负向调节树突状细胞对心脏移植大鼠调节性T细胞的影响

目的:探讨受者树突状细胞(DC)与体外光化学法(PUVA)处理的供者脾淋巴细胞共培养,对心脏移植受者CD4+CD25+调节性T细胞(Treg)及移植心存活时间的影响。方法:以DA大鼠为供者,Lewis大鼠为受者,SD大鼠为无关供者,建立大鼠腹部异位心脏移植模型。分离正常的供者脾淋巴细胞(SP),制备经PUVA处理的供者脾淋巴细胞(PU-VA-SP)。在体外将DA大鼠PUVA-SP或SP与受者骨髓来源的DC共同培养,收集经上述处理后受者DC,流式细胞术(FCM)检测其表面分子CD80、CD86以及OX6的表达状况。根据受者术前静脉输注的成分将实验动物随机分为3组:①Control组:单纯输注PBS,n=7;②SPDC组:输注加载供者SP的受者大鼠DC,n=8;③PUVA-SPDC组:输注加载PUVA处理的供者SP的受者大鼠DC,n=8。移植术前7d,经外周静脉给受者输注与PUVA-SP共培养后的DC(PUVA-SPDC组)、正常受者DC(DC组)或只输注PBS(Control组),移植术后观察受者移植物的存活时间,检测受者外周血中CD4+CD25+T细胞、CD4+CD25highT细胞的比例及其Foxp3表达状况。过继转移PUVA-SPDC组受者大鼠的T细胞后,检测正常LEW大鼠对供者抗原或无关抗原的DTH反应。结果:受者DC与供者未经处理的脾淋巴细胞(SP)混合培养后,其表面分子CD80、CD86以及OX6的表达分别为16.6%±0.72%、36.5%±0.87%及65.6%±1.45%,明显高于未处理DC组(3.53%±0.27%、13.0%±0.57%及27.7%±1.23%)(P0.01);而受者DC与PUVA处理过的供者脾淋巴细胞(PUVA-SP)混合培养后,其表面分子的表达仍保持较低的水平,CD80、CD86以及OX6的表达分别为3.9%±0.12%、13.4%±0.59%及28.0%±1.73%,与未经任何处理的受者DC无统计学差异(P0.05)。移植术后,PUVA-SPDC组受者,外周血CD4+CD25+T、CD4+CD25highT细胞占CD4+T的比例分别是18.97%和3.81%,明显高于输注DC组(4.40%和0.81%)和Control组(3.11%和0.09%)的大鼠(P0.01)。PUVA-SPDC组大鼠外周血CD4+CD25+T细胞中Foxp3表达率为29%±1.73%,CD4+CD25highT细胞中Foxp3阳性率高达95%±1.67%,均明显高于对照组(12%±0.58%和19.3%±2.03%)及DC(16.3%±0.88%和52.0%±1.73%)组(P0.01)。PUVA-SPDC组大鼠移植心存活时间为(27.3±0.98)d,与Control组(6.7±0.29)d及DC组(11.0±0.32)d相比,明显延长(P0.01)。过继转移实验显示,接受PUVA-SPDC组受者T细胞的正常LEW大鼠对DA大鼠抗原的刺激呈特异性免疫低应答状态。结论:PUVA-SPDC能够在移植受者体内诱生CD4+CD25+Foxp3+Treg,同时诱导抗原特异性免疫低反应,进而延长异基因移植物的存活时间。     

肝移植106例术后急性排斥反应的诊断和治疗

目的:总结肝移植急性排斥反应的新表现及诊治经验. 方法:回顾我中心106例肝移植资料,对其中发生急性排斥反应病例的临床表现、病理组织学改变、诊治方案加以分析. 结果:106例肝移植中,术后发生急性排斥反应17例(16.0%);其中临界型1例,轻度6例,中度7例,重度3例. 这些病例在具备病理组织学改变的同时缺乏典型的临床特征和肝功能生化指标的改变. 结论:由于强效免疫抑制剂的应用,肝移植术后急性排斥反应发生的临床症状和体征不典型,我们应该重视急性排斥反应的诊断并积极治疗.     

老年活体供肾移植术后供者安全性及受者移植效果的分析

Objective To investigate the safety for donors and the effectiveness for recipients of living-related donor (LRD) kidney transplantation from elder donors. Methods 251 cases of LRD kidney transplantation were reviewed. According to the age of LRDs, the patients were divided into 2 groups:≥55 years group (group A) and <55 years (group B). The parameters studied included serum creatinine (Cr), glomerular filtration rate (GFR), creatinine clearance (Ccr), perioperative complications, average hospital stay, and acute rejection rate of LRDs and recipients were compared. Results (1)There was no significant difference in serum Cr between groups A and B at different time points (P>0.05). (2)There was no significant difference in Ccr between two groups pre-donation (P = 0.45). But at the 10th day after the donor nephrectomy, Ccr level in group A was significant lower than in group B (P<0.01). (3)Total GFR pre-donation, remaining renal GFR, and remaining renal GFR on the day 10 after donation had no significant difference in both groups A and B (P>0.05). Remaining renal GFR on the day 10 before and after donation had no significant difference in group A (P>0.05), but on the day 10 after donation that was significantly increased in group B as compared with that pre-donation (P<0.01). (4) The serum Cr of recipients at different time points after transplantation had no significant difference between two groups (P>0.05). (5) The mean hospital stay after donation of LRDs and recipients had no significant difference between two groups. (6) The incidence of recipients" acute rejection was 6.50 % (5/77) in group A, and 5.75%(10/174) in group B within 6 months after operation (P = 0.95). Conclusion Transplantations performed from the elderly donors will yield similar results from younger donors if the eider donors are evaluated or assessed as the standards.     

