儿童肾移植的临床研究

目的 总结儿童肾移植的临床经验.方法 回顾性分析1980年6月至2008年12月41例儿童肾移植的临床资料,其中1980-1993年(G1)有8例患儿,均未进行免疫诱导,术后采用以环孢素A+硫唑嘌呤+泼尼松为基础的免疫抑制方案;1994-2001年(G2)有18例患儿,均应用抗淋巴细胞球蛋白免疫诱导,术后采用他克莫司(或环孢素A)+吗替麦考酚酯(或硫唑嘌呤)+泼尼松的方案;2002年后(G3)有15例患儿,均应用抗白细胞介素-2受体单克隆抗体(IL-2RA)免疫诱导,术后采用他克莫司(或环孢素A)+吗替麦考酚酯+小剂量泼尼松(或无泼尼松)的方案.分别对三个阶段患儿术后急性排斥反应(AR)和移植肾功能恢复延迟(DGF)等并发症发生率、存活率及生长发育情况等进行比较.结果 41例患儿术后1、3、5年人/肾存活率分别为97.6%/90.2%、95.1%/82.9%和90.2%/75.6%,其中G1为87.5%/75.0%、75.0%/50.0 %和75.0%/50.0%、G2为100.0%/94.4 %、100.0%/83.3%和94.4%/72.2%以及G3为100.0%/100.0%、100.0%/100.0%和100.0%/93.3%,G3明显高于G1(P<0.05),但与G2无明显差异.41例中共有13例发生AR,发生率为31.7%,其中G3的AR发生率分别为13.3%,明显低于G1和G2的50.0%和38.9%(P<0.01).G1、G2和G3患儿的身高分别增长了(2.9±0.6)、(3.2±0.6)和(3.8±0.9)cm,G3患儿身高的增长幅度最为明显(P<0.05).G1、G2和G3患儿间DGF发生率无明显差异,高血压和感染是最为多见的并发症.结论 良好的组织配型、适宜的手术方法、恰当的免疫抑制剂血药浓度及AR早期诊断是保证儿童肾移植成功的关键.IL-2RA免疫诱导能够有效地降低AR发生率,而小剂量激素或无激素方案最大程度的改善了影响患儿骨骼发育的限制因素,促进患儿生长.

Clinical research on pediatric renal transplantation

Objective To summarize the experiences in pediatric renal transplantation. Methods Clinical data of the pediatric transplantation were analyzed retrospectively. A total of 41 pediatric recipients were divided into three groups according to immunosuppressive (IS) protocols employed as following: group Ⅰ .without induction, CsA, Aza (or not) and Pred as maintenance therapy (G1: CsA ± Aza + Pred, n = 8); group Ⅱ , with ATG induction, CsA or Tac and MMF or Aza and Pred as maintenance therapy (G2: ATG,CsA/TAC+ MMF/Aza + Pred,n = 18); group Ⅲ, with IL-2 receptor antibody induction,CsA or Tac and MMF and Pred (5 mg/d) or steroid avoidance as maintenance therapy (G3: IL-2RA, CsA/TAC + MMF ± Pred 5 mg/d, n= 18). Incidences of acute rejection (AR),delayed graft function (DGF) and complications, patient/graft survival and catch-up growth increase were analyzed and compared respectively among three groups. Results The patient/ graft survival rate at 1,3 and 5 year for all 41 patients was 97. 6 %/90. 2 %,95. 1 %/82. 9 % and 90. 2 %/75. 6 % respectively. The patient/graft survival rate in G3 at 1,3 and 5 year was 100. 0 %/ 100.0 %, 100.0 %/100.0 % and 100.0 %/93. 3 % respectively, which was higher than that in G1 (87.5 %/75.0 %, 75.0 %/50.0 % and 75.0 %/50.0 %,P<0.05), but similar to that in G2 (100. 0 %/94. 4 %,100. 0 %/83. 3 % and 94. 4 %/72. 2 %,P>0. 05). Thirteen (31. 7 %) patients experienced AR episode. The incidence of AR is G3 was 13.3 %, which was lower than both G1 (50. 0 %,P<0. 01) and G2 (38. 9 % ,P<0. 01). The patients in G3 got the most significant increase for skeletal growth after transplantatioa There was no significant difference in DGF rate among groups. Hypertension and infection were the most common complications for pediatric recipients. Conclusion Excellent HLA matches, precise surgical techniques, prompt diagnosis and control of AR and proper IS level are keys to improve long-term outcome for pediatric renal transplantation. Steroid minimization or avoidance strategies is possible under the umbrella of a powerful IL-2RA induction and maintenance IS, which benefits catch-up growth potential in children.