吻合血管同种异体骨移植后存活状况研究

目的报道吻合血管同种异体骨移植术后不同时段存活状况。方法建立吻合血管同种异体股骨干移植动物模型，在术后不同时段进行活体解剖，观察血管的通畅度．并切取移植骨进行组织学、电镜及SDH染色检测。结果术后4周对照组血管基本完全闭塞，而实验组术后血管保持通畅。组织学检查显示对照组术后移植骨骨陷窝内骨细胞缺失，哈弗斯管内血管亦消失；而实验组术后骨陷窝内始终有骨细胞充填。电镜表现为对照组术后移植骨出现骨细胞核浓缩．核碎裂，直至骨陷窝内骨细胞丢失；实验组术后骨细胞超微结构正常、对照组术后2周．骨组织SDH染色已无蓝染的骨细胞，而实验组术后可见同心圆排列蓝染的骨细胞。结论在免疫调控下，吻合血管的同种异体骨移植术后供体始终保持活力状态。     

Living donor renal transplantation with incidental renal cell carcinoma from donor allograft

To report our series of cases with living donor kidney transplant by laparoscopic nephrectomy with incidental renal cell carcinomas (RCC) at the time of transplant. We performed a search of cases of renal allografts from living donors with incidental tumors which were confirmed as RCC in final pathology. The graft nephrectomy was performed via hand‐assisted laparoscopic procedure. All cases underwent partial nephrectomy of the tumor during the back‐table preparation of the graft and sent for pathological analysis. We performed 435 living donor kidney transplants at our Institution and identified four cases consistent with the diagnosis of RCC. Two of them were clear cell type, one papillary and one multilocular RCC. All the tumors presented at stage I of TNM classification. After a median follow‐up of 36 months, three patients remain free of dialysis with good allograft function. One noncompliant patient presented with a glomerular filtration rate (GFr) below 15 ml/min after a BK viral infection. At the end of follow‐up period, all patients had remained free of tumor. Donors with suspicious renal masses might be accepted for living donation. Partial nephrectomy before transplantation could offer a cure for the disease without risks for the recipient with therapeutic benefit for the donor.     

Renal allograft hemodynamic and diameter changes after living donor transplantation

Renal ultrasound is a valuable tool to measure allograft diameters and hemodynamic changes, some of which may help us to predict ongoing rejection. Longitudinal (L) and horizontal (H) diameters, and resistive index (RI) of intrarenal arteries of kidneys were measured before transplantation in the donor site, as well as 1 week after transplantation in the recipient site (7.5 MHz probe). We excluded patients with acute rejection, delayed graft function, perinephric collection, suspected allograft artery stenosis, or serum creatinine >2 mg/dL. Finally, allograft measurements were compared with the donor parameters. The mean values of L and H diameters in 32 normal allografts were: L 119 +/- 10.4 mm; H 54 +/- 8.4 mm; L/H ratio 2.25 +/- 0.27; RI 0.57 +/- 0.55. The mean values of these measurements when the kidney was in the donor body were: L 110 +/- 9.4 mm; H 44.3 +/- 5.4 mm; L/H ratio 2.97 +/- 0.25; RI 0.61 +/- 0.040. Both L and H diameters were increased significantly after transplantation, but the L/H ratio and RI were decreased significantly (P < .05). The presumed physiologic explanations for these findings in allograft are increased blood flow, decreased intrarenal arterial resistance, stress relaxation, and lack of sympathetic innervation.     

同种异体心脏移植中供体特异输注对肿瘤坏死因子-α的影响

目的　通过术前 2 4h特异输注与环孢酶素A(CsA)联合应用研究其对肿瘤坏死因子 α(TNF α)的影响。方法　将小鼠随机分组为CsA/红细胞 ,CsA/全血 ,以及红细胞 ,周围淋巴细胞 ,全血 ,低剂量CsA ,空白对照磷酸盐缓冲液 (PBS)组。术前给予相应的供体特输注 (DST) ,空白对照组注射PBS液。心脏移植方法采用耳后方法 ,实验终止后用放射免疫方法测定受体血清中的TNF α。结果　单独DST组 ,低剂量CsA组和空白对照液组之间的TNF α含量差异无显著性(P >0 .0 5 )。CsA/DST组的含量明显低于低剂量CsA组 ,空白对照PBS组和DST组 (P <0 .0 1) ,其中CsA/周围淋巴细胞组中TNF α含量为最低 2 .3 9± 0 .49(P <0 .0 1)。结论　术前 2 4h单独输注DST并不能降低受体血清中TNF α的含量 ,然而DST和CsA联合应用可以降低受体血清中的TNF α含量 ,其中以周围淋巴细胞和CsA联合应用效果最佳。     

