巴利昔单抗联合小剂量抗人T细胞兔免疫球蛋白诱导在肾移植中的应用效果分析

目的分析在肾移植免疫诱导治疗中联合使用巴利昔单抗和小剂量抗人T细胞兔免疫球蛋白(ATG-F)的安全性和有效性。方法回顾分析2014-01-01～2014-12-31在该院首次行同种异体肾移植术受者的临床资料以联合使用巴利昔单抗和ATG-F免疫诱导治疗的受者作为观察组,其对侧供肾受者且接受ATG-F单诱导者作为对照组,两组均采用他克莫司(FK-506)+霉酚酸酯+美卓乐三联维持治疗,共14对患者入组观察。对比两组患者术后1年内移植肾功能延迟恢复(DGF)、急性排斥反应(AR)、肺部感染和继发性糖尿病的发生率,以及肾功能、血FK-506谷浓度的差异。结果两组术后1年内均无移植肾失功及死亡患者。观察组和对照组的AR的发生率分别为14.29%(2/14)、7.14%(1/14),DGF的发生率分别为14.29%(2/14)、14.29%(2/14),观察组未出现继发性糖尿病,对照组出现1例,差异均无统计学意义(P0.05)。观察组术后1年内肺部感染的发生率为14.29%(2/14),对照组为21.43%(3/14),差异无统计学意义(P0.05)。观察组FK-506谷浓度在术后第3个月、6个月、9个月显著低于对照组(P0.05)。结论巴利昔单抗联合ATG-F的免疫诱导方案能有效预防肾移植术后排斥反应,不增加感染性并发症的发生率,同时可减少早期肾移植患者体内钙调神经蛋白抑制剂(CNIs)类药物的暴露量。     

少数民族患者肾移植后行利昔单抗、ATG免疫诱导的安全性比较

目的 比较少数民族患者肾移植后行巴利昔单抗、抗胸腺细胞球蛋白（ATG）免疫诱导的安全性.方法 选择肾移植后患者117例（10个民族）,随机分为巴利昔单抗免疫诱导48例（A组）、ATG免疫诱导34例（B组）、无免疫诱导35例（C组）,比较3组急性排斥反应（AR）、肺部感染、移植肾功能延迟恢复（DGF）及不良事件发生情况.结果 C组AR发生率为37.1％,明显高于A、B组的10.4％、11.8％（P均＜0.01）;3组总肺部感染率比较P＞0.05,巨细胞病毒（CMV）感染率A组低于B、C组（P均＜0.05）;C组DGF发生率明显高于A、B组（P均＜0.01）;3组术后不良事件发生率比较P＞0.05.结论 巴利昔单抗和ATG都可降低少数民族患者肾移植后的AR、DGF发生率,不增加肺部感染率,不影响术后不良事件发生,增加其安全性;在降低CMV感染率方面巴利昔单抗优于ATG.     

肥厚型心肌病患者心率震荡的临床意义

目的探讨窦性心率震荡对肥厚型心肌病患者预后的临床意义。方法根据有效24h动态心电图表现,分析比较肥厚型心肌病34例、心肌梗死和对照组各30例的TO、TS。结果与对照组TO、TS(-1.4±5.0%、16.6±9.8ms/RRI)比较,心肌梗死组TO高(-1.1±2.8%)、TS低(10.5±8.6ms/RRI),差异均有非常显著性意义(P均<0.01);而肥厚型心肌病组(-2.1±3.5%、17.9±13.8sm/RRI)差异均无显著性意义(P>0.05)。随访40±18.6月,3例肥厚型心肌病、10例心肌梗死患者出现不良心血管事件(心脏性死亡或充血性心力衰竭)。心肌梗死有无不良心血管事件患者比较,前者TO高(1.1±2.8%、-1.8±2.8%),TS低(5.6±4.3ms/RRI、12.1±9.0ms/RRI),差异均有显著性意义(P均<0.05);而肥厚型心肌病有无不良心血管事件患者比较,TO(-2.1±2.0%、-2.0±3.1%)、TS(18.7±10.8ms/RRI、18.2±14.0ms/RRI)差异均无显著性意义(P均>0.05)。结论肥厚型心肌病患者窦性心率震荡无异常,不能预测其临床预后。     

