Femoral head necrosis after renal transplantation

doi:10.3969/j.issn.2095-4344.2013.18.004

Abstract

Abstract:

BACKGROUND: Femoral head necrosis is a serious complication after renal transplantation which will seriously affect the quality of life of patients. Therefore, its prevention is particularly important.
OBJECTIVE: To explore the clinical features, related risk factors, diagnosis, prevention and treatment measure of avascular necrosis of femoral head after renal transplantation, and to provide the basis for clinical treatment.
METHODS: We retrospectively analyzed the clinical data of 486 patients with femoral head necrosis after renal transplantation selected from the First Affiliated Hospital of Zhengzhou University from January 2008 to July 2012. The dialysis method and duration before transplantation, dose and duration of corticoid administration after transplantation, changes of body mass of the patients, lipids situation, and the time from transplantation to onset of femoral head necrosis were observed.
RESULTS AND CONCLUSION: 454 out of 486 patients were followed-up (averaged for 22.7 months) and four patients were diagnosed with femoral head necrosis. The incidence rate was 0.8%, and the mean duration of occurrence was 8.25 months. The mean dose of methylprednisolone for 5 days after transplantation was (2 707.5±154.45) mg, and the mean dose of prednisone for the first month after transplantation was (617.5± 180.76) mg. All the four patients above received hemodialysis, and the lipids and body mass were increased after renal transplantation; the amount of corticoid was decreased or stopped after diagnosis and then treated with blood circulation drugs and conservative treatment. Three cases were improved, and the other one case was newly diagnosed with femoral head necrosis. Application of corticoid is the main reason for femoral head necrosis after renal transplantation, while to stop hormone therapy and give the blood circulation drugs after the onset can get better effect.

Key words: organ transplantation, renal transplantation, femoral head necrosis, incidence rate, glucocorticoid, immunosuppressant, genetic predisposition, complications, risk factors, dialysis

CLC Number:

R318

Wang Xiao-bo, Wang Yue, Feng Gui-wen, Li Jin-feng, Shang Wen-jun, Pang Xin-lu. Femoral head necrosis after renal transplantation[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(18): 3255-3262.

