改进的套袖法吻合肾动脉建立大鼠原位肾移植模型

目的 观察改进的套袖法吻合肾动脉用于大鼠肾移植的可行性.方法 选择F344大鼠和Lewis大鼠分别作为肾移植的供、受者.切取供者左侧肾脏时,先剪断输尿管,然后阻断肾动、静脉水平上下的腹主动脉和下腔静脉,靠近下腔静脉剪断左肾静脉根部,经腹主动脉注入含肝素的4℃生理盐水对供肾进行原位灌洗后,靠近腹主动脉剪断肾动脉根部,取出供肾,放入4℃生理盐水中保存.切除受者左侧肾脏时,尽可能长的保留肾动、静脉以利于吻合.供肾植入时,采用改进的套袖法:用显微镊轻轻扩张供肾动脉后,协助显微持针器将针从供肾动脉血管外向血管内穿入,并从血管断端穿出第1针;接着穿入受者肾动脉断端,从受者肾动脉腔内向腔外穿出第2针;然后再从供肾动脉腔内、靠近第1针进针点处向腔外穿出,并与第1针的另外一端打结,此时受者的肾动脉已套入供肾动脉内;将供肾动脉边缘与受者肾动脉外膜固定2针,2针呈180度对角.供、受者的肾静脉及输尿管均行端端吻合.术后5 d内.若受者死亡,则认为手术失败.结泉共行肾移植20次,整个手术耗时70～90 min,供肾热缺血时间为4～9 s,冷缺血时间为30～40 min,肾动脉吻合用时(4.6±0.6)min,肾静脉吻合用时(11.8±1.2)min,输尿管吻合用时(12.2±1.4)min.术后5 d内,受者不明原因死亡1只,存活19只,手术成功率为95%.结论 采用改进的套袖法吻合肾动脉具有便捷、易于掌握、可靠及实用等优点,大鼠肾移植的成功率较高.     

简化的大鼠异位全小肠移植术

目的:建立简化的大鼠异位全小肠移植术技术,以提高手术成功率,为相关研究奠定基础.方法:供、受体均为雄性近交系Wistar大鼠,共180只,配对手术.采用供肠的肠系膜上动脉与受体肾下腹主动脉端侧吻合、门静脉与受体左肾静脉套管法端端吻合重建移植小肠血供,移植小肠远端腹壁造口.结果:手术耗时130min,移植小肠热缺血时间约30min.90只受全大鼠术扣即时存活率为100%,长期存活率(＞7d)为95.6%.结论:简化术式具有操作简便,移植小肠的热缺血时间短,手术成功率高等优点,有利于后续研究工作的开展.     

大鼠肾移植模型手术改良技巧探讨

目的探讨大鼠肾移植模型手术的改良方法。方法供体Sprague-Dawley(SD)大鼠21只,受体Wistar大鼠42只。采用双侧供肾。受体左肾切除后借助自制导管,行受体肾动脉与供体肾动脉、受体肾静脉与供体下腔静脉端端吻合,供体输尿管带膀胱瓣与受体膀胱吻合,最后切除右肾,腹腔内注入头孢米诺10 mg,关腹。记录手术时间,动、静脉吻合时间,冷、热缺血时间等手术数据;术后大鼠存活3 d认为模型建立成功,计算建模成功率,分析死亡原因。结果供体手术时间为(32.7±5.6)min,供肾修整时间为(4.2±1.1)min。受体手术时间为(42.3±4.9)min,其中动脉吻合时间为(10.1±3.2)min,静脉吻合时间为(13.9±2.5)min,尿路重建时间为(6.3±1.4)min。热缺血时间为(5.4±1.8)s,冷缺血时间为(56.2±7.3)min。42只受体大鼠中,建模成功40只,成功率为95%。另2只受体大鼠死亡,其中1只死于血管吻合口出血,1只死于尿瘘引致的腹膜炎。结论采用改良的血管端端吻合法建立大鼠肾移植模型具有操作简单、手术时间短、成功率高的特点。     

