Clinical Application of Multimodal Ultrasound in Monitoring DBD Renal Transplantation
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摘要:
目的 评估多模态超声在DBD移植肾功能及术后并发症监测中的价值。 方法 选取昆明医科大学附属甘美医院2019年7月至2021年6月脑死亡器官捐献移植肾（DBD）67例，运用多模态超声对移植肾进行评估。以血肌酐将移植肾分为功能正常组和异常组，异常组以穿刺病理分为急性排斥组、慢性排斥组，病毒性肾病组，纤维化组、药物损伤组。采用相关性分析动脉峰值流速（PSV）、舒张期流速（EDV）、阻力指数（RI）与血肌酐的相关性。比较超声造影与病理或DSA在移植肾并发症中的诊断效能，分析超声造影参数与移植肾功能间相关性。采用秩和检验分别比较各异常组与正常组杨氏模量值。绘制ROC曲线，以约登指数最高时的杨氏模量值作为区分正常和异常移植肾的截断值，计算相应敏感度、特异度。 结果 移植肾各血流参数与血肌酐的相关性一般，相关系数均 < 0.5。慢性排斥组（8例）较正常组（10例）到达时间和达峰时间明显延长，差异具有统计学意义。超声造影诊断假性动脉瘤2例，移植肾缺血2例，移植肾静脉血栓形成1例，均经病理或DSA证实。根据血肌酐值将62例移植肾分为正常组22例、异常组40例（急性排斥组5例、慢性排斥组11例，病毒性肾病组10例，纤维化组10例、药物损伤组4例）。急性排斥组肾主动脉RI高于正常组、慢性排斥组叶间动脉RI高于正常组，主、叶间EDV低于正常组，叶间动脉PSV低于正常组、纤维化组主PSV低于正常组。以上差异具有统计学意义（P < 0.05）；病毒性肾病、药物损伤组与正常组各参数差异无统计学意义（P > 0.05）。异常组和正常组移植肾STE杨氏模量值分别为22.550（17.1，28.1）和13.370（11.8，15.9） kPa，差异有统计学意义（P < 0.01）。截断值 = 17.31 kPa时，剪切波弹性成像诊断移植肾病变的灵敏度、特异度为75%、91%。异常组和正常组移植肾STQ杨氏模量值分别为21.760（16.4，33.4）和13.870（10.5，16.8） kPa，差异有统计学意义（P < 0.01）。截断值=18.16 kPa时，剪切波弹性成像诊断移植肾病变的灵敏度、特异度为70%、91%。急性排斥组、慢性排斥组、病毒性肾病组、纤维化组、药物损伤组STE杨氏模量值分别为13.370（11.8，15.9）、15.550（13.4，16.6）、26.870（21.6，38.6）、26.660（19.5，34.2）、16.310（13.2，23.1）、27.690（24.6，29.2）；STQ杨氏模量值分别为13.870（10.5，16.8）、16.330（15.5，17.4）、23.780（19.2，40.7）、22.760（19.9，36.0）、16.540（14.5，26.0）、33.355（29.1，35.4），各组间差异有统计学意义（P < 0.05）。其中慢性排斥组、病毒性肾病组、药物损伤组高于正常组，差异具有统计学意义（P < 0.05），急性排斥组、纤维化组与正常组间差异不具有统计学意义（P > 0.05）。病毒性肾病弹性值较急性排斥高，STE：26.660（19.5，34.2）vs15.550（13.4，16.6）kPa（P < 0.01），STQ：22.760（19.9，36.0）vs16.330（15.5，17.4）kPa（P < 0.01），差异有统计学意义。 结论 移植肾血流参数可早期评估移植肾功能，对正常、急慢性排斥、病毒性肾病的鉴别具有指导意义。超声造影对移植肾并发症鉴别具有指导意义。弹性成像可无创评估移植肾硬度，在及时发现移植肾并发症及鉴别诊断中具有一定的临床应用价值。 Abstract:Objective To evaluate the value of multimodal ultrasound in monitoring renal function and postoperative complications of DBD transplantation. Methods 67 cases of brain dead organ donor kidney transplantation （DBD） in Ganmei Hospital Affiliated to Kunming Medical University from July 2019 to June 2021 were selected to evaluate the transplanted kidney by multimodal ultrasound. The transplanted kidneys were divided into normal function group and abnormal group according to blood creatinine. The abnormal group was divided into acute rejection group, chronic rejection group, viral nephropathy group, fibrosis group and drug injury group according to puncture pathology. The correlation between arterial peak velocity （PSV）, diastolic velocity （EDV）, resistance index （RI） and serum creatinine was analyzed. To compare the diagnostic efficacy of contrast-enhanced ultrasound with pathology or DSA in renal transplantation complications, and to analyze the correlation between contrast-enhanced ultrasound parameters and renal transplantation function. Rank sum test was used to compare the young’ s modulus between abnormal