器官捐献肾移植功能延迟恢复的预后因素分析

目的探讨中国公民逝世后器官捐献(Chinese donation after citizens’death,CDCD)发生肾移植功能延迟恢复(delayed graft function,DGF)的预后因素。方法回顾性分析2014年1月~2015年11月在武汉大学中南医院138例行同种异体肾移植手术的临床资料,21例发生DGF(DGF组),117例移植肾功能稳定(immediate graft function,IGF)为IFG组,采用χ~2检验进行单因素分析,再用logistic模型对有统计学差异的因素进行多因素分析。结果 DGF发生率为15.2%(21/138),单因素分析显示DGF的预后因素包括受者术前血透时间≥12个月(P=0.024)、脑出血死亡供者(P=0.020)、供者血清肌酐≥177μmol/L(P=0.013)、热缺血时间≥15 min(P=0.041)、冷缺血时间≥12 h(P=0.025)及供者经历心肺复苏(P=0.001)有显著性差异。logistic多因素分析显示供者血清肌酐≥177μmol/L(OR=7.138,95%CI:1.418~35.937,P=0.017)、供者心肺复苏(OR=30.207,95%CI:3.653~111.778,P=0.001)及热缺血时间≥15 min(OR=7.762,95%CI:1.953~30.845,P=0.004)是DGF的独立预后因素。结论供者血清肌酐≥177μmol/L、供者经历心肺复苏及热缺血时间≥15 min是导致CDCD发生DGF的预后因素。     

颅脑损伤尿崩症供者维护策略及其供肾移植疗效分析

目的总结颅脑损伤尿崩症供者维护策略并评价其供肾移植后临床疗效。 方法回顾性分析2016年1月至2018年9月武汉大学人民医院器官移植科完成的颅脑损伤尿崩症供者供肾移植供、受者临床资料，总结此类供者临床维护策略、吻合方式及供肾移植术后受者情况。采用配对t检验比较尿崩症供者治疗前后血压、每小时尿量、心率、血钠水平、尿比重、体温、血浆渗透压及血清肌酐等指标。P<0.05为差异有统计学意义。 结果经系统性抗尿崩治疗后，12例尿崩症供者血压、每小时尿量、心率、血钠水平、尿比重、体温、血浆渗透压及血清肌酐均明显改善，差异均有统计学意义(P均<0.05)。供肾获取时均灌注良好，颜色和质地佳，无血栓和瘀斑等情况。修整后复灌均采用输血器灌注，灌注良好。24例受者中，19例移植后移植肾立即发挥功能，血清肌酐恢复至133 μmol/L以下，平均时间为术后(10±3)d；5例发生移植肾功能延迟恢复(DGF)，术后维持血液透析时间为(9±3) d，DGF恢复[eGFR≥30 mL·min^－1·(1.73 m²)^－1]平均时间为术后(23±4) d。1例发生DGF受者于术后第2天因移植肾出血，二次手术止血后于术后第19天恢复。术后3个月，24例受者平均血清肌酐为(105±43) μmol/L。2例受者于围手术期发生急性排斥反应，应用兔抗人胸腺细胞球蛋白(rATG)后逆转。截至2018年12月，7例受者出现移植后并发症：4例发生急性排斥反应，其中2例经甲泼尼龙冲击治疗后恢复，2例经甲泼尼龙＋rATG治疗后恢复；2例出现肺部感染，经积极抗感染治疗后恢复；1例术后3个月出现移植肾动脉狭窄，行移植肾动脉支架植入术后恢复。 结论尿崩症是颅脑损伤供者常见临床综合征，其发生可能会影响供肾质量，对尿崩症进行全面监测和积极治疗后，有助于供肾功能的维护，促进移植肾功能早期恢复。     

