is one of the most dangerous complications of kidney transplantation, which can result in graft loss. This condition needs immediate surgical intervention. Conservative management has dismal results. Its prevalence varies from 0.3% to 3%. Rupture occurs in first few weeks after transplantation. Predisposing factors for graft rupture are acute rejection, acute tubular necrosis, and renal vein thrombosis. There are growing reports about successful results of repairing these ruptured kidneys. In this study, we reviewed the medical records of 1682 patients who received kidney allografts from living donors from 1986 through 2003. There were six (0.35%) cases of renal allograft rupture. All were preceded by acute graft rejection. They were treated with antirejection medications. In first three cases, the kidney allografts were removed because the procedure of choice in this situation is graft nephrectomy; but in three next cases we repaired the ruptured grafts with good results in two of them. In conclusion, the procedure of choice for kidney allograft rupture is graft repair.     

Renal rupture after transplantation

Nine instances of spontaneous allograft rupture have been identified in a series of 325 renal transplantations. Repair of the graft was accomplished in 4 cases. One graft functioned for five and one-half years, one kidney was removed immediately because of uncontrolled hemorrhage, and two grafts were subsequently removed because of rejection. Immediate nephrectomy was performed in 5 cases of irreversible rejection. The duration of ischemia and method of preservation appeared to have no etiologic importance. Evidence of severe acute rejection was present in all 9 cases. The recent increase in graft rupture parallels the increasing frequency of severe early acute rejection reactions.     

Surgical repair of spontaneous renal allograft rupture: a new procedure

Background: The purpose of the present paper is to introduce a new surgical procedure using the external oblique aponeurosis (EOA) for repair of spontaneous renal allograft rupture. Methods: Thirty‐eight cases with spontaneous renal allograft rupture were encountered in 1000 consecutive kidney transplants between April 1991 and August 2000. Thirty‐three cases underwent surgical exploration with two grafts undergoing nephrectomy, while a further 31 were repaired using the new surgical procedure. The external oblique aponeurosis (EOA) from the incision was trimmed into 1 cm × 1 cm square pieces. A 2/0 Dexon suture was placed through each piece of the EOA, then through the parenchyma of the kidney perpendicular to the rupture. Each suture was then placed through another piece of EOA and tied. Results: Two repaired grafts were removed on day 7 and day 10, one due to graft re‐rupture and another with ischaemia secondary to irreversible acute rejection. The graft function of 29 cases had recovered completely at 30 days following surgical repair with one graft improving rapidly. Thirteen grafts were diagnosed as undergoing mild to moderate acute rejection, whereas a further 20 cases were considered to have acute tubular necrosis on histopathology. The allograft survival rate at 1 year and 5 years post grafting was 86% and 64%, respectively. No patients died from postoperative complications following repair using this procedure. Conclusions: Spontaneous renal allograft rupture is a relatively common post‐transplant complication secondary to either acute tubular necrosis or acute rejection. This new surgical procedure is proposed as a reliable and practical method of repair following graft rupture. Preservation of graft function and viability following rupture appears achievable both in the medium and long‐term.     

自发性肾脏破裂出血18例

目的 提高对自发性肾脏破裂出血的诊治水平。方法 回顾分析18例自发性肾脏破裂出血患的临床资料。结果 肾包膜下出血10例，肾周血肿8例。其中错构瘤10例，保守治疗3例，肾切除2例，肿瘤剜除术5例；囊肿3例，保守治疗2例，探查血肿清除1例；移植肾破裂2例，均行移植肾切除；肾癌1例，行根治性肾切除；无明显原因2例，1例保守治疗，1例行血肿清除。结论 自发性肾脏破裂出血的治疗取决于原发病的性质及出血的严重程度。     

Renal allograft rupture caused by acute tubular necrosis

Renal allograft rupture is a rare but potentially lethal complication of kidney transplantation. A renal allograft recipient receiving quadruple immunosuppressive therapy developed a spontaneous allograft rupture 13 days after kidney transplantation. Warm ischaemia time during the transplant was 80 minutes. The ruptured kidney graft could not be salvaged because of the patient's haemodynamic instability. The histopathological examination showed interstitial oedema with severe acute tubular necrosis with no signs of acute rejection. The most common causes of renal graft rupture are acute rejection and vein thrombosis, while acute tubular necrosis may only rarely be responsible for this complication. Renal graft rupture may be the result of interstitial damage attributed both to the prolonged warm ischaemia time during the transplant and to post-transplant acute tubular necrosis in the absence of graft rejection. In those patients whose haemodynamic status cannot be stabilized by appropriate aggressive haemodynamic support therapy, graft nephrectomy should be considered the only definitive treatment.     