Microvascular reconstructive "bench" surgery for donor kidneys before transplantation: techniques and results

Forty kidneys (10 from live donors) with either multiple renal arteries or damaged vasculature were reconstructed accurately ex vivo with microsurgical techniques before transplantation. The end product in all cases was a kidney requiring a single arterial and venous in situ anastomosis. The warm ischemia time was minimized by this adjunctive "bench" microsurgery. There was no surgical complication relating to the vascular reconstruction. The potential technical and hemodynamic benefits of this surgical approach to kidneys with multiple vessels are discussed. In addition, some kidneys with damaged vasculature can be salvaged for transplantation with microvascular reconstruction.     

Microvascular reconstruction of the hepatic artery in live donor liver transplantation: experience across a decade

HYPOTHESIS: Hepatic arterial anastomosis by means of a microvascular technique can be performed with a high success rate in live donor liver transplantation in adult recipients. DESIGN: Retrospective analysis of data collected prospectively. SETTING: Tertiary referral center. PATIENTS: From September 28, 1993, through December 23, 2002, 28 children received left lateral segment grafts (n = 23) or left lobe grafts (n = 5), and 124 adults received left lobe (n = 6) or right lobe (n = 118) grafts. Microvascular technique was used for hepatic arterial anastomosis. Attention was paid to exposure, orientation of the axis of arterial ends, and matching of size. Long microinstruments were used for arterial ends deeply located inside an adult's abdominal cavity. An average of 16 stitches was used for a vessel anastomosis 3 mm in diameter. INTERVENTIONS: Intraoperative and postoperative Doppler ultrasonography were performed. MAIN OUTCOME MEASURES: Hepatic artery thrombosis rate. RESULTS: All hepatic arterial anastomoses were patent after reconstruction. Complications occurred in 3 patients. They had hepatic arterial thrombosis at 19 days, 25 days, and 3 months after liver transplantation. The overall complication rate was 2%. CONCLUSION: With attention to exposure, appropriate instruments, and experience, a low complication rate of 2% can be achieved in hepatic arterial anastomosis by using a microvascular technique, even in adult patients with the liver graft situated deeply in the abdominal cavity.     

Cellular allograft rejection affecting the donor aorta after combined heart-lung transplantation

BACKGROUND: Infectious pseudoaneurysms of the ascending aorta are a recognized major complication after heart-lung transplantation. METHOD: This report describes an unusual and previously unreported complication, that of cellular allograft rejection, which caused a pseudoaneurysm of the donor's ascending aorta in a patient who underwent combined heart-lung transplantation. Repair was performed by primary suture after mobilization of the aortic segments. RESULT: On histological examination the resected aneurysm showed evidence of proliferative vasculitis with perivascular infiltration of the vasa vasorum by mononuclear cells. The mononuclear cells were identified as CD4+ and CD8+ by immunohistological staining. CONCLUSIONS: This report shows that cellular allograft rejection may affect the donor aorta after heart-lung transplantation and may result in pseudoaneurysm formation, even under triple-drug immunosuppression after ABO-compatible allograft transplantation.     

Immunological monitoring of posttransplant allograft sensitization following living related donor renal transplantation

