无血缘夫妻活体供肾7例肾移植

背景：通过诱导移植受体产生供-受体嵌合体或免疫耐受以利于受体长期存活,一直是器官移植的研究热点,并且在实验动物模型中获得了大量成功的经验和知识。在临床实践中也观察到结婚多年的夫妻,丈夫-妻子器官移植后排斥反应小,具有比其他的亲属器官移植有更多的优点。 目的：回顾性分析无血缘关系的活体供肾移植—丈夫对妻子供肾移植的临床效果。 方法：选择7例夫供妻活体肾移植,供者年龄 32~58岁,受者年龄 31~56岁,双方婚龄在5~36年。供、受者 ABO血型完全相同者 4例,O-B 1例,O-A 1例,A-AB型 1例。淋巴细胞毒交叉配合试验阴性。HLA配型情况：1个抗原错配 1例,2个抗原错配 2例,3个抗原错配3例,4抗原错配 1例。开放手术取肾,6例左肾,1例右肾。术后采用三联免疫抑制方案：环孢素A/他克莫司+麦考酚酸吗乙酯+泼尼松预防排斥反应,7对供受者随访3~70个月。 结果与结论：手术成功率100%,供受者均未发生手术相关并发症,所有供者血压、尿常规及肾功正常,受者及移植肾全部存活。验证了虽然移植前组织配型结果较差,但由于夫妻间长期生活在一起产生的免疫耐受,使夫供妻肾移植后排斥反应小、移植效果理想,具有比其他的亲属肾移植有更多的优点。     

老龄供者亲属肾移植120例

背景：为了保证老龄供肾的移植效果,应当慎重选择供者。国内活体肾移植开展较晚,对老龄亲属供肾移植经验仍较欠缺。 目的：对老龄供肾亲属肾移植的效果和安全性进行分析。 方法：纳入120例行活体肾移植的供、受者资料进行回顾性分析,其中夫妻间供肾12例,父母供给子女75例,其他亲属供肾33例,供者 55岁以上52例。比较老年供者和非老年供者移植前血清肌酐值,移植后肾功能恢复状况及并发症发病率等,同时对2组受者的移植前后血清肌酐及并发症进行比较。 结果与结论：两组供者移植后肾功能恢复良好,无显著性差异;两组受者在移植后1周,1个月,1年内比较血清肌酐差异无显著性意义,急性排斥发病率差异亦无显著性意义。提示,老龄供者制定合理入选标准,对供者是安全的,受者和移植肾近期效果良好。     

肾移植受者游离血浆中微嵌合体与移植肾免疫耐受的相关性研究

目的:研究在移植受者血液标本中供者和受者源性DNA嵌合体存在是否可以作为预测移植器官免疫状态的一个标准.方法:126名获得男性肾脏的女性移植受者被纳入该项研究,通过RT-PCR方法检测这些女性受者血浆中Y染色体的特异基因序列SRY1,DYZ11st,DYZ12nd.结果:126名获男性肾脏的女性肾移植受者中,97名(77%)血浆中可检测到SRY1,DYZ11st,DYZ12nd序列.移植肾功能维持正常的平均持续时间,在微嵌合体阳性组及微嵌合体阴性组分别为8.7年和5.4年;肾移植术后急性排斥反应发生率在微嵌合体阳性组和阴性组分别为10%和28%;微嵌合体阳性病人血清肌酐水平明显低于微嵌合体阴性病人.结论:肾移植术后某些受者血浆中存在DNA微嵌合体,通过使用定量RT-PCR检测血浆中DNA微嵌合体可能成为衡量移植肾耐受状态的一个预测指标.     

高龄亲属活体供肾移植7例中长期效果：同一机构2年资料回顾分析

背景：随着肾移植中肾供体的短缺,“边缘”供肾提供了一条缓解途径。 目的：观察高龄亲属活体供肾移植的安全性和中长期临床效果。 方法：回顾性分析随访36~64个月的7例≥65岁亲属活体供肾移植的供者和受者的临床资料。 结果与结论：供、受者移植后均恢复顺利,无严重并发症。受者1周内移植肾功能正常、供者肾功能较术前略有增高、但均在正常范围内。无排斥反应发生。5例人/肾正常存活36~64个月;2例移植后≥1年死亡。供者均正常存活,无蛋白尿、高血压,肾功能正常。提示≥65岁高龄亲属活体供肾应经过严格筛选,部分可为临床扩大供肾来源。     

