采用Orem自理模式提高肾移植术后患者的自理能力

目的增强肾移植术后患者的自理能力,提高其生活质量.方法将200例肾移植术后患者随机分为对照组与观察组各100例.对照组采用术后常规护理,观察组应用Orem护理系统中部分补偿系统和辅助教育系统进行护理干预.采用自理能力问卷调查两组患者术后2周及出院后3个月的自理能力.结果两组患者在术后2周时自理能力比较,差异无显著性意义(P>0.05);但出院后3个月观察组患者自理能力显著优于对照组(P<0.05).结论肾移植患者术后自理能力较低,Orem自理模式的应用可提高其术后自理能力.     

中青年与老年脑卒中患者发病危险因素及自护行为比较

目的 增强肾移植术后患者的自理能力，提高其生活质量。方法 将200例肾移植术后患者随机分为对照组与观察组各100例。对照组采用术后常规护理，观察组应用Orem护理系统中部分补偿系统和辅助教育系统进行护理干预。采用自理能力问卷调查两组患者术后2周及出院后3个月的自理能力。结果 两组患者在术后2周时自理能力比较，差异无显著性意义（P〉0．05）；但出院后3个月观察组患者自理能力显著优于对照组（P〈0．05）。结论 肾移植患者术后自理能力较低，Orem自理模式的应用可提高其术后自理能力。     

Acute Polymyositis Following Renal Transplantation

Myositis is a rare complication following renal transplantation and is most commonly the result of drug-mediated myotoxicity. Other causative disorders include viral infection, electrolyte imbalance and myositis of autoimmune origin. We describe a 60-year-old patient who developed acute polymyositis 4 weeks after a 000 human leukocyte antigen (HLA) mismatch cadaveric renal transplant. Following an uncomplicated transplant course with maintenance triple immunosuppression (prednisolone, mycophenolate mofetil and cyclosporine), the patient presented with severe symmetrical proximal muscle weakness associated with a rise in serum creatine kinase to 46800 U/L. Electromyography confirmed myopathic changes and muscle biopsy demonstrated extensive muscle-fiber necrosis with an inflammatory infiltrate. There were no obviously culpable drugs and viral studies were negative. Prompt initiation of high-dose steroid therapy led to clinical and biochemical recovery. Acute polymyositis may occur following renal transplantation. Potential mechanisms include viral antigen transmission or a localized form of graft vs. host disease.     

Skeletal Complications Following Renal Transplantation

The occurrence of skeletal complications was examined in a series of 204 renal graft recipients who had maintained graft function for more than 12 months. Osteonecrosis was observed in 22 of the patients (11 per cent) from 5 to 46 months after the transplant operation. The lesions were often multifocal, with as many as 40 joints affected. The most common site was the femoral head, necrosis of which was recorded in 24 instances. The lesions here present a major clinical problem, and total hip replacement was deemed necessary in 4 cases, in all of which an excellent result was achieved.

Fractures had occurred after the transplantation in 53 patients (26 per cent), against only 6 before the operation. A total of 109 fractures had been sustained after periods ranging from 1 to 58 months, the most common site being the pelvic bones. The fractures were treated according to standard principles; no complications were encountered.

The skeletal complications were equally common among the males and females; they tended to occur at advanced ages.

They occurred to roughly the same extent whether the graft was from a related or a cadaveric donor and whether the patient had received one or more grafts.     

Outcomes of Renal Transplantation Following Bone Marrow Transplantation

This single center retrospective study was undertaken to determine the outcome of kidney transplantation (KT) after bone marrow transplantation (BMT) and also to determine the need for immunosuppressive therapy after KT when the BMT marrow donor is the KT donor. Kidney transplantation was performed in 10 patients with BMT nephropathy (BMTN). In six patients, the KT donor was the BMT donor; these individuals were given no long-term immunosuppression. Four other patients received KT from donors who were not the marrow donor (two living donors, two cadaveric donors). After median follow up of 34 months, no patient had an episode of acute rejection. All graft losses (n = 4) resulted from patient death. Three were because of infectious processes, including two infectious deaths in patients not on immunosuppression. Median estimated actuarial patient and graft survival (Kaplan-Meier) was 105 months. We conclude that patients with BMTN who receive KT from their marrow donor do not require immunosuppression. Whether immunosuppressive therapy is given or not, outcome appears to be determined largely by BMT-related immune dysfunction.     

