小儿重度肾积水穿刺造瘘术后肾功能可恢复性的临床研究

摘要

目的 探讨小儿重度肾积水穿刺造瘘术后肾功能可恢复性的临床意义.方法 回顾性分析2013年1月至2016年1月河北省儿童医院50例先天性肾盂输尿管连接处狭窄导致的重度肾积水患儿的临床资料.男25例,女25例.年龄2个月～9岁7个月,平均(3.0±0.3)岁.病变位于左侧40例,右侧10例.所有患儿一期均行经皮肾穿刺造瘘术,术后根据患肾功能恢复情况二期行肾盂成形术或肾切除术.收集穿刺造瘘术前和术后分肾功能、造瘘管尿渗透压、尿pH、尿β2-微球蛋白(β2-microglobulin,β2-MG)等指标,术后行放射性核素肾扫描评估肾功能恢复情况及超微血流成像(superb micro-vascular imaging,SMI)技术测定肾血管阻力指数,对比造瘘术前后的指标,从而分析小儿重度肾积水实施保肾手术的可行性.结果 本组50例患儿中49例一期肾造瘘术后患肾皮质厚度及生化指标有所恢复,行二期肾盂成形术;余1例患儿一期造瘘术后肾功能恢复不良,术后造瘘管尿量极少,考虑瘢痕萎缩肾,待行肾切除术.50例患儿术后肾皮质厚度较术前明显增厚[(5.9±1.0) mm与(2.9±0.9) mm,P=0.03],患肾分肾功能较术前明显提高[(25.7％±7.9％)与(13.5％±5.2％),P=0.007].SMI技术检测肾血管阻力指数术后较术前明显降低[(0.72±0.03)与(0.79±0.04),P=0.021],患儿术后尿渗透压较术前明显增加[(518.0±240.0)mmol/L与(126.5±100.5)mmol/L,P＜0.001].术后尿pH值和尿β2-MG[(6.18 ±0.21) mg/L和(562.16±49.78)mg/L]较术前均明显降低[(7.38 ±0.32) mg/L和(954.28 ±69.45) mg/L],差异均有统计学意义(P=0.039和P＜0.001).结论 小儿重度肾积水经姑息肾穿刺造瘘术肾功能可有不同程度恢复,术前评估肾功能极差的患肾多数是可以保留的;超声SMI技术可对肾功能评估提供可靠的量化依据.%Objective To analyze the recovery of the renal function in the severe hydronephrosis children after percutaneous nephrostomy.Methods 50 cases of uretero-pelvic junction obstruction (UPJO) children were retrospectively studied from January 2013 to January 2016.There were 25 boys and 25 girls,and the mean age was 3.0 years (ranged from 2 months to 9 years and 7 months).The children were taken the percutaneous nephrostomy in the first stage and pyeloplasty or nephrectomy in the second stage according to the recovery of renal function.Split renal function,urine osmotic pressure,urine pH and urine β2-microglobulin (β32-MG) were compared between pre-operation and post-operation.The recovery of the renal function after the operation were evaluated by the single photon emission computed tomography (SPECT) and superb micro-vascular imaging (SMI) to analysis the feasibility of the pyeloplasty surgery in the severe hydronephrosis children.Result The postoperative renal function of 49 patients in the group recovered after percutaneous nephrostomy,only one child showed unrecoverable.After the first stage management,the renal cortical thickness [(5.9 ± 1.0)mm vs.(2.9 ± 0.9) mm,P =0.03],the separate renal function mmo]/L vs.(126.5 ± 100.5) mmol/L,P ＜ 0.001] were significantly improved compared with preoperation,andRI [(0.72 ±0.03) vs.(0.79 ±0.04),P=0.021],urine pH [(6.18±0.21) vs.(7.38 ± 0.32),P =0.039] and urine β2-MG [(562.16 ± 49.78) mg/L vs.(954.28 ± 69.45) mg/L,P ＜0.001] significantly reduced.Conclusions The renal function of the severe hydronephrosis children could be recoverable after the surgery of the percutaneous nephrostomy and pyeloplasty.Most children's kidneys suffered the severe hydronephrosis could be spared by surgery.SMI technology could provide reliable quantitative basis to evaluate renal function.