老年活体供肾移植术后供者安全性及受者移植效果的分析

Objective To investigate the safety for donors and the effectiveness for recipients of living-related donor (LRD) kidney transplantation from elder donors. Methods 251 cases of LRD kidney transplantation were reviewed. According to the age of LRDs, the patients were divided into 2 groups:≥55 years group (group A) and <55 years (group B). The parameters studied included serum creatinine (Cr), glomerular filtration rate (GFR), creatinine clearance (Ccr), perioperative complications, average hospital stay, and acute rejection rate of LRDs and recipients were compared. Results (1)There was no significant difference in serum Cr between groups A and B at different time points (P>0.05). (2)There was no significant difference in Ccr between two groups pre-donation (P = 0.45). But at the 10th day after the donor nephrectomy, Ccr level in group A was significant lower than in group B (P<0.01). (3)Total GFR pre-donation, remaining renal GFR, and remaining renal GFR on the day 10 after donation had no significant difference in both groups A and B (P>0.05). Remaining renal GFR on the day 10 before and after donation had no significant difference in group A (P>0.05), but on the day 10 after donation that was significantly increased in group B as compared with that pre-donation (P<0.01). (4) The serum Cr of recipients at different time points after transplantation had no significant difference between two groups (P>0.05). (5) The mean hospital stay after donation of LRDs and recipients had no significant difference between two groups. (6) The incidence of recipients" acute rejection was 6.50 % (5/77) in group A, and 5.75%(10/174) in group B within 6 months after operation (P = 0.95). Conclusion Transplantations performed from the elderly donors will yield similar results from younger donors if the eider donors are evaluated or assessed as the standards.     

肝癌患者肝移植术前外周血AFP mRNA的表达与肿瘤复发及患者生存的关系

目的:探讨原发性肝细胞肝癌患者在肝移植术前外周血AFP mRNA的表达及其与术后肿瘤复发、患者预后的关系.方法:以2003年2月～2004年2月收入天津市第一中心医院的31例肝细胞肝癌行原位肝移植患者为研究对象,采用实时定量RT-PCR检测患者术前外周血AFP mRNA表达水平,均采用尸体供肝经典原位肝移植.以SPSS 12.0软件分析AFP mRNA的表达与患者术后肿瘤复发及生存的相关性.结果:31例患者中有10例AFP mRNA表达阳性,表达量为57～10 400 copy/μg,中位数为360 copy/μg.患者Child-pugh分级,肿瘤的大小、个数,病理Edmond分级与术前AFP mRNA的表达水平无关.肿瘤TNM分期为Ⅲ～Ⅳ期的患者AFP mRNA的阳性表达率显著高于Ⅰ～Ⅱ期患者(P=0.001);脉管浸润的患者AFP mRNA的表达水平显著高于无脉管浸润者(P=0.029).肝移植术前AFP mRNA阴性组的无瘤生存及总体生存显著高于AFP mRNA阳性组.结论:术前AFP mRNA表达的水平是肿瘤复发的危险因素,是术前可能存在肝外微转移的指标,可作为预后的判断因子.     

3例结节性硬化症合并肾血管平滑肌脂肪瘤的诊断与治疗

目的：探讨结节性硬化症伴巨大肾血管平滑肌瘤（AML）的临床诊治特点和自发性肾破裂出血的治疗措施。方法：报告3例结节性硬化症伴多发性双肾AML的临床诊治资料。3例均为女性,年龄16～26岁,均有典型的智力低下、面部皮脂腺瘤体症,2例因腰部剧烈胀痛伴休克入院,1例因腹胀并癫痫发作入院。3例均经CT检查证实大脑钙化结节灶。结果：1例行DSA肾肿瘤栓塞治疗,1例行肾切除术治疗,1例经抗癫痫药物治疗稳定后行肾切除治疗。3例均成功治愈出院。结论：结节性硬化症合并肾血管平滑肌脂肪瘤肿瘤巨大、症状严重、存在潜在破裂出血及可疑癌变者,可行根治切除或部分切除,破裂出血者宜首选选择性肾动脉栓塞术。     

