加速康复外科在肾移植围手术期管理中的应用

目的探讨加速康复外科(ERAS)应用于肾移植围手术期管理的有效性和安全性。 方法回顾性分析浙江大学医学院附属第一医院肾脏病中心2016年7月至2017年8月474例同种异体肾移植受者临床资料，2016年7月至2017年4月实施传统围手术期管理的315例受者为传统组，2017年5月至2017年8月实施ERAS方案的159例受者为ERAS组。EARS组受者围手术期管理主要内容包括取消肠道准备、术前饮用碳水化合物、早期进食、早期活动及多模式镇痛等。观察并比较两组受者术后平均住院时间、血清肌酐水平，以及胃肠道反应、移植肾功能延迟恢复(DGF)、术后90 d内急性排斥反应、移植后新发糖尿病发生率和术后90 d内非计划再入院率。两组受者年龄、体质量、术前透析时间等计量资料比较采用成组t检验，两组受者DGF、术后90 d急性排斥反应发生率等计数资料比较采用χ²检验。 结果ERAS组和传统组受者性别、年龄、身高、体质量、术前透析时间、供肾类型、HLA错配数差异均无统计学意义(P均>0.05)。ERAS组活体和尸体肾移植受者术后住院时间分别为(7.7±2.0) d和(12.8±8.3)d，均短于传统组(9.0±3.8)d和(16.7±12.6) d]，差异具有统计学意义(t＝－2.594和－2.692，P均<0.05)。两组术后7、30和90 d血清肌酐水平差异均无统计学意义(P均>0.05)。ERAS组腹泻发生率为5.7%(9/159)，明显低于传统组(20.7%，65/315)，差异有统计学意义(χ²＝18.092，P<0.05)。两组尸体肾移植受者DGF、术后90 d内急性排斥反应、移植后新发糖尿病、其他并发症发生率以及术后90 d内非计划再入院率差异均无统计学意义(P均>0.05)。 结论将ERAS应用于肾移植围手术期管理是有效、安全的，能够降低受者术后平均住院时间和腹泻发生率，同时未增加其他并发症的发生。

The application of enhanced recovery after surgery in kidney transplantation recipients during perioperative managemant

ObjectiveTo explore the validity and security of enhanced recovery after surgery (ERAS) in kidney transplantation recipients during perioperative managemant. MethodsThe clinical data of 474 kidney transplantation recipients who received kidney transplantation in Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University during July 2016 to August 2017 were retrospectively analysed, among which 315 recipients who got traditional perioperative managemant during July 2016 to April 2017 were divided into traditional group, and 159 recipients who got ERAS during perioperative managemant were diveded into ERAS group. The main content of ERAS included bowel preparation removal, preoperative carbohydrate loading, early-stage feeding, early mobilization, multimodal approach to opioid-sparing pain control and so on. Indexes like mean post operation hospitalization duration, serum creatinine, gastrointestinal reaction, delayed graft dysfunction (DGF), acute reaction during 90 days after surgery, incidence rate of new-onset diabetes mellitus after transplantation and unscheduled readmission rate during 90 days after surgery were compared between the 2 groups. Measurement data like age, weight and time of dialysis preoperative between the 2 groups were compared by Student′s t-test, and enumeration data like incidence rate of DGF and acute reaction during 90 days after surgery between the 2 groups were compared by chi-square test. ResultsNo statistical difference was found in gender, age, height, weight, time of dialysis preoperative, type of donor kidney and HLA mismatch number between the 2 groups (P all >0.05). The post operation hospitalization duration of living donor renal transplantation recipients and cadaveric donor renal transplantation recipients in ERAS group were (7.7±2.0) d and (12.8±8.3) d, respectively, which were shorter than traditional group (9.0±3.8) d and (16.7±12.6) d], and the difference was statistically significant (t=-2.594 and -2.692, P all <0.05). No statistical difference was found in serum creatinine of 7, 30 and 90 days after transplantation between the 2 groups (P all >0.05). The incidence rate of diarrhea of ERAS group and traditional group were 5.7% (9/159) and 20.7% (65/315), respectively, which had statistical difference (χ²=18.092, P<0.05). No statistical difference was found in DGF, acute reaction during 90 days after transplantation, new-onset diabetes mellitus after transplantation, incidence rate of other complications and unscheduled readmission rate during 90 days after surgery between the 2 groups (P all >0.05). ConclusionsERAS protocol can decreased post operation hospitalization duration and incidence rate of diarrhea without influence on other complications, which was safe and effective.