Renner F C, Czekalinska B, Kemkes-Matthes B, Feustel A, Stertmann W A, Padberg W, Weimer R
Department of Internal Medicine, Nephrology and Renal Transplantation, University of Giessen, Germany.
Transplant Proc. 2010 Dec;42(10):4164-6. doi: 10.1016/j.transproceed.2010.09.056.
Since 2007, we have performed 14 AB0-incompatible (AB0i) living kidney transplantations to increase the number of living kidney transplantations.
To prevent clotting, donor kidneys were perfused with an HTK/heparin solution with heparin washed out immediately pretransplantation. However, in 4/14 recipients, significant postoperative diffuse hemorrhage occurred with the need for surgical intervention in 3 patients. To analyze the cause of postoperative diffuse bleeding, sequentially before and after opening the graft anastomosis, we prospectively performed coagulation studies: partial thromboplastin time (PTT), thrombin time, thromboplastin time, fibrinogen, antithrombin, D-dimers, plasminogen, and thrombelastography.
We found no clotting disturbances owing to blood group-specific immunoadsorption. However, 3/4 patients with bleeding complications showed elevated PTT values even 2 hours after opening the anastomosis, which was proven to be a heparin effect by in vitro application of heparinase. Hyperfibrinolysis and disturbances of platelet aggregation were not detected. Because of these results, we lowered the heparin dose administered after donor nephrectomy from initially 10,000-20,000 to 4000 IU resulting in significantly lower PTT values at 2 hours (34.6 ± 4.5 s among patients 6-14 vs 69.0 ± 16.3 s among patients 1-5; P = .012). There were no further bleeding complications. Lowering the heparin dosage had no impact on graft function: serum creatinine at discharge of 1.5 ± 0.1 versus 1.6 ± 0.2 mg/dL.
Our data indicated that postoperative hemorrhage after AB0i kidney transplantation was associated with the amount of heparin used for graft perfusion after donor nephrectomy. The use of antifibrinolytic agents may be harmful; no hyperfibrinolysis takes place in the AB0i transplant setting.
自2007年以来，我们已进行了14例ABO血型不相容（ABOi）活体肾移植，以增加活体肾移植的数量。
为防止凝血，供肾用HTK/肝素溶液灌注，在移植前立即冲洗掉肝素。然而，在14例受者中有4例出现了严重的术后弥漫性出血，其中3例需要手术干预。为分析术后弥漫性出血的原因，在打开移植吻合口前后，我们前瞻性地进行了凝血研究：部分凝血活酶时间（PTT）、凝血酶时间、凝血致活酶时间、纤维蛋白原、抗凝血酶、D-二聚体、纤溶酶原和血栓弹力图。
我们未发现血型特异性免疫吸附导致的凝血障碍。然而，3/4例有出血并发症患者在打开吻合口后2小时PTT值仍升高，通过体外应用肝素酶证明这是肝素作用。未检测到高纤维蛋白溶解和血小板聚集障碍。基于这些结果，我们将供肾切除术后给予的肝素剂量从最初的10000 - 20000单位降至4000单位，导致2小时时PTT值显著降低（6 - 14号患者为34.6±4.5秒，而1 - 5号患者为69.0±16.3秒；P = 0.012）。未再出现出血并发症。降低肝素剂量对移植肾功能无影响：出院时血清肌酐分别为1.5±0.1与1.6±0.2mg/dL。
我们的数据表明，ABOi肾移植术后出血与供肾切除术后用于灌注移植肾的肝素量有关。使用抗纤维蛋白溶解剂可能有害；在ABOi移植情况下未发生高纤维蛋白溶解。
