中医药结合胫骨交锁髓内钉闭合穿钉治疗的效果评价

目的探讨中医药结合胫骨交锁髓内钉闭合穿钉治疗的临床效果。方法将50例胫骨平台骨折患者按照1∶1的比例随机地均分为对照组与观察组,对照组仅采用胫骨交锁髓内钉闭合穿钉治疗,观察组在此基础上联合使用中药内服外敷治疗。比较两组治疗优良率、手术相关指标、治疗前后Rasmussen膝关节功能评分及不良反应发生情况。结果(1)对照组优良率为68.00%,显著低于观察组(88.00%)(P<0.05);(2)两组手术时间及术中出血量差异无统计学意义(P>0.05);(3)两组治疗前后Rasmussen膝关节功能评分差异均具有统计学意义(P<0.05);(4)两组不良反应发生率差异无统计学意义(P>0.05)。结论中药联合胫骨交锁髓内钉闭合穿钉治疗胫骨平台骨折疗效显著,膝关节功能改善明显,应加以推广应用。     

Bortezomib may stabilize pediatric renal transplant recipients with antibody-mediated rejection

Background

Current therapeutic strategies to effectively treat antibody-mediated rejection (AMR) are insufficient. Thus, we aimed to determine the benefit of a therapeutic protocol using bortezomib for refractory C4d + AMR in pediatric kidney transplant patients.

Methods

We examined seven patients with treatment-refractory C4d + AMR. Immunosuppression included antithymocyte globulin or anti-CD25 monoclonal antibody for induction therapy with maintenance corticosteroids, calcineurin inhibitor, and anti-metabolite. Estimated glomerular filtration rate (eGFR) calculated by the Schwartz equation, biopsy findings assessed by 2013 Banff criteria, and human leukocyte antigen (HLA) donor-specific antibodies (DSA) performed using the Luminex single antigen bead assay were monitored pre- and post- bortezomib therapy.

Results

Seven patients (86 % male, 86 % with ≥6/8 HLA mismatch, and 14 % with pre-formed DSA) age 5 to 19 (median 15) years developed refractory C4d + AMR between 1 and 145 (median 65) months post-transplantation. All patients tolerated bortezomib. One patient had allograft loss. Of the six patients with surviving grafts (86 %), mean pre-bortezomib eGFR was 42 ml/min/1.73 m² and the mean 1 year post-bortezomib eGFR was 53 ml/min/1.73 m². Five of seven (71 %) had improvement of histological findings of AMR, C4d staining, and/or acute cellular rejection. Reduction in HLA DSAs was more effective for class I than class II.

Conclusions

Bortezomib appears safe and may correlate with stabilization of eGFR in pediatric kidney transplant patients with refractory C4d + AMR.

     

Variables affecting estimated glomerular filtration rate after renal transplantation in children: A NAPRTCS data analysis

Moudgil A, Martz K, Stablein DM, Puliyanda DP. Variables affecting estimated glomerular filtration rate after renal transplantation in children: A NAPRTCS data analysis.
Pediatr Transplantation 2010: 14:288–294. © 2009 John Wiley & Sons A/S. Abstract: Short‐term graft survival has improved in renal transplants without significant effect on long‐term graft survival. As GFR decline precedes graft loss, an understanding of variables affecting eGFR after TX may help improve graft survival. NAPRTCS data were analyzed to assess effects of donor, recipient, and other variables on Schwartz eGFR after transplantation. For 8438 children with a functioning graft at day 30, data were censored for children dying with a functioning graft, and those with <3 yr follow‐up. Multivariate linear regression and repeated measures analyses identified factors related to eGFR at day 30 after TX and during follow‐up. Young, female, non‐black, children without ATN and acute rejection in the first 30 days, TX after 1995, those with better eGFR at day 30, and receiving tacrolimus had better long‐term eGFR. Transplant from ideal (6–35 yr) donors had best short‐term eGFR, young donors (<5 yr) had lower eGFR and poor graft survival. After one yr, eGFR improved in surviving grafts of young donors and matched ideal donors. Acute rejection, BP medications, and hospitalizations in prior six months had negative association with subsequent eGFR. Regardless of variables, eGFR deteriorated with time. Slope of eGFR decline has not changed in the recent era indicating the need for innovative therapies.     