供体亚低温状态对公民逝世后器官捐献移植肾功能的影响

目的探讨供体亚低温状态对公民逝世后器官捐献肾移植早期肾功能影响。方法将符合入选条件的36例公民逝世后器官捐献供体根据处理方式随机分为常温组(体温36.5~37.5℃,19例)和亚低温组(体温34.0~35.0℃,17例)。对应供体分组的肾移植受体包括常温组(38例)和亚低温组(34例)。比较两组供体、受体的围手术期情况和两组受体术后移植肾功能恢复情况,包括移植物功能延迟恢复(DGF)和原发性无功能(PNF)发生率。结果两组供体围手术期的尿量、血清肌酐(Scr)、收缩压、血氧饱和度、热缺血时间和冷缺血时间比较,均无统计学意义(均为P0.05)。两组受体的手术时间、术中平均血糖、术中平均动脉压比较,差异均无统计学意义(均为P0.05)。亚低温组和常温组受体术后DGF发生率分别为6%和24%,两组受体DGF发生率比较,差异有统计学意义(χ~2=4.393,P=0.036)。亚低温组和常温组受体术后PNF发生率均为3%,两组受体PNF发生率比较,差异无统计学意义(χ~2=0.000,P=1)。结论供体亚低温状态可以显著降低受体DGF的发生率,对PNF的发生率则无明显影响。     

亲属活体肾移植中父母供肾对移植肾长期存活的影响

目的研究父母供肾对亲属活体肾移植受者移植肾长期存活的影响。方法回顾性分析首都医科大学附属北京友谊医院行父母供肾的亲属活体肾移植并存活5年以上的119例受者临床资料。其中,男性96例,女性23例,平均年龄(28±13)岁。119例供者中,父亲供肾52例,母亲供肾67例,平均年龄(51±13)岁。119例受者均于2010年10月行群体反应性抗体(PRA)检测,并于2014年10月至12月检测肾功能,观察受者抗HLA抗体、供者年龄和性别对移植肾功能的影响。采用χ2检验比较上述指标,P0.05为差异有统计学意义。结果 119例受者中,28例产生抗HLA抗体,其中26例移植肾功能下降,占92.9%;无抗HLA抗体的91例受者中32例移植肾功能下降,占35.2%,差异有统计学意义(χ2=26.26,P0.05)。父亲供肾与母亲供肾移植术后肾功能下降的受者比例分别为38.5%(20/52)和59.7%(40/67),差异有统计学意义(χ2=4.47,P0.05)。119例供者中,81例年龄≥50岁,对应受者中41例肾功能下降(50.6%,41/81);38例供者年龄50岁,对应受者中17例肾功能下降(44.7%,17/38);不同年龄供者供肾移植术后出现肾功能异常的受者比例差异无统计学意义(χ2=0.018,P0.05)。结论父母供肾的亲属活体肾移植中,抗HLA抗体是肾功能下降的重要影响因素,供者性别也可能与术后肾功能下降有关。     

伴急性肾损伤的脑死亡器官捐献供者供肾移植治疗的体会

目的总结伴急性肾损伤(AKI)的脑死亡器官捐献(DBD)供者供肾移植的治疗效果。方法选取成功完成DBD供肾移植的59例供者纳入本研究,根据入重症监护室(ICU)时的血清肌酐(Scr)水平,将DBD供者分为AKI组(14例)与正常组(45例),相应的101例受者根据供者情况分为AKI组(23例)与正常组(78例)。总结59例供者器官捐献情况,比较两组供者获取前的主要指标。比较两组受者术后肾功能、住院情况及临床结局。结果 59例供者中,14例发生AKI(24%),其中2例在其维护期间行持续性肾脏替代治疗。与正常组供者相比,AKI组供者的急性生理与慢性健康(APACHE)Ⅱ评分明显升高(P0.05),中枢性尿崩症的发生率更高(P0.01),入ICU时和获取前的Scr水平更高(均为P0.01),获取前24 h尿量更少(P0.01)。与正常组受者相比,AKI组受者术后2、3 d的Scr水平更高(均为P0.05),住院时间和住院花费亦明显升高(P0.01,P0.05)。两组受者术后移植肾功能延迟恢复、急性排斥反应、感染、恢复透析的发生率比较,差异无统计学意义(均为P0.05)。术后3个月,两组受者均好转出院,移植肾存活率为100%。结论伴AKI的DBD供者供肾移植,经过积极的器官维护可纠正AKI,达到与非AKI供肾同样的效果,可以作为扩大供肾来源的途径。     