A better understanding of the immunobiological processes and predictors of graft rejection holds promise for development of new therapeutic strategies and also for individualization of immunosuppression. The objective of this study was to analyze the clinical relevance of immune parameters, such as recipient sensitization status, donor-specific antibodies, and anti-HLA antibodies, which are major predictors of graft outcome following renal transplantation. Sera from 264 renal recipients at different posttransplant period were included for detection of anti-donor antibodies (by flowcytometry); anti-HLA, antibody (by ELISA), and panel-reactive antibodies (PRA) by complement-dependent cytotoxicity (CDC) methods. Graft survival was analyzed in relation to posttransplant PRA at 2 years follow-up time: overall survival was significantly compromised in the highly sensitized group (group III) compared to the other two groups (overall chi2 = 24.20, P = 5.5 x 10(-06)). Flow cytometric cross-matches revealed the presence of anti-donor class I antibodies (T+) in 39 patients who had a poor graft survival of 51% compared with 85% survival in 225 antibody-negative patients. (chi2 = 22.260, P = 2.381 x 10(-.06)). Further analysis was performed based on the presence or absence of FCXM and ELISA-detected antibodies. Recipients belonging to group I (ELISA+/FCXM+) showed significantly lower graft survival (43%) compared with that observed in group II, which were essentially nonsensitized individuals (90%; P = 3.1 x 10(-08)). The graft survival in the ELISA-/FCXM+ group was 63%, which was significantly lower than that in group II (P = 5.14 x 10(-03)). Group IV (ELISA+/FCXM-) including 38 (14%) serum samples with nondonor but HLA-specific antibodies was associated with significantly poorer graft survival (63%) compared with group II (P = 6.6 x 10(-05)). Our data also show that while FCXM is the most sensitive test to detect donor-specific antibodies, the ELISA method offers the additional advantage of detecting anti-HLA class-I antibodies, which are detrimental for renal graft survival. Thus the use of multiple parameters to assess recipient immune profile can predict graft outcome more accurately thus helping the individualization and optimization of immunosuppression.     

活体肾移植供肾多支血管处理的体会

目的探讨活体肾移植供肾多支血管的处理及重建方法。方法 49例供体,供肾有多支动脉变异45例,有多支静脉变异7例,其中3例为肾动脉、静脉同时多支血管变异。供肾切取术中,对于供血面积直径小于3cm且影响操作的分支动脉,术中即予结扎、离断;多支静脉,如直径为主干的1/3以下且试夹闭该静脉未发现明显淤血等血液回流障碍者,给予结扎、离断。5例采用体外血管重建。受体肾移植术中根据分支动脉管径、长度及位置及受者髂动脉和腹壁下动脉的情况等综合条件来选择受者相应的动脉吻合。结果 48例动脉分支吻合者在开放血流后搏动良好、吻合口通畅,术后1～7d内肾功能恢复正常、术后1～2周彩色多普勒超声检查,提示该分支动脉供血区域丰富。肾静脉分支结扎者未发现淤血现象。1例高龄供肾者发生肾功能延迟恢复。术后无出血、肾动脉栓塞、尿瘘、输尿管坏死和新发高血压等并发症。结论正确处理移植肾多支血管变异,可获得良好移植效果。     

Duct-to-duct biliary reconstruction in living donor liver transplantation utilizing right lobe graft

OBJECTIVE: To assess the feasibility and safety of duct-to-duct biliary anastomosis for living donor liver transplantation (LDLT) utilizing the right lobe. SUMMARY BACKGROUND DATA: Biliary tract complications remain one of the most serious problems after liver transplantation. Roux-en-Y hepaticojejunostomy has been a standard procedure for biliary reconstruction in LDLT with a partial hepatic graft. However, end-to-end choledochocholedochostomy is the technique of choice for biliary reconstruction and yields a more physiologic bilioenteric continuity than can be achieved with Roux-en-Y hepaticojejunostomy. The authors performed right lobe LDLT with end-to-end duct-to-duct biliary anastomosis, and this study assessed retrospectively the relation between the manner of reconstruction and complications. METHODS: Between July 1999 and December 2000, 51 patients (11-67 years of age) underwent 52 right lobe LDLTs with duct-to-duct biliary reconstruction and remained alive more than 1 month after their transplantation. Interrupted biliary anastomosis was performed for 24 transplants and the continuous procedure was used for 28. A biliary tube was inserted downward into the common bile ducts through the recipient's cystic duct in 16 transplants (cystic drainage), or a biliary stent tube was pushed upward into the anastomosis through the cystic duct in four transplants (cystic stent), or upward into the anastomosis through the wall of the common bile duct in 31 transplants (external stent). RESULTS: Biliary anastomotic procedures consisted of 34 single end-to-end anastomoses, 11 double end-to-end anastomoses, and 7 single anastomoses for double hepatic ducts. Overall, 5 patients developed leakage (9.6%) and 12 patients suffered stricture (23.0%). For biliary anastomosis with interrupted suture, the incidence of stricture was significantly higher in the cystic drainage group (53.3%, 8/15) than in the stent group consisting of cystic stent and external stent (0%, 0/8). While the respective incidences of leakage and stricture were 20% and 53.3% for intermittent suture with a cystic drainage tube (n = 15), they were 7.7% and 15.4% for a continuous suture with an external stent (n = 26). There was a significant difference in the incidence of stricture. CONCLUSIONS: Duct-to-duct reconstruction with continuous suture combined with an external stent represents a useful technique for LDLT utilizing the right lobe, but biliary complications remain significant.     