严重心力衰竭患者血清C反应蛋白变化及与预后的关系

目的:血清C反应蛋白(CRP)为急性反应蛋白,可反映机体免疫、应激和炎症状态。本研究旨在观察严重心力衰竭患者血清CRP水平变化,并进一步探讨其对严重心力衰竭患者预后的价值。方法:2003年3 月至2004年8月于我院心脏中心住院患者中连续观察138例严重心力衰竭(心功能Ⅳ级)患者,其中男88例, 女50例,年龄34-72(平均54±6.5)岁;缺血性心肌病66例,高血压心脏病14例,扩张性心肌病28例;除外合并感染和急性心肌梗死。入院次日和第七天空腹测定CRP水平(散射速粘法),记录住院心功能变化和心脏事件发生。入院一周内用超声心动图测定左室射血分数(LVEF)及左室舒张末容量(LVEDV),全部患者常规抗心衰治疗。结果:入院后患者按CRP水平被分为CRP升高组(A组,CRP 15±4.5 mg/L,75例)和CRP正常组(B组,CRP 2.5±1.7 mg/L,63例)。两组LVEF(%)和LVEDV(ml)分别为0.34±0.10、110±18及0.33±0.08、108±16,组间没有显著性差异。A组和B组住院期间死亡率分别为12%(9/75),1.7% (1/63),P<0.01;心功能改善率(≥1级)为20%(15/75),44.4%(28/63),P<0.01;住院时间为24±10 d,14±3 d(P<0.01)。结论:严重心力衰竭患者伴C反应蛋白增高者住院死亡率高,经系统药物治疗心功能恢复较差,住院时间明显延长,短期预后较差。C反应蛋白检测方法简单易行,可作为临床上判断心力衰竭患者预后的有效指标。     

冠状动脉支架术后三联抗血小板药物治疗对血小板功能的影响

目的探讨三联抗血小板药物治疗对冠状动脉(冠脉)支架术后患者血小板活化和聚集功能的影响。方法120例冠心病行冠脉支架植入术患者,随机分为三联组(阿司匹林、氯吡格雷和西洛他唑)和两联组(阿司匹林和氯吡格雷),三联组于术后第1天起加服西洛他唑。两组分别于术后第1天服用西洛他唑前及第5天测定血小板活化复合物(PAC-1)和CD_(62)p,同时测定5μmol/L及20μmol/L ADP诱导的血小板最大聚集率(MPAR)。结果两组临床基线资料及CD_(62)p、PAC-1和MPAR基线值差异均无统计学意义。分别计算各指标第二次测定值与基线值的差值,两组ΔMPAR差异无统计学意义,但三联组和两联组ΔCD_(62)p和ΔPAC-1分别为[(5.12±11.25)%比(1.08±4.97)%,P＜0.05]和[(12.12±12.30)%比(2.22±15.15)%,P＜0.01]。对急性冠脉综合征(ACS)患者亚组分析结果表明三联组ΔMPAR(5μmol/L)[(8.68±10.35)％比(2.92±13.06)%,P=0.018]、ΔMPAR(20μmol/L)[(11.05±11.14)%比(5.16±13.27)%,P=0.019]、ΔCD_(62)p[(5.57±12.08)％比(1.35±4.42)%,P=0.028】和ΔPAC-1[(11.62±12.73)%比(1.29±15.73)%,P= 0.001]均显著高于两联组。3个月临床随访显示三联组与两联组主要不良心、脑血管事件发生率分别为0和3.3%(2/60),出血发生率分别为5%(3/60)和3.3%(2/60),均无统计学意义。结论三联抗血小板药物治疗与常规两联治疗相比能更有效地抑制冠脉支架术后血小板活化和聚集,但其疗效和安全性还需大规模临床试验证实。     

