Lee Eliza, Ramos-Gonzalez Gabriel, Staffa Steven J, Rodig Nancy, Vakili Khashayar, Kim Heung Bae
Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
Department of Surgery, Pediatric Transplant Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Pediatr Transplant. 2019 Nov;23(7):e13553. doi: 10.1111/petr.13553. Epub 2019 Jul 22.
Kidney transplantation remains the treatment of choice for children with ESRD. Optimal perioperative management is critical in small recipients of ASK to assure adequate graft perfusion. We present a single-center experience outlining management for patients weighing <20 kg who underwent primary renal transplantation with ASKs between 2007 and 2016. Sixty-three patients met study criteria and underwent 34 living-related, six living-unrelated, and 23 deceased donor kidney transplants. Median age and weight at transplant were 25 months (IQR 18-37 months; range 11 months-6 years) and 11.0 kg (IQR 9.2-14.5 kg; range 7.1-19.5 kg). Eighty-nine percent of patients required vasoactive agents intra-operatively, with twenty patients requiring prolonged vasoactive agents post-operatively. Intra-operatively, patients received 51.9 mL/kg of crystalloid, 27.3 mL/kg of 5% albumin, and 13.6 mL/kg of packed red blood cells. Most (93.7%) patients were extubated on POD#0. Weights peaked on post-operative days three through five. Over a median follow-up of 49 months (IQR 31-86 months; range 0-130 months), four grafts were lost, two due to thrombosis and two secondary to chronic rejection. There was one patient death six months post-transplant due to causes unrelated to transplantation. Graft survival at 1, 5, and 10 years was 98.4%, 96.6%, and 84.2%, respectively. Of surviving allografts, the median 1, 5, and 10 years post-transplant eGFR was 122.9, 90.0, and 59.2 mL/min/1.73 m as determined by the 2009 Schwartz formula. Renal transplantation in small children using ASKs requires meticulous perioperative management including adequate fluid resuscitation and judicious use of pressors to assure adequate graft perfusion. The use of ASKs from living or deceased donors results in satisfactory short and long-term outcomes.
肾移植仍然是终末期肾病儿童的首选治疗方法。对于接受小体积供肾的患儿，优化围手术期管理对于确保移植肾充足灌注至关重要。我们介绍了单中心的经验，概述了2007年至2016年间体重<20 kg接受原发性肾移植的小体积供肾患者的管理情况。63例患者符合研究标准，接受了34例亲属活体供肾、6例非亲属活体供肾和23例尸体供肾移植。移植时的中位年龄和体重分别为25个月（四分位间距18 - 37个月；范围11个月 - 6岁）和11.0 kg（四分位间距9.2 - 14.5 kg；范围7.1 - 19.5 kg）。89%的患者术中需要血管活性药物，20例患者术后需要长时间使用血管活性药物。术中，患者接受了51.9 mL/kg的晶体液、27.3 mL/kg的5%白蛋白和13.6 mL/kg的浓缩红细胞。大多数（93.7%）患者在术后第0天拔管。体重在术后第3至5天达到峰值。中位随访49个月（四分位间距31 - 86个月；范围0 - 130个月），4个移植肾丢失，2个因血栓形成，2个继发于慢性排斥反应。有1例患者在移植后6个月因与移植无关的原因死亡。1年、5年和10年的移植肾存活率分别为98.4%、96.6%和84.2%。在存活的同种异体移植肾中，根据2009年施瓦茨公式测定，移植后1年、5年和10年的中位估算肾小球滤过率分别为122.9、90.0和59.2 mL/min/1.73 m²。小儿使用小体积供肾进行肾移植需要精心的围手术期管理，包括充分的液体复苏和谨慎使用升压药以确保移植肾充足灌注。使用活体或尸体供体的小体积供肾可获得满意的短期和长期结果。