Early outcomes comparing induction with antithymocyte globulin vs alemtuzumab in two steroid‐avoidance protocols in pediatric renal transplantation

Steroid avoidance in pediatric kidney transplants was found effective with extended daclizumab induction. Upon discontinuation of daclizumab, lymphocyte‐depleting agents became used, with little comparative data. We assessed outcomes in children undergoing low immunologic‐risk deceased donor (DD) kidney transplants using induction with antithymocyte globulin (ATG) compared to alemtuzumab. We reviewed consecutive DD kidney transplants from January 2015 to September 2017 at two pediatric centers that used different lymphocyte‐depleting agents in steroid‐avoidance protocols: ATG (Center A) and alemtuzumab (Center B), with tacrolimus and MMF as maintenance immunosuppression . Anti‐infective prophylaxis was based on center protocol. Over the first year post‐tx, there were similar rates of infections. EBV and BK viremia were comparable though Center A manifested more low‐grade CMV viremia (A 46% vs B 0%; P = .0009) at median onset 1.8 months, followed by early seroconversion. Reduction of immunosuppression did not differ between groups. DSA at 1 year was similar (A 8% vs 13%) with low rates of BPAR. Need for steroid‐based conversion was low. There were no graft losses and no differences in median eGFR at 30, 90, 180, and 365 days. (a) 1‐year graft outcomes are excellent in steroid‐avoidance regimens using ATG or alemtuzumab induction; (b) conversion to steroid‐based therapy is low; (c) alemtuzumab/high‐dose MMF is associated with lower WBC and more GCSF use; (d) alemtuzumab/higher dose MMF results in more diarrhea and azathioprine conversion than ATG/lower dose MMF; (e) CMV viremia is seen more often with ATG use with infection prophylaxis reduction; however, seroconversion occurs promptly.     

Risk factors for the development of antibody‐mediated rejection in highly sensitized pediatric kidney transplant recipients

ABMR remains a significant concern for early graft loss, especially for those who are HS against HLA antigens. We sought to determine the risk factors leading to ABMR in HS pediatric kidney transplant recipients. From January 2009 to December 2015, 16 HS pediatric kidney transplant patients at our center (age range 2‐21) were retrospectively reviewed for outcomes and risk factors for ABMR. All HS patients received desensitization with high‐dose IVIG/rituximab prior to transplant. Two groups were examined: ABMR⁺ (n = 7) and ABMR^? (n = 9). Patient survival was 100%; however, one patient in the ABMR⁺ group suffered graft loss from ABMR 16 months post‐transplant. ABMR⁺ patients had higher Class I PRA at the time of transplant (Class I: 73.1 ± 19.1 vs 49.1 ± 28.3, P = .075), although not statistically significant. ABMR⁺ patients were more likely to have a history of transplant nephrectomy (P = .013). The characteristic that most strongly correlated with ABMR was the DSA‐RIS (P = .045), a scoring system used to quantify cumulative intensity of all DSA. In conclusion, DSA, as quantified by the RIS at the time of transplant, should be considered as part of the initial allocation strategy and patients with high RIS monitored closely for ABMR post‐transplant.     

Younger Age and Antibody Induction Increase the Risk for Infection in Pediatric Renal Transplantation: A NAPRTCS Report

Infections now exceed rejection as a cause of hospitalization in the first 2 years post-renal transplantation. We analyzed data from the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) to determine risks for hospitalization for infection (HI), either bacterial (HBI) or viral (HVI). 3106 children transplanted between 1996 and 2002 with 2-year follow-up were analyzed. Univariate and multivariate logistic regression analyses identified factors for cause-specific hospitalization. Results: 23.4% experienced HBI, 23.9% HVI; 8.9% were hospitalized for both. Children 0-1 years age at transplant had higher rates of HI (64.2%), HBI (40.3%) and HVI (43.3%) compared to >12 years (31%, 17.5% and 18.9%, p < 0.0001). In comparison to no induction, patients receiving monoclonal or polyclonal antibody were more likely to have HI (>42% vs. 34.0%), HBI (>24% vs. 21%) or HVI (>29% vs. 21%, all p < 0.003) but had equivalent graft survival (p = NS). Higher rates of HI, HBI and HVI were also seen with prophylactic antimicrobial use and with >5 transfusions pretransplant. Since antibody induction in recent era was not associated with better graft or patient survival but was associated with more HI and HVI, the need for routine antibody induction in children needs to be reassessed.     

