患病供者肾移植功能延迟的危险因素

A. Shabunin, P. Drozdov, I. Nesterenko, D. A. Makeev, O. S. Zhuravel, S. А. Astapovich
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Recipient risk factors include age, gender, body mass index, presence/absence and amount of urine, presence of preformed anti-HLA antibodies and/or repeated kidney transplantation, number of mismatches for six HLA antigens, number of mismatches for HLA-DR, presence and type of renal replacement therapy, etiology of end stage kidney disease. Among the perioperative risk factors are the duration of cold preservation, the time of second warm ischemia, the volume of intraoperative blood loss, the intraoperatively determined renal arterial resistive index of the renal graft, and the maximum concentration of tacrolimus in the first 4 days after kidney transplantation. After that the relationship between the presence of delayed kidney graft function and the development of early postoperative complications was assessed and its effect on the long-term survival of grafts and recipients was analyzed.Results. Out of 237 cases, 9 showed no function of the transplanted kidney, and therefore the grafts were removed. The incidence of delayed renal graft function was 24.5% (58/237). According to the results of a univariate analysis, a statistically significant relationship with the development of delayed kidney graft function had donor body mass index (p=0.019), male gender of the recipient (p=0.048), recipient body mass index (p=0.038), amount of urine (p=0.003), anuria (p=0.002), presence of preformed antibodies (p=0.025), repeated transplantation (p=0.002), time of second warm ischemia (p=0.036), intraoperative renal arterial resistive index (p=0.004) and maximum tacrolimus concentration in the first 4 days (p=0.022). In the multivariate model, donor body mass index >30 kg/m2 and peak tacrolimus concentration >23 ng/mL in the first 4 days were statistically significant (p=0.018 and p=0.025, respectively). A trend towards statistical significance was noted in the presence of oligoanuria before kidney transplantation (p=0.066) and resistance index >0.75 after surgery (p=0.056). One-year renal transplant survival in the absence and presence of delayed kidney graft function was 92.4% and 87.7%, two-year survival was 89.4% and 76.1%, respectively. The effect of delayed kidney graft function on graft survival was statistically significant (p=0.01), while overall recipient survival did not differ between the groups.Conclusion. During the univariate analysis, we identified 9 statistically significant factors, of which at least 3 are potentially modifiable. In the multivariate model, the most significant modifiable risk factor was an increased concentration of tacrolimus, which prompted the authors to reconsider the existing immunosuppressive protocol at the City Clinical Hospital n.a. S.P. Botkin. 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引用次数: 4

