儿童亲属肾脏移植的临床研究

目的 探讨儿童亲属患者肾移植的疗效及其优越性,研究儿童肾脏移植手术方案、术后免疫抑制药物应用的特点以及术后并发症的处理.方法 分析14例肾移植患儿的临床资料、肾脏移植手术方法、免疫抑制剂应用和随访情况.结果 移植术后早期主要并发症:移植肾急性排斥反应2例,严重高钠血症3例,泌尿系感染1例,移植肾周积液3例.长期主要并发症:高血压6例、高脂血症3例、各种感染4例、药物性肝损害5例.1年人/肾存活率均为100%,研究结束时,14例患儿平均血肌肝为96.43 mmol/L(43～125 mmol/L),所有患儿均认为移植术后生活质量明显提高. 结论 亲属肾移植是治疗儿童慢性肾功能不全最为理想的方法,儿童肾移植的术式应根据受者血管情况选择.术后免疫抑制治疗建议联合应用他克莫司+霉酚酸酯+激素.     

肾移植术后远期移植肾功能丧失的原因浅析

近年来,随着临床肾移植技术的提高和免疫抑制方案的不断改善,肾移植后急性排斥反应发生率已经显著降低,移植肾术后近期存活率也不断提高.目前,如何提高移植肾远期存活率已成为大家关注的问题.不少临床研究显示,肾移植1年后,受者的移植肾功能会出现进行性减退,一部分受者会在术后5～10年内最终发生移植肾功能丧失,需再次行血液透析或再次肾移植.本文将对肾移植术后远期移植肾功能丧失的原因进行探讨,以供参考.     

儿童肾移植138例分析

目的 总结多个移植中心138例儿童肾移植的治疗效果.方法 回顾性分析8个移植中心自1986年3月至2010年5月间138例儿童肾移植的临床资料.受者年龄为(13.8±1.4)岁,其中男性92例,女性46例.138例均随访观察1年以上.初始免疫抑制方案均为以钙调磷酸酶抑制剂为主的三联方案,部分受者应用抗体诱导治疗.结果 术后1年受者和移植肾存活率分别为99.3％和95.7％.术后38例(27.5％)发生急性排斥反应,15例出现移植肾功能恢复延迟,但均在1个月内恢复.其他并发症为移植肾动脉狭窄8例,尿瘘5例,输尿管坏死2例,高血压57例,高脂血症38例,多毛症32例,药物性肝损伤26例,尿路感染25例,牙龈增生22例,肺部感染21例,骨髓抑制12例,单纯性疱疹10例,糖尿病8例.受者术后1年体重增加4～13 kg,身高增加2～7 cm.结论 细致地围手术期处理,免疫抑制剂的合理应用,加强随访,提高受者服药依从性是儿童肾移植获得良好效果的关键.     

他克莫司与环孢素A在高致敏肾移植受者中的应用比较

目的 观察和比较高致敏肾移植受者应用他克莫司(FK506)与环孢素A(CsA)的有效性和安全性.方法 根据术后免疫抑制方案的不同,将147例高致敏肾移植受者(其中术前群体反应性抗体＞50%的首次肾移植受者59例,2次肾移植受者88例)分为FK506组(53例)和CsA组(94例),两组的免疫抑制方案分别为FK506(或CsA)+霉酚酸酯+泼尼松.观察并分析两组受者术后移植肾存活率、血肌酐水平以及并发症的发生率.结果 FK506组术后1、3和5年的移植肾存活率(86.8%、82.3%和75.3%)略高于CsA组(81.9%、75.4%和66.9%),但差异无统计学意义(P＞0.05);FK506组术后1年时血肌酐水平为(100.72±15.88)μmol/L,CsA组为(117.29±11.77)μmol/L,两组比较,差异有统计学意义(P＜0.01);FK506组与CsA组相比,术后急性排斥反应、慢性排斥反应、肝功能损害、高血压和高血脂的发生率显著降低(P＜0.05),而高血糖的发生率明显升高(P＜0.01),两组移植肾功能延迟恢复和感染的发生率无明显差异(P＞0.05).结论 FK506与CsA相比,能有效降低高致敏受者肾移植术后急、慢性排斥反应的发生率,减少术后并发症的发生,提高移植肾的长期存活率,对高致敏肾移植受者是非常有效和安全的.     

