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中华移植杂志(电子版) ›› 2025, Vol. 19 ›› Issue (01) : 16 -21. doi: 10.3877/cma.j.issn.1674-3903.2025.01.003

儿童肾移植

儿童复发性移植肾肾病临床特点及诊治
姜梦婕1, 黄淑娟1, 裴瑜馨1, 容丽萍1, 许园园1, 林知朗1, 丘原全1, 刘龙山2, 蒋小云1, 陈丽植1,()   
  1. 1. 510080 广州,中山大学附属第一医院儿童肾脏风湿病中心
    2. 510080 广州,中山大学附属第一医院器官移植中心
  • 收稿日期:2024-12-02 出版日期:2025-02-25
  • 通信作者: 陈丽植
  • 基金资助:
    国家重点研发计划(2022YFC2705104)

Clinical features and treatment of recurrent allograft nephropathy in children

Mengjie Jiang1, Shujuan Huang1, Yuxin Pei1, Liping Rong1, Yuanyuan Xu1, Zhilang Lin1, Yuanquan Qiu1, Longshan Liu2, Xiaoyun Jiang1, Lizhi Chen1,()   

  1. 1. Department of Pediatric Nephrology and Rheumatology, Sun Yat-sen University, Guangzhou 510080, China
    2. Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
  • Received:2024-12-02 Published:2025-02-25
  • Corresponding author: Lizhi Chen
引用本文:

姜梦婕, 黄淑娟, 裴瑜馨, 容丽萍, 许园园, 林知朗, 丘原全, 刘龙山, 蒋小云, 陈丽植. 儿童复发性移植肾肾病临床特点及诊治[J/OL]. 中华移植杂志(电子版), 2025, 19(01): 16-21.

Mengjie Jiang, Shujuan Huang, Yuxin Pei, Liping Rong, Yuanyuan Xu, Zhilang Lin, Yuanquan Qiu, Longshan Liu, Xiaoyun Jiang, Lizhi Chen. Clinical features and treatment of recurrent allograft nephropathy in children[J/OL]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(01): 16-21.

目的

总结儿童复发性移植肾肾病的临床特点及诊治经过,为早期诊断和治疗提供经验。

方法

回顾性分析总结2014年1月至2024年10月于中山大学附属第一医院诊治的年龄≤18岁免疫性肾小球疾病肾移植术后复发患儿的临床及病理资料。

结果

18例复发性移植肾肾病患儿中男性11例、女性7例。诊断构成:移植肾局灶节段性肾小球硬化(FSGS)9例,移植肾IgA肾病(IgAN)5例,移植肾抗中性粒细胞胞质抗体相关肾炎(AAGN)2例,移植肾IgA血管炎相关性肾炎(IgAVN)2例。9例移植肾FSGS患儿,经治疗后4例达到完全缓解,术后随访3个月~7年,6例肾功能正常,5例尿蛋白持续未转阴(其中2例移植肾失功、1例移植肾功能不全、2例肾功能正常)。5例IgAN患儿,2例表现为大量蛋白尿,分别于术后2、7年进展至终末期肾病。2例移植后IgAVN均对糖皮质激素治疗有反应,1例经利妥昔单抗治疗后症状消失,1例经历2次复发后维持部分缓解,术后2年9个月、3年肾功能均正常;2例移植后AAGN治疗后完全缓解、肾功能正常。

结论

儿童常见的复发性移植肾肾病包括FSGS、IgAN、AAGN和IgAVN。积极肾活检协助诊断及有效干预可取得较好的疗效。

Objective

To summarize the clinical and pathological features, diagnosis, and treatment of recurrent allograft nephropathy in children, and to provide experience for early diagnosis and treatment.

Methods

The clinical and pathological data of children ≤18 years old with recurrent immune glomerular disease after kidney transplantation diagnosed and treated in the First Affiliated Hospital of Sun Yat-sen University from January 2014 to October 2024 were retrospectively analyzed and summarized.