亲属活体供肾动脉轻度狭窄对肾移植受者术后早期肾功能和并发症的影响

目的探讨亲属活体供肾动脉轻度狭窄对肾移植受者术后早期肾功能和并发症的影响。方法回顾性分析14例供肾动脉轻度狭窄的亲属活体肾移植与50例标准亲属活体肾移植供、受者的临床资料。比较两组供者术后血清肌酐(Scr)水平。比较两组受者术后1、3、6个月的Scr水平;比较两组受者移植肾存活率及移植物功能延迟恢复(DGF)、急性排斥反应、肺部感染的发生率。结果两组供者术后Scr水平比较,差异均无统计学意义(均为P0.05)。两组术后1、3、6个月Scr水平比较,差异均无统计学意义(均为P0.05)。两组受者移植肾存活率,DGF、急性排斥反应、肺部感染的发生率比较,差异亦均无统计学意义(均为P0.05)。结论亲属活体供肾动脉轻度狭窄对肾移植受者术后肾功能和并发症的影响不大,可纳入标准供体供肾范围。     

应用LifePort器官转运器改善肾移植效果的大宗临床研究(附573例报告)

目的探讨供肾脉冲灌注保存转运器(LifePort)保存心脏死亡器官捐献(DCD)供肾和扩大标准供体(ECD)供肾对肾移植术后受者肾功能恢复的影响。方法回顾性分析466例器官捐献(DCD+ECD)供者和882例肾移植受者围手术期的临床资料。根据供肾保存方式不同,将309例DCD供者的左右两侧肾脏随机分为LifePort(DCD-LP)组(309例)和DCD冷藏组(309例);132例ECD供者的双侧供肾全部采用LifePort保存并转运,设为ECD-LP组(264例)。分别观察3组受者术后总体情况、术后早期移植肾功能指标、术后并发症发生情况;对比观察肾移植术前零点穿刺肾组织病理学检查结果;比较肾移植术后有否发生移植物功能延迟恢复(DGF)受者的供肾LifePort灌注参数。结果与DCD冷藏组比较,DCD-LP组、ECD-LP组受者的住院时间明显缩短,差异均有统计学意义(均为P0.05)。DCD冷藏组、DCD-LP组、ECD-LP组围手术期的人存活率均为100%,肾存活率分别为99.7%、100%、99.2%,差异均无统计学意义(均为P0.05)。与DCD冷藏组比较,DCD-LP组、ECD-LP组的DGF发生率明显降低,差异均有统计学意义(均为P0.05)。3组受者的术后早期肾功能,急性排斥反应、感染和外科并发症的发生率比较,差异均无统计学意义(均为P0.05)。病理学检查结果显示,采用LifePort灌注能明显减轻肾小管的水肿、变性、坏死。发生DGF者的供肾LifePort灌注阻力指数明显高于未发生DGF者,而供肾LifePort灌注流量则明显低于未发生DGF者,差异均有统计学意义(均为P0.05)。结论 LifePort能有效改善离体DCD和ECD供肾质量,降低术后DGF发生率,促进移植肾功能恢复,并可在离体肾脏维护及评估中对术后恢复情况作出预判。     

应用机械灌注保存心脏死亡器官捐献供肾的效果分析

目的探讨采用机械灌注保存心脏死亡器官捐献(DCD)供肾移植后移植肾功能延迟恢复(DGF)的发生及对早期移植物功能的影响。方法回顾性分析武汉大学中南医院2010年3月至2012年11月期间44例DCD供肾移植受者的临床资料,根据其供肾保存方式不同,分为机械灌注组(n=10)和静态冷储组(n=34例),比较两组受者DGF发生情况和早期移植物功能。结果两组供、受者一般资料具有可比性。术后1周,机械灌注组无受者发生功能性DGF,而静态冷储组功能性DGF发生率为32.4%(1/34),差别有统计学意义(χ2=6.68,P<0.05);机械灌注组DGF发生率为10%(1/10),静态冷储组DGF发生率为29.4%(10/34),差异无统计学意义(χ2=1.15,P>0.05)。机械灌注过程中肾动脉流量小于60mL/min和阻力系数大于0.5mmHg.mL-1.min-1时,受者发生DGF的概率明显增高。结论机械灌注能有效降低DCD供肾移植受者功能性DGF发生率,是临床维持和修复DCD供肾的重要方法;机械灌注阻力系数和流量可以作为临床评估DCD供肾质量的重要参数,也是判断预后的有益指标。     