公民逝世后器官捐献原位肝移植后早期肝功能不全的危险因素分析

目的 观察公民逝世后器官捐献原位肝移植术后早期肝功能不全（early allograft dysfunction,EAD）的发生情况,探讨早期肝功能不全的危险因素。方法 回顾性分析2017年1月至2019年12月间我院65例行肝移植供、受体资料。根据术后情况将患者分为EAD组（n=29）及非EAD组（n=35）。对相关因素先进行单因素分析,然后将统计学差异的因素进行多因素Logistic回归模型分析。结果 65例原位肝移植患者术后早期肝功能不全的患者有29例,发生率为44.6%。单因素分析显示EAD组与非EAD组供体血清钠[（157.53±21.71）mmol/L vs（146.06±15.24）mmol/L,P=0.019]、热缺血时间[（21.6±6.5）min vs（10.6±4.3）min,P=0.016]、冷缺血时间[（8.3±1.2）h vs（5.4±1.2）h,P=0.012]、ICU住院时间[（78.1±19.5）h vs（49.7±17.6）h,P=0.007]及受体的无肝期时间[（98.3±16.3）h vs（66.0±17.6）h,P=0.037]差异均有统计学意义。多因素Logistic回归分析结果显示影响术后早期肝功能不全的独立危险因素为供体血清钠水平（OR 18.372,95%CI 1.846～24.173,P=0.019）及热缺血时间（OR 8.105,95%CI 1.513～37.205,P=0.013）。结论 供体血清钠水平及热缺血时间是公民逝世后器官原位肝移植术后EAD的独立危险因素。     

A novel system for transplantation of isolated hepatocytes utilizing HBsAg-producing transgenic donor cells

Hepatocytes from donor transgenic mice that produce an easily assayable circulating marker have been used to develop a novel hepatocyte transplantation system. Isolated G7 HBV transgenic donor hepatocytes secreting HBsAg were transplanted into congeneic or allogeneic mouse recipients. Serum HBsAg was present three days after hepatocyte transplantation in congeneic animals and persisted indefinitely when hepatocytes were transplanted into the spleen. Transplanted hepatocytes within the splenic pulp were identified by morphologic and histochemical analysis. Migration of hepatocytes injected into the spleen to the liver was demonstrated by in situ hybridization using an RNA probe for HBsAg. Transplantation into nonimmunosuppressed allogeneic recipients resulted in disappearance of detectable hepatocytes in the spleen within two weeks. This novel transplantation system should facilitate studies of hepatocyte engraftment and survival, modulation of allograft rejection, and development of hepatocyte-directed gene therapy.     

Impact of donor and recipient factors on allograft survival in lung transplantation: A single-center analysis

BACKGROUND: It remains unclear which donor and recipient factors influence long-term allograft function in lung transplantation (LTx). METHODS: From October 1988 to February 2005, a total of 280 recipients underwent LTx at our center. Donor data and cause of death (CoD) were analyzed. The CoD was categorized according to rate of increase in intracranial pressure at the time of death. Each donor and recipient factor was correlated with long-term graft function. Recipient details, type of transplant, indication for transplant, and time on waiting list were analyzed. Recipients were stratified based on allograft ischemia time (AIT): 0 to 6, 6 to 8, 8 to 10, and >10 hours. RESULTS: Mean donor age was 30.9 years (36.7% male); 49.8% were cytomegalovirus (CMV) positive. Donor CoD was characterized by a slow rise in intracranial pressure (ICP) in 34.4%, rapid ICP in 18.7%, an intermediate ICP in 44.3%, and with no rise in 2.6%. A graft survival benefit was seen with female donors (P = .048); 34.4% of recipients ultimately developed graft failure at long term follow-up. Mean recipient age was 48 years; 63% were male and mean body-mass index (BMI) was 23.6; 60.2% had single lung transplantation, and mean wait list time was 323 days. Mean AIT totaled 421 minutes. Graft survival was longer with AIT of 8 to 10 hours compared to 6 to 8 hours (P = .03). CONCLUSIONS: Donor factor analysis implied only female donor status conferred a long-term graft survival advantage. Intracranial pressure rise differences appear clinically unimportant. Prolonged cold ischemic time (>10 hours) or low recipient BMI did not adversely affect allograft function in our review.     