大鼠颈部异位肾移植术

目的建立一种简单、稳定、成功率高的大鼠颈部异位肾移植模型。方法取健康成年雄性近交系清洁级Wistar大鼠208只,体重220～260g,随机配对。整块获取带肾动脉、肾静脉和带膀胱瓣输尿管的供肾,血管重建采用供体肾动脉与受体的左颈总动脉套叠式吻合、供体肾静脉与受体右颈外静脉套管吻合。供肾输尿管远端行膀胱瓣皮肤造口。结果共进行大鼠异位肾移植术104次,其中预实验阶段62次,成功50次（80．6％）,失败12次,主要原因为麻醉意外、动脉吻合口血栓和大出血、静脉空气栓塞、静脉闭塞等;正式实验42次,成功40次（95．2％）,失败2次,分别为迟发性动脉吻合口出血和吻合口血栓引起。手术时间（40士6）min,其中供体手术时间（20±5）min,供肾修整时间（8±2）min;受体手术时间（18±3）min,其中动脉吻合时间（5±2）min,静脉吻合时间（2±1）min。移植肾冷缺血时间（15±3）min。移植术后1周移植肾血供良好,移植肾均长期存活（超过6个月）。6个月时受体大鼠一般状况良好,生长发育正常。结论大鼠颈部异位肾移植操作简便,冷缺血时间短,成功率高。     

心脏死亡供者供肾儿童肾移植一例

目的 探讨心脏死亡供者供肾儿童肾移植的临床效果.方法 供者为男性,年龄49岁,属“中国心脏死亡器官捐献分类标准”中的中国三类;受者为男性,14岁,原发病为肾病综合征、慢性肾功能衰竭.取供者右侧肾脏作为供肾,供肾动、静脉分别与受者髂总动脉、静脉行端侧吻合,移植肾输尿管内置带线双J管后与受者膀胱行隧道式包埋手术,将移植肾放置于受者右侧髂窝上方腹膜后腔.供肾热缺血时间为12 min,冷缺血时间为2h.使用巴利昔单抗和甲泼尼龙行免疫诱导治疗,术后采用他克莫司+吗替麦考酚酯+甲泼尼龙的三联免疫抑制方案.结果 术后1d时,受者出现ALT急剧升高,诊断为急性药物性肝损害,给予保肝降酶治疗后,ALT降至正常;术后3d时,受者出现腹部肠道不完全梗阻症状,经积极对症处理后症状消失,未发生急性排斥反应及移植肾功能恢复延迟等并发症.术后1个月时,受者顺利出院,至今随访6个月,移植肾功能正常.结论 心脏死亡供者供肾儿童肾移植手术安全、有效,但远期效果需要进一步观察.     

移植肾间隔室综合征一例

我院2008年12月成功治疗1例移植肾间隔室综合征(RACS),随访25个月余,肾功能正常,现报道如下. 临床资料 一、一般资料 患者为男性,32岁,因尿毒症行血液透析治疗8个月,无其他系统的严重并发症,术前群体反应性抗体阴性.供者为男性,28岁,无血管及输尿管变异.供、受者HLA有4个抗原相合,淋巴细胞毒交叉配合试验为0.03.供肾热缺血时间约4 min,冷缺血时间为12 h.手术常规采用全身麻醉,供肾置于右侧髂窝,其动、静脉分别与受者的髂外动、静脉行端侧吻合,输尿管与受者的膀胱行黏膜下遂道术吻合,开放血流后约2 min见输尿管残端清亮尿液喷出.     

肾移植术中供肾二次缺血再灌注一例

我们由于失误 ,导致术中供肾二次缺血 ,恢复血流后移植肾功能恢复正常 ,现将本例报道如下。患者为男性 ,4 5岁。供肾移植于受者右侧髂窝 ,肾静脉与髂外静脉行端侧吻合 ,肾动脉与髂内动脉行端端吻合。开放血流后 ,移植肾色红润 ,但张力差 ,搏动弱 ,调整肾脏位置后肾脏又呈暗紫色。查看肾动静脉 ,见肾动脉吻合在静脉前(应在静脉后 ) ,导致肾动脉扭曲 ,肾静脉受压。调整肾脏位置仍不满意。开放血流后 6 0min输尿管无蠕动及尿液流出。只得再次阻断肾、动静脉 ,切除动脉吻合口段 ,静脉壁纵行切开 0 .5cm ,用 4℃HC A液灌洗肾脏 ,肾周放置碎冰屑…     

马蹄形供肾肾移植术二例报告

20 0 1年 4月我们利用一个马蹄形供肾为 2例尿毒症患者行肾移植术 ,现报告如下。例 1,男 ,4 3岁。 1987年因慢性肾小球肾炎、尿毒症行第 1次肾移植术 ,1999年因移植肾慢性排斥恢复腹膜透析。 2 0 0 1年 4月 2 0日行第 2次肾移植术 ,术前群体反应抗体 (PRA) 14 .3%。术中将马蹄形肾从峡部分开后 ,右侧供肾动脉与受者髂内动脉端端吻合 ,供肾下极异位动脉与受者腹壁下动脉端端吻合 ,供肾静脉与受者髂外静脉端侧吻合 ,供肾输尿管与受者膀胱隧道式吻合。术后尿量约 5 0 0 0ml/d ,术后第 6天肾功能恢复正常。目前患者肾功能良好 ,作者单位 :5 10…     