group and normal group. The ROC curve was drawn, and the young’ s modulus at the highest yoden index was used as the cut-off value to distinguish normal and abnormal transplanted kidneys, and the corresponding sensitivity and specificity were calculated. Results The correlation between blood flow parameters of transplanted kidney and serum creatinine was general, and the correlation coefficients were less than 0.5. The arrival time and peak time of chronic rejection group （8 cases） were significantly longer than those of normal group （10 cases）, and the difference was statistically significant. Two cases of pseudoaneurysm, two cases of graft ischemia and one case of graft venous thrombosis were diagnosed by contrast-enhanced ultrasonography, which were confirmed by pathology or DSA. According to the serum creatinine value, 62 cases of transplanted kidney were divided into 22 cases in the normal group and 40 cases in the abnormal group （5 cases in the acute rejection group, 11 cases in the chronic rejection group, 10 cases in the viral nephropathy group, 10 cases in the fibrosis group and 4 cases in the drug injury group）. The RI of renal aorta in acute rejection group was higher than that in normal group, the RI of interlobar artery in chronic rejection group was higher than that in normal group, the EDV of main and interlobar artery was lower than that in normal group, the PSV of interlobar artery was lower than that in normal group, and the main PSV of fibrosis group was lower than that in normal group. The above differences were statistically significant （P < 0.05）; There was no significant difference in parameters between viral nephropathy, drug injury group and normal group （P > 0.05）. The young’ s modulus of ste in abnormal group and normal group were 22.550 （17.1, 28.1） and 13.370 （11.8, 15.9） kPa, respectively （P < 0.01）. When the cut-off value = 17.31 kpa, the sensitivity and specificity of shear wave elastography in the diagnosis of renal allograft lesions were 75% and 91%. The young’ s modulus of STQ in abnormal group and normal group were 21.760 （16.4, 33.4） and 13.870 （10.5, 16.8） kPa, respectively, with significant difference （P < 0.01）. When the cut-off value = 18.16 kpa, the sensitivity and specificity of shear wave elastography in the diagnosis of renal allograft lesions were 70% and 91%. The young’ s modulus of ste in acute rejection group, chronic rejection group, viral nephropathy group, fibrosis group and drug injury group were 13.370 （11.8, 15.9）, 15.550 （13.4, 16.6）, 26.870 （21.6, 38.6）, 26.660 （19.5, 34.2）, 16.310 （13.2, 23.1） and 27.690 （24.6, 29.2） respectively; The young’ s modulus values of STQ were 13.870 （10.5, 16.8）, 16.330 （15.5, 17.4）, 23.780 （19.2, 40.7）, 22.760 （19.9, 36.0）, 16.540 （14.5, 26.0） and 33.355 （29.1, 