骨髓干细胞输注联合低剂量他克莫司在肾移植中诱导嵌合体的形成

背景:骨髓细胞嵌合体通过有效的免疫耐受机制,使其成为临床用于移植免疫耐受的主要候选方法。目的:探讨大鼠肾移植及活体肾移植中骨髓干细胞移植对免疫耐受的诱导作用及机制。方法:①大鼠肾移植:40只Wistar大鼠(雌雄各半)随机分为实验组和对照组,进行肾移植手术,术前经门静脉分别注射骨髓干细胞及生理盐水,30d后观察肉眼和光镜下排斥反应及检测嵌合体的形成。②活体肾移植:实验组为夫妻或亲属共5对,供者均为男性,受者为女性。术前应用他克莫司口服,供者皮下注射生白细胞药物,采集白细胞悬浊液,以流式细胞仪测定CD34细胞比例,0.7%以上为骨髓干细胞含量合格,并通过外周静脉输注至受者体内,10d后同法再输注1次,1周内行移植手术,术后复查肾功,于半年后采用荧光原位杂交的方法检测Y基因片段。对照组为正常活体肾移植手术,未行骨髓干细胞移植。结果与结论:动物实验组大体和光镜下排斥反应均较轻微,嵌合体检测均为阳性,活体实验组嵌合体检测4例为阳性,而对照组仅1例为阳性。提示应用他克莫司并输注供者骨髓干细胞,可诱导一定的免疫耐受。移植前输注供者骨髓干细胞形成的嵌合体与免疫耐受有关。     

夫妻间活体供肾移植

背景：近几年随着各项移植法规相继出台,中国做为器官移植大国,发展迅速,除了尸体肾移植外,活体肾移植亦得到健康快速发展,夫妻供肾做为没有直接血缘关系的活体移植,在器官移植界占据着重要地位。 目的：观察夫妻间供肾亲属活体肾移植的疗效。 方法：郑州人民医院器官移植科2008-10/2010-09进行夫妻间供肾移植11例,同期尸体供肾肾移植83例为对照组。两组受者均采用供肾静脉与髂外静脉端侧吻合,供肾动脉与髂内动脉端端吻合,输尿管-膀胱乳头式吻合,隧道包埋。免疫抑制诱导方案采用甲基泼尼松龙,基础免疫抑制采用钙调磷酸酶抑制剂(他克莫司或环孢素)、吗替麦考酚酯、肾上腺皮质激素(激素)三联免疫治疗,根据血药谷浓度调整他克莫司或环孢素的用量。移植后6个月内进行随访,评价两组受者移植后的肾功能恢复及早期并发症发生情况。 结果与结论：肾移植后两组急性排斥反应、移植物功能延迟恢复等早期并发症发生率比较,夫妻肾移植组优于尸体肾移植组,差异有显著性意义(P < 0.05)。结果提示夫妻间肾移植由于移植前准备充分,肾脏缺血时间短及夫妻间长期共同生活产生相应的免疫耐受,其疗效优于同样无血缘关系的尸体供肾移植。     

手辅助腹腔镜及开放手术在切取活体供肾中的应用

目的 探讨利用手辅助腹腔镜及开放手术切取亲属活体供肾两种不同手术方法的可行性及临床效果。方法 分别采用手辅助腹腔镜及开放手术进行亲属活体供肾切取，常规方法移植给受者，并对肾移植供、受者的恢复情况进行观察。结果 2例均成功切取左肾并移植给受者，热缺血时间分别为3min及30s，血管开放后5min及2rain供肾泌尿，无排斥反应及并发症。供者术后6d及7d出院，无并发症。结论 手辅助腹腔镜及开放手术行供肾切取在技术上均安全，对供肾功能无影响。手辅助腹腔镜对供者创伤相对小，恢复快；开放手术时供肾的热缺血时间更短。     

亲属活体肾移植供者的临床评估

背景：随着活体肾移植的广泛开展,如何保证活体肾移植供者的长期存活愈发引人关注。 目的：总结79名亲属活体供肾移植的临床评估情况,评价其效果及安全性。 方法：广西中医学院附属瑞康医院移植泌尿外科在2007-06/2010-08共完成亲属活体供肾移植评估79名,回顾分析供者相关的临床资料及移植的效果。 结果与结论：经评估共有38名供者合格,所有供者手术时间1.0-2.0 h,供肾热缺血时间15 s左右,冷缺血时间1.0-2.0 h,围手术期间无外科及内科并发症发生。随访至2011年8月,所有供、受者均正常生存,移植肾功能均保持在正常范围。采用比较严格的供者评估方式是保证供者长期存活的必要手段。     

