肾移植联合脾窝异位辅助性肝移植治疗高致敏尿毒症受者的初步体会

摘要

目的 研究肾移植联合脾窝异位辅助性肝移植治疗高致敏尿毒症受者的安全性和有效性.方法 2014年3月对1例群体反应性抗体阳性(Ⅰ类31％,Ⅱ类63％)的高致敏二次肾移植受者实施来源于同一供者的肾移植联合脾窝异位辅助性肝移植术进行治疗.在肾移植术前,将源于同一供者的部分肝脏植入受者脾窝.观测移植后是否发生超急性排斥反应,监测移植肾功能并检测术前、移植肝恢复灌注后、术后各个时间点受者体内抗体水平.结果 手术历时505 min,出血700 ml.术后未发生超急性排斥反应,移植肝血流开放后3h所有预存人类白细胞抗原抗体水平转为阴性.术后第6天血肌酐降至141 μmol/L,同时群体反应性抗体升至80％,术后第7天发生临床急性排斥反应,经过连续血浆置换、抗人胸腺细胞免疫球蛋白、静脉用免疫球蛋白等综合治疗,急性排斥反应得以逆转.随访12个月,血肌酐为131 μmol/L.结论 利用来自同一供者肝脏的保护作用,肾移植联合脾窝异位辅助性肝移植可以有效解决尿毒症患者在高致敏状态下不能进行肾移植的问题.%Objective To report the clinical effectiveness and safety of combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation for highly sensitized recipients with uremia.Methods In March 2014,combined kidney transplantation and splenic fossa auxiliary heterotopic liver transplantation from the same donor was performed in a highly sensitized recipient with positive panel reactive antibodies (PRA) (31％ class Ⅰ,63％ class Ⅱ).Compendious technical scheme:the partial liver from the same donor was transplanted in splenic recess of the recipient before the renal transplantation operation.Hyperacute rejection and the function of kidney after the transplantation were observed.Serum samples were also collected before and after reperfusion of the liver and each time points after the transplant surgery to detect the antibody level.Results The operation took 8 hours and 25 minutes with bleeding of 700 ml.The renal transplant functioned well without hyperacute rejection after transplantation.All the human leukocyte antigen antibodies turned to negative at 3 hour post-transplantation.The concentration of serum creatinine was 141 μmol/L and the level of PRA was 80％ at 6 day post-transplantation.At 7 day post-transplantation,the creatinine level increased and acute rejection of transplant kidney occurred,which was controlled by plasmapheresis,anti-thymocyte globulin and intravenous immunoglobulin.The recipient was followed up for 12 months,serum creatinine value was 131 μmol/L.Conclusions A simultaneous transplantation of a partial auxiliary liver graft from the same donor in splenic fossa,with the sole purpose of protecting the kidney from harmful lymphocytotoxic antibodies,may solve the problem of kidney transplantation in highly sensitized recipients.