伴急性肾损伤的DBD供肾肾移植的临床结局

王红宇; 王红; 沈松颖; 赵贺; 秦兴松; 秦威; 千新玲; 董慧君; 赵云峰; 王亚方; 李培亮

doi:10.3969/j.issn.1674-7445.2024027

伴急性肾损伤的DBD供肾肾移植的临床结局

doi: 10.3969/j.issn.1674-7445.2024027

1.
450003　郑州，河南中医药大学第五临床医学院
2.
河南中医药大学人民医院郑州人民医院器官移植中心

基金项目: 河南省高等学校重点科研项目（23A320025）

详细信息

作者简介:

通讯作者:
李培亮（ORCID 0009-0003-0509-6689），主任医师，研究方向为器官捐献政策研究，Email：156863001@qq.com

中图分类号: R617, R692
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出版历程
- 收稿日期: 2024-02-18
- 刊出日期: 2024-07-15

Clinical outcome of kidney transplantation from DBD donors complicated with acute kidney injury

1.
The Fifth Clinical Medical College of Henan University of Chinese Medicine, Zhengzhou 450003, China

More Information

Corresponding author: Li Peiliang, Email: 156863001@qq.com

摘要

摘要: 目的探讨伴急性肾损伤（AKI）的脑死亡器官捐献（DBD）供者供肾肾移植的临床结局。方法回顾性分析216例DBD供者的资料，按照改善全球肾脏病预后组织（KDIGO）标准将分为AKI组（69例）与正常组（147例），AKI组进一步分为KDIGO 1期和2~3期两组，AKI组受者135例，正常组受者288例。总结受者术后肾功能恢复情况及临床结局。分析移植物功能延迟恢复（DGF）发生的危险因素。结果 AKI组供者血清肌酐（Scr）最高值、获取前Scr值、血钠最高值、获取前血钠值均高于正常组，升压药物应用时间长于正常组，48 h内液体复苏用量高于正常组，入院HCO₃⁻值低于正常组，尿崩症、低血压发生率高于对照组；KDIGO 2~3期供者Scr最高值、获取前Scr值较KDIGO 1期供者高（均为P<0.05）。与正常组比较，AKI组受者DGF、急性排斥反应发生率较高，行连续性肾脏替代治疗的比例较高，术后90 d内Scr水平较高，术后3 d尿量较少；与KDIGO 1期受者比较，KDIGO 2~3期受者术后3、4、5、15 d Scr水平较高，术后2 d尿量较少（均为P<0.05）。单因素分析结果显示供者年龄、Scr最高值、血钠最高值、48 h内液体复苏用量是肾移植术后受者发生DGF的危险因素，多因素分析结果显示，供者年龄是肾移植术后受者发生DGF的独立危险因素（均为P<0.05）。结论伴AKI的DBD供者供肾用于肾移植，经过积极的器官维护可纠正AKI，对术后6个月移植物功能和存活率没有影响，可达到与非AKI供肾同样的效果，可作为扩大供肾来源。
- 急性肾损伤 /
- 脑死亡 /
- 器官捐献 /
- 肾移植 /
- 边缘供者 /
- 器官维护 /
- 移植物功能延迟恢复 /
- 原发性无功能
Abstract: Objective To evaluate the clinical outcome of kidney transplantation from donation after brain death (DBD) donors complicated with acute kidney injury (AKI). Methods Clinical data of 216 DBD donors were retrospectively analyzed, and they were divided into the AKI group (n=69) and control group (n=147) according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Donors in the AKI group were further divided into the KDIGO stage 1 and stage 2-3 subgroups. One hundred and thirty-five recipients were assigned into the AKI group and 288 recipients in the control group. Postoperative recovery of renal function and clinical outcomes of the recipients were recorded. The risk factors of delayed graft function (DGF) were identified. Results The highest serum creatinine (Scr) level, Scr level before procurement, the highest blood sodium level and blood sodium level before procurement in the AKI group were higher than those in the control group. The application duration of vasopressors in the AKI group was longer than that in the control group. In the AKI group, the amount of fluid resuscitation within 48 h was higher, the HCO₃⁻ level at admission was lower, and the incidence of diabetes insipidus and hypotension was higher than those in the control group. The highest Scr level and the Scr level before procurement in KDIGO stage 2-3 donors were significantly higher than those in KDIGO stage 1 counterparts (all P<0.05). Compared with the control group, the incidence of DGF and acute rejection was higher, the proportion of continuous renal replacement therapy was higher, the Scr level within postoperative 90 d was higher, and the urine amount within postoperative 3 d was less than those of recipients in the AKI group. Compared with KDIGO stage 1 recipients, KDIGO stage 2-3 recipients had higher Scr levels at postoperative 3, 4, 5 and 15 d, and less urine amount at postoperative 2 d (all P<0.05). Univariate analysis showed that donor age, the highest Scr level, the highest blood sodium level and the amount of fluid resuscitation within 48 h were the risk factors for DGF in recipients after kidney transplantation. Multivariate analysis showed that donor age was the independent risk factor for DGF in recipients after kidney transplantation (all P<0.05). Conclusions For the application of DBD donors complicated with AKI, active organ maintenance should be performed to alleviate AKI. It exerts no effect upon graft function and survival rate at postoperative 6 months, which may achieve equivalent efficacy as non-AKI donors and may be used as a source of extended criteria donor kidneys.
- Acute kidney injury /
- Brain death /
- Organ donation /
- Kidney transplantation /
- Marginal donor /
- Organ maintenance /
- Delayed graft function /
- Primary nonfunction