35.4） respectively. There was significant difference among the groups （P < 0.05）. The chronic rejection group, viral nephropathy group and drug injury group were significantly higher than those in the normal group （P < 0.05）, but there was no significant difference between the acute rejection group, fibrosis group and the normal group （P > 0.05）. The elastic value of viral nephropathy was higher than that of acute rejection, ste: 26.660 （19.5, 34.2） vs 15 550 （13.4, 16.6）kPa （P<0.01）, STQ: 22.760 （19.9, 36.0）vs16. 330 （15.5, 17.4） kPa （P < 0.01）, the difference was statistically significant. Conclusions The blood flow parameters of transplanted kidney can early evaluate the function of transplanted kidney, and have guiding significance for the differentiation of normal, acute and chronic rejection and viral nephropathy. Contrast-enhanced ultrasound has guiding significance in the differentiation of renal transplant complications. Elastography can noninvasively evaluate the hardness of transplanted kidney, and has a certain clinical value in the timely detection of transplanted kidney complications and differential diagnosis. -
Key words:
- Multimodal ultrasound /
- Kidney transplantation /
- Complication /
- Graft function /
- Rejection
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图 1 移植肾血流参数与肌酐相关性散点图
A：移植肾主动脉PSV与肌酐相关性；B：移植肾主动脉EDV与肌酐相关性；C：移植肾主动脉RI与肌酐相关性；D：移植肾段动脉PSV与肌酐相关性；E：移植肾段动脉EDV与肌酐相关性；F：移植肾段动脉RI与肌酐相关性；G：移植肾叶间动脉PSV与肌酐相关性；H：移植肾叶间动脉EDV与肌酐相关性；I：移植肾叶间动脉RI与肌酐相关性；
Figure 1. Scatter plot of correlation between blood flow parameters and creatinine in transplanted kidney
图 3 慢性排斥组超声造影曲线
Figure 3. Contrast-enhanced ultrasound curve of chronic rejection group
图 4 移植肾假性动脉瘤造影图（10、14、21 s造影表现）
A：假性动脉瘤腔造影剂开始填充；B：假性动脉瘤腔造影剂完全填充；C：明显增强区为假性动脉瘤腔，周围低灌注区为移植肾。
Figure 4. Angiogram of pseudoaneurysm of transplanted kidney （10，14 and 21 s angiogram）
图 5 移植肾下极局部梗死灶
A：造影表现实质内局部无灌注区；B：局部放大图。
Figure 5. Local infarct in the inferior pole of transplanted kidney
图 6 移植肾静脉血栓造影图
A：移植肾肾主静脉及肾下、肾中段静脉血栓形成（完全栓塞）；B：移植肾上段静脉血栓形成（不完全性）。
Figure 6. Venography of transplanted kidney
图 7 剪切波弹性成像检查移植肾的受试者工作特征曲线
A：STE剪切波弹性成像检查移植肾的受试者工作特征曲线；B：STQ剪切波弹性成像检查移植肾的受试者工作特征曲线。
Figure 7. Subject working characteristic curve of shear wave elastography for transplanted kidney
图 8 剪切波弹性成像检查移植肾示例
A：正常；B：急性排斥；C：慢性排斥；D：病毒性肾病；E：纤维化；F：药物损伤。
Figure 8. Examples of shear wave elastography for transplanted kidney
表 1 不同病理改变与血流参数相关性分析[M（P25，P75）]
Table 1. Correlation analysis between different pathological changes and blood flow parameters [M（P25，P75）]
血流参数 正常组
（n = 22）急性排斥组
（n = 5）慢性排斥组
（n = 11）纤维化
（n = 10）病毒性肾病
（n = 10）药物损伤组
（n = 4）H P 主PSV 126.750
（114.0，156.1）111.000
（95.0，169.5）86.000
（73.0，110.0）97.000
（82.8，119.5）Δ94.000
（70.0，112.0）112.000
（88.0，133.0）16.183 0.006* 主EDV 36.650
（28.7，53.3）24.000