Conservative surgery of spontaneous rupture of renal grafts]

17 cases of spontaneous rupture of renal allografts were noted after 285 renal transplantations performed during the years 1967-1978. All ruptures occurred within the first two weeks after transplantation. Acute rejection, combined with hypertension, dialysis and/or anticoagulation seem to be the main etiological factors of graft rupture. Due to severe hemorrhage surgical exploration had to be performed in 15 patients. While removal of the graft was necessary in 4 patients the kidney could be preserved by tamponade and suture in 11 patients. 5 patients later lost their graft, due to chronic rejection, while 8 patients (6 of the 15 patients who needed surgical exploration) currently have satisfactory graft function.     

Should the ruptured renal allograft be removed?

During a 16-month period when 93 renal transplants were performed, eight kidney graft ruptures were detected within 18 days of transplantation, without evidence of venous obstruction. Six grafts were removed at the time of an exploratory operation for rupture and only one showed signs of probable irreversible rejection when examined by microscopy. Two graft ruptures were repaired and one of these grafts has had good long-term function 22 months later. These observations suggest that if bleeding at the site of grafts has had good long-term function 22 months later. These observations suggest that if bleeding at the site of graft rupture can be securely controlled and if the conditions of the patient and of the graft are favorable except for the rupture, it may be possible to save more than one of eight grafts.     

移植肾破裂肾包膜切开止血法

移植肾自发性破裂是同种异体肾移植术后早期的一个严重并发症，采用肾包膜多处切开结合止血绫－粘涂胶止血法保肾，并行双滤过法血浆分离术（ＤＦＰＰ）和应用抗胸腺细胞球蛋白（ＡＴＧ）治疗６例严重移植肾破裂患者，止血效果达到１００％，４例肾脏得以保存，２例切除移植肾。认为肾包膜多处切开结合止血绫－粘涂胶止血术是治疗严重移植肾破裂的一个安全、可靠和简便的止血保肾法     

Severe tubulopathy and kidney graft rupture after coadministration of mannitol and ciclosporin.

Spontaneous allograft rupture after kidney transplantation is a rare complication usually due to an acute rejection of the interstitial type. In a 32-year-old man kidney transplantation was performed under immunosuppression with prednisolone and ciclosporin (CS). The dose of CS was 5 mg/kg body weight intravenously for the first 24 h, on the 2nd day 10 mg/kg/day orally, with gradually decreasing doses thereafter. The patient remained oliguric in the postoperative period and received additionally 600 ml mannitol solution intravenously for osmodiuresis within a period of 6 days. On the 8th postoperative day, 48 h after the last intravenous infusion of mannitol, spontaneous renal rupture occurred. The CS concentrations in the blood during the days before the rupture were within the upper normal range for effective immunosuppression (300-600 ng/ml). Intraoperatively the kidney appeared enlarged due to edematous swelling of the graft, but it showed no signs of rejection. The histological finding was a toxic tubulopathy with extensive isometric vacuolization and peritubular congestion, a known side effect of both of CS and of mannitol. The rupture was successfully repaired. Thirty-four days after the transplantation diuresis increased and hemodialysis therapy could be discontinued. In a second biopsy of the kidney the signs of toxic tubulopathy with isometric vacuolization were reduced. On the following days the serum creatinine dropped below 160 mumol/l. It can be assumed that the combination of CS therapy and administration of massive and continued doses of mannitol in an oliguric patient with allograft kidney may potentiate severe tubulopathy with concomitant edematous swelling of the graft. This can result in an increasing danger of spontaneous renal rupture.