本文選題：腎移植　切入點(diǎn)：心臟死亡供體　出處：《浙江大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:結(jié)合心臟死亡供體(Donor after cardiac death,DCD)腎移植受體術(shù)后隨訪情況探尋腎移植合理的熱缺血評(píng)估方式。方法:回顧性分析本院腎臟病中心自2011年5月至2015年6月獲取的194例DCD供體,共367例接收腎移植手術(shù)的受體。根據(jù)受體術(shù)后是否發(fā)生DGF分為DGF組和非DGF組;術(shù)后1月及術(shù)后1年的隨訪中eGFR水平是否大于等于60 ml/min/1.73m2分為高腎功能組及低腎功能組,比較不同分組其供體基本情況及血氧、收縮壓變化情況。Logistic回歸分析DGF發(fā)生影響因素,多因素分析影響DCD受體術(shù)后1年eGFR影響因素。結(jié)果:DGF組供體捐獻(xiàn)時(shí)肌酐高于非DGF組(129.04±84.07 vs 92.22±73.70μmol/Lmp=0.002),DGF 組供體捐獻(xiàn)時(shí) eGFR 顯著低于非 DGF 組(80.58±41.40 vs 107.87±43.80 ml/min/1.73m2,p0.001)。DGF 組受體體表面積顯著大于非DGF組(1.74±0.18 vs 1.70±0.17 m2m,p0.042)。DGF組供受體體表面積比值顯著低于非DGF組(1.03±0.17 vs 0.98±0.21,p=0.033)。根據(jù)撤除呼吸后不同時(shí)間點(diǎn)供體收縮壓以及血氧進(jìn)行的熱缺血評(píng)估均未發(fā)現(xiàn)DGF組及非DGF組間存在顯著性差異。進(jìn)行Logistic回歸分析發(fā)現(xiàn):供體捐獻(xiàn)時(shí)eGFR、供受體BSA比值是DCD腎移植受體術(shù)后DGF的獨(dú)立預(yù)測(cè)因子。術(shù)后1月高腎功能組的捐獻(xiàn)時(shí)平均eGFR、平均供受體體表面積比值均顯著高于低腎功能組(捐獻(xiàn)時(shí) eGFR:112.43±42.59 vs 88.71±43.74 ml/min/1.73m2,p0.001、供受體體表面積比值:1.04±0.17vs1.00±0.19.p=0.011)。高腎功能組的平均供體年齡、平均受體年齡、捐獻(xiàn)時(shí)平均肌酐、受體平均BMI、受體平均體表面積、平均小球病理評(píng)分、術(shù)后DGF發(fā)生率均顯著低于低腎功能組(供體年齡:33.50±13.54vs38.28±15.20 歲,p=0.002、受體年齡:39.87±10.97vs 42.46±11.31 歲,p=0.031、捐獻(xiàn)時(shí)肌酐:89.55±80.66 vs 112.58±68.55μmol/L,p=0.005、受體 BMI:20.63±2.72vs21.79±3.54kg/m2,p=0.001、受體體表面積：·1.68±0.17 vs 1.73±0.18 m2,p=0.005、小球病理評(píng)分:0.30±0.59 vs 0.48±0.71,p=0.032、DGF 發(fā)生率:11/211(5.21%)vs 50/91(54.95%),p0.001)。高腎功能組供體撤除生命支持裝置至血氧測(cè)不出的時(shí)間顯著長于低腎功能組(7.99±5.29 vs 6.66±4.35min,p=0.016),高腎功能組初始血氧下降至90%、80%、70%、60%的平均時(shí)間顯著長于低腎功能組。在速率比較中也發(fā)現(xiàn),高腎功能高腎功能組撤除生命支持裝置后,初始血氧下降至90%、,70%、60%的平均下降速率,顯著低于低腎功能組。但高腎功能組供體血氧飽和度低于70%至灌注開始的時(shí)間顯著短于低腎功能組(15.33±4.39 vs 17.08±6.24 min,p=0.026)。在遠(yuǎn)期預(yù)后中:術(shù)后一年隨訪情況,高腎功能組供體捐獻(xiàn)時(shí)平均eGFR、供體男性百分比顯著高于低腎功能組(供體捐獻(xiàn)時(shí)eGFR:110.02±45.20 vs 86.73±38.28 ml/min/1.73m2,p0.001、供體男性百分比:86.49%vs 74.07%,p=0.009)。高腎功能組供受體平均年齡、供體平均BMI、供腎小球病理及小管病理評(píng)分顯著低于低腎功能組(供體年齡:32.62±13.80vs43.53±12.34歲,p0.001、受體年齡:40.00±10.98 vs 43.88±10.74 歲,p=0.006、供體 BMI:21.77±2.83 vs 22.49±2.52kg/m2,P=0.04、供腎小球病理評(píng)分:0.30±0.59vs0.48±0.71,p=0.011、供腎小管病理評(píng)分:0.37±0.64vs0.43±0.52,p=0.006)。高腎功能組供體從撤除生命支持裝置至血氧測(cè)不出的時(shí)間顯著長于低腎功能組(8.00±5.19 vs 6.10±4.35 min,p=0.006)。高腎功能組供體分別從血氧90%、80%、70%、60%下降至血氧飽和度測(cè)不出的時(shí)間均顯著長于低腎功能組,且高腎功能組血氧從撤除生命支持裝置至血氧無法測(cè)及這段時(shí)間的平均血氧下降速率顯著慢于低腎功能組(19.60±17.49vs25.80±22.85%/min,p=0.038)。將DCD 腎移植預(yù)后影響因素單因素分析后,篩選納入p值小于等于0.05且剔除篩選存在共線性的因素后,進(jìn)行多元線性回歸分析發(fā)現(xiàn):供體年齡、受體年齡、受體BSA與受體術(shù)后1年時(shí)eGFR呈負(fù)相關(guān),供體男性、血氧存續(xù)時(shí)間(定義為從撤除生命支持裝置至血氧飽和度無法測(cè)及)與受體術(shù)后1年時(shí)eGFR呈正相關(guān)。結(jié)論:DCD腎移植預(yù)后受供受體年齡、供體性別及供體基礎(chǔ)腎功能等影響,供腎零點(diǎn)腎穿結(jié)果對(duì)于中遠(yuǎn)期預(yù)后具有一定的提示作用。在供腎熱缺血評(píng)估中,將熱缺血評(píng)估分為兩個(gè)時(shí)期更為精準(zhǔn),即高血氧時(shí)期(撤除生命支持裝置-血氧飽和度70%)以及低血氧時(shí)期(血氧飽和度低于70%-灌注)兩階段,高血氧時(shí)期一定范圍內(nèi)較長的血氧下降時(shí)間以及較慢血氧下降速度對(duì)于供腎預(yù)后也許具有保護(hù)作用,低血氧時(shí)期過長可能導(dǎo)致器官損傷,定義為供體血氧低于70%-灌注開始的熱缺血時(shí)間,可更有效評(píng)估術(shù)后1月腎功能預(yù)后,并且應(yīng)在考慮預(yù)后時(shí)將供體的一般情況考慮在內(nèi)�？紤]到目前嚴(yán)峻的器官短缺形式,在保證術(shù)后患者生存質(zhì)量的同時(shí),探究各影響因素的安全臨界值,盡量擴(kuò)大供體范圍,將是未來發(fā)展腎臟移植的關(guān)鍵。