两种免疫抑制方案在肾移植术后的应用比较

我们比较了不同抗排斥方案的肾移植患者在预后、术后各种并发症等方面的情况，旨在探讨理想的免疫抑制方案。 1．对象和方法：收集自1993年至2003年成功实施肾移植患者249例，根据免疫抑制方案的不同分为两组：硫唑嘌呤（Aza）组（应用Aza＋环孢素A＋激素）与霉酚酸酯（MMF）组（MMF＋环孢素A＋激素），其中Aza组89例，MMF组160例。统计分析两组移植肾及受者1年存活率、1年无病症比例（肾移植术后1年内无任何并发症，肾功能良好者）及各种并发症（包括急性排斥、加速性排斥反应、急性肾小管坏死、感染、肝损害、白细胞减少等）等。     

肾移植301例次报告

目的　总结肾移植的临床经验。方法　回顾性分析301例次肾移植患者的临床资料,从人和(或)肾存活率,肾移植术前准备、供肾及移植情况、术后并发症及处理、免疫抑制剂的应用、HLA配型及群体反应性抗体(PRA)检测等方面对移植肾效果影响进行分析总结。结果　1、3、5 年人/肾存活率分别为 96%/91% (243/254)/(230/254), 81%/76% (114/143)/(107/143)和68%/56%(38/57)/(32/57)。67例发生1~2次急性排斥反应,其中PRA致敏受者急性排斥反应发生率高达 48.57%。术后并发移植肾功能延迟恢复(DGF)48例;各种感染40例;急性左心衰竭12例。结论　充分的术前准备是安全度过围手术期的关键;良好的供肾和组织配型、术后免疫抑制剂的合理应用、并发症的预防和及时治疗,是提高肾移植术后人、肾存活率的重要保证。     

儿童肾移植23例临床分析

目的　探讨儿童肾移植的临床特点及围手术期处理特点。方法　回顾性分析平均年龄(15 4± 1 0 )岁的 2 3例儿童肾移植患者的临床资料 ,统计术后移植肾功能变化、急性排斥及并发症发生率。结果　 2 3例手术过程顺利 ,均未出现外科并发症。 1例治疗非顺应致移植肾失去功能 ,2 2例术后平均 5 5d恢复肾功能。术后 6个月内科并发症包括高血压 13例 (5 7% )、肺部感染 4例 (17% )、骨髓抑制与药物性肝损害各 3例 (13% )。术后 1年内急性排斥反应 4例 (17% )。术后第 1年体重平均增加 2 3kg ,身高平均增高 1 0cm。 1年、3年人 /肾生存率分别为 10 0 % / 96 %、90 % / 80 %。结论　肾移植是治疗儿童终末期肾病的有效治疗措施。合适的术式、术后免疫抑制药物的合理应用、并发症的预防和及时治疗是提高人、肾存活率的关键。     

亲属活体肾移植(附162例报告)

目的探讨亲属活体肾移植的疗效。方法亲属活体肾移植162例,除7例为夫妻间供肾外,其余为血缘亲属供肾。人类白细胞抗原(human leukocyte antigen,HLA)抗原错配5个4例、抗原错配4个6例、抗原错配3个101例、抗原错配2个51例。全部供者经开放手术取肾。受者术后采用环孢素或他克莫司+麦考酚吗乙酯+泼尼松龙三联免疫抑制治疗方案预防排斥反应。结果供者中除2名出现一过性血清肌酐升高外,其余肾功能均在正常范围内。162例受者中,术后早期肾功能恢复正常157例,肾功能延迟恢复5例,急性排斥反应5例,输尿管血栓形成2例,慢性排斥反应3例。1、3、5年人存活率均为96.9%,1、3、5年肾存活率分别为96.3%、95.8%、95.0%。死亡5例,死亡时间为移植后3个月内,均死于重度肺部感染并呼吸衰竭。结论亲属活体肾移植的组织配型好,供者术前准备充分,供肾缺血时间短,受者术前有充足的免疫诱导时间,免疫抑制剂用量小,排斥反应发生率低,移植肾存活率高。     