脑死亡供肾肾移植受者的近期状况分析

背景：供者短缺严重限制了肾移植的发展,脑死亡供肾在一定程度上缓解了供肾短缺的问题。 目的：比较脑死亡供肾与尸体供肾肾移植患者移植后短期预后情况,初步探讨脑死亡供者在肾移植临床应用中的安全性。 方法：回顾性分析肾移植90例患者移植过程中和移植后情况,其中80例供者为尸体供肾,10例为脑死亡供肾,比较两组受者移植中出血量、手术时间、移植后移植肾功能恢复情况、各种并发症的发生率及移植后近期生存情况(围手术期、移植后6个月)的差异。 结果与结论：两组间移植时间、移植过程中出血量比较差异无显著性意义,移植后1,6个月生存率及移植后并发症的发生率比较,差异亦无显著性意义。说明脑死亡供肾与尸体供肾肾移植患者移植后早期预后无明显差异,安全可靠。     

亲属活体供肾移植后低剂量钙调蛋白酶抑制剂的应用

背景：亲属活体肾移植供、受者移植前准备充分,供肾热、冷缺血时间较短,HLA配型的组织相容性好,移植后排斥反应发生率低,为亲属活体供肾肾移植后采用低剂量免疫抑制剂方案提供了可能性。 目的：探讨亲属活体供肾移植后低剂量钙调蛋白酶抑制剂的安全性和有效性。 方法：选取2006-01/2008-06在南京医科大学第一附属医院肾移植中心行亲属活体供肾移植的受者38例,移植后常规使用环孢素A/他克莫司+吗替麦考酚酯+泼尼松的三联免疫抑制方案。将38例患者随机分为两组：CNI常规剂量组(n=18),移植后初始药物剂量为环孢素A 6 mg/(kg•d)或他克莫司0.12 mg/(kg•d);CNI低剂量组(n=20),术后初始药物剂量为环孢素A 4 mg/(kg•d)或他克莫司0.08 mg/(kg•d);两组吗替麦考酚酯和泼尼松使用剂量相同。移植后密切随访,比较两组患者移植后不同时期的肾功能以及急性排斥反应、肺部感染、肝功能损害、肾毒性等并发症的发生情况。 结果与结论：随访12个月,CNI常规剂量组重度肺部感染死亡1例,CNI低剂量组无死亡病例。两组移植肾功能及急性排斥反应发生率比较差异均无显著性意义(P > 0.05);CNI低剂量组肝功能损害、钙调蛋白酶抑制剂肾毒性发生率显著低于CNI常规剂量组 (P < 0.05)。此外,采用低剂量钙调蛋白酶抑制剂免疫抑制方案明显减轻了亲属肾移植患者的经济负担。说明亲属活体供肾移植后采用低剂量钙调蛋白酶抑制剂的免疫抑制剂方案安全、有效。     

夫妻活体供肾移植与血缘亲属供肾移植

背景：夫妻间活体肾移植尽管在组织配型方面差于血缘关系供肾移植,但在临床实践观察中夫妻肾移植与血缘关系肾移植间近期疗效并无明显差异。 目的：对比同期实施的夫妻活体供肾移植和血缘亲属供肾移植的临床疗效,总结夫妻活体供肾移植的临床经验。 方法：回顾性分析郑州人民医院实施的夫妻活体供肾移植18例及血缘亲属供肾移植100例的临床资料,通过对两组移植前组织配型情况和移植后(1,3,6个月)肾功能恢复情况,移植肾功能延迟恢及半年内急性排斥反应发生率、感染发生率等指标的分析,对夫妻活体供肾移植和血缘亲属供肾移植的临床疗效进行比较。 结果与结论：同期进行的18例夫妻活体供肾移植组织配型情况较血缘关属供肾移植患者情况差。在移植方案及免疫抑制治疗方案相同的情况下,夫妻活体供肾移植后6个月内血肌酐恢复情况、术后移植肾功能延迟恢、急性排斥反应发生率、感染发生率,均与同期进行的血缘亲属活体供肾移植差异无显著性意义(P > 0.05)。结果表明,无血缘关系的夫妻间供肾移植与血缘亲属供肾移植治疗效果相近。     