Smoking Following Renal Transplantation in Hungary and Its Possible Deleterious Effect on Renal Graft Function

Smoking is a known risk factor for kidney damage and also influences graft function following renal transplantation. Because smoking habits following kidney transplantation are not systematically evaluated, we analyzed them in a single center in Hungary. The survey was conducted among 402 randomly selected kidney graft recipients. We assessed smoking-related questions as well as clinical kidney disease and transplantation data. Posttransplantation renal function was analyzed based on serum creatinine values at 1 month and at 3 years after transplantation. In our study 25% (n = 102) of patients continued to smoke after transplantation. Smokers who received grafts displayed a significantly younger age compared with nonsmokers (40.1 ± 13.4 vs 47.1 ± 12.7 years; P < .001) independent of underlying kidney disease. Posttransplantation kidney function in smokers did not differ at 1 month after engraftment, but was significantly impaired at 3 years as assessed based on serum creatinine levels: 138.9 ± 42.4 versus 128.4 ± 48.5 μmol/L (P < .05). Decrease of renal function correlated with smoking intensity defined in pack-years (r² = 0.102; P < .05). Smoking is common following kidney transplantation in Hungary and might represent a risk factor for kidney damage following renal transplantation. Therefore, effective tobacco-dependence treatment is necessary in this patient population.     

Acute Cytomegalovirus Cholecystitis Following Renal Transplantation

Solid organ transplant recipients are at risk of infection from cytomegalovirus (CMV). A wide range of disease is associated with CMV infection and we report two cases of CMV cholecystitis in patients following renal transplantation. Both patients presented with severe hemorrhagic cholecystitis, which required immediate resuscitation and emergency cholecystectomy. The diagnosis of CMV infection was confirmed in both cases using CMV-specific staining of the gallbladder. The diagnosis of CMV cholecystitis must be considered in all patients with upper abdominal pain after renal transplantation.     

Obesity and Outcome Following Renal Transplantation

Single institution series have demonstrated that obese patients have higher rates of wound infection and delayed graft function (DGF), but similar rates of graft survival. We used UNOS data to determine whether obesity affects outcome following renal transplantation. From the UNOS database, we identified patients who underwent primary kidney-only transplantation between 1997 and 1999. Recipient and donor body mass index (BMI) was categorized as underweight (BMI < 18.5), normal (BMI 18.5-24.9), overweight (BMI 25-29.9), obese (BMI 30-34.9) or morbidly obese (BMI > or = 35). We correlated BMI with intermediate measures of graft outcome and overall graft survival, and created multivariate models to evaluate the independent effect of BMI on graft outcome, adjusting for factors known to affect graft success. The study sample comprised 27,377 recipients. Older age, female sex, African American race and increased comorbidity were associated with obesity (p < 0.001). Compared with normal weight patients, morbid obesity was independently associated with an increased risk of DGF (p < 0.001), prolonged hospitalization (p < 0.001), acute rejection (p = 0.006) and decreased overall graft survival (p = 0.001). Donor BMI did not affect overall graft survival (p > or = 0.07). Recipient obesity is associated with an increased risk of DGF and decreased graft survival following renal transplantation.     

Serum Hepcidin Level Correlates With Hyperlipidemia Status in Patients Following Allograft Renal Transplantation

Hepcidin is synthesized and secreted by liver cells and has been reported as one of the hormone molecules that regulates iron homeostasis. To determine whether serum level of hepcidin can be used as a biomarker for the evaluation of chronic inflammatory status, iron level and renal function in patients following allograft renal transplantation, serum levels of hepcidin, interleukin (IL)-6, ferritin, serum iron, and renal functions were measured. Sixty patients were included in the current study and were further separated into groups with or without hyperlipidemia. We found that allogeneic kidney transplant recipients with hyperlipidemia have significantly increased serum levels of hepcidin, IL-6, and ferritin. The increased serum hepcidin is positively correlated with serum IL-6 and ferritin as analyzed by single-factor correlation analysis. Multivariant correlation analysis in all specimens further demonstrated that serum hepcidin negatively correlated with glomerular filtration rate, and positively correlated with serum total cholesterol, triglycerides, serum ferritin, and IL-6. Our study demonstrated that serum level of hepcidin after allogeneic kidney transplantation not only reflects the status of chronic inflammation but can also indicate changes in renal function. Thus, hepcidin has the potential to be used as a promising marker for the detection and monitoring of the status of chronic inflammation, hyperlipidemia, and renal function in patients following allograft renal transplantation.     

