肾移植术后早期移植肾动脉狭窄的诊断与治疗

目的总结肾移植术后早期发生移植肾动脉狭窄(TRAS)受者诊疗经验。 方法回顾性分析2014年1月1日至2018年8月31日复旦大学附属中山医院肾移植术后并发TRAS的16例受者(TRAS组)临床资料，并选取同期16例未发生TRAS的肾移植受者作为对照组。采用配对t检验比较两组受者介入治疗前年龄、等待移植时间、血清肌酐、估算肾小球滤过率(eGFR)、收缩压/舒张压、移植肾动脉峰值流速(PSV)和段间动脉阻力指数(RI)，以及TRAS组治疗后与TRAS组治疗前、对照组治疗后血清肌酐、eGFR、收缩压/舒张压、移植肾动脉PSV、段间动脉RI的差异。采用χ²检验比较两组受者性别、供肾来源、透析方式、供肾侧别、供肾动脉吻合方式及移植肾功能延迟恢复发生情况；采用Fisher确切概率法比较两组受者移植前糖尿病、高血压和急性排斥反应发生情况。P<0.05为差异有统计学意义。 结果TRAS组受者中13例行球囊扩张，2例置入球扩支架。随访至2018年8月31日，期间除1例受者因慢性排斥反应行移植肾切除术外，余15例受者移植肾功能均稳定。两组受者年龄、性别、移植前糖尿病、移植前高血压、等待移植时间、供肾来源、透析方式、供肾侧别、供肾动脉吻合方式、移植前血清肌酐、移植肾功能延迟恢复及急性排斥反应发生情况差异均无统计学意义(P均>0.05)。介入治疗前，TRAS组受者平均血清肌酐、收缩压及移植肾动脉PSV分别为(5.6±3.5)mg/dL、(144±9)mmHg(1 mmHg＝0.133 kPa，下同)和(3.4±1.6)m/s，均高于对照组[(1.9±0.8)mg/dL、(130±19)mmHg和(1.3±0.5)m/s]，差异均有统计学意义(t＝3.94、2.35和4.73，P均<0.05)；TRAS组受者平均eGFR和段间动脉RI分别为(18±15)mL/min和0.5±0.1，均低于对照组[(49±20)mL/min和0.6±0.1]，差异均有统计学意义(t＝－4.84和－3.88，P均<0.05)。介入治疗后，TRAS组受者平均血清肌酐、收缩压、舒张压和移植肾动脉PSV分别为(3.2±1.5)mg/dL、(128±16)mmHg、(76±8)mmHg和(2.0±1.0)m/s，较治疗前均有所下降，差异均有统计学意义(t＝3.63、4.40、3.72和3.03，P均<0.05)，但平均血清肌酐高于仍高于对照组[(1.5±0.5)mg/dL]，差异有统计学意义(t＝3.93，P<0.05)。TRAS组受者平均eGFR和段间动脉RI分别为(26±13)mL/min和0.6±0.1，均高于治疗前，差异均有统计学意义(t＝－4.65和－3.25，P均<0.05)；但平均eGFR仍低于对照组[(58±17)mL/min]，差异有统计学意义(t＝－5.75，P<0.05)。 结论对于肾移植术后怀疑发生TRAS的受者应先进行彩色多普勒血流显像检查，然后再根据血管动脉造影进行确诊。介入治疗可有效改善TRAS受者移植肾功能。

Diagnosis and treatment of early stage transplant renal artery stenosis

ObjectiveTo summarize the experience of diagnosis and treatment for early stage transplant renal artery stenosis (TRAS). MethodsThe clinical data of 16 renal transplantation recipients who were diagnosed with TRAS from 2014 January 1st to 2018 August 31st in the Department of Urology, Zhongshan Hospital, Fudan University, were retrospectively analyzed, and 16 renal transplantation recipients without TRAS at the same time were selected as control group. Pair t-test was used to compare the indexes of age, waiting time, serum creatinine, estimated glomerular filtration rate (eGFR), systolic/diastolic blood pressure, graft artery peak systolic velocity (PSV) and resistance index (RI) of segmental arteries, the chi-square test was used to compare the indexes of gender, source of donor kidneys, type of dialysis, different sides of donor kidney, anastomosis method of arteries and occurrence of delayed graft function, the Fisher′s exact probability test was used to compared the indexes of the occurrence of diabetes, hypertension and acute rejection before transplantation. P<0.05 was considered statistically significant. ResultsThirteen recipients in TRAS group recieved balloon dilatation, 2 recipients recieved balloon-expandable stent. Up to 2018 August 31st, the function of he transplant kidneys in TRAS group were all stable, except 1 recipient got nephrectomy because of chronic rejection. There was no significant difference for the age, gender, diabetes, hypertension and serum creatinine before transplantation, mean waiting time, source of donor kidneys, type of dialysis, different sides of donor kidney, anastomosis method of arteries, the occurrence of delayed graft function and acute rejection between TRAS group and control group (P all>0.05). Before interventional therapy, the mean serum creatinine, systolic blood pressure and PSV of TRAS group [(5.6±3.5) mg/dL, (144±9) mmHg (1 mmHg=0.133 kPa) and (3.4±1.6) m/s] were all higher than control group [(1.9±0.8) mg/dL, (130±19) mmHg and (1.3±0.5) m/s], the difference was statistically significant (t=3.94, 2.35 and 4.73, P all<0.05), and the mean eGFR and RI of TRAS group [(18±15) mL/min and 0.5±0.1] were all lower than control group [(49±20) mL/min and 0.6±0.1], the difference was statistically significant (t=-4.84, -3.88, P all<0.05). After interventional therapy, the mean serum creatinine, systolic/diastolic blood pressure and PSV of TRAS group [(3.2±1.5) mg/dL, (128±16) mmHg, (76±8) mmHg and (2.0±1.0) m/s] were all lower than pre-treatment, the difference was statistically significant (t=3.63, 4.40, 3.72 and 3.03, P all<0.05), while the mean serum creatinine was still higher than control group [(1.5±0.5) mg/mL], the difference was statistically significant (t=3.93, P<0.05); the mean eGFR and RI of TRAS group [(26±13) mL/min and 0.6±0.1] were all higher than pre-treatment, the difference was statistically significant (t=-4.65 and -3.25, P all<0.05), while the mean eGFR was still lower than control group [(58±17) mL/min], the difference was statistically significant (t=-5.75, P<0.05). ConclusionsScreening of color doppler flow imaging could yield a preliminary diagnosis of TRAS. The golden standard for diagnosis relied on graft artery radiography. Interventional therapy can effectively improve the renal function of recipients with TRAS.