肾移植患者个体化免疫诱导治疗方案的临床评价

目的:评价兔抗人T淋巴细胞免疫球蛋白(ATG-F)、巴利昔单抗(Basiliximab)在肾移植个体化免疫诱导治疗中的有效性及安全性,探讨肾移植免疫抑制诱导的个体化治疗方案. 方法:回顾性分析381例肾移植受者的临床资料,其中应用ATG-F诱导179例,Basiliximab诱导124例,78例未接受免疫诱导者为对照组.所有肾移植受者术后均采用常规免疫抑制方案抗排斥治疗.对不同组受者术前的一般情况、术后肾功能恢复、移植人/肾存活率及早期并发症的发生情况等进行对比. 结果:ATG-F组与Basiliximab组急性排斥反应、早期移植肾功能恢复、12月的移植人/肾存活率差异无统计学意义(P＞0.05),均优于对照组(P＜0.05);ATG-F组与Basiliximab组感染及相关并发症发生率稍高于对照组,但三组间比较无显著的统计学差异. 结论:临床应用抗体诱导治疗是安全、有效的,但应严格遵守适应证和禁忌证的筛选原则,采取个体化的免疫诱导疗法,积极预防相关并发症,有利于减少排斥反应的发生,提高移植人/肾的存活率.     

围术期应用胺碘酮预防治疗心脏术后心房颤动

目的评价心脏手术围术期预防性应用胺碘酮对术后心房颤动(简称房颤)的预防作用。方法采用双盲、随机研究,将124例心脏手术者随机分为胺碘酮组(n=64),对照组(n=60)。胺碘酮组术前每天服用胺碘酮200mg,3次/天,至少7天,术后改为每天口服200mg,1次/天,直到出院。对照组则服用安慰剂,其剂量及服药方法与胺碘酮组相同。术前服用时间为13±7天,总剂量为4.8±0.9g。结果胺碘酮组术后房颤发生率、房颤时的心室率均较对照组低(23.4%vs41.7%,112±21次/分vs135±31次/分,P均<0.05),两组围术期并发症的发生率及死亡率均无显著差异。胺碘酮组的住院时间较对照组短(14.9±3.3天vs20.5±2.6天,P<0.05)。结论心脏手术围术期预防性服用胺碘酮是安全的,并且能显著降低术后房颤的发生率及房颤发生时的心室率,缩短住院时间。     

老年人全胃切除术后的早期肠内营养支持

目的探讨术后早期肠内营养对老年全胃切除术后患者营养状态、免疫功能、感染性并发症、住院时间及营养支持费用的影响。方法57例老年全胃切除术后患者分为常规营养组、早期肠外营养组(肠外营养组)和早期肠内营养组(肠内营养组)。于手术前后检测营养和免疫指标,观察术后感染性并发症,统计住院天数及营养支持费用。结果术后9d,肠外营养组的血清白蛋白、转铁蛋白、前白蛋白、CD3、CD4、CD4/CD8分别为(34.3±3.5)g/L、(1.7±0.2)g/L、(258.8±20.2)mg/L、(39.7±5.4)%、(34.3±4.0)%和(1.5±0.3),肠内营养组分别为(33.9±3.1)g/L、(1.7±0.2)g/L、(260.5±24.7)mg/L、(42.8±6.5)%、(37.2±4.5)%和(1.7±0.2),均显著高于常规营养组的(29.5±3.0)g/L、(1.3±0.2)g/L、(235.4±13.9)mg/L、(34.8±5.0)%、(30.4±4.4)%和(1.2±0.2),差异均有统计学意义(P<0.01);肠内营养组的CD3、CD4、CD4/CD8水平显著高于肠外营养组(P<0.05)。肠外营养组感染性并发症少于常规营养组,高于肠内营养组。肠外营养组和肠内营养组的住院天数分别为(14.4±2.1)d和(11.2±1.8)d,均显著少于常规营养组的(19.5±3.3)d,差异均有统计学意义(均为P<0.01),而肠内营养组又显著少于肠外营养组(P<0.05)。肠内营养组营养支持费用为(1540.9±164.7)元,显著少于肠外营养组的(3986.4±456.5)元(P<0.01)。结论对于老年全胃切除术后患者,早期肠外营养和早期肠内营养均可行,但早期肠内营养可作为第一选择。     