甲状腺激素水平与移植肾功能关系的临床研究

目的 探讨肾移植受者的血清甲状腺激素水平与移植肾功能的关系.方法 57例肾移植受者根据移植后肾功能恢复情况分为移植肾功能恢复延迟(DGF)组(7例)和稳定组(50例).检测两组术前及术后不同时间的血清三碘甲状腺原氨酸(T3)、甲状腺素(T4)、促甲状腺素(TSH)和血清肌酐(Scr)水平.另检测30名健康志愿者的4项指标水平,作为正常对照.将稳定组术后第10天甲状腺激素水平与Scr水平进行相关性分析.结果 稳定组和DGF组术前血清T3、T4水平低于对照组(P＜0.01),而两组术前TSH水平与对照组相比较,差异无统计学意义(P＞0.05).稳定组与DGF组间术前各指标的差异无统计学意义(P＞0.05).稳定组术后第1天T3较术前下降约30％(P＜0.05),下降幅度大于其他指标,直到术后1周开始上升,术后2周接近正常水平,术后3周时已高于术前(P＜0.01);T4术后早期降低,10d后呈上升趋势,术后3周才接近术前水平;术后各时间段TSH水平与术前相比较,差异均无统计学意义(P＞0.05);Scr于术后7d恢复至正常水平.DGF组T3于术后21 d达到正常水平,T4于术后30 d达到术前水平;Scr于术后30 d达到正常水平.术后第10天,稳定组受者血清T3与Scr呈负相关(相关系数=0.546,P＜0.01),T4与Scr呈负相关(相关系数=0.423,P＜0.01).TSH与Scr无相关性.结论 T3、T4水平与移植后肾功能有相关性,要重视肾移植受者术后早期甲状腺功能状态及对受者恢复的影响.     

儿童器官捐献供肾肾移植疗效的临床研究

目的探讨儿童器官捐献供肾移植的近期临床疗效。方法回顾性分析2013年11月至2015年12月西安交通大学第一附属医院肾移植科完成的15例儿童器官捐献供者,供给28例肾移植受者(其中双肾移植2例)的供、受者临床资料。结果 28例受者手术均获成功。移植肾热缺血时间中位数为12.5 min(0~17.0 min),冷缺血时间中位数为4.3 h(1.5~7.7 h)。术后出现移植物功能延迟恢复(DGF)4例、透析1例、因肺部感染死亡2例、肾吻合口狭窄和供肾血栓形成后切除移植肾各1例。术后随访1~24个月,受者存活26例(93%),带肾存活受者24例(86%),其移植肾功能均正常。结论儿童器官捐献供者双肾整块移植及单肾移植早期临床疗效较好。     

Influence of genetic polymorphisms in GSTM1, GSTM3, GSTT1 and GSTP1 on allograft outcome in renal transplant recipients

