比较肾移植术后移植肾动脉狭窄(TRAS)不同诊断方法的价值并总结血管内介入治疗经验。

回顾性分析2010年1月至2017年6月武汉大学人民医院器官移植科25例肾移植术后发生TRAS受者临床资料。所有受者均行移植肾彩色多普勒血流显像(CDFI)、磁共振血管成像(MRA)、移植肾数字减影血管造影(DSA)检查。TRAS经DSA确诊后立即行介入治疗，轻度狭窄受者术中予球囊扩张，中、重度狭窄受者根据球囊扩张后的狭窄段管径及长度植入合适动脉支架。根据移植肾动脉峰值流速(PSV)将TRAS受者分为高速血流组(PSV>120 cm/s)和低速血流组(PSV<50 cm/s)，比较两组介入治疗前后移植肾动脉平均PSV和阻力指数。采用Fisher确切概率法比较CDFI与MRA对TRAS确诊率；采用配对t检验比较受者介入治疗前后24 h尿量、平均动脉压、血清肌酐、肾小球滤过率(GFR)，采用配对t检验比较高速血流组和低速血流组平均PSV、阻力指数。P<0.05为差异有统计学意义。

CDFI与MRA对TRAS确诊率分别为68%(17/25)、84.0%(21/25)，差异无统计学意义(P＝0.57)。DSA检查示轻、中、重度狭窄分别为7、13、5例。7例轻度狭窄受者均予术中球囊扩张；2例肾动脉主干近端及远端两处狭窄受者(重度狭窄)、1例肾动脉及1支副肾动脉均狭窄受者(重度狭窄)术中接受球囊扩张后再植入2根动脉支架；1例肾动脉及2支副肾动脉均狭窄受者(重度狭窄)术中接受球囊扩张后再植入3根动脉支架；余14例受者(中度狭窄13例、重度狭窄1例)术中接受球囊扩张后再植入1根动脉支架。介入治疗前后24 h尿量、平均动脉压、血清肌酐和GFR分别为(1 956±615)和(2 752±729)mL、(117±13)和(96±8)mmHg(1 mmHg＝0.133 kPa)、(190±50)和(109±22)μmol/L、(39±12)和(66±8)mL/min，差异均有统计学意义(t＝4.17、6.59、7.35、9.48，P均<0.05)。17例高速血流组介入治疗前后肾动脉平均PSV、阻力指数分别为(151±27)和(87±28)cm/s、(0.77±0.05)和(0.56±0.06)，差异均有统计学意义(t＝6.35、4.38，P均<0.05)；8例低速血流组介入治疗前后肾动脉平均PSV、阻力指数分别为(39±9)和(80±16)cm/s、0.56±0.06和0.66±0.04，差异均有统计学意义(t＝6.33、3.92，P均<0.05)。截至2017年10月，随访时间4～36个月，25例TRAS受者介入治疗后未见动脉血栓、再狭窄等并发症；介入治疗后分别各有1例出现上消化道出血、移植侧髂外静脉血栓，经治疗后均好转；1例于介入治疗后第3天出现肺部感染，1个月后因呼吸衰竭死亡。

MRA与CDFI对于TRAS的诊断价值相似，介入治疗可明显改善TRAS患者相关症状，有效恢复其肾脏血流灌注、改善肾脏功能。

To compare the value of different diagnostic methods on transplant renal artery stenosis (TRAS) and summarize the treatment experience of interventional therapy on TRAS.

The clinical data of 25 recipients who suffered TRAS after renal transpantation in Renmin Hospital of Wuhan University from January 2010 to June 2017 were analysed. All recipients accepted color doppler flowing image (CDFI), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA). Recipients received interventional therapy immediately after they were diagnosed with TRAS by DSA, mild stenosis recipients were treated with balloon dilatation, moderate stenosis and severe stenosis recipients were treated with balloon dilatation and artery stent. TRAS recipients were divided into fast blood flow group and slow blood flow group, the media peak systolic velocity (PSV) of transplant artery and resistance index between the 2 groups were compared. Diagnosis rate of CDFI and MRA on TRAS were compared with Fisher′s exact test. The indexes like 24 hour urine volume, mean arterial pressure, serum creatinine and glomerular filtration rate (GFR) before and after operation were compared with paired t test; the media PSV and resistance index of fast blood flow group and slow blood flow group were also compared with paired t test. P<0.05 was considered statitically significant.

Diagnosis rate of CDFI and MRA on TRAS were 68% (17/25) and 84.0% (21/25), which had no statitical significance (P=0.57). The test results of DSA showed that there were 7 cases of mild stenosis recipients, 13 cases of moderate stenosis recipients and 5 cases of severe stenosis recipients. All the mild stenosis recipients received balloon dilatation, other recipients received balloon dilatation and artery stent. Twenty-four hour urine volume, mean arterial pressure, serum creatinine and GFR of fast blood flow group and slow blood flow group before and after operation were (1 956±615) and (2 752±729) mL, (117±13) and (96±8) mmHg, (190±50) and (109±22) μmol/L, (39±12) and (66±8) mL/min, all of them had statitical significance (t=4.17, 6.59, 7.35, 9.48, P all<0.05). Media PSV and resistance index of fast blood flow group (n=17) before and after operation were (151±27) and (87±28) cm/s, 0.77±0.05 and 0.56±0.06, all of them had statitical significance (t=6.35, 4.38, P all<0.05). Media PSV and resistance index of slow blood flow group (n=8) before and after operation were (39±9) and (80±16) cm/s, (0.56±0.06) and (0.66±0.04), all of them had statitical significance (t=6.33, 3.92, P all<0.05). Postoperative follow-up time of 25 TRAS recipients was 4-36 months up to October 2017, complications like artery thrombosis and restenosis were not observed; gastrointestinal bleeding (n=1) and vena iliaca externa thrombosis (n=1) were observed after interventional therapy; 1 case catched pulmonary infection on the third day after interventional therapy and died of respiratory failure 1 month later.

MRA and CDFI perform similar value in diagnosing TRAS. Interventional therapycould rectify the clinical symptoms and renal function by restoring transplant renal blood filtration.