移植肾动脉吻合口狭窄的再手术治疗二例

例1为男性，40岁。因慢性肾小球肾炎、尿毒症接受肾移植术。供肾血管无畸形，动、静脉各一支，动脉直径约5mm，静脉出口直径约15mm。供肾动脉与受者的髂内动脉行端端吻合，供肾静脉与受者的髂外静脉行端侧吻合，受者的髂内动脉直径约6mm。恢复循环后．移植肾迅速红润，张力、色泽良好，1min后即有尿液泌出。但术后尿量少，血尿素氮（BUN）为37．5mmol／L，肌酐（Cr）为1177μmol／L。术后第2d移植肾B型超声波检查提示移植肾图象异常，移植肾内血流速度明显减低，     

一种改进的大鼠肾移植模型

目的建立一种改进的大鼠异体肾移植模型。方法应用120只Wistar大鼠分别作为供体和受体，采用原位灌注、将供肾的血管与受体的同名血管作端-端吻合以及输尿管直接植入膀胱的方法建立大鼠原位肾移植模型。结果建立并改进了大鼠同种异体肾移植模型，成功率达到90％。热缺血时间小于3s，冷缺血（低温灌洗、供肾修整和冷保存）时间（40±5）min，血管吻合时间约35min，总手术时间为（160±10）min。结论该模型稳定性强，重复性好，适合于移植免疫的基础研究。     

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.     

手助腹腔镜肾切取术在活体供肾移植中的应用体会(附30例报告)

目的:评价手助腹腔镜活体供肾切取术的安全性及临床效果。方法:分析2013年8月至2016年8月采用手助腹腔镜活体供肾切取术获取30例活体供肾的临床资料。供者男7例,女23例,均取左肾,供受体关系为:父—子5例,母—子13例,母—女2例,兄弟2例,兄—妹4例,妻—夫3例,叔—侄1例。供肾者32~63岁,平均(51.8±8.5)岁。血型相同29例,相容1例,群体反应性抗体、淋巴毒均为阴性。30例患者均行手助腹腔镜活体供肾切取,切取后常规移植给受者,记录手术时间、出血量、供体冷热缺血时间、供者住院时间、术中副损伤及供受者术后恢复情况。结果:供者均切取左肾,手术成功,无一例中转开腹,供肾切取时间105~160 min,平均(100.4±19.5)min;失血量50~110 ml,平均(52.5±24.5)ml;供肾热缺血时间2.0~3.8 min,平均(2.4±0.5)min;冷缺血时间60~90 min,平均(68.2±26.7)min。供者术后1~3 d即可进食并下床活动,平均(2.5±0.6)d;住院3~6 d,平均(4.0±1.6)d。供受体无任何手术并发症发生,受者手术均获成功。随访3个月~3年,供体肾功能均正常。2例受者分别于肾移植术后1年8个月、1年2个月因自行减药,发生排斥反应,导致移植肾肾功能丢失,恢复透析,其余受体肾功能均正常。结论:手助腹腔镜活体供肾切取术结合了腹腔镜活体供肾切取术与开放手术的优点,既减轻了手术对供者的创伤,又保证了供肾质量,是安全、可靠的手术方法。     

肾动脉内套法建立大鼠肾移植模型

目的探索一种操作简单、成功率高的建立大鼠肾移植模型的手术方法。方法选择SD大鼠24只作为供体,Wistar大鼠48只作为受体,采用。肾动脉内套法建立大鼠。肾移植模型。所有受体大鼠均接受左侧原位肾移植,自体右肾切除。受体大鼠动脉重建借助自制动脉套管将受体肾动脉内套人供肾动脉,缝线固定及3点外膜加固行肾动脉重建,受体肾静脉与供体后腔静脉借助自制导管行端一端吻合,尿路改建采用供体输尿管膀胱瓣与受体膀胱吻合。结果研究共实施48例大鼠肾移植术。24只供体大鼠平均手术时间（354±6）min,供肾修整时间（3．9±1．2）rain,供肾热缺血时间（5．7±1．5）s,冷缺血时间（52±6）rain。48只受体大鼠手术时间（39±6）min,动脉吻合时间（6．9±2．5）min,静脉吻合时间（14．2±2．3）min,尿路重建时间（6．6±1．1）min。术后3d内,2只大鼠因血管吻合口出血死亡,2只因移植肾动脉内血栓形成死亡,1只因尿瘘致腹膜炎死亡,其余43只大鼠均获手术成功,成功率89．6％。截至术后14d,共7只受体大鼠存活,所有受体大鼠中位存活时间6d10结论肾动脉内套法操作简单,受体大鼠成功率高,初学者掌握快,易于推广。     