Serum Vasopressin Concentrations During Orthotopic Liver Transplantation

Background

We report measurements of the temporal response of serum vasopressin concentrations in the period after reperfusion of the liver graft during orthotopic liver transplantation (OLT).

Methods

Vasopressin concentrations were determined in 11 adult patients undergoing OLT by radioimmunoassay of samples collected after induction, at 5 minutes prior to reperfusion, and at 10, 20, 30, 40, 50, 60, 90, and 120 minutes after reperfusion.

Results

Pre-incision vasopressin concentrations ranged from <0.5 to 2.6 pg/mL (reference serum vasopressin, <1.7 pg/mL). Overall, levels increased before reperfusion, but fell thereafter. Individual patients manifested elevated levels during the period after reperfusion. Values immediately before reperfusion exhibited most variability, ranging from 0.8 to 40 pg/mL (median, 15; interquartile range [IQR], 4-29) Median vasopressin concentrations 10 minutes postreperfusion were 7.6 pg/mL (IQR, 3-27). Only 3 of the 11 patients failed to generate vasopressin levels >20 pg/mL. In each of these patients, hemodynamics were satisfactory without the need for additional pressor infusion. Maximum vasopressin concentration measured in any patient was 85 pg/mL. There was no correlation between vasopressin concentration and mean blood pressure or systemic vascular resistance index.

Conclusion

Vasopressin concentrations during OLT vary widely and are elevated periodically during the anhepatic and postreperfusion stages, with no apparent relationship between vasopressin concentrations and blood pressure. Although vasopressin concentrations were not as high as those measured during some other clinical situations, these data suggest that a relative vasopressin deficiency is not a direct cause of hypotension during OLT.     

Immunosuppression and Results in Renal Transplantation

Keeping a balance between the effective prevention of rejection and the side effects of immunosuppressants is a key point for long-term renal transplantation success. Today antibody induction (either basiliximab or depleting polyclonal antibodies for high-risk patients) together with an initial combination therapy of calcineurin inhibitor (CNI), mycophenolate, and steroids is recommended and results in excellent early outcomes. Yet despite the significant decrease in the incidence of acute rejection, long-term graft loss has remained rather constant over the last 25 yr. Thus new immunosuppressive combination strategies, avoiding or minimising CNIs, have been a goal in many randomised controlled trials during the last decade. Although it is too early to reach conclusions about the success of these strategies, some results are rather encouraging, in particular strategies including novel biotherapies like belatacept. This review updates the current knowledge and indications of modern immunosuppressants in the setting of renal transplantation and offers an overview of the regimen strategies available to minimise long-term side effects and prolong the survival of both patients and allografts.Patient summary Modern immunosuppression strategies with calcineurin inhibitors (CNIs) and mycophenolate have reduced incidence of acute rejection but failed to improve long-term renal outcome. Efforts to minimise or replace CNIs have led to encouraging results, but long-term follow-up and integration of new drugs in these strategies are required to really improve long-term results after renal transplantation.     

Concurrent Verrucous and Varicelliform Rashes Following Renal Transplantation

Verrucous rashes associated with varicella zoster virus (VZV) infection are well recognized in HIV infection. Seen rarely in transplant patients, no histologically confirmed case has been published in the transplant setting. We now report chronic, localized, verrucous VZV in a renal transplant recipient presenting with cutaneous dissemination. This case highlights the need to consider chronic VZV infection in the differential diagnosis of skin lesions even in the VZV seronegative transplant recipient without substantial exposure to antiviral agents.     

Renal Cell Carcinoma on the Native Kidney Following Kidney Transplantation

A 48-year-old man with histories of IgA nephropathy for 33 years, hemodialysis for 29 years, and a kidney transplant from a deceased donor 5 years ago was admitted to our institute complaining of high fever and back pain. Although repeated follow-up of computed tomography failed to detect any de novo issues, he was eventually diagnosed as a renal cell carcinoma with multiple metastases, developing from his native-acquired cystic disease kidney with multiple cysts using a positron emission tomography. We should be cautious of de novo renal cell carcinoma in kidney transplantation recipients, and careful follow-up might be helpful to detect it.     

Cecal Volvulus Following Laparoscopic Nephrectomy and Renal Transplantation

Cecal volvulus is a rare cause of bowel obstruction that carries a high mortality. Recent surgery is known to be a risk factor for the development of cecal volvulus. We present a case of cecal volvulus following laparoscopic nephrectomy and renal transplantation.     