Abstract: Introduction: Glutathione S‐transferases (GSTs) are important in protection against xenobiotic compounds and toxicity caused by immunosuppressants in renal transplant recipients. In the present study we hypothesize that genetic variability in GSTM1, GSTM3, GSTP1 and GSTT1 genes may be associated with allograft outcome. Methods: The study included 223 controls and 273 transplant recipients categorized into 184 stable graft function (SGF), 57 rejection episodes (RE) and 32 delayed graft function (DGF). The polymorphism was studied using multiplex PCR and PCR‐RFLP. Results: GSTM1 null genotype showed a 3.35‐fold higher risk for rejection in SGF vs. RE category [95% confidence interval (CI) 1.27–8.84, p = 0.014]. Mutant (G) allele of GSTP1 was associated with a 5.52‐fold risk for DGF (95% CI 1.37–22.17, p = 0.016). Kaplan–Meier analysis revealed significantly lower mean time to first RE in null genotype as compared with GSTM1 present patients (Log p = 0.002). The dose adjusted C₂ levels in null genotype was higher as compared with GSTM1 present patients at one (p = 0.007) and three months (p = 0.027) post transplantation. Conclusion: Patients with variant genotype of GSTM1 and GSTP1 were at higher risk for rejection and delayed functioning of the allograft, respectively, supporting the hypothesis for involvement of GST isoform variants in allograft outcome in renal transplant recipients.     

加速康复外科在肾移植术后静脉补液中的应用

目的探讨加速康复外科(ERAS)在肾移植术后静脉补液中的应用。 方法回顾性分析陆军军医大学第一附属医院124例肾移植受者临床资料。根据肾移植术后多尿期每24小时静脉补液量分为3组，A组每24小时静脉补液量2 500～<4 000 mL，术后6 h进食流质；B组每24小时补液量4 000～6 000 mL，肛门排气后进食；C组每24小时补液量>6 000 mL，肛门排气后进食。采用单因素方差分析比较3组受者术后1周中心静脉压(CVP)、心率、血压、尿量和血糖以及平均特护时间、平均住院日和术后1个月血清肌酐。采用χ²检验比较3组受者性别、供肾类型以及术后高血糖、伤口延迟愈合和移植肾功能延迟恢复(DGF)发生率。P<0.05为差异有统计学意义。 结果A、B和C组受者术后1个月血清肌酐分别为(110±23)、(114±22)和(118±22)μmol/L，差异无统计学意义(F＝1.19，P>0.05)。A组受者术后1周CVP、收缩压、尿量和血糖均低于B、C组(P均<0.05)，平均特护时间和平均住院日均短于B、C组(P均<0.05)。3组受者术后高血糖和DGF发生率差异均无统计学意义(χ²＝4.581和0.404，P均>0.05)，A组受者伤口愈合延迟发生率低于C组(χ²＝7.303，P<0.017)。仅C组1例受者因心力衰竭和肺水肿死亡。 结论ERAS适用于肾移植受者术后静脉补液策略，鼓励受者尽早饮水进食，在保证血压正常或偏高的情况下，适当减少静脉补液量，有利于减少并发症，促进受者恢复。     

Genetic determinants of delayed graft function after kidney transplantation

BACKGROUND: Intracellular concentration of reactive oxygen species is held within tight physiological limits by enzymes with scavenging and repair functions. Under extreme conditions such as prolonged cold ischemia, these enzymes may be unable to adequately protect the organ, resulting in reperfusion injury that renders the graft dysfunctional after transplantation. In this study, we investigated normal human variation of some of these inducible enzymes to determine if certain phenotypes could be identified that are associated with a reduced risk of delayed graft function (DGF). METHODS: Polymerase chain reaction was performed to differentiate polymorphisms for manganese superoxide dismutase and three classes of glutathione-S-transferase in donors and recipients of transplants with over 24 hr of cold ischemia. The data attained was analyzed compared with the presence or absence of DGF, defined as the requirement of hemodialysis in the first week after transplantation. RESULTS: Enzyme polymorphisms were defined for 229 recipients and 104 of their respective donors. Patients receiving a kidney from a donor who expressed GSTM1*B either alone or in combination with GSTM1*A experienced significantly lower rates of DGF (P <0.05). No association was found between any enzyme polymorphism in the recipients and the development of DGF. CONCLUSIONS: The identification of a genetic allele, which is protective against reperfusion injury, generates the possibility for defining polymorphisms at the time of tissue typing to give insight to the inherent biological risk of DGF that an organ possesses.     