[Abstract]:Objective: combined with cardiac death donor (Donor after cardiac death, DCD) in renal transplantation recipient follow-up to explore reasonable assessment of renal transplantation ischemia. Methods: a retrospective analysis of 194 cases of DCD kidney disease center of our hospital from May 2011 to June 2015 for the donor, a total of 367 patients receiving renal transplantation according to the receptor receptor. After the occurrence of DGF was divided into DGF group and non DGF group; eGFR level after 1 years in January and postoperative follow-up is greater than or equal to 60 ml/min/1.73m2 divided into high and low group renal renal function group, compare group the basic situation and the oxygen donor, systolic blood pressure changes.Logistic DGF regression analysis of influence multi factor analysis of influence factors, DCD factors affecting eGFR recipients after 1 years. Results: DGF group of donor creatinine was higher than that of DGF group (129.04 + 84.07 vs 92.22 + 73.70 mol/Lmp=0.002), group DGF donors donated eGFR Was significantly lower than that in non DGF group (80.58 + 41.40 vs 107.87 + 43.80 ml/min/1.73m2, p0.001).DGF receptor surface area was significantly higher than that of non DGF group (1.74 + 0.18 vs 1.70 + 0.17 M2M, p0.042).DGF group and donor body surface area was significantly lower than that in non DGF group (1.03 + 0.98 + 0.17 vs 0.21, p= 0.033). According to the assessment of respiratory heat ischemia at different time points after removal of donor blood pressure and the blood oxygen were not found significant difference between DGF group and non DGF group. Logistic regression analysis found that donor eGFR, donor BSA ratio is an independent predictor of DGF DCD in renal transplant recipients after kidney donation high. In January the group after operation, the average eGFR, the average for the receptor surface area ratio were significantly higher than low renal function group (eGFR:112.43 + 42.59 vs donated 88.71 + 43.74 ml/min/1.73m2, p0.001, and surface area ratio: receptor 1.04 + 0.17vs1.00 + 0.19.p=0.01 1). The average age of high donor renal function group, the average donation recipient age, average creatinine, average BMI receptor, receptor average surface area, average glomerular pathology score, the incidence of postoperative DGF was significantly lower than the low renal function group (donor age: 33.50 + 13.54vs38.28 + 15.20, p=0.002 receptor, age: 39.87 42.46 + 10.97vs + 11.31, p=0.031: 89.55, donation creatinine + 80.66 vs 112.58 + 68.55 mol/L, p=0.005, BMI:20.63 + 2.72vs21.79 + 3.54kg/m2 receptor, p=0.001 receptor, surface area: 1.68 + 0.17 vs 1.73 + 0.18 m2, p=0.005, ball pathological score: 0.30 + 0.59 vs 0.48 + 0.71, p=0.032. The incidence rate of DGF: 11/211 (5.21%) vs (54.95%) 50/91, p0.001). The high donor renal function group of withdrawal of life support device to be measured oxygen time significantly longer than the low renal function group (7.99 + 5.29 vs 6.66 + 4.35min, p=0.016), high oxygen group of initial renal function decreased to 90 %, 80%, 70%, 60% of the average time was significantly longer than the low group. Renal function was found in high rate comparison, renal function and renal function were high after withdrawal of life support device, the initial oxygen decreased to 90%, 70%, average decline rate of 60%, significantly lower than that of the low renal function but high renal function group group. The donor oxygen saturation below 70% to the start of perfusion time was significantly shorter than the low renal function group (15.33 + 4.39 vs 17.08 + 6.24 