The Effect of Renal Transplantation on Plasma Protein Binding

The in vitro plasma protein binding was determined in nine maintenance hemodialysis patients who later underwent renal transplantation. The organic acid fluorescein (10 ug/ml) or the organic base quinidine (5 ug/ml) was added to the pre and post transplant serum of these patients. Drug concentrations were measured spectrophotofluorometrically after equilibrium dialysis. The results were compared with the plasma protein binding of eight normal volunteers. The patients on maintenance hemodialysis had lower plasma protein binding of fluorescein than normals (78 ± 5% vs 89 ± 4, p < 0.001). Plasma protein binding improved significantly after renal transplantation (85 ± 3, p < 0.01) but was still lower than in normals (p < 0.05). Plasma protein binding of quinidine was not significantly different than in normal volunteers (77 ± 8%) either prior to (72 ± 10%) or after (73 ± 12%) kidney transplantation. Plasma protein binding of quinidine remains unaffected by renal transplantation. However, the abnormal plasma protein binding of organic acids in chronic renal failure may be significantly improved by renal transplantation.     

The Influence of Socioeconomic Deprivation on Outcomes Following Renal Transplantation in the United Kingdom

Socio‐economic deprivation is an important determinant of poor health and is associated with a higher incidence of end‐stage renal disease, higher mortality for dialysis patients and lower chance of being listed for transplantation. The influence of deprivation on outcomes following renal transplantation has not previously been reported in the United Kingdom. The Welsh Index of Multiple Deprivation was used to assess the influence of socio‐economic deprivation on outcomes for 621 consecutive renal transplant recipients from a single centre in the United Kingdom transplanted between 1997 and 2005. Outcomes measured were rate of acute rejection and graft survival. Patients from the most deprived areas were significantly more likely to experience an episode of acute rejection requiring treatment (36% vs. 27%, p = 0.01) and increasing overall deprivation correlated with increasing rates of rejection (p = 0.03). Income deprivation was significantly and independently associated with graft survival (HR 1.484, p = 0.046). Among patients who experienced acute rejection 5‐year graft survival was 79% for those from the most deprived areas compared with 90% for patients from the least deprived areas (p = 0.018). Overall socio‐economic deprivation is associated with higher rate of acute rejection following renal transplantation and income deprivation is a significant and independent predictor of graft survival.     

Heart Rate Variability During Hemodialysis and Following Renal Transplantation

Previous studies have shown awareness of uremic dysfunction in end-stage renal disease (ESRD) patients. Dysautonomia in ESRD patients may be reversible after renal transplantation. We used a power spectral analysis (PSA) of heart rate variability (HRV) to assess alterations of autonomic activity in 14 controls and 14 nondiabetic hemodialysis ESRD patients who had undergone renal transplantation. Compared with matched control subjects, the power frequency determinations of low frequency (LF; 3.42 ln(ms²) vs 6.38 ln(ms²); P < .05 high frequency (HF; 2.29 ln(ms²) vs 5.27 ln(ms²); P < .05)), and total power (TP; 5.39 ln(ms²) vs 7.53 ln(ms²); P < .05) were significantly suppressed in ESRD patients undergoing hemodialysis. ESRD patients showed significantly improved HRV after renal transplantation. After renal transplantation, there was no significant difference in the TP (6.82 ln(ms²) vs 7.53 ln(ms²); P = .15) component between measurements in both patient subgroups. We further divided the ESRD patients into 2 groups based on their pretransplantation HRV, observing alterations in HRV after renal transplantation. Patients with significantly improved HRV were those with more suppressed HRV before transplantation (HF <3 In(ms²). Autonomic dysfunction in ESRD patients was not irreversible even if severe, and recovery was observed as early as 6 months after transplantation.     

Late Steroid Withdrawal Following AB0-Incompatible Renal Transplantation

Background

Current evidence on steroid withdrawal following AB0-incompatible (AB0i) renal transplantation is low. We compared clinical outcomes of patients who agreed to late steroid withdrawal and patients who remained on steroid treatment.

The Effect of Renal Transplantation on Plasma Atrial Natriuretic Peptide

The changes in plasma atrial natriuretic peptide (ANP) werestudied in four adult patients after cadaveric renal transplantation.In three patients who achieved good renal function, the correctionof volume overload, as reflected by reduction in weight andright atrial pressure, was associated with a steady fall inplasma ANP and a parallel decrease in both fractional excretionof sodium and plasma cyclic guanosine monophosphate. The fourthpatient. with severe acute rejection, developed severe peripheraloedema, and fractional sodium excretion remained low despitehigh values of ANP.