Results

There were 11 males and 7 females. Of the 18 patients, 9 cases of focal segmental glomerulosclerosis (FSGS), 5 cases of IgA nephropathy (IgAN), 2 cases of anti-neutrophil cytoplasmic antibody associated glomerulonephritis (AAGN), and 2 cases of IgA vasculitis associated glomerulonephritis (IgAVN). Among the 9 cases of FSGS, 4 cases achieved complete remission after treatment, 6 cases had normal renal function 3 months to 7 years after operation, and 5 cases had no proteinuria. Among them, 2 cases had graft failure, 1 case had graft insufficiency, and 2 cases had normal renal function. Of the 5 IgAN patients, 2 cases showed massive proteinuria and entered ESRD at 2 and 7 years after operation. Two cases of IgAVN responded to glucocorticoid therapy. One case was treated with rituximab and the symptoms disappeared. The other case experienced two relapses and maintained partial remission. Two patients with AAGN achieved complete remission with normal renal function after treatment.

Conclusions

The common recurrent allograft nephropathy in children includes FSGS, IgAN, AAGN, and IgAVN. Active renal biopsy and effective intervention can achieve good curative effects.

表1 儿童复发性移植肾局灶节段性肾小球硬化治疗与预后
患儿 主要治疗方案 转归 术后随访时间 末次随访检测
尿蛋白 血清肌酐(μmol/ L)
例1 MP 冲击+血浆置换15 次(术后1 个月),福辛普利,静脉输注环孢素(术后6 个月),RTX(术后7~8 个月),输注间充质干细胞2 次,ACTH 维持治疗(术后15 个月~4 年3 个月) 治疗52 个月后尿蛋白转阴 7 年 阴性 57
例2 MP 冲击+血浆置换8 次(术后3 d~1 个月),福辛普利 治疗后2 周内尿蛋白转阴 3 个月 阴性 53
例3 MP 冲击+血浆置换15 次(术后1~2 个月),RTX(术后1~2 个月),福辛普利,ACTH 治疗(术后3~4 个月) 持续大量蛋白尿, 术后16 个月移植肾失功切除 1 年4 个月 无尿 移植肾失功
例4 MP 冲击+血浆置换10 次+ RTX(术后1~2 个月) 尿蛋白持续未转阴 8 个月 ++ 122
例5 首次:MP 冲击+血浆置换20 次+RTX(术后1~2 个月),输注间充质干细胞4 次再次复发:控制感染+MP 冲击+血浆置换15 次(复发后1~2 个月),RTX (复发后2 个月) 首次治疗8 个月后尿蛋白转阴术后5 年后因感染复发,治疗2 个月后尿蛋白转阴 7 年5 个月 阴性 78
例6 MP 冲击+血浆置换12 次+RTX(术后1~2 个月),福辛普利,ACTH 治疗(4 次,术后3~4 个月) 尿蛋白持续未转阴 1 年3 个月 ++ 57
例7 血浆置换5 次+RTX(术后1 个月),血浆置换12 次+MP冲击(术后9 个月),福辛普利 尿蛋白持续未转阴 1 年 +++ 75
例8 血浆置换3 次(术后2 个月)+MP 冲击,福辛普利,RTX(术后12、29 个月各1 次) 尿蛋白持续未转阴,肾功能恶化,规律透析 3 年2 个月 + 移植肾失功
例9 调整免疫抑制维持方案(他克莫司调整为环孢素),福辛普利 尿蛋白转阴 1 年3 个月 阴性 50
表2 儿童复发性移植肾IgA肾病治疗与预后
1
Denton MD, Singh AK. Recurrent and denovo glomerulonephritis in the renal allograft[J]. Seminars in Nephrology, 2000, 20(2): 164-175.
2
伍倩倩, 文吉秋. 移植受者原发性肾小球疾病复发诊治进展[J].肾脏病与透析肾移植杂志, 2020, 29(6): 577-582.
3
Haas M, Loupy A, Lefaucheur C, et al. The Banff 2017 kidney meeting report:revised diagnostic criteria for chronic active T cellmediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials[J].Am J Transplant, 2018, 18(2):293-307.
4
Ponticelli C. Recurrence of focal segmental glomerular sclerosis(FSGS) after renal transplantation[J]. Nephrol Dial Transplant,2010, 25(1): 25-31.
5
Nijim S, Vujjini V, Alasfar S, et al. Recurrent IgA nephropathy after kidney transplantation[J]. Transplant Proc, 2016, 48(8):2689-2694.
6
Lee SM, Rao VM, Franklin WA, et al. IgA nephropathy:morphologic predictors of progressive renal disease[J]. Human Pathology, 1982, 13(4): 314-322.
7
于峰, 赵洪雯, 秦燕, 等. 中国移植肾系统性疾病肾损害复发临床诊疗指南[J]. 器官移植, 2024, 15(6): 846-862.
8
Berden AE, Ferrario F, Hagen EC, et al. Histopathologic classification of ANCA-associated glomerulonephritis[J]. J Am Soc Nephrol, 2010, 21(10): 1628-1636.