Liver allograft outcomes after laparoscopic-assisted and minimal access live donor hepatectomy for transplantation

Background

The critical shortage of deceased organ donors has led to live-donor hepatectomy as an alternative donor option for transplantation. Although laparoscopic hepatectomy has been well described for management of liver tumors and can be performed safely, few studies have examined early recipient allograft outcomes after laparoscopic live-donor hepatectomy. We describe our initial experience with laparoscopic-assisted and minimal-access donor hepatectomy and its potential as a safe alternative with graft function comparable with open resection in live-donor liver transplantation.

Methods

We performed a retrospective analysis of our past 30 successive live-donor transplants between 2005 and 2009. Fifteen allografts were procured by standard open live-donor (OLD) hepatectomy, and 15 by laparoscopic-assisted (LALD) or minimal-access (MA) live-donor hepatectomy. Left lateral segment grafts were subcategorized and analyzed further.

Results

Mean donor age, sex, and liver anatomy were comparable between donor groups. Early graft function as measured by peak total bilirubin level, aspartate aminotransferase level, alanine aminotransferase level, and international normalized ratio on postoperative days 2, 7, 30, and 90 were similar between groups, although the international normalized ratio was slightly more increased on postoperative day 7 in LALD grafts (1.75 ± .45 vs 1.28 ± .16; P = .02). Perioperative allograft biliary (2 of 15 vs 0 of 15; P = .48) and vascular (3 of 15 vs 1 of 15; P = .6) complication rates also were comparable between OLD and LALD/MA grafts. One-year graft and patient survival for LALD/MA was 100% compared with 93% for OLD.

Conclusions

Our experience shows that LALD or MA live-donor hepatectomy is a safe procedure and produces early graft function comparable with standard OLD hepatectomy. Multicenter, larger-volume experience will determine the widespread application of this technique.     

供者骨髓基质干细胞输注延长大鼠移植心存活时间的探讨

目的 探讨供者骨髓基质干细胞(MSC)输注在大鼠同种心脏移植术后的免疫调节及延长移植心存活时间的作用.方法 供者为近交系Wistar大鼠,受者为Fisher 344大鼠.处死供者后抽取其股骨和胫骨中骨髓,分离和培养MSC.通过混合淋巴细胞试验观察不同密度的MSC对异源性T淋巴细胞增殖反应的抑制作用.建立大鼠异位心脏移植模型,根据处理方式的不同,将受者分为MSC输注组和对照组,每组8只.Msc输注组:将含有2×106个MSC的林格氏液分别于术前1周、术中及术后连续3 d经尾静脉注入受者体内;对照组:用与MSC输注组相同的方法在相同时间点注入不含MSC的林格氏液.术后第5天,采用实时逆转录聚合酶链反应检测移植心组织中细胞因子的表达情况.结果 供者MSC可明显抑制异源性T淋巴细胞的增殖反应,且MsC密度越高抑制作用越强.MSC输注组Th1类细胞因子白细胞介素(IL)-1β和γ干扰素的表达要显著低于对照组;MSC输注组Th2类细胞冈子IL-4和IL-10呈高表达,而对照组基本不表达.MSC输注组移植心平均存活时间为(12.4±5.3)d,与对照组的(6.4±2.0)d比较,差异有统计学意义(P＜0.01).结论 输注供者MSC可通过改变Th1/Th2类细胞因子的平衡向Th2偏移诱导受者产生免疫调节作用,从而延长移植心存活时间.