A pilot study of calcineurin inhibitors (CNIs) and steroid avoidance immunosuppressive protocol among living donor kidney transplant recipients

Calcineurin Inhibitors (CNIs) and Corticosteroids have been the main immunosuppressive agents in solid organ transplantation. Many studies have confirmed the positive impacts of withdrawal/avoidance of these agents, separately, on their side effect profiles. A pilot study was performed avoiding both agents among low-immunological-risk living donor kidney transplant recipients at a single center. Seventeen recipients were maintained on the double avoidance protocol during the study period beginning July 2002 through December 2003. Three rejection episodes occurred (out of ten) among related donor kidney recipients and six episodes (out of seven) among unrelated donor kidney recipients. Although most of the rejections were reversed with a short course of corticosteroids, the protocol was revised to exclude the unrelated donor kidney recipients. There were higher incidences of wound complications among recipients who received the initial loading dose of Sirolimus. Double avoidance of CNIs and corticosteroids is possible in living donor kidney transplant recipients with an acceptable incidence of rejection. Proper management of the side effects of Sirolimus could further minimize the incidence of rejection. A multi-center randomized study is recommended in order to recognize the benefits of avoiding CNIs and corticosteroids in renal transplant recipients.     

活体亲属供肾肾移植的临床分析

目的　总结分析活体亲属供肾肾移植的手术和治疗经验 ,探讨其临床效果 .方法　回顾性分析 33例活体亲属供肾肾移植的临床资料 ,包括手术方法和创新、免疫抑制药物的用药方案及临床效果 .结果　本组全部切取左肾 ,经腹手术 ,手术顺利 ,移植肾在开放血液循环后 1～ 10分钟内分泌尿液 .供体肾功能在 1周内恢复正常 ,未出现严重并发症 .受者仅 2例出现急性排斥反应 .全部受者至今存活 ,肾功能良好 .结论　活体亲属供肾 ,移植效果明显优于尸体供肾肾移植 .排斥反应发生率低 ,恢复顺利     

Clinical correlations of peripheral blood microchimerism after liver transplantation

The aim of this study was to evaluate microchimerism after human liver transplantation (LT). This study included 13 female recipients who received hepatic allograft from male donors at Asan Medical Center. A nested PCR specific for Y-chromosome gene (DYZ3) was used to analyze the small number of male cells in the peripheral blood mononuclear cells of the female recipients. Microchimerism was observed in 6 of 13 recipients and 16 out of 35 samples. Only 3 patients showed microchimerism 3 months after LT. There was no statistical difference between the presence of microchimerism and clinical findings such as type of donor, type of immunosuppression, episode of rejection and age of recipient. This study did not show any clinical relevance of microchimerism and further larger study are needed to confirm the results.     

Renal transplantation in children. A report of the North American Pediatric Renal Transplant Cooperative Study.

BACKGROUND. Previous studies of renal transplantation in children have focused on the survival of grafts and patients. Little information is available about the cause of renal disease, the sources of donated organs, or children's growth after transplantation. The North American Pediatric Renal Transplant Cooperative Study was organized to identify the diseases that require transplantation and to analyze factors that affect the success of transplantation in children. METHODS. We collected data from 73 pediatric transplantation centers from 1987 through 1990. These data included information about demographic characteristics of patients, graft function, and therapy one month after transplantation and every six months thereafter for each patient 17 years of age or younger. RESULTS. Altogether, 1550 children received 1667 renal allografts during this period; 31 percent of the children were five years of age or younger. Forty-three percent of the transplanted kidneys came from a living related donor, and 57 percent from a cadaver. The two most common causes of renal disease leading to transplantation were congenital malformations of the kidneys and urinary tract (42 percent of the patients) and focal segmental glomerulosclerosis (12 percent). One year after transplantation, the rate of graft survival in recipients of a kidney from a living related donor was 89 percent; it was 80 percent after three years. For recipients of cadaver kidneys, the comparable rates were 74 percent and 62 percent, respectively (P less than 0.001). The best growth was observed in patients who were no more than five years old at the time of transplantation. During follow-up, 79 patients died, and cancer developed in 12 patients. CONCLUSIONS. The most common causes of end-stage renal disease in children and adolescents are congenital malformations of the kidneys and urinary tract and focal segmental glomerulosclerosis. The rates of graft survival at one and three years are better in children and adolescents who receive a kidney from a living related donor than in those who receive a kidney from a cadaver.     