Figures/Tables 1

2.1 随访情况 486例肾移植患者中，32例死亡，454例获得随访，无失访，平均随访时间22.7个月(8-56个月)。 2.2 股骨头坏死的发病情况获得随访的454例患者中发生股骨头坏死4例，发病率为0.8%。4例患者肾移植后前5 d平均静脉应用注射用甲泼尼龙琥珀酸钠(2 707.50±154.45) mg，肾移植后第1个月平均口服醋酸泼尼松片(617.50±180.76) mg。4例发生股骨头坏死的患者中男女各2例，均为双髋股骨头坏死。接受肾移植时年龄分别为32，35，10，23岁，平均25岁，首次出现症状的时间分别为移植后第10，9，6，8个月，平均8.25个月。依据临床症状、体征、影像学检查诊断，分期参照国际骨循环研究会标准分期。4 例患者明确诊断后均减量并停用激素，不负重或减少负重，接受中医及介入治疗，未接受外科治疗，3例好转，余1例为新近发现股骨头坏死患者。 2.3 病历详细资料患者一：男，32岁，汉族，已婚，原发病为慢性肾小球肾炎，患者诊断肾功能不全之前曾有烟酒史，吸烟1包/d，白酒5两/d，移植前行规律血液透析4个月，患者姐姐为其供肾，均为A型血，人类白细胞抗原配型6位点错配2个，DR位点无错配，于2008年1月14日行亲属活体肾移植，移植前12 h给予醋酸泼尼松片80 mg口服，肾移植过程中静脉滴注注射用甲泼尼龙琥珀酸钠1 000 mg，移植后12 h静脉滴注注射用甲泼尼龙琥珀酸钠125 mg，移植后5 d共静脉滴注注射用甲泼尼龙琥珀酸钠1 330 mg，第6天改为口服醋酸泼尼松片25 mg，1次/d。移植后第1个月静脉滴注注射用甲泼尼龙琥珀酸钠2 455 mg，口服醋酸泼尼松片510 mg，免疫抑制方案为环孢素A+吗替麦考酚酯+醋酸泼尼松，患者肾功能恢复良好，血肌酐最低降至78 μmol/L。肾移植后1个月患者血肌酐突然升高，每天升高约100 μmol/L，在4 d内连续静脉滴注注射用甲泼尼龙琥珀酸钠2 000 mg冲击治疗后效果欠佳，后确诊为输尿管吻合口狭窄，经介入治疗解除梗阻后肾功能恢复正常。患者于2008年11月首次出现髋关节疼痛症状，未在意，2009年12月，因摔倒引起髋关节疼痛，入院后行X射线检查发现双侧股骨头塌陷，诊断为股骨头坏死，右侧Ⅲ期，左侧Ⅱb期，对症给予活血药物，前列地尔20 μg，2次/d，红花黄色素氯化钠注射液 100 mL，1次/d，减量并停用醋酸泼尼松片。患者病情未再进展，髋关节活动轻度受限。患者二：女，35岁，已婚，原发病为慢性肾小球肾炎，移植前行血液透析2个月，患者哥哥为其供肾，均为B型血，人类白细胞抗原配型6位点错配3个，一个DR位点相配，于2009年4月行亲属活体肾移植手术，移植前12 h给予醋酸泼尼松片80 mg口服，肾移植过程中给予注射用甲泼尼龙琥珀酸钠1 000 mg，移植后5 d分别给予注射用甲泼尼龙琥珀酸钠500，500，375，250，125 mg静脉滴注后改为每天口服醋酸泼尼松片25 mg。患者肾功能恢复良好，血肌酐最低降至67 μmol/L，免疫治疗方案为环孢素A+他克莫司+醋酸泼尼松。 2009年12月出现双侧髋关节疼痛，行X射线检查未见明显异常，未行核磁检查。于 2010年11月因急性排斥入院治疗，对症给予注射用甲泼尼龙琥珀酸钠冲击治疗后，肾功能逐渐恢复，期间因髋关节疼痛行磁共振诊断证明双侧股骨头坏死塌陷，确诊为双侧股骨头缺血性坏死，随即停用醋酸泼尼松并给予相关对症治疗，应用前列地尔，红花黄色素氯化钠注射液等活血药物治疗，患者股骨头坏死未进展，目前活动仍轻度受限，不能负重，需借助双拐出行。患者三：女，汉族，未婚，10岁，原发病为慢性肾小球肾炎，患者母亲为其供肾，血型均为B型，人类白细胞抗原配型6位点错配2个，DR位点无错配，于2010年10月25日行亲属活体肾移植，移植前行血液透析2年。肾移植过程中给予注射用甲泼尼龙琥珀酸钠1 000 mg静脉滴注，移植后前5 d共给予注射用甲泼尼龙琥珀酸钠2 875 mg冲击治疗，后改为每天口服醋酸泼尼松片25 mg，逐渐减至10 mg。患者肾功能恢复良好，血肌酐最低降至27 μmol/L，免疫治疗方案为吗替麦考酚酯+他克莫司+醋酸泼尼松。移植后6个月时出现双侧髋关节疼痛症状，可耐受，X射线片未见异常，未行核磁检查，3个月后X射线检查发现双侧股骨头塌陷，确诊为双侧股骨头坏死，随即给予停用激素并应用活血药物及内科保守治疗，患者恢复好，股骨头坏死未进展，可从事正常学习工作。患者四：男，23岁，已婚，原发病为慢性肾小球肾炎，患者母亲为其供肾，患者为B型血，其母亲为O型，人类白细胞抗原配型6位点错配3个，DR位点错配1个，移植前行血液透析1个月。于2011年3月15日行亲属活体肾移植，移植前给予醋酸泼尼松片80 mg顿服，肾移植过程中静脉滴注注射用甲泼尼龙琥珀酸钠1 000 mg，移植后5 d静脉滴注注射用甲泼尼龙琥珀酸钠1 750 mg，第1个月口服醋酸泼尼松片750 mg。患者肾移植后并发尿瘘及肾动脉狭窄，治愈后出院，免疫抑制方案为他克莫司+吗替麦考酚酯+醋酸泼尼松。于2011年5月因急性排斥反应入院治疗，给予大量激素冲击治疗，并调整免疫抑制方案为他克莫司+西罗莫司+吗替麦考酚酯+醋酸泼尼松，肾功能逐渐恢复出院，血肌酐降至121 μmol/L，出院后逐渐停用他克莫司，改为西罗莫司+吗替麦考酚酯+醋酸泼尼松。患者于2012年7月因腹泻入院治疗，期间因双侧髋关节疼痛行X射线检查未见明显异常，后行双髋关节MRI平扫示双侧股骨头塌陷，诊断为股骨头缺血性坏死，随即停口服激素，并给予活血化瘀、口服仙灵骨葆胶囊对症治疗。目前诊断为股骨头坏死Ⅲ期，现患者感双髋疼痛，拄拐步行，不能负重，髋关节活动受限。"

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