Two-year results of renal transplantation in kidney recipients from > or = 65-year-old deceased donors: a French region experience

The use of elderly deceased donors requires refining criteria for both the donor and the recipient. This report attempted to identify parameters susceptible to further improvement. This retrospective multicenter study analyzed the outcomes of kidney recipients from 15 consecutive elderly deceased donors in the south French region (IR9). Donors were 65 to 74 years old. Mean creatinine clearance was 80 mL/min/1.73 m(2). The donor risk factors for allograft dysfunction were stroke, hypertension, cardiovascular disease, cardiac death, smoking, arrhythmia, and diabetes. The recipients were 35 to 70 years old. The median cold ischemia time was 24 hours. Four patients (16%) suffered delayed graft function (DGF). Three recipients (12%) died within the first 2 months after transplantation. The postoperative complications (29%) were 2 renal artery thromboses, 4 renal artery stenoses, and 1 toe ischemia. Two years after transplantation, their mean serum creatinine was 157 micromol/L. The patient and graft survivals were 88% and 70%, respectively. These results seemed worse than those reported in the literature, but it was a small cohort and a new experience. DGF is probably linked to improvable management to reduce cold ischemia time. The elevated rate of surgical complications might be related to a lack of experience in donor and recipient evaluations. Kidney transplantation from elderly donors requires an efficient organization and an accurate evaluation of both donor renal function and recipient cardiovascular state.     

Targeting complement activation in brain-dead donors improves renal function after transplantation

Kidneys recovered from brain-dead donors have inferior outcomes after transplantation compared to kidneys from living donors. Since complement activation plays an important role in renal transplant related injury, targeting complement activation in brain-dead donors might improve renal function after transplantation. Brain death (BD) was induced in Fisher rats by inflation of an epidurally placed balloon catheter and ventilated for 6h. BD animals were treated with soluble complement receptor 1 (sCR1) 1h before or 1h after BD. Kidney transplantation was performed and 7 days after transplantation animals were sacrificed. Plasma creatinine and urea were measured at days 0, 1, 3, 5 and 7 after transplantation. Renal function was significantly better at day 1 after transplantation in recipients receiving a sCR1 pre-treated donor kidney compared to recipients of a non-treated donor graft. Also treatment with sCR1, 1h after the diagnosis of BD, resulted in a better renal function after transplantation. Gene expression of IL-6, IL-1beta and TGF-beta were significantly lower in renal allografts recovered from treated donors. This study shows that targeting complement activation, during BD in the donor, leads to an improved renal function after transplantation in the recipient.     

Early and late injury to renal transplants from non-heart-beating donors

BACKGROUND: The lack of adequate numbers of kidneys for transplantation has stimulated interest in the use of organs from non-heart-beating donors (NHBDs). The short- and long-term effects of this risk factor on kidney isografts and allografts were examined with a rat model. METHODS: NHBDs were killed by ether overdose. Kidney isografts (male Lewis rats [LEW]-->LEW) were transplanted orthotopically into bilaterally nephrectomized recipients 15, 30, 45, and 90 min after asystole to determine short-term survival patterns, which were compared to those of rats bearing kidneys from living donors (LDs, 0 min). Isografts and allografts (Fisher 344 rats-->LEW) from 45-min and 105-min NHBDs and from LD controls were placed in additional recipients in which contralateral native nephrectomy was performed on day 10 to allow the injured graft to recover from its ischemic insult. Serum creatinine, proteinuria, and graft morphology were assessed serially over a 24-week follow-up period. RESULTS: Early survival and renal dysfunction of isografted rats correlated with the interval of donor cardiac arrest before transplantation. Long-term survival of recipients of kidneys from LDs and between 45-min and 105-min NHBDs was also significantly different (100% vs. 87% vs. 37% at 24 weeks, respectively, P<0.03). Proteinuria increased progressively over time, proportionate to the period of donor asystole, and was associated with increasing cellular infiltration, tubular atrophy, and glomerulosclerosis in the grafts. The development of important functional and structural changes was intensified in NHBD allografts. LD allografts showed early changes of chronic rejection. CONCLUSIONS: The results emphasize the continuum between an initial nonspecific, donor-associated renal injury and late functional and morphologic changes associated with the interval of donor cardiac arrest. These events are accelerated in NHBD allografts that experience the added insult of host alloreactivity.     