再次肾移植受者和移植肾长期预后影响因素分析

目的探究再次肾移植受者和移植肾存活情况及长期预后影响因素。 方法回顾性分析1991年1月1日至2017年12月31日于浙江大学医学院附属第一医院肾脏病中心接受肾移植受者临床资料。共纳入再次肾移植受者37例,首次肾移植受者5 374例。根据再次肾移植受者移植肾存活时间长短,将其分为长期存活组(19例,>5年)和短期存活组(18例,≤5年)。采用成组t检验比较长期和短期存活组供受者年龄、首次与再次肾移植间隔时间、HLA错配数和再次移植供肾冷/热缺血时间。采用卡方检验比较长期和短期存活组受者性别、再次移植供肾类型、再次移植前后群体反应性抗体阳性比例、首次移植失功移植肾切除比例、再次移植前免疫诱导比例及再次移植后移植肾功能延迟恢复(DGF)和急性排斥反应发生比例。采用Kaplan-Meier法分析再次和首次肾移植受者/移植肾1、5和10年存活率。采用Cox比例风险模型分析影响再次肾移植术后移植肾长期存活影响因素。P<0.05为差异有统计学意义。 结果截至2018年3月1日,37例再次肾移植受者中位随访时间为152个月(11～323个月),2例死亡,18例发生移植肾失功,17例移植肾功能稳定。5 374例首次肾移植受者中位随访时间为108.9个月(0.1～350.0个月),459例死亡,1 343例发生移植肾失功。再次移植组受者/移植肾1、5和10年存活率分别为86%/81%、86%/62%和82%/36%,首次移植组受者/移植肾1、5和10年存活率分别为99%/98%、93%/89%和88%/80%。再次移植组移植肾1、5和10年存活率均低于首次移植组(χ²＝60.816、25.110和43.900,P均<0.05);再次移植组受者1年存活率低于首次移植组,差异有统计学意义(χ²＝40.409,P<0.05)。长期和短期存活组受者再次移植后移植肾DGF和急性排斥反应发生比例差异均有统计学意义(χ²＝4.039和4.748,P均<0.05)。Cox回归分析结果示DGF和急性排斥反应是影响再次肾移植受者移植肾长期存活的独立危险因素,差异有统计学意义(RR＝4.317和4.571,P均<0.05)。 结论再次肾移植受者移植肾存活率低于首次肾移植受者,DGF和急性排斥反应是影响再次移植受者移植肾存活的独立危险因素。     

Delayed graft function after renal transplantation: an unresolved problem

Unlike other areas in renal transplantation, delayed graft function (DGF) remains an apparently unavoidable complication owing to the characteristics of current donors. The aim of this study was to analyze risk factors for DGF in relation to graft and patient survivals. We retrospectively analyzed 507 renal transplant recipients with a median follow-up of 74.83 ± 45.06 months. DGF, which occurred among 189 patients (36.8%) was defined as requirement for dialysis within the first week after transplantation. Donor (P = .000) and recipient (P = .000) age were greater in the DGF group without differences in recipient or donor gender, HLA sensitization, or dialysis time before transplantation. Donor factors as the cause of death associated with DGF were secondary cerebrovacular stroke (P = .002) and hypertensive history (P = .000). Recipient characteristics associated therewith were higher body mass index (P = .000), smoking habit (P = .003), ischemic cardiopathy (P = .01), and dyslipidemia (P = .05). Moreover, the DGF group showed longer cold ischemia (P = .01) and vascular anastomosis (P = .02) times. On multivariate analysis, recipient age (P = .00) and smoking habit (P = .01) together with a donor history of hypertension (P = .02) were independent risk factors for DGF. No differences were observed in acute rejection incidence (P = .07) with worse renal function during follow-up (P < .05). Graft (81% vs 88%; P = .00) and patient (89% vs 95%; P = .00) survivals at 5 years were lower among the DGF group. In conclusion, DGF which was associated with factors related to the donor, the recipient, and the surgical times, produced worse graft and patient survivals. Shortening the cold ischemia time seems to be a modifiable variable to reduce DGF.     

Daclizumab (humanized anti-IL2Ralpha mAb) prophylaxis for prevention of acute rejection in renal transplant recipients with delayed graft function.