儿童肾移植后应用他克莫司为主的免疫抑制方案的临床观察

目的 总结儿童肾移植受者术后应用以他克莫司(Tac)为主的免疫抑制方案的体会.方法 35例受者,年龄为(12.4±1.5)岁(10～18岁),均接受成人尸体供肾,其中33例为首次肾移植,2例为再次肾移植.所有受者肾移植后均采用Tac、霉酚酸酯(MMF)和糖皮质激素预防排斥反应.术后3个月内、3～6个月、6～12个月时Tac的用量分别为0.15～0.32 mg·kg-1·d-1、0.12～0.15 mg·kg-1·d-1、0.07～0.11 mg·kg-1·d-1,Tac浓度谷值分别为(10.5±1.4)μg/L、(8.5±0.8)μg/L、(7.2±0.5)μg/L.35例中,18例术前进行免疫诱导治疗.结果 术后移植肾1、3、5年存活率分别为100%、97.1%、93.9%,受者1、3、5年存活率分别为100%、94.1%、90.9%.术后第1年受者的体重增加了(6.6±2.2)kg,身高增加了(3.7±1.1)cm.术后共有7例(20.0%,7/35)发生急性排斥反应.治疗后均逆转.其他并发症包括高血压11例(31.4%),高血脂5例(14.3%).药物性肝损伤4例(11.4%),肺部感染4例(11.4%),骨髓抑制2例(5.7%),糖尿病2例(5.7%),单纯性疱疹1例(2.8%),受者均无牙龈增生及多毛症.结论 儿童肾移植受者采用Tac、MMF和糖皮质激素预防排斥反应有效,应注意Tac和激素的用量和用法.术前行免疫诱导治疗对降低急性排斥反应的发生有益.     

肾移植术1053例次总结

目的　对临床肾移植的经验进行总结。方法　回顾分析 10 5 3例次肾移植受者的临床资料 ,从供肾及移植情况、术后并发症及处理、免疫抑制剂的应用、HLA配型及群体反应性抗体检测等对移植效果的影响等几个方面进行分析总结。结果　 1988年前免疫抑制治疗采用硫唑嘌呤 (Aza)和泼尼松 (Pred)二联用药 ,人 /肾 1年存活率为 6 9.3% /6 9.0 % ,3年为 4 3.0 % /42 .6 % ,5年为 30 .7% /2 7.8% ;1989年后采用环孢素A(CsA)、Aza和Pred三联用药 ,人 /肾 1年存活率为 93.2 % /92 .4 % ,3年为 79.3% /78.2 % ,5年为 6 6 .2 % /6 4 .2 %。术后早期并发症以急性排斥反应为主 ,晚期主要是移植肾慢性功能丧失 ,后者是导致受者死亡的主要原因。只要治疗及时 ,80 %的急性排斥反应能够得到逆转。结论　良好的供肾和组织配型 ,术后免疫抑制药的合理应用 ,并发症的预防和及时治疗 ,是提高肾移植术后人、肾存活率的重要保证     

23例儿童肾移植临床分析

目的：探讨儿童肾移植的临床特点，提高肾移植效果。方法：对23例3～17岁的儿童肾移植资料进行回顾性分析。结果：术后随访5d至72个月，平均26．1个月，死亡1例，人、肾1年存活率分别为93．3％和86．6％。术后7例发生急性排斥反应，6例治疗后逆转，1例因并发移植肾静脉栓塞，切除移植肾；2例发生慢性排斥反应，1例移植肾功能丧失，恢复血液透析，另一例仍在随访治疗中；其它并发症有肺部感染4例，心力衰竭2例，肾静脉阻塞2例，肝功能损害2例，急性肾小管坏死1例。结论：儿童肾移植具有一定的特殊性，其血管较细、急性排斥反应发生率较高以及药物代谢快等都是应妥善处理的问题。     

Laparoscopic adult donor nephrectomy for pediatric renal transplantation

To evaluate retrospectively our laparoscopic adult donor nephrectomy experience for pediatric transplantation. Since February 1995, 7 adult donors have undergone laparoscopic donor nephrectomy for pediatric renal transplantation (recipients younger than 18 years and weighing less than 30 kg). The outcomes of these donors and pediatric recipients were evaluated. The 7 laparoscopic renal donors had a median operative time of 306 minutes, median allograft warm ischemia time of 275 seconds, median blood loss of 200 mL, median hospital stay of 3 days, and 14.2% overall complication rate. No graft loss or patient mortality occurred. The pediatric recipients of the laparoscopic live-donor allografts had a median creatinine clearance level of 52.1, 52.1, 44, and 41.1 mL/min at 3, 6, 12, and 18 months, respectively. The overall complication rate was 14.2%. The 1 and 2-year graft survival rates were 100%. No mortality occurred in the pediatric recipients. Laparoscopic donor nephrectomy is well tolerated by the adult donors and appears to provide acceptable recipient and allograft outcomes in the pediatric population.     