First two AB-incompatible living kidney transplantations in the Balkans--should it be a procedure of choice in a developing country?

Kidney transplantation is the best available medical intervention for the treatment of end-stage renal failure. However, as a consequence of the growing gap between organ supply and demand, many patients die waiting for an organ each year. In order to increase the number of organs, living donor (LD) transplantation from unrelated and ABO-incompatible (ABOi) donors have been introduced over the last few decades. While in the past ABOi transplantation resulted in hyperacute or acute antibody-mediated rejection, the tremendous progress in this area in recent years has shown that it can be overcome by careful patient management, including protocols to remove or lower antibodies, along with stronger immunosuppression and intensive monitoring. The organ shortage problem is even more prominent in regions such as the Balkans where cadaver transplantation has not been well developed. In addition to the introduction of expanded criteria for living donation (elderly and marginal donors), we performed the first two ABOi/LD transplantations in the Balkans in the last 2 years using an already established preconditioning regimen and maintenance therapy with cyclosporine, mofetil mycophenolate and prednisolon. We report our modest experience of a case in which the patient developed lymphadenopathy, sarcomatosis and died after one year; and a second case with accelerated acute rejection and hemorrhagic necrosis with explantation of the graft after a month. Taking into account the high cost of the desensitization procedure and induction therapy as well as the need for intensive monitoring throughout the standardized procedures and facilities, we might reconsider whether ABOi living kidney transplantation should be a procedure of choice in developing countries.     

Donor bone marrow infusion in deceased and living donor renal transplantation

The infusion and persistence in a transplant recipient of donor-derived bone marrow cells (DBMC) of multi-lineage can lead to a state of permanent chimerism. In solid vascular organ transplantation, the donor bone marrow lineage cells can even be derived from the transplant organ, and these cells can be detected in very small numbers in the recipient. This has been called microchimerism. Much controversy has developed with respect to the function of chimeric cells in organ transplantation. One idea is that the occurrence of these donor cells found in microchimerism in the recipient are coincidental and have no long-term beneficial effect on engraftment. A second and opposing view, is that these donor cells have immunoregulatory function that affect both the acute and chronic phases of the recipient anti-donor responses. It follows that detecting quantitative changes in chimerism might serve as an indication of the donor-specific alloimmune or regulatory response that could occur in concert with or independent of other adaptive immune responses. The latter, including autoimmune native disease, need to be controlled in the transplant organ. The safety and immune tolerance potential of DBMC infusion with deceased and living donor renal transplants was evaluated in a non-randomized trial at this center and compared with non-infused controls given identical immunosuppression. Overall DBMC infusions were well tolerated by the recipients. There were no complications from the infusion(s), no episodes of graft-vs-host disease (GVHD) and no increase infections or other complications. In the deceased DBMC-kidney trial, actuarial graft survival at 5 years was superior especially when graft survival was censored for recipient death. Acute rejections were significant reduced in patients given two DBMC infusions, and chronic rejection was dramatically reduced in all DBMC treated patients. The most interesting finding was that the degree of microchimerism slowly increased over the years the DBMC group that had exhibited no rejection episodes. In the DBMC-living related trial, the incidence of acute rejection did not differ between groups. However, DBMC chimerism in recipient iliac crest marrow had increased more rapidly than might be predicted from results previously seen in the cadaver group, despite four times fewer DBMC infused, with the generation of T- regulartory cells in-vitro assays.     

新疆地区活体肾移植178例随访

背景：新疆的特殊之处在于是国内少数民族与汉族混杂聚集地,新疆地区目前尚无少数民族与汉族间活体肾移植有种族差异的明确报道。 目的：比较新疆地区少数民族与汉族间活体肾移植的种族差异。 方法：回顾性分析新疆地区1999/2010行活体肾移植受者的临床资料,并对移植前、后一般临床资料,以及移植后少数民族与汉族间移植肾存活率进行比较分析,将可能影响移植肾存活率的各种因素进行单因素分析。 结果与结论：纳入随访资料完善者178例,其中少数民族131例,汉族47例。汉族组受者的移植肾存活率较少数民族组患者稍高,但差异无显著性意义。对可能影响长期移植肾生存的因素进行Cox单因素分析,显示急性排斥反应对移植肾生存有明显影响。提示新疆地区不同民族间接受同种民族活体肾移植的短中期移植肾存活率差异无显著性意义,急性排斥反应为影响移植肾存活的重要因素。