口服Daptopril改善慢性充血性心力衰竭

本文研究了6例心肌病所致的严重充血性心力衰竭病人对Captopril的血液动力学反应。6例均为男性,35～54岁。4例特发性充血性心肌病,1例缺血性心肌病,1例肌强直性营养不良。全部血清电解质正常。2例血清肌酐升高,分别为2.7和1.7mg/dl。结果在1～3小时内右房压从10±2.6降至5±1.9mmHg(P<0.01),出现于心指数、体循环血管阻力变化之前。平均动脉压从73±5降至55±6.8mmHg(P<0.001),心指数从2.06±0.16增至2.85±0.32L/min/M~2(P<0.02),体循环血管阻力从1438±213降至837±188dyn·sec~(-1)·cm~(-5)(P<0.001)。所有病人左心室充盈压从平均24±2.2下降至18±2.9mmHg。心输出量增加,心率无改变。这些指数全部     

40例肾动脉狭窄血管内介入治疗降压疗效分析

目的探讨血管内介入治疗肾动脉狭窄患者的降压疗效。方法回顾分析40例肾动脉狭窄(狭窄>70%)患者行经皮肾动脉球囊血管扩张成形术(percutaneous transluminal balloon angioplasty,PTBA)和/或经皮肾动脉支架植入术(percutaneous transluminal renal artery stenting,PTRAS)的疗效,观察术前术后血压。结果总共治疗62支肾动脉,其中8支肾动脉行PTBA,54支肾动脉行PTBA+PTRAS,均成功。患者收缩压由术前(158.93±26.20)mmHg降至术后第一天的(138.45±22.46)mmHg(P<0.01),舒张压由术前(84.33±14.38)mmHg降至术后第一天的(77.25±12.08)mmHg(P<0.01),服用降压药物种数由术前(2.80±1.04)种减少为术后的(2.40±1.16)种(P<0.05)。1例患者术后3月猝死;余39例患者术后12月,收缩压降至(134.74±14.73)mmHg,舒张压降至(78.69±12.38)mmHg:39例患者中,3例治愈(7.69%),29例改善(74.35%),7例失败(17.95%),高血压获益率82.13%。结论血管内介入治疗可有效降低肾动脉狭窄患者的高血压。     

Relationship between acute rejection and cyclosporine or mycophenolic acid levels in Japanese heart transplantation.

BACKGROUND: Cyclosporine (CsA), Mycophenolate mofetil (MMF) and prednisolone (PSL) are widely used for the prevention of acute rejection after heart transplantation. Recently, the serum concentration - time curves (AUC) of CsA and MMF have been demonstrated to be precise predictors of acute rejection. METHODS AND RESULTS: Fourteen heart transplant patients were treated concomitantly with CsA, MMF, and PSL between May 1999 and November 2005 at the National Cardiovascular Center and of them 3 had acute rejection episodes [International Society for Heart & Lung Transplantation grade 3a]. Two patients (man in his 30 s; woman in her 40 s) had acute rejection with a mycophenolic acid (MPA) AUC(0-12 h) <30 microg x h x ml(-1) and low CsA AUC (AUC(0-4 h); 2,408 ng x h x ml-1, 1,735 ng x h x ml-1). However, 1 patient (man in his 30 s) with a high CsA AUC(0-4 h) (4,019 ng x h x ml-1) did not develop cardiac allograft rejection even if the MMF was temporarily stopped. These 3 patients were investigated to evaluate the relationship between acute rejection and pharmacokinetic parameters, including the CsA C0, C2, AUC(0-4 h) and MPA AUC(0-12 h). CONCLUSIONS: The findings suggest that a high CsA AUC(0-4 h) may prevent rejection of a cardiac allograft, even if MMF is stopped or drastically reduced.     