淋巴细胞清除剂与IL-2受体拮抗剂诱导疗法在活体肾移植中的安全性比较

目的 比较两种抗体诱导剂(淋巴细胞清除剂和IL-2受体拮抗剂)在活体肾移植中的安全性.方法 回顾性分析2007年2月-2012年4月行活体肾移植的191例受者的病例资料,根据接受诱导剂的不同分为3组:淋巴细胞清除剂组(n=56),4例给予兔抗人胸腺细胞免疫球蛋白(rATG)、52例给予猪抗人胸腺细胞免疫球蛋白(pATG);IL-2受体拮抗剂组(n=54),40例给予巴利昔单抗、14例给予噻尼哌;对照组(n=81),不给予任何抗体诱导剂.比较3组在1年内的排斥、感染等并发症发生率和人/肾存活率.结果 淋巴细胞清除剂组、IL-2受体拮抗剂组和对照组1年内急性排斥反应的发生率分别为12.5％、11.1％、28.4％,差异有统计学意义(P=0.003),前两组比较差异无统计学意义(P＞0.05);3组移植物功能延迟恢复(DGF)发生率分别为8.9％、7.4％、13.6％,差异无统计学意义(P＞0.05).3组的感染并发率和1年人/肾存活率差异无统计学意义(p＞0.05).结论 两种诱导疗法均可显著减少术后急性排斥反应的发生,但并不增加感染和不良事件的发生率,且不影响术后人/肾存活,安全有效.     

活体供肾与尸体供肾：1个器官移植中心2年65︰169例肾移植效果比较

背景：活体供肾移植的数量在部分医院已经超过尸体供肾移植,但其安全性、优越性、手术技巧、其所面临的伦理学问题还有待进一步探讨。 目的：回顾总结同期完成的活体供肾移植及尸体供肾移植的临床经验,分析不同肾脏来源的肾脏移植术后疗效。 方法：收集2006-01/2008-03在解放军第309医院全军器官移植中心接受活体供肾移植的65例受者、接受尸体供肾移植169 例受者的临床资料,对不同肾脏来源受者的性别、年龄、HLA 位点配型、手术情况、术中和术后近、远期并发症、免疫抑制方案、肾功能恢复情况及长期随访资料进行对照研究,进一步明确活体亲属供肾移植的临床意义。 结果与结论：65例活体供肾移植手术均获成功,人/肾1年存活率为100%;尸体供肾移植手术成功,2 例因术后3个月出现脑出血等非感染并发症死亡,6例在术后1年内因重症肺部感染呼吸衰竭死亡,人/肾1年存活率95.26%。两种不同来源的肾脏移植在并发症以及人/肾1年存活率等指标上活体供肾移植优于尸体供肾移植。活体供肾移植等待时间短,组织配型好,供肾缺血时间短,排斥反应发生少,移植肾存活率高,是一种安全可行的治疗手段。 关键词：活体;尸体供肾;肾移植;存活;并发症     

再次肾移植21例

回顾性分析2000-01/2007-01收治的再次肾移植患者21例的临床资料,统计移植后1,3,5年人/肾存活率,分析影响存活率的因素.首次移植肾失功的原因包括排斥反应17例,输尿管梗阻1例,血栓形成3例(肾动脉、肾静脉、肾内静脉各1例).再次移植后1,3,5年人/肾存活率分别76%/62%,76%/53%和59%/42%.使用和未用抗体诱导患者1年肾存活率分别为83%和33%,群体反应性抗体阴性和阳性患者1年肾存活率分别67%和0,差异均有显著性意义(P＜0.05).而患者年龄是否超过40岁及距离首次肾移植的时间是否超过6个月均与1年肾生存率无关(P＞0.05).21例患者中发生排斥反应11例次,发生率52%.其中超急性排斥反应3例,发生率14%,3例群体反应性抗体均为阳性,分别为10%,15%和22%,立即切除移植肾继续血液透析治疗;急性排斥反应8例次,发生率38%,经过激素冲击或OKT3治疗后均逆转;移植肾功能延迟恢复6例,发生率29%,其中4例经血液透析后肾功恢复.受者年龄和距离首次移植时间与移植肾存活率不存在明确关系,采用抗体诱导治疗和选择群体反应性抗体阴性受者有利于移植肾的存活,移植后用药应选择肝毒性小的免疫抑制剂,当首次移植肾完全失功时为避免出现并发症及减轻患者经济负担应切除失功肾.     

肺移植后真菌感染1例并文献复习

回顾分析1例肺移植患者病理过程及诊疗经过,并复习相关文献,总结相关的临床治疗经验.原发性肺动脉高压并三尖瓣关闭不全、充血性心力衰竭女性患者,33岁,2006-04在体外循环下行同种异体原位双肺移植术,术后出现严重的低血容量性休克,伴有严重高钠血症,同时合并严重代谢性碱中毒,pH值最高达7.6,经积极治疗后,血钠水平于术后第14天恢复正常,术后第3天起,从痰培养、气管切开伤口分泌物、血液培养中分离出细菌、真菌共计12种,根据药敏试验给予相应抗生素治疗,真菌培养结果仍持续阳性,于术后第72天死亡.肺移植术后真菌感染是危及生命的严重并发症,对其进行早期诊断、消除各种诱发因素、及时给予足量、联合抗真菌药物治疗是移植后真菌感染防治的关键.