（18.0，36.5）22.000
（14.0，26.0）Δ25.000
（19.5，51.0）25.000
（21.0，31.0）18.000
（11.0，30.0）15.143 0.010* 主RI 0.705
（0.7，0.8）0.850
（0.8，0.9）Δ0.780
（0.8，0.8）0.730
（0.7，0.8）0.700
（0.7，0.7）0.840
（0.8，0.9）19.297 0.002* 段PSV 78.250
（68.4，97.0）64.000
（55.0，72.5）50.000
（45.0，72.0）66.000
（45.5，79.3）48.000
（32.0，55.0）46.000
（46.0，61.0）16.684 0.005* 段EDV 27.250
（17.6，32.2）20.000
（15.5，30.0）15.000
（13.0，22.0）22.000
（12.8，33.3）15.000
（13.0，18.0）12.000
（12.0，14.0）12.355 0.030* 段RI 0.670
（0.6，0.7）0.730
（0.6，0.8）0.700
（0.7，0.8）0.675
（0.6，0.7）0.620
（0.6，0.7）0.740
（0.7，0.7）9.183 0.102 叶间PSV 52.950
（40.0，59.8）29.000
（21.0，39.0）29.000
（23.0，37.0）Δ40.000
（23.8，49.5）39.000
（23.0，40.0）23.000
（17.0，57.0）18.151 0.003* 叶间EDV 18.150
（15.2，21.8）11.000
（7.3，17.5）7.000
（5.8，9.5）Δ14.000
（9.0，21.8）16.000
（9.0，18.0）8.000
（4.0，12.0）19.232 0.002* 叶间RI 0.600
（0.6，0.7）0.750
（0.6，0.8）0.730
（0.7，0.8）Δ0.645
（0.6，0.7）0.600
（0.5，0.6）0.750
（0.6，0.8）17.063 0.004* *P < 0.05。与正常组比较，ΔP < 0.05。 
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表 2 移植肾正常组与慢性排斥组皮质超声造影参数比较（
$ \bar x \pm s $ ）Table 2. Comparison of cortical contrast-enhanced ultrasound parameters between normal renal transplantation group and chronic rejection group （
$ \bar x \pm s $ ）组别 n AT（s） TTP（s） PI（s） AUC（dB/s） 正常组 10 6.15 ± 1.08 13.15 ± 2.28 60.94 ± 2.87 2554.00 ± 249.86 慢性排斥组 8 7.90 ± 1.10 17.15 ± 3.18 63.19 ± 2.19 2768.38 ± 316.87 t 3.398 3.115 1.825 1.607 P 0.004* 0.007* 0.087 0.128 * P < 0.05。
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表 3 病变组与正常组杨氏模量值[M（P25，P75），kPa]
Table 3. Young’s modulus of lesion group and normal group [M（P25，P75），kPa]
项目 正常组（n = 22） 异常组（n = 40） U z P STE 13.370（11.8，15.9） 22.550（17.1，28.1） 106.000 −4.914 < 0.001* STQ 13.870（10.5，16.8） 21.760（16.4，33.4） 106.500 −4.907 < 0.001* *P < 0.05。
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表 4 不同病变组移植肾杨氏模量值比较 [M（P25，P75），kPa]
Table 4. Comparison of Young’s modulus of transplanted kidney in different lesion groups [ M（P25，P75），kPa]
项目 正常组
（n = 22）急性排斥组
（n = 5）慢性排斥组
（n = 11）病毒性肾病组
（n = 10）纤维化组
（n = 10）药物损伤组
（n = 4）H P STE 13.370
（11.8，15.9）15.550
（13.4，16.6）26.870
（21.6，38.6） Δ26.660
（19.5，34.2） Δ16.310
（13.2，23.1）27.690
（24.6，29.2） Δ39.647 < 0.001* STQ 13.870
（10.5，16.8）16.330
（15.5，17.4）23.780
（19.2，40.7）Δ22.760
（19.9，36.0）Δ16.540
（14.5，26.0）33.355
（29.1，35.4）Δ34.869 < 0.001* *P < 0.05。与正常组比较，ΔP < 0.05。
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表 5 病毒性肾病组与急性排斥反应组移植肾杨氏模量值比较[M（P25，P75），kPa]
Table 5. Comparison of Young’s modulus of transplanted kidney between viral nephropathy group and acute rejection group [M（P25，P75），kPa]
项目 急性排斥组（n = 5） 病毒性肾病组（n = 10） U z P STE 15.550（13.4，16.6） 26.660（19.5，34.2） 0.000 −3.062 0.002* STQ 16.330（15.5，17.4） 22.760（19.9，36.0） 0.000 −3.062 0.002* *P < 0.05。
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