生体同種腎移植における術後早期の補液管理

Abstract

1973年9月から1979年11月までの6年間に行なわれた生体腎同種移植患者50例, 51回の移植後の補液管理について検討した.受腎者の補液管理の方法の相違により, グループ1:中心静脈圧を観察しつつ, 移植1時間ごとに尿量を測定し, その同量を補液, グループ2:中心静脈圧, 一部スワンガンツカテーテルを挿入し, さまざまのパラメーターを観察しつゝ心不全が起こらない限り, 尿量と無関係に可及的大量の補液を行なった, 2群に分けた.腎移植後1週間以内に血清クレアチニンが2.5 mg/dl以下に低下しない症例を, 移植後急性尿細管壊死発生症例(虚血性障害発生群), 2.5 mg/dl以下に低下した症例を機能良好群と定義した.検討成績では, グループ1の術中および術当日の補液量はグループ2と比べあきらかに少なかった.またグループ1の術中および術当日尿量はグループ2と比べ有意に少なかった.グループ1はグループ2に比し, 術後血清クレアチニンの低下が遅延し, クレアチニンクリアランスが低い傾向がみられたが統計的有意差はみられなかった.グループ1の術当日のFENaはグループ2より高い傾向を示した.グループ1の機能良好群の血流再開5時間後, 10時間後, 15時間後, 20時間後のCVPの平均値はグループ2の機能良好群の各々の平均と比べあきらかに低かったが, グループ1, 2の虚血性障害発生群との間に差を認めなかった.グループ1の急性尿細管壊死の発生頻度は22例中8例(36.3%)で, グループ2の29例中3例(10.3%)と比べ, あきらかに高かった.グループ1の1年移植腎実測生着率は72.4%で, グループ2の75.9%と差はみられなかった.グループ1の1年患者実測生存率は77.3%で, グループ2の96.6%に比しあきらかに低かった.以上より, 生体同種腎移植後は心不全が起こらないかぎり, 術後尿量にかゝわらず可及的大量の補液をすることが, 移植後急性尿細管壊死による腎障害の防止に重要であることを強調した

A major concern during the early post-transplantation period is fluid management. This study analyzes the difference between two approaches to fluid management in 49 subjects who had had renal transplants plus one subject who had had two renal transplants because of chronic rejection. All patients were divided into two groups. In group 1 (LDI-22), the urine lost each hour was replaced with an equal volume of half normal saline and 5 % glucose in water, and in group 2 (LD23-51), massive fluid management with half or quarter saline was undertaken, cardiac parameters were checked and the administration of fluids was controlled by a Swan-Ganz catheter to avoid cardiac failure, additional fluids being administered when the Swan-Ganz catheter reading was lower than normal. The cases in which serum creatinine after one postoperative week remained above 2.5 mg/dl were classified as acute tubular necrosis (ATN), and those with lower values as non-ATN. The average volume of infusion during operation (1l46±490 vs 2698±939 ml/m2BSA) and on transplant day (2262±892 vs 2897 ±855 ml/m2BSA) was significantly smaller in Group I (P<O. 005). The average urine output during operation (187 ± 135 vs 524±306 mljm2BSA) and on the transplant day (2125± 1399 vs 3548 ± 1435 ml/m2BSA) was also significantly smaller in Group I (P<0.005). Postoperative serum creatinine reduction in Group I was some what delayed, but the delay was not statistically significant. FENa during the first postoperative day was higher in Group (4. 38±3. 20 vs 2. 75±1. 75%). The GVP monitored for 20 hours after declamping in the cases without ATN was significantly lower in Group 1 than in Group 2, but, in the cases with ATN, the difference between Group 1 and 2 was not statistically significant. The incidence of cases with ATN was significantly higher in Group 1 (36.3 vs 10.3%) (P<0.01). The actuarial one-year graft survival was 72.4% in group 1 and 75.9% in Group 2 and the difference was not statistically significant. The actuarial one-year patient survival rate was lower in Group 1 (77.3 vs 96.6%) (P<0.05). From the data described above, it might be tentatively concluded that checking the cardiac parameters to avoid cardiac failure "and massive fluid management through the use of the Swan-Ganz catheter might be useful in preventing postoperative ATN in living related renal allogreft recipients.