Outcome of living kidney transplant: pediatric in comparison to adults

BACKGROUND: Renal transplantation is the most optimal way to manage children with end-stage renal disease. Despite its benefits, pediatric renal transplantation is a challenge for several transplantation centers in terms of achieving a satisfactory outcome. We sought to compare the long-term outcome of pediatric versus adult recipients who underwent renal transplantation. METHOD: We examined, 2631 recipients of a first kidney from a living donor between 1982 and 2002. The two groups were matched for immunosuppressive therapy and number of HLA mismatches. The patients were divided into a pediatric (n=301; age 18 years) to compare 5-year patient and graft survivals. RESULTS: The mean ages of the pediatric and adult groups were 40 +/- 13 and 14 +/- 13 years, respectively. The 5-year graft survival was lower among the pediatric versus the adult group (56% vs 68%; P=.015) with no difference in patient survival (88% vs 86%; P>.05). CONCLUSION: The poorer graft survival in pediatric transplantation may be due to the nature of pediatric transplantation, in terms of inconsistent adherence to medication regimens, worse side effects of medications, higher rate of graft rejection due to recurrent disease, and more intense immunoreactivity of children.     

Renal transplantation following previous heart, liver, and lung transplantation: an 8-year single-center experience

BACKGROUND: Long-term follow-up of heart, liver, and lung transplantation has led to an increased recognition of secondary end-stage renal failure (ESRF) in transplant recipients. This study examines our center's experience with renal transplantation following previous solid organ transplantation. METHODS: From January 1, 1992, to September 30, 1999, our center performed 18 renal transplants in previous solid organ recipients. During the same period, 815 total renal transplants were performed. One- and 3-year graft and patient survival, recipient demographics, donor type, and reason for transplantation were compared between these groups. RESULTS: Of the 18 recipients, 7 had prior heart transplants, 4 had prior liver transplants, and 7 had prior lung transplants. Cyclosporine toxicity contributed to renal failure in 17 (94.4%) of the patients-either as a sole factor (11 patients) or in combination with hypertension, renal artery stenosis, or tacrolimus toxicity (6 patients). Kaplan-Meier 1- and 3-year patient survival was 82.9% and 73.7%, compared with 95.5% and 90.7% in all renal transplant recipients. No surviving patient has suffered renal allograft loss. Mean current creatinine level is 1.4 mg/dL. CONCLUSIONS: Renal transplantation is an excellent therapy for ESRF following prior solid organ transplantation. One and 3-year patient and graft survival demonstrate the utility of renal transplantation in this patient population.     

Pediatric transplantation

Analysis of the OPTN/SRTR database demonstrates that, in 2002, pediatric recipients accounted for 7% of all recipients, while pediatric individuals accounted for 14% of deceased organ donors. For children fortunate enough to receive a transplant, there has been continued improvement in outcomes following all forms of transplantation. Current 1-year graft survival is generally excellent, with survival rates following transplantation in many cases equaling or exceeding those of all other recipients. In renal transplantation, despite excellent early graft survival, there is evidence that long-term graft survival for adolescent recipients is well below that of other recipients. A causative role for noncompliance is possible. While the significant improvements in graft and patient survival are laudable, waiting list mortality remains excessive. Pediatric candidates awaiting liver, intestine, and thoracic transplantation face mortality rates generally greater than those of their adult counterparts. This finding is particularly pronounced in patients aged 5 years and younger. While mortality awaiting transplantation is an important consideration in refining organ allocation strategies, it is important to realize that other issues, in addition to mortality, are critical for children. Consideration of the impact of end-stage organ disease on growth and development is often equally important, both while awaiting and after transplantation.     

