Lorenzo Armando J, Taylor Katherine, Farhat Walid A, Gnech Michele, Rickard Mandy, Koyle Martin A
Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Ontario, Canada.
Department of Anesthesia, Hospital for Sick Children and University of Toronto, Ontario, Canada.
Pediatr Transplant. 2019 Jun;23(4):e13398. doi: 10.1111/petr.13398. Epub 2019 Mar 27.
RT remains the best available strategy for addressing stage 5 chronic kidney disease in children and adolescents. Technical aspects of the procedure can have a clear impact on complications and health of the allograft, including DGF. Immediate optimal perfusion is paramount, thus choosing a target vessel has to take into account the flow demands imposed by an adult-size kidney in a proportionally smaller recipient. Herein, we explore the hypothesis that vascular anastomosis location can impact DGF adjusting for patient age and body size.
Retrospective review of a single institution referral center transplant database, including information on 156 patients. We collected data on patient characteristics (age, height, BSA, gender, preoperative need for dialysis), donor source (deceased vs living), WIT/CIT, hemodynamics during the procedure, use of inotropes or diuretics, and location of the arterial and venous anastomoses. The primary outcome, DGF, was assessed by measuring the ttNC (in days), adjusting for age and BSA.
Location of the arterial anastomosis was clearly impacted by age and donor size (Figure 1A). On univariate analyses, longer ttNC was associated with deceased vs living donor (11.8 ± 11.5 and 4.3 ± 5.0; P < 0.001), preoperative need for dialysis (9.7 ± 11.0 and 6.5 ± 6.0, P = 0.02), location of arterial anastomosis (aorta [n = 21] 4.9 ± 6.1, common iliac [n = 93] 7.1 ± 7.3, external iliac 14.7 ± 14.5; P < 0.001, Figure 1B) and venous anastomosis (vena cava [n = 21] 5.6 ± 6.3, common iliac [n = 89] 7.1 ± 7.6, external iliac [n = 44] 13.8 ± 14); P < 0.001). On multivariable analysis, this association remained statistically significant when adjusting for recipient age, height, BSA, donor source, change in blood pressure with unclamping, and use of inotropes and preoperative dialysis. The detrimental effect on ttNC was more salient when comparing external iliac vs common iliac and aorta or vena cava.
Our data suggest that anastomosis to a smaller caliber target vessel (ie, external iliac) in comparison with the common iliac or aorta/vena cava may be a risk factor for delayed return of graft function, independent of recipient size and donor source. This finding merit further evaluation, as it may help with intraoperative decision making during pediatric and adolescent RT.
肾移植（RT）仍然是治疗儿童和青少年5期慢性肾病的最佳可用策略。该手术的技术方面会对并发症和移植肾的健康产生明显影响，包括移植肾功能延迟恢复（DGF）。立即进行最佳灌注至关重要，因此选择目标血管时必须考虑到成人体积肾脏对比例相对较小的受者所施加的血流需求。在此，我们探讨血管吻合位置会影响DGF这一假设，同时对患者年龄和体型进行调整。
对单一机构转诊中心的移植数据库进行回顾性分析，纳入156例患者的信息。我们收集了患者特征（年龄、身高、体表面积、性别、术前透析需求）、供体来源（脑死亡供体与活体供体）、冷缺血时间/热缺血时间、手术过程中的血流动力学、血管活性药物或利尿剂的使用以及动静脉吻合位置的数据。通过测量ttNC（以天为单位）评估主要结局DGF，并对年龄和体表面积进行调整。
动脉吻合位置明显受到年龄和供体大小的影响（图1A）。单因素分析显示，ttNC较长与脑死亡供体与活体供体相关（分别为11.8±11.5和4.3±5.0；P<0.001）、术前透析需求（分别为9.7±11.0和6.5±6.0，P=0.02）、动脉吻合位置（主动脉[n=21]4.9±6.1，髂总动脉[n=93]7.1±7.3，髂外动脉14.7±14.5；P<0.001，图1B）以及静脉吻合位置（腔静脉[n=21]5.6±6.3，髂总静脉[n=89]7.1±7.6，髂外静脉[n=44]13.8±14；P<0.001）有关。多因素分析显示，在对受者年龄、身高、体表面积、供体来源、开放血管夹时血压变化、血管活性药物使用和术前透析进行调整后，这种关联仍具有统计学意义。比较髂外动脉与髂总动脉以及主动脉或腔静脉时，对ttNC的有害影响更为显著。
我们的数据表明，与髂总动脉或主动脉/腔静脉相比，吻合至较小口径的目标血管（即髂外动脉）可能是移植肾功能延迟恢复的危险因素，与受者体型和供体来源无关。这一发现值得进一步评估，因为它可能有助于小儿和青少年肾移植手术中的术中决策。