Prevention of early acute rejection with daclizumab and triple immunosuppression in cadaveric renal allograft recipients

We carried out a prospective study of the safety and efficacy of daclizumab combined with triple immunosuppression in adult recipients of at least one HLA-mismatched cadaveric renal allograft. All studied patients received the same immunosuppression: a daclizumab infusion of 1 mg/kg immediately before transplantation, and at 2, 4, 6, and 8 weeks following the transplantation. Infusion of cyclosporine (CsA) (0.08 mg/kg/h) was started at the time of the operation and continued by CsA microemulsion (CsA-Neoral), 3 mg/kg twice daily on day 2, methylprednisolone, 0.4 mg/kg intravenously at operation, and mycophenolate mofetil started on day 1. The dose of CsA-Neoral was adjusted to maintain target blood trough levels. Oral methylprednisolone was tapered by 4 mg per week to achieve a maintenance dose of 0.08 mg/kg/day. Fifty-five patients, with a mean age of 48 +/- 11 years, were studied. Six of them received a second renal allograft. The mean donor age was 38 +/- 14 years. Mean cold ischemia time was 19.5 +/- 6.5 h, mean value of HLA-antigen mismatches was 2.7 +/- 0.9, mean latest PRA value was 3 +/- 7%. Fifteen patients experienced delayed graft function. During a follow-up period of 3 months three acute rejection episodes occurred. One patient died because of systemic aspergillosis. After 3 months mean serum creatinine was 104 +/- 38 micromol/L. Five renal allografts failed, one of them due to rejection. Patient and graft survival was 98.2% and 90.9%, respectively. Daclizumab with this triple therapy represents safe and efficient immunosuppression strategy, demonstrated with low incidence of early acute rejection episodes and an acceptable adverse event profile in cadaveric renal allograft recipients.     

肾移植术后抗排斥药FK506的临床应用

目的研究FK506预防肾移植术后排斥反应的效果和安全性。方法肾移植患者22例,其中18例为始用组,4例为切换组。FK506起始用0.2me／(kg·d),以后逐步减量,3个月后维持血浓度于3～12μg/L水平。切换组于停用CsA24h后应用FK506,剂量和血浓度与始用组相同。同时合并应用MMF0.5g,每日3次口服,以及术后前10天大剂量甲基强的松龙静滴,第11天改强的松口服并减量,6个月后维持强的松15mg／d。所有病例均严密观察并行血尿等生化分析。结果始用组移植肾功能好,平均血肌酐水平l02μmol／L,无一例出现排斥反应。切换组中2例异常的肝功能好转;肾功能进行性减退的2例切换后,血肌酐相对稳定。有血糖升高4例和高血压5例,用药后能控制,其他副反应有上呼吸道和下尿路感染、胸痛、恶心、呕吐、腹泻、腹部不适等。结论FK506是肾移植术后有确切疗效的基础抗排斥药,与MMF、皮质醇合用能有效地预防急性排斥的发生,并可控制慢性排斥的进展。应用剂量适当,无明显的肝、肾毒副作用,但有血糖升高及高血压副作用,药物可以控制。其它呼吸道、尿路、消化道和神经系统副反应轻,不妨碍临床用药。     

Formation of microchimerism in rat small bowel transplantation by splenocyte infusion