尸体肾移植1210例总结分析

目的 总结尸体肾移植手术经验，提高肾移植长期存活率。方法 回顾分析1986-2003年1210例肾移植患者取肾、手术技术、免疫抑制药应用及手术并发症发生等资料。男773例，女437例，年龄6～75岁。病因主要为慢性肾炎（1047例），1210例淋巴毒细胞试验均〈10％，640例行PRA测定，340例HLA-A、B、DR配对。结果 1986-1996年免疫抑制剂采用环孢素A（CsA）、泼尼松（Pred）、硫唑嘌呤（Aza），人／肾1、3、5年存活率分别为96％／95％、85％／80％、65％／64％，主要死亡原因为心脑血管疾病（99／205，48％）。1997-2003年免疫抑制剂采用CsA、Pred、骁悉（MMF），人／肾1、3、5年存活率分别为96％／96％、87％／82％、66％／65％，主要死亡原因为感染（14／25，56％）。结论 良好的供肾和组织配型，术后合理应用免疫抑制剂，预防和及时治疗并发症是提高人／肾长期存活率的重要保证。     

肝移植治疗终末期自身免疫性肝病的预后分析

目的探讨肝移植治疗终末期自身免疫性肝病(AILD)的预后情况。方法回顾性分析1996年5月至2013年4月在第二军医大学附属长征医院实施原位肝移植术的48例终末期AILD受者的临床资料。计算受者的术后累积生存率,分析死亡病例的死因,了解术后排斥反应、病毒性肝炎新发感染及AILD复发情况。结果 48例AILD受者中,存活38例,AILD受者术后5年累积生存率为76%。10例死亡受者的死亡原因包括多器官功能衰竭、移植肝衰竭、脓毒症、肺部感染、出血、肝动脉栓塞、肾衰竭。48例AILD受者中,肝移植术后发生急性排斥反应者9例(19%),有3例分别在术后1~2年内新发乙型肝炎病毒感染,有2例原发性胆汁性肝硬化受者于术后2年出现原发病复发,经积极治疗均长期生存。结论终末期AILD肝移植受者多数可获得长期生存,应重视肝移植术后早期免疫抑制方案的制定,预防感染及排斥反应和术后新发病毒性肝炎,及时发现原发病复发等问题。     

Outcome of renal transplantation in children less than two years of age.

Twenty-two renal transplants were performed in 21 children less than two years of age at Children's Hospital. Fourteen were from living related donors and eight were from cadaveric donors. The five year patient and graft survivals of these recipients were compared to all other pediatric recipients between two and 18 years of age who received renal transplants over the same time period. Five year graft survival for recipients less than two years of age was 86% following living-related donor transplantation and 38% following cadaver donor transplantation. Older pediatric recipients aged between two and 18 years had a five year graft survival of 73% following living-related donor renal transplantation, which was similar to that for recipients less than two years of age. Although older cadaveric recipients had a comparable five year graft survival to younger recipients, at 42%, the patterns of graft loss were different. Graft failures in young recipients occurred within the first seven months post-transplant, whereas the older recipient's grafts failed more gradually. Actuarial five-year patient survival in recipients less than two years of age was 86% following living-related donor renal transplantation and 70% following cadaver-donor renal transplantation. Recipients less than two years of age had a poorer patient survival than older recipients following both living-related donor renal transplantation (P = 0.06) and cadaver-donor renal transplantation (P less than 0.05). These findings suggest that the graft survival of living-related donor renal transplantation in recipients less than two years of age is better than that of cadaver-donor renal transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cyclosporine versus azathioprine: a review of 200 consecutive cadaver renal transplant recipients

Most renal transplant centers report an increase in graft survival when cyclosporine is used as a primary immunosuppressant. We report the outcome of 200 consecutive cadaver renal transplant recipients among whom initial immunosuppression and risk factors were similar except for the substitution of cyclosporine for azathioprine in the second 100 recipients. Azathioprine-treated recipients had significantly increased (p less than 0.05) mean hospital stays (31.9 versus 18.3 days), incidence of first rejection episodes (85 versus 31) and methylprednisolone dose (3.38 versus 0.06 gm. per patient). Cyclosporine-treated recipients had a significantly higher 1-year mean serum creatinine level (1.85 versus 1.56 mg. per dl.) and 1-year actual graft survival (83 versus 58 per cent). Despite mild nephrotoxicity, cyclosporine is superior to azathioprine as a primary immunosuppressant in cadaver kidney transplantation.