摘要

的目标。确定移植肾功能迟发的有统计学意义的危险因素。评估移植肾功能延迟对其他并发症的发生、移植物和受体生存的影响。材料和方法。在237例连续肾移植受者(2018年6月至2021年12月)中,我们评估了其术后早期的功能。延迟功能被认为是术后第一周需要血液透析。在供者因素中,评估供者类型、年龄、体重指数、有无血管加压素支持、供者在重症监护的时间、随访期间肌酐的最高水平。受者的危险因素包括年龄、性别、体重指数、存在/不存在和尿量、预先形成的抗HLA抗体的存在和/或重复肾移植、6种HLA抗原错配的数量、HLA- dr错配的数量、肾脏替代治疗的存在和类型、终末期肾病的病因。围手术期的危险因素包括冷保存时间、第二次热缺血时间、术中出血量、术中测定的移植肾肾动脉阻力指数、肾移植后前4天他克莫司的最大浓度。评估移植肾功能迟滞与术后早期并发症发生的关系,并分析其对移植物和受者长期生存的影响。237例中,9例显示移植肾无功能,因此移植物被切除。移植肾功能延迟发生率为24.5%(58/237)。单因素分析结果显示:供体体重指数(p=0.019)、供体性别(p=0.048)、供体体重指数(p=0.038)、尿量(p=0.003)、无尿(p=0.002)、预形成抗体(p=0.025)、重复移植(p=0.002)、第二次热缺血时间(p=0.036)、术中肾动脉阻力指数(p=0.004)及前4 d他克莫司最大浓度(p=0.022)。在多变量模型中,供体体重指数>30 kg/m2和他克莫司浓度>23 ng/mL在前4天的差异均有统计学意义(p=0.018和p=0.025)。肾移植前少尿(p=0.066)和术后阻力指数>.75 (p=0.056)有统计学意义。无肾移植功能延迟和存在肾移植功能延迟的1年生存率分别为92.4%和87.7%,2年生存率分别为89.4%和76.1%。移植肾功能延迟对移植肾存活的影响有统计学意义(p=0.01),而两组间移植肾总存活无统计学差异。在单变量分析中,我们确定了9个具有统计学意义的因素,其中至少3个是可以改变的。在多变量模型中,最重要的可改变的危险因素是他克莫司浓度的增加,这促使作者重新考虑在城市临床医院n.a.s.p.b otkin现有的免疫抑制方案。我们认为寻找可改变的具有统计学意义的患者危险因素,对其进行分析并实施预防措施是每个肾移植中心的重要任务。
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Risk factors for delayed kidney graft function from a deseased donor
Aim. To determine statistically significant risk factors for delayed renal graft function. To assess the impact of delayed kidney graft function on the development of other complications, graft and recipient survival.Material and methods. In 237 consecutive kidney transplant recipients (from June 2018 to December 2021), we assessed its function in the early postoperative period. Delayed function was considered to be the need for hemodialysis in the first week after surgery. Among the donor factors, the type of donor, age, body mass index, the presence of vasopressor support, the time the donor was in intensive care, and the maximum level of creatinine during the follow-up were evaluated. Recipient risk factors include age, gender, body mass index, presence/absence and amount of urine, presence of preformed anti-HLA antibodies and/or repeated kidney transplantation, number of mismatches for six HLA antigens, number of mismatches for HLA-DR, presence and type of renal replacement therapy, etiology of end stage kidney disease. Among the perioperative risk factors are the duration of cold preservation, the time of second warm ischemia, the volume of intraoperative blood loss, the intraoperatively determined renal arterial resistive index of the renal graft, and the maximum concentration of tacrolimus in the first 4 days after kidney transplantation. After that the relationship between the presence of delayed kidney graft function and the development of early postoperative complications was assessed and its effect on the long-term survival of grafts and recipients was analyzed.Results. Out of 237 cases, 9 showed no function of the transplanted kidney, and therefore the grafts were removed. The incidence of delayed renal graft function was 24.5% (58/237). According to the results of a univariate analysis, a statistically significant relationship with the development of delayed kidney graft function had donor body mass index (p=0.019), male gender of the recipient (p=0.048), recipient body mass index (p=0.038), amount of urine (p=0.003), anuria (p=0.002), presence of preformed antibodies (p=0.025), repeated transplantation (p=0.002), time of second warm ischemia (p=0.036), intraoperative renal arterial resistive index (p=0.004) and maximum tacrolimus concentration in the first 4 days (p=0.022). In the multivariate model, donor body mass index >30 kg/m2 and peak tacrolimus concentration >23 ng/mL in the first 4 days were statistically significant (p=0.018 and p=0.025, respectively). A trend towards statistical significance was noted in the presence of oligoanuria before kidney transplantation (p=0.066) and resistance index >0.75 after surgery (p=0.056). One-year renal transplant survival in the absence and presence of delayed kidney graft function was 92.4% and 87.7%, two-year survival was 89.4% and 76.1%, respectively. The effect of delayed kidney graft function on graft survival was statistically significant (p=0.01), while overall recipient survival did not differ between the groups.Conclusion. During the univariate analysis, we identified 9 statistically significant factors, of which at least 3 are potentially modifiable. In the multivariate model, the most significant modifiable risk factor was an increased concentration of tacrolimus, which prompted the authors to reconsider the existing immunosuppressive protocol at the City Clinical Hospital n.a. S.P. Botkin. We consider the search for modifiable statistically significant risk factors for patients, their analysis and implementation of preventive measures to be an important task for each kidney transplant center.
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