AIM: To investigate the effect of donor splenocyte infusion combined with cyclosporine A (CsA) on rejection of rat small bowel transplantation (SBT). METHODS: Male Sprague-Dawley (SD) rats and female Wistar rats weighing 230-270 g were used as donors and recipients respectively in the study. Heterotopic small bowel transplantation was performed. The rats were divided into three groups: group one receiving allotransplantation (SD rarr Wistar), group two receiving allotransplantation (SD rarr Wistar) + donor splenocyte infusion, group three receiving allotransplantation (SD rarr Wistar) + donor splenocyte infusion + CsA followed by CsA 10 mg/kg per day after transplantation, in which recipient Wistar rats were injected with 2 x 10(8) SD splenocytes 28 d before transplantation, and treated with CsA after transplantation. Finally, the specific DNA fragment of donor Y chromosome was detected in recipient peripheral blood and skin by PCR. The survival time after small bowel transplantation was observed. Gross and histopathological examinations were performed. RESULTS: The survival time after small bowel trans-plantation was 7.1 +/- 1.2 d in group 1, 18.4 +/- 3.6 d in group 2 and 31.5 +/- 3.1 d in group 3. The survival time was significant longer (P < 0.01) in group 3 than in groups 1 and 2. The gross and histopathological examination showed that the rejection degree in group 3 was lower than that in groups 1 and 2. CONCLUSION: Donor splenocyte infusion combined with CsA decreases remarkably the rejection and prolongs the survival time after rat small bowel transplantation.     

Changes in lipoprotein(a) concentration after orthotopic heart transplantation

BACKGROUND: Elevated concentrations of lipoprotein(a) have been considered an important risk factor in the development of premature cardiovascular disease and have been proposed as a risk factor in the development of accelerated cardiac allograft vasculopathy after orthotopic heart transplantation. METHODS: We prospectively measured lipoprotein(a), fasting cholesterol, and triglyceride concentrations before (n = 38), 6 months (n = 38), and 1 year (n = 21) after orthotopic heart transplantation. The mean age of the patients was 52 +/- 2 years. Eighty-seven percent of the patients were men, 82% were white, and 61% had ischemic cardiomyopathy. RESULTS: Mean lipoprotein(a) concentration was lower 6 months after transplantation than it was before the operation (23 +/- 3 mg/dL vs 17 +/- 3 mg/dL; P =.014) and remained low 1 year after transplantation (23 +/- 3 mg/dL vs 18 +/- 4 mg/dL; P = not significant). In contrast, mean cholesterol concentration was higher 6 months after transplantation (171 +/- 8 mg/dL vs 221 +/- 8 mg/dL; P <.001) and 1 year (171 +/- 8 mg/dL vs 205 +/- 10 mg/dL; P <.01) than it was before transplantation. Triglyceride concentration was higher 1 year after transplantation than it was before the operation (146 +/- 13 mg/dL vs 184 +/- 20 mg/dL; P =.017). CONCLUSIONS: Lipoprotein(a) concentrations decrease during the 6 months after transplantation and stay low for at least 1 year after the operation. Additional studies are needed to ascertain the effect these changes in lipoprotein(a) concentration on the development of cardiac allograft vasculopathy.     

Influence of liver nonparenchymal cell infusion combined with cyclosporin A on rejection of rat small bowel transplantation

AIM: To investigate the effect of liver nonparenchymal cell infusion combined with cyclosporin A (CsA) on rejection of heterostrain rat small bowel transplantation.METHODS: The liver nonparenchymal cell suspension was prepared by density gradient centrifugation method with Percoll centrifugal solution. Heterotopic small bowel transplantation was performed. Then the rats were divided into four groups. Group one: homogenic transplantation (F344/N→F344/N), group two: allotransplantation (F344/N →Wistar), group three: allotransplantation (F344/N→Wistar)+ CsA, with CsA 1O mg.kg-1.d-1 after transplantation, group four: allotransplantation + CsA (F344/N→Wistar) + liver nonparenchymal cell infusion + CsA (F344/N→Wistar), in which recipient Wistar rats had been injected with 2×108 F344/N liver nonparenchymal cells 20 days before transplantation, and treated with CsA after transplantation.Finally, the survival time after small bowel transplantation,gross and histopathological examination, and IL-2 levels in serum were observed.RESULTS: The survival time after small bowel transplantation was 7.14±0.33 d, 16.32±0.41 d and 31.41±0.74 d in group 2, 3, and 4, respectively. The survival time was significant longer (P＜0.01) in group 4. The gross and histopathological examination showed that the rejection degree in group 4 was lower than those in groups 2 and 3. Serum IL-2 level in group 4 was also lower than those in groups 2 and 3 (P＜0.01).CONCLUSION: Liver nonparenchymal cell infusion combined with CsA can prolong the survival time of rat small bowel transplantation, and the anti-rejection effect is good.     