Atrial natriuretic factor does not improve the outcome of cadaveric renal transplantation.

Atrial natriuretic factor (ANF) ameliorates renal damage in animal models of acute ischemic renal failure. Consequently, ANF could blunt acute tubular necrosis related to ischemia that occurs frequently in cadaveric renal transplants. Ten pairs of cadaveric kidneys were transplanted into 20 recipients. Paired recipients received either alpha-human ANF (hANF) or vehicle alone in a prospective, double-blind protocol. Upon revascularization of the allograft, either hANF or vehicle was administered intravenously as a 50-micrograms bolus, followed by a 4-h infusion (0.1 microgram/kg/min). Glomerular filtration rate ([125I]iothalamate clearance) was measured between 4 and 7 days posttransplant and again between 14 and 21 days posttransplant. Serum creatinine was measured daily when patients were in the hospital, then twice weekly as patients were examined in the outpatient clinic. Between the groups, there was no significant difference in age of the recipients or donors, cold ischemia time, or histocompatibility leukocyte antigen match. Infusion of hANF had no adverse effects. When subjects receiving hANF were compared with those treated with vehicle alone, there were no significant differences in serum creatinine or glomerular filtration rate. Three hANF and four vehicle recipients required dialysis postoperatively. At 1 month posttransplant, 19 of 20 patients had functioning allografts; an allograft from one hANF recipient never functioned. It was concluded that hANF, when given by the protocol of this study, had no beneficial effect on the outcome of cadaveric renal transplantation in humans.     

心脏死亡供体经典原位肝移植的单中心临床研究

目的总结心脏死亡器官捐献（donation after cardiac death,DCD）供体供肝获取及应用于肝移植的临床经验和可行性。方法2011年11月至2012年9月,西安交通大学第一附属医院采用Maastricht标准或中国标准,共获取18例DCD供肝,于该院完成经典原位肝移植14例,送往其他移植中心3例,放弃1例。对18例供体与在该院完成肝移植的14例受体的临床资料进行回顾性分析,了解供肝情况、受体围手术期及随访结果。结果18例供体中符合Maastricht标准Ⅲ类5例、V类2例,符合中国标准Ⅲ类（即脑一心双死亡标准器官捐献,donation after brain death plus cardiac death, DBCD）11例。按规范器官获取流程取得供肝。供肝的热缺血时间为11～18min,平均为14．5min;冷缺血时间为90—600min,平均为350min。14例受体均顺利完成移植手术。其中12例受体预后良好,肝功能逐渐恢复,未出现原发性移植肝无功能、血栓形成、排斥反应,但2例出现胆道狭窄并发症,经胆道支架置人术后引流通畅;重症监护室（ICU）治疗时间平均7d,术后住院时间平均23d,病情稳定后出院。1例受体术后2d死于肝衰竭,其供体原发病为冠状动脉粥样硬化性心脏病,需给予大量多巴胺维持其血压;另1例于术后当日死于腹腔内大出血,其供体为重症哮喘、心肺复苏后死亡。12例受体者平均随访时间为6个月,总体存活率为85％,肿瘤患者尚未发现复发转移。结论DCD可以扩大供肝来源且近期效果良好,具有可行性。实施可控型DCD捐献,严格掌握供者适应证、加强器官评估、缩短热缺血时间和冷缺血时间,是保障供肝质量的重要因素。     

Contribution of prolonged ischemia and donor age to chronic renal allograft dysfunction

As a consequence of an advancing discrepancy between supply of suitable grafts and demand from potential recipients, less than optimal organs are increasingly being used. Although clinical studies demonstrate the involvement of various risk factors, including donor age and duration of ischemia on long-term graft outcome, their individual contribution and correlation has not been followed experimentally. After cold ischemic times of 5, 60, and 120 min, kidney allografts of 3-, 12-, and 18-mo-old Fischer 344 donors were transplanted into 3-mo-old Lewis rats. Age-related changes were examined in matched native uninephrectomized controls. Proteinuria and creatinine clearance were determined, and histologic and immunohistologic studies were assessed and quantified at the end of the observation period (20 wk). All grafts functioned satisfactorily with the exception of one graft each from 12- and 18-mo-old donors with prolonged ischemia (120 min). Functional deterioration and structural changes progressed in parallel to increasing donor age and prolonged ischemia. The impact of expanded ischemia was particularly detrimental in grafts from older donor animals. Donor age and duration of ischemia act in a synergistic manner in our model. Brief ischemic times seem of particular relevance when grafts from older donors are being used.