9
Koskela M, Ylinen E, Ukonmaanaho EM, et al. The ISKDC classification and a new semiquantitative classification for predicting outcomes of Henoch-Schönlein purpura nephritis[J]. Pediatric Nephrology (Berlin, Germany), 2017, 32(7): 1201-1209.
10
Cosio FG, Cattran DC. Recent advances in our understanding of recurrent primary glomerulonephritis after kidney transplantation[J].Kidney International, 2017, 91(2): 304-314.
11
张桓熙, 李军, 黄铭川, 等. 儿童肾移植244例次临床分析[J].中华器官移植杂志, 2020, 41(1): 9-14.
12
Kasiske BL, Zeier MG, Chapman JR, et al. Kidney Disease:Improving Global Outcomes. KDIGO clinical practice guideline for the care of kidney transplant recipients: a summary[J]. Kidney Int,2010, 77(4):299-311.
13
Kienzl-Wagner K, Waldegger S, Schneeberger S. Disease recurrencethe sword of damocles in kidney transplantation for primary focal segmental glomerulosclerosis[J]. Front Immunol, 2019, 10: 1669.
14
Chen L, Wu J, Ying D, et al. Application of adrenocorticotropic hormone in recurrent focal segmental glomerulosclerosis posttransplantation: a case report and literature review[J]. Pediatr Transplant, 2022, 26(2): e14184.
15
Park S, Baek CH, Cho H, et al. Glomerular crescents are associated with worse graft outcome in allograft IgA nephropathy[J]. Am J Transplant, 2019, 19(1): 145-155.
16
Moroni G, Longhi S, Quaglini S, et al. The long-term outcome of renal transplantation of IgA nephropathy and the impact of recurrence on graft survival[J]. Nephrol Dial Transplant, 2013, 28(5): 1305-1314.
17
Hetland LE, Susrud KS, Lindahl KH, et al. Henoch-Schönlein purpura: a literature review[J]. Acta Dermato-Venereologica,2017, 97(10): 1160-1166.
18
Kanaan N, Mourad G, Thervet E, et al. Recurrence and graft loss after kidney transplantation for henoch-schonlein purpura nephritis: a multicenter analysis[J]. Clin J Am Soc Nephrol, 2011,6(7):1768-1772.
19
Crayne CB, Eloseily E, Mannion ML, et al. Rituximab treatment for chronic steroid-dependent Henoch-Schonlein purpura: 8 cases and a review of the literature[J]. Pediatr Rheumatol Online J, 2018, 16(1):71.
20
尹晶, 赵倩倩, 马继军, 等. 利妥昔单抗治疗儿童难治性免疫球蛋白A血管炎二例[J]. 中华风湿病学杂志, 2021, 25(12):823-826.
21
Iudici M, Quartier P, Terrier B, et al. Childhood-onset granulomatosis with polyangiitis and microscopic polyangiitis: systematic review and meta-analysis[J]. Orphanet J Rare Dis, 2016, 11(1): 141.
22
Pagnoux C, Hogan SL, Chin H, et al. Predictors of treatment resistance and relapse in antineutrophil cytoplasmic antibodyassociated small-vessel vasculitis: comparison of two independent cohorts[J]. Arthritis Rheum, 2008, 58(9): 2908-2918.
23
Rhee RL, Davis JC, Ding L, et al. The utility of urinalysis in determining the risk of renal relapse in ANCA-associated vasculitis[J]. Clin J Am Soc Nephrol, 2018, 13(2): 251-257.
24
Wu J, Pei Y, Rong L, et al. Clinicopathological analysis of 34 cases of primary antineutrophil cytoplasmic antibody-associated vasculitis in Chinese children[J]. Front Pediatr, 2021, 9:656307.
25
中华医学会肾脏病学分会专家组. 抗中性粒细胞胞质抗体相关肾炎诊断和治疗中国指南[J]. 中华肾脏病杂志, 2021, 37(7):603-620.
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