BACKGROUND: The purpose of this retrospective study was to determine the benefits of daclizumab, (Zenapax, Roche Pharmaceuticals) a humanized anti-interleukin-2Ralpha (IL-2Ralpha) monoclonal antibody, for prevention of acute rejection in renal transplant recipients with delayed graft function (DGF). METHODS: Data from two multicenter randomized placebo-controlled trials were pooled. DGF was defined by urine output <30 cc/hour, decline in serum creatinine of <0.5 mg/dl, or the need for dialysis within the first 24 hours after transplantation. RESULTS: At one year posttransplantation, the incidence of biopsy-proven acute rejection in patients with DGF was reduced from 44% in the placebo group to 28% in the daclizumab group. (P=0.03) Prophylaxis with daclizumab also delayed the onset of the first biopsy-proven acute rejection episode in patients with DGF from 29+/-43 days in the placebo group to 73+/-70 days in the daclizumab group. (P=0.004) The graft survival rates in patients with DGF at 1 year posttransplantation were 78% in the placebo group and 82% in the daclizumab treated group. (P=ns) Three patients in the placebo-treated group with DGF experienced graft loss due to acute rejection, whereas no patients in the daclizumab-treated group with DGF had graft loss due to acute rejection. The 1-year patient survival rate in those with DGF in the placebo and daclizumab groups were 93% and 98%, respectively. (P=ns) CONCLUSIONS: Daclizumab effectively reduced the incidence and delayed the onset of biopsy-proven acute rejection in this high-risk subgroup of patients with DGF after renal transplantation. Graft and patient survival rates were similar between placebo- and daclizumab-treated patients with DGF.     

Time-dependent variations in urine output after renal transplantation

INTRODUCTION: Diuresis begins soon after renal transplantation. Although controversial, early post kidney transplant urine volume may correlate with favorable short- and long-term allograft survival. The aim of the present study was to examine the potential changes in urine volume within the first 6 months after renal transplantation. METHODS: In a prospective study, the first month serum creatinine level and daily urine volume were measured at 24 and 48 hours, and at 1 month after renal transplantation in patients with stable kidney function without the evidence of allograft rejection (n = 54). Fifteen patients were also followed for their urine output at least 6 months post kidney transplantation. Data are expressed in mean values +/- SD. Statistical analysis was performed by SPSS version 13.0 using ANOVA. Correlation between continuous variables was performed using the Pearson test. The P value was set at .05. RESULTS: The mean age of the renal allograft recipients was 35.5 +/- 12.1 years with a male to female ratio of approximately 1.3. The mean first month serum creatinine was 1.26 +/- 0.4 mg/dL. The mean urine outputs were 10.06 +/- 5.89, 5.45 +/- 3.05, and 3.44 +/- 1.25 L at 24 and 48 hours and 1 month post renal transplantation. Those patients who were followed for 6 months post transplant (n=15) were observed to have a mean urine volume of 3.20 +/- 1.24 L at the end of this period. This trend showed that urine volume steadily decreased from 24 and 48 hours to 1 month after renal transplantation (P<.05). However, urine volumes were rather comparable at one month and 6 months after transplantation (P>.05). A positive correlation was found between the first-month serum creatinine and the urine volume at one month (r=0.302 and P=.035). CONCLUSION: Although urine volume showed considerable variation early after renal transplantation, it stabilized by 1 month after transplantation, which was also positively correlated with the first-month serum creatinine. Moreover, we concluded that in stable patients, the final urine output was related to early graft function.     

Pravastatin decreases cold ischemia--but not alloantigen-dependent transplant arteriosclerosis