Influence of race in heart failure and cardiac transplantation: mortality differences are eliminated by specialized,comprehensive care

BACKGROUND: Differences in mortality are thought to exist between African Americans and Caucasians with heart failure. These differences may be due to a variety of factors, including differences in disease process, socioeconomic status, and access to health care. Additionally, little data exist on racial differences between these two groups after cardiac transplantation. This study examines a single center, urban experience in treating African Americans and Caucasians with heart failure and after cardiac transplantation. We hypothesize that treatment in a specialized, comprehensive heart failure/cardiac transplantation program results in similar survival between African Americans and Caucasians. METHODS: We retrospectively reviewed the Rush Heart Failure and Cardiac Transplant Database from July 1994 to August 2000. Variables analyzed in the cardiomyopathy patients included survival (until death, placement of left ventricular assist device or cardiac transplantation), number of hospitalizations per year, length of stay per year, and utilization of outpatient resources. Follow-up period was from initial visit to death, transplantation, or implantation of left ventricular assist device. In those who underwent cardiac transplantation, we examined rejection rates (cellular and humoral), rejection burden, hospitalization data, and 5-year survival. A subgroup bridged to cardiac transplantation with a left ventricular device was also analyzed. RESULTS: Seven hundred thirty-four cardiomyopathy patients were identified: 203 were African Americans and 531 were Caucasians. The etiology of cardiomyopathy was more commonly ischemic in Caucasians as compared to non-ischemic in African Americans (P <.01). African Americans had more admissions to the hospital per year compared with Caucasians, 1.2 +/- 2.1 versus.5 +/- 1.1 (P <.01) with longer length of stay per year, 1.4 +/- 25.2 days versus 4.4 +/- 14.3 days (P <.01). Utilization of outpatient resources was significantly higher in African Americans compared with Caucasians with more use of continuous inotropes (13% versus 6%, P <.01), intermittent inotropes (11% versus 5%, P <.01), and home nursing after hospital discharge (52% versus 32% of hospital discharges, P <.01). Survival by Kaplan-Meier analysis was comparable between the two groups (mean survival 1,470 +/- 72 days in African Americans versus 1521 +/- 46 days in Caucasians, log rank test [P =.6]). During this time, 30 African Americans and 73 Caucasians underwent cardiac transplantation. Fifty-three were bridged to transplantation with a left ventricular assist device (20 African Americans, 33 Caucasians). There were no differences in 5-year survival by Kaplan-Meier analysis despite higher peak preoperative panel reactive antibody levels in African Americans versus Caucasians (12% +/- 30% compared with 5% +/- 15%, P =.04), more overall treated rejection episodes per year in the African Americans (P <.01), as well as more posttransplant hospitalizations (2.2 +/- 1.2 times per year as compared with 1.7 +/- 2.1 times per year, P =.04). CONCLUSION: Delivery of care to heart failure patients in a comprehensive, specialized program results in similar survival regardless of race despite higher utilization of inpatient and outpatient resources. The finding that, after cardiac transplantation, African Americans do not have higher mortality rates, despite having higher rates of rejection overall and more hospitalizations, further supports the hypothesis that optimal care can improve outcomes despite unfavorable baseline clinical characteristics.     