min, p=0.026). In the long term prognosis in follow-up one year after the operation, the high renal donor group average eGFR, male was significantly higher than the low percentage of donor renal function group (donor when eGFR:110.02 + 45.20 vs 86.73 + 38.28 ml/min/1.73m2, p0.001, the donor male percentage: 86.49%vs 74.07%, p=0.009). The average age of donor renal function group, the average BMI for donor, glomerular pathology and pathological scores were significantly lower than the renal tubular function group (donor age: 32 .62 + 13.80vs43.53 + 12.34, p0.001 receptor, age: 40 + 10.98 vs 43.88 + 10.74, p=0.006 + 2.83 vs donor BMI:21.77 22.49 + 2.52kg/m2, P=0.04, and glomerular pathology score: 0.30 + 0.59vs0.48 + 0.71, p=0.011, and renal tubule pathological score: 0.37 + 0.64vs0.43 + 0.52, p=0.006). The high kidney the function of the donor group from the withdrawal of life support device to be measured oxygen time significantly longer than the low renal function group (8 + 5.19 vs 6.10 + 4.35 min, p=0.006). The high donor renal function group respectively from 80%, 70%, 90% oxygen, oxygen saturation decreased from 60% to undetectable time were significantly longer than that of low kidney functional group, renal function and high oxygen group from the withdrawal of life support device to measure the average oxygen to oxygen and this time the decline rate was significantly slower than low renal function group (19.60 + 17.49vs25.80 + 22.85%/min, p=0.038). The factors affecting the prognosis of DCD after renal transplantation single factor analysis Screening, included in the p value is less than or equal to 0.05 and eliminate the multicollinearity screening factors, multivariate linear regression analysis showed that age of donor, recipient age, receptors BSA and eGFR after 1 year was negatively correlated with male donor, oxygen duration (defined as withdrawal of life support from the device to the oxygen saturation can not be measured and after 1 years) and the receptor of eGFR was positively correlated. Conclusion: the prognosis of DCD in renal transplant donor recipient age, donor sex and donor renal function based on donor renal biopsy zero results have some tips for long-term prognosis for renal ischemia. In the evaluation, the evaluation of warm ischemia the two period is more accurate, high oxygen period (withdrawal of life support device - oxygen saturation and low oxygen (70%) during the period of oxygen saturation below 70%- perfusion) two stage, a long period of high oxygen oxygen within a certain range of fall time And the slower rate of decline of oxygen may have protective effect on renal prognosis, low oxygen period is too long can lead to organ damage, defined as the donor oxygen less than 70%- perfusion to warm ischemia time, can be more effective in January to assess the progression of renal function after operation, consider the general situation and should be considered when the donor in the pre, taking into account. At present, the severe shortage of organs, while ensuring the quality of life of patients after operation, to explore the influencing factors of the safety critical value, to expand the scope of the donor, will be key to the future development of kidney transplantation.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R699.2

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本文編號(hào)：1644838