BACKGROUND: Alloantigen mismatch and cold ischemia have been shown to induce transplant arteriosclerosis. Pravastatin (PR) decreases arteriosclerosis probably related to an immunosuppressive effect. Statins possess other nonimmune properties that may be beneficial to transplantation. We studied the effect of PR on cold ischemia and alloantigen-induced transplant arteriosclerosis in syngeneic (SYN) and allogeneic (ALLO) aortic transplantation models. METHODS: Lewis rats served as the donors and recipients for SYN transplants and Brown Norway rats were donors for ALLO transplants. Aortic segments that had been preserved at 4 degrees C in Euro-Collins solution for 0 or 24 hours were transplanted to the infrarenal aorta of the recipients PR (10 mg/kg/d) was administered for 12 weeks prior to morphometric studies. Areas of intimal thickness and its relation to total vessel area were calculated. Lipid levels were measured at 12 weeks. RESULTS: Aorta rings preserved for 24 hours showed marked intimal thickening compared to controls (SYN, CI 0 hours = 21.5% +/- 16.5% vs SYN, CI 24 hours = 50.7 +/- 9.5%, P <.05). PR significantly decreased thickening (SYN, CI 24 hours + PR = 41.7 +/- 12.2 (P <.05) vs SYN, CI 0 hours on SYN, CI 24 hours). There was a nonsignificant decrease in thickening among ALLO transplants treated with PR (ALLO = 31.4 +/- 15.9 vs ALLO + PR = 23.8 +/- 18.8; P >.05). PR had no effect on lipid levels. PR decreases cold ischemia induced transplant arteriosclerosis in this syngeneic aortic transplant model, but does not affect an alloantigen-mediated process. The beneficial effect of PR is not related to its lipid-lowering properties but probably to a nonimmune effect.     

Delayed Graft Function in Renal Transplant Recipients: Risk Factors and Impact on 1-Year Graft Function: A Single Center Analysis

Delayed graft function (DGF), a frequent complication after kidney transplantation, occurs among about 60% of recipients of kidneys from deceased donors. DGF has a multifactorial etiology. It is characterized by acute tubular necrosis (ATN) upon biopsy. In this study we sought to identify among a group of recipients of kidneys from deceased donors, the incidence, risk factors, and impacts on patient and graft survivals of DGF.

Materials and Methods

We retrospectively analyzed medical records from renal transplant recipients aged >18 years who received a deceased donor kidney graft between January 2003 and December 2006. Kidneys lost during the first week posttransplantation were excluded from this series.

Results

Among 165 transplants, 111 (67%) displayed DGF, defined as the need for dialysis during the first week posttransplantation. The incidence of DGF was higher among patients with a cold ischemia time (CIT) > 24 hours: 85% vs 60%, DGF vs no DGF (P < .05), as well as for grafts from older donors. After 1-year follow-up, the DGF group showed worse graft function (serum creatinine 1.6 ± 0.7 vs 1.3 ± 0.4 mg/dL; P < .05) as well as a greater incidence of graft loss.

Conclusion

Prolonged cold ischemia and older donor age were associated with a greater incidence of DGF in this series, leading to prolonged hospitalization, increased risk for an acute rejection episode, and reduced graft function and survival after 1 year.     

Nomogram for predicting the likelihood of delayed graft function in adult cadaveric renal transplant recipients

Delayed graft function (DGF) is the need for dialysis in the first week after transplantation. Studied were risk factors for DGF in adult (age >/=16 yr) cadaveric renal transplant recipients by means of a multivariable modeling procedure. Only donor and recipient factors known before transplantation were chosen so that the probabilities of DGF could be calculated before transplantation and appropriate preventative measures taken. Data on 19,706 recipients of cadaveric allografts were obtained from the United States Renal Data System registry (1995 to 1998). Graft losses within the first 24 h after surgery were excluded from the analysis (n = 89). Patients whose DGF information was missing or unknown (n = 2820) and patients missing one or more candidate predictors (n = 2951) were also excluded. By means of a multivariable logistic regression analysis, factors contributing to DGF in the remaining 13,846 patients were identified. After validating the logistic regression model, a nomogram was developed as a tool for identifying patients at risk for DGF. The incidence of DGF was 23.7%. Sixteen independent donor or recipient risk factors were found to predict DGF. A nomogram quantifying the relative contribution of each risk factor was created. This index can be used to calculate the risk of DGF for an individual by adding the points associated with each risk factor. The nomogram provides a useful tool for developing a pretransplantation index of the likelihood of DGF occurrence. With this index in hand, better informed treatment and allocation decisions can be made.