Conversion to mycophenolate mofetil for modulating recurrent hepatitis C in liver transplant recipients

BACKGROUND: The aim of this study was to analyze the influence of cyclosporine A (CsA) taper in conjunction with mycophenolate mofetil (MMF) therapy on recurrent hepatitis C virus (HCV) in liver transplant patients. PATIENTS AND METHODS: Nineteen liver recipients with serologically and morphologically confirmed recurrent HCV were included in this study. After MMF introduction up to a maximum dose of 2000 mg/day, CsA dose was significantly tapered. In the control group immunosuppression remained unchanged. Allograft function and morphology, viral loads, and renal function were analyzed continuously. RESULTS: MMF treatment was well tolerated without risk of rejection. Allograft fibrosis progressed in 6 patients of the MMF group (66.6%) and none (0%) of the controls at 12-month biopsy (P=0.005). Moreover, aminotransferases and viral loads increased slightly in the MMF-treated patients. Renal function improved significantly (serum creatinine: 239.3+/-90.2 micromol/L vs. 175.8+/-46.0 micromol/L; P=0.008) in the treatment group, while deteriorating (serum creatinine: 156.8+/-44.6 micromol/L vs. 214.8+/-120.1 micromol/L; P=0.06) in the controls. CONCLUSION: MMF introduction allows a safe CsA taper in HCV-positive liver transplant patients and results in significant improvement of renal function. However, there seems to be a risk of marked progression of HCV-induced allograft injury.     

肾移植术后雷帕霉素临床短期对照试验

目的：评价肾移植术后应用雷帕霉索（sirolimus，SRL）的疗效和药物的不良反应。方法：实验组：20例同种异体尸体供肾移植患者，免疫抑制方案为环孢素A（CsA）＋SRL＋强的松（Pred）；对照组：15例同种异体尸体供肾移植患者，免疫抑制方案为CsA＋霉酚酸酯（MMF）＋Pred。对比二组在术后6个月内的疗效和药物的不良反应。结果：两组患者肾脏6个月内均带功能存活。实验室检查无统计学差异，但急性排斥发生率、并发症及药物的副作用明显不同。实验组（n=20）：急性排斥1例（5％），移植肾功能延迟1例（5％），肺部感染3例（15％），血脂异常11例（55．0％，胆固醇升高3例，三酰甘油升高4例，二者皆升高4例），肝功能异常3例（15％）；对照组（n=15）：急性排斥2例（13．3％），肺部感染2例（13．3％），血脂异常5例（33．3％，胆固醇升高1例，三酰甘油升高2例，二者皆升高2例）；腹泻6例（40％），白细胞减少1例。结论：肾移植术后应用CsA＋SRL＋Pred三联免疫抑制治疗方案，其急性排斥发生率低于CsA＋MMF＋Pred的方案，但血脂异常发生率较高。     

中老年肾移植患者早期撤除激素的免疫抑制方案研究

目的 评价中老年肾移植患者早期撤除激素的安全性及有效性. 方法 80例中老年肾移植患者随机分为撤激素组39例和常规治疗组41例.所有患者开始均采用环孢素A(CsA)+吗替麦考酚酯(MMF)+泼尼松(Pred)三联免疫抑制方案,Pred开始剂量为20 mg/d,撤激素组Pred逐渐减量(每周减量5 mg),术后1个月停用;常规治疗组Pred 3个月后减量为10 mg/d,6个月后减为5 mg/d维持.MMF、CsA起始用量相同.随访观察患者急性排斥反应(AR)发生率、移植肾功能、人存活率、肾存活率,感染情况、血糖、血压、体质量、血脂等指标. 结果 撤激素组、常规治疗组AR发生率相似(分别为23.1%和19.5%,χ~2=0.15,P>0.05).两组患者1、2、3年人存活率分别为97.4%、94.8%、88.0 0A和97.6%、97.6%、87.8%,差异无统计学意义(χ~2=0.1 7,P>0.05);肾存活率分别为94.9%、88.6%、83.7%和95.1%、91.5%、79.5%,差异无统计学意义(χ~2=0.07,P>0.05). 结论 老年肾移植患者早期撤除激素是可行的.