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FIG. 3260. FIG. 3260.

FIG. 3260.. FIG. 3260.

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图 1 两组受者术后Scr及尿量变化趋势图

注：A图为两组受者术后6个月Scr变化趋势；B图两组受者术后5 d尿量变化；C图为KDIGO 1期、2~3期受者术后6个月Scr变化趋势；D图为KDIGO 1期、2~3期受者术后5 d尿量变化。^aP<0.05。

Figure 1. Trends of postoperative Scr and urine volume changes of recipients in the two groups

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表 1 两组供者一般资料比较

Table 1. Comparison of general information of donors between two groups

指标	AKI组（n=69）	正常组（n=147）	统计值	P值	KDIGO 1期（n=43）	KDIGO 2~3期（n=26）	统计值	P值
性别男[n（%）]	63（91）	125（85）	1.636	0.201	39（91）	24（92）	0.053	1.000
年龄[M（P₂₅,P₇₅），岁]	46（42,54）	50（43,56）	1.501	0.133	45（41,45）	49（41,54）	−0.310	0.757
身高[M（P₂₅,P₇₅），cm]	172（170,176）	170（167,175）	−2.080	0.038	172（170,178）	172（170,176）	−0.638	0.523
体质量[M（P₂₅,P₇₅），kg]	75（68,80）	70（65,75）	−3.011	0.003	75（65,80）	75（70,80）	−0.559	0.576
BMI[M（P₂₅,P₇₅），kg/m²]	25（23,26）	24（22,26）	−2.222	0.085	25（22,26）	25（23,26）	−0.923	0.356
既往病史[n（%）]
高血压	28（41）	57（39）	0.064	0.800	20（47）	8（31）	1.665	0.197
糖尿病	6（9）	6（4）		0.205	3（7）	3（12）	0.425	0.665
心脏病	2（3）	1（1）		0.240	1（2）	1（4）	0.133	1.000
死亡原因[n（%）]			1.683	0.794			3.500	0.321
颅脑外伤	23（33）	54（37）			14（33）	9（35）
脑出血	37（54）	75（51）			23（53）	14（54）
脑梗塞	4（6）	9（6）			4（9）	0
缺血缺氧性脑病	5（7）	7（5）			2（5）	3（12）
其他	0	2（1）			0	0
发病至器官获取时间[M（P₂₅,P₇₅），d]	5（3,8）	5（3,7）	−0.766	0.444	5（3,8）	5（4,6）	−0.093	0.926
Scr最高值[M（P₂₅,P₇₅），µmol/L]	161（128,212）	67（53,82）	−11.358	<0.001	137（117,160）	243（192,299）	−6.496	<0.001
获取前Scr值[M（P₂₅,P₇₅），µmol/L]	98（73,107）	53（40,68）	−8.525	<0.001	91（68,102）	102（81,117）	−2.348	0.019
血钠最高值[M（P₂₅,P₇₅），mmol/L]	158（151,166）	145（140,151）	−7.296	<0.001	158（151,165）	159（150,168）	−0.217	0.828
获取前血钠值[M（P₂₅,P₇₅），mmol/L]	145（138,151）	139（135,145）	−3.556	<0.001	145（138,151）	143（138,150）	−0.192	0.848
升压药应用时间[M（P₂₅,P₇₅），d]	4.0（0,7.0）	0（0,3.0）	−4.737	<0.001	3.0（0,7.0）	4.0（0.8,7.0）	−0.848	0.397
48 h内液体复苏用量（$\overline x\pm s $，mL）	9 701±2 686	6 961±2 233	−7.869	<0.001	9 369±2 111	10 250±3 410	−1.328	0.189
入院时HCO₃^—（$\overline x\pm s $，mmol/L）	20±5	22±5	3.577	<0.001	20±4	19±6	−0.746	0.458
获取前HCO₃^—（$\overline x\pm s $，mmol/L）	22（18,25）	21（18,24）	−0.741	0.459	22（18,25）	21（17,26）	−0.292	0.770
尿崩症[n（%）]	38（55）	46（31）	11.173	<0.001	26（60）	12（46）	1.341	0.247
低血压[n（%）]	47（68）	53（36）	19.415	<0.001	27（63）	20（77）	1.490	0.222

