伊藤 泰平

Although organ transplantation is becoming general practice, little is known about the safety of delivery. This is the first known case that describes injury to the kidney by the uterine fundal pressure maneuver during cesarean section in a pancreas and kidney transplant recipient. A 40-year-old pregnant woman (gravida 0, para 0) was referred to our clinic. She had undergone living donor kidney transplantation 11 years earlier and brain-dead donor pancreas transplantation 1 year earlier owing to type 1 diabetes. Cesarean section was indicated when the patient's blood pressure was 150/100 mmHg at 37 weeks. We pushed the uterine fundus during delivery of the infant, with our usual caution. Serum creatinine levels were 1.6-2.6 mg/dl postoperatively. As this elevation was considered to be due to kidney graft dysfunction, we performed computed tomography, which revealed a hematoma around the kidney graft. Fifteen days after the cesarean section, surgical removal of the hematoma was performed by the transplant surgery team. Following hematoma removal, the serum creatinine level decreased to <1.4 mg/dl. We present a case of kidney graft injury during cesarean section in a pancreas and kidney transplant recipient.

2001～2121年度の膵臓移植474例のうち膵移植後の抗体関連型拒絶反応(ABMR)に対し免疫グロブリン静注療法(IVIG)を用いた4例(男性2例、女性2例、移植時年齢40代3例、50代1例)について調査した。原疾患は4例全てI型糖尿病で、糖尿病性腎症の合併による血液透析中2例、腎移植後2例であった。観察期間中、全例で抗ドナー特異抗体(DSA)陽性を認めた。転帰は、ABMRを制御できず膵・腎グラフトを摘出しインスリン、透析再導入1例、膵グラフト生着3例のうち1例はABMR発症後にインスリン再導入となった。IVIG治療による有害事象は無く、治療後1年時点で全例生存しており生命予後は良好であった。

OBJECTIVES: About 90% of Japanese kidney transplantations are conducted from living donors, and their safety and the maintenance of their renal function are critical. This study aims to identify factors that affect the compensation of renal function in living kidney donors after donor nephrectomy. METHOD: In a retrospective cohort study, we reviewed data from 120 patients who underwent nephrectomy as living kidney transplant donors in our department from 2012 to 2021. Univariable and multivariable linear regression analyses were performed for donor factors affecting renal function after donor nephrectomy. RESULT: The multivariable linear regression model revealed that the donor's age (p = 0.025), preoperative estimated Glomerular Filtration Rate (eGFR) (p < 0.001), and hemoglobin A1c (HbA1c) (p = 0.043) were independent risk factors for eGFR at six months after nephrectomy. The eGFR deterioration was more strongly associated with age in females than in males, whereas higher HbA1c values were more strongly associated with eGFR deterioration in males. Higher donor age and higher HbA1c each enhance the deterioration of eGFR six months after living donor nephrectomy. The data suggest that old age in especially female donors and preoperative higher HbA1c in male donors have a harmful impact on their renal function compensation.