Induction therapy in pediatric renal transplant recipients: an overview

Induction therapy to prevent the acute rejection of mismatched allografts with the ultimate aim of prolonging the life of the allograft has been the cornerstone of immunosuppression since the introduction of renal transplantation. Agents used for induction therapy have changed over time. Their role in transplantation is expanding to include corticosteroid avoidance and immunosuppression minimization. This review provides an overview of induction therapies for renal transplantation including historic therapies such as total lymphoid irradiation and Minnesota antilymphocyte globulin, and current therapies with polyclonal and monoclonal antibodies and chemical agents, with special emphasis on children. Data from adult studies, and pediatric studies whenever available, are summarized. A brief summary of experimental therapies with fingolimod and belatacept is provided. Historically, induction therapies were targeted at T cells. The role of induction therapies targeted at B cells is emerging in select groups of patients that include highly sensitized recipients and those receiving transplants from blood group incompatible donors. With the advent of newer maintenance immunosuppressive medications and with very low rates of acute rejection, induction protocols for renal transplantation need to be targeted so that excessive immunosuppression and infections are avoided. Several single-center and registry data analyses in children suggest that the addition of an interleukin (IL)-2 receptor antagonist may improve graft survival compared with no induction. The safety profile of IL-2 receptor antagonists is indistinguishable from that of placebo, with no apparent difference in the incidence of infection or post-transplant lymphoproliferative disease. IL-2 receptor antagonists and polyclonal lymphocyte-depleting antibodies offer equivalent efficacy in standard-risk populations. However, in high-risk patients, acute rejection rates and graft outcomes may be improved with the use of lymphocyte-depleting agents such as Thymoglobulin. However, cytomegalovirus infection and other infections may be more common with this therapy. Therefore, in patients at high risk of graft loss, Thymoglobulin may be the preferred choice for induction therapy, while for all other patients, IL-2 receptor antagonists should be considered the first-line choice for induction therapy. Newer lymphocyte-depleting agents such as alemtuzumab may be better utilized in minimization regimens involving one or two oral maintenance immunosuppressive agents.     

Preventing recurrence of focal segmental glomerulosclerosis following renal transplantation: a case report

While the recurrence of FSGS in a primary renal transplant has been well studied, strategies to prevent subsequent recurrence in later transplants, has not been well formulated. This is important considering that one center's experience with adults reported an initial recurrence rate of 57% with reoccurrence of 37% in subsequent transplants. However, renal function was maintained in 62% (1). In pediatrics, data from a single-center reported 100% recurrence of FSGS in the second allograft after an initial recurrence of 52% (2). Two commentaries reviewing such data, one each in adults and pediatrics, suggested that the benefits of living-related donation might not be realized in patients with FSGS because of this frequent recurrence (3, 4). Here, we report a patient who was considered to be at very high risk for post-transplant recurrence of FSGS, because of the established risk factors, who was successfully retransplanted after a course of pretransplant plasmapheresis, followed by post-transplant plasmapheresis and the use of cyclosporine. Eighteen months post-transplant, he has no proteinuria and his serum creatinine is 1.2 mg/dL.     

高强度聚焦超声终止早孕机声场的辐射力计算与声功率测量

目的 :验证作者所导出的公式对 HIFU终止早孕机的输出声功率测量的准确性。方法 :应用几何声学方法和声叠加原理 ,利用 Beissner的球冠形聚焦换能器的声辐射力公式 ,导出了球台形超声换能器的声辐射力计算公式。并为此设计了一台测量高强度聚焦超声 ( HIFU)终止早孕机的声场的声辐射力的力平衡装置。应用导出的公式测定 HIFU终止早孕机的输出声功率并与量热法测得的同一输出声功率相比。结果 :两种测量方法的同一超声场的声功率 ,偏差小于 3%。结论 :说明所导出的公式是合理的     

Outcome of management strategies for BK virus replication in pediatric renal transplant recipients

Abstract:  Management of BKV infection is not well defined. Eighteen pediatric renal transplant patients with BKV-PCR (+) were divided into three groups; Group 1: Viruria only (6), Group 2: Viremia with stable GFR (4), Group 3: Viremia with >25% decline in GFR and BKVAN on biopsy (8). With initial BKV-PCR(+), Group 1 received no treatment; Group 2 had MMF reduced 30%; Group 3: 6/8 had CNI discontinuation, 2/8 had reduced MMF and cidofovir. BKV, GFR and histology were compared pre- and post-treatment. In Group 1 viruria decreased in all patients; GFR remained stable. Group 2 showed reduced viremia with no GFR change. Group 3 showed reduced viremia in 8/8 patients. Patients with >50% decline in GFR from baseline (6/8) showed worse histology: 2/6 lost grafts despite no BKV on follow-up biopsy. Our results show that with viruria alone no treatment is necessary; with viremia and stable GFR, reduced immunosuppression decreases viremia and maintains GFR. With viremia and reduced GFR, immunosuppression reduction with or without cidofovir decreases viremia and stabilizes GFR in most patients. Greater than 50% reduction in GFR at BKVAN diagnosis correlates with risk for graft loss. Serial monitoring of BKV viremia with early intervention may prevent BKVAN graft loss in children.