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表 2 两组肾移植受者临床资料比较

Table 2. Comparison of clinical data of kidney transplant recipients between two groups

指标	AKI组（n=135）	正常组（n=288）	统计值	P值	KDIGO 1期（n=85）	KDIGO 2~3期（n=50）	统计值	P值
性别男[n（%）]	104（77.0）	223（77.4）	0.008	0.928	68（80）	36（72）	1.139	0.286
年龄[M（P₂₅,P₇₅），岁]	39（32,47）	40（32,47）	−0.562	0.574	39（33,47）	39（31,47）	−0.716	0.474
身高[M（P₂₅,P₇₅），cm]	170（165,174）	170（165,174）	−0.547	0.584	170（165,173）	170（162,175）	−0.628	0.530
体质量[M（P₂₅,P₇₅），kg]	62（56,72）	66（56,74）	−1.386	0.166	61（57,70）	68（55,73）	−0.654	0.513
BMI[M（P₂₅,P₇₅），kg/m²]	22（20,24）	22（20,25）	−1.034	0.301	22（20,24）	22（20,24）	−0.868	0.385
移植前Scr值（$\overline x\pm s $，µmol/L）	852±203	830±193	1.0756	0.283
移植前尿量（$\overline x\pm s $，mL/d）	239±95	247±91	−0.890	0.374
热缺血时间（$\overline x\pm s $，min）	2.8±0.9	2.8±1.1	−0.374	0.708
冷缺血时间（$\overline x\pm s $，h）	4.0±1.9	3.9±1.8	0.570	0.568
6个月移植肾存活[n（%）]	130（96.3）	279（96.9）	0.901	0.390	80（94）	50（100）	1.849	0.291
12个月时失功[n（%）]	14（10.4）	28（9.7）	0.055	0.814	10（12）	4（8）	0.577	0.448
DGF[n（%）]	55（40.7）	87（30.2）	4.471	0.034	30（35）	25（50）	2.820	0.093
急性排斥反应[n（%）]	16（11.9）	12（4.2）	8.783	0.003	8（9）	8（16）	1.308	0.253
感染[n（%）]	7（5.2）	6（2.1）		0.127	4（5）	3（6）		0.710
CRRT[n（%）]	29（21.5）	33（11.5）	7.382	0.007	15（18）	14（28）	2.001	0.157
PNF[n（%）]	4（3.0）	4（1.4）		0.274	4（5）	0		0.296
谵妄[n（%）]	8（5.9）	11（3.8）	0.921	0.337	5（6）	3（6）		1.000

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表 3 移植物功能延迟恢复的危险因素分析

Table 3. Analysis of risk factors of delayed graft function

项目	单因素分析			多因素分析
项目	比值比	95%可信区间	P值	比值比	95%可信区间	P值
供者年龄	1.035	1.016~1.054	<0.001	1.045	1.024~1.065	<0.001
供者BMI	1.000	0.942~1.062	0.999
供者Scr最高值	1.003	1.000~1.006	0.023	1.002	0.999~1.005	0.266
供者血钠最高值	1.023	1.006~1.041	0.010	1.027	1.004~1.050	0.018
供者升压药应用时间	0.986	0.916~1.061	0.707
供者48 h内液体复苏用量	1.089	1.009~1.175	0.028	1.035	0.945~1.135	0.459
供者入院HCO₃⁻	1.024	0.982~1.068	0.265
供者尿崩症	1.037	0.686~1.568	0.863
供者低血压	0.844	0.563~1.267	0.414

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