肾移植术后妊娠对移植肾的影响

目的 探讨肾移植术后妊娠对移植肾的影响。方法 对1978年4月至2002年3月妊娠超过5个月的13例肾移植受者资料进行回顾性分析。结果 免疫抑制方案，4例采用环孢素A（CsA)及泼尼松（Pred)。5例为CsA，霉酚酸酯（MMF）及Pred。4例为他他克莫司（FK506），MMF及Pred。13例中，10例患者妊娠足月，生产，母，婴均存活，移植肾功能稳定；1例产后2周因并发肺部感染，心力衰竭死亡，死亡时移植肾有功能，婴儿存活；2例妊娠中期出现蛋白尿，病理证实移植肾发生慢性排斥反应，终止妊娠，但抗排斥治疗无效，切除移植肾，恢复血液透析，目前11名子女健康，无发育异常。结论 肾移植患者若情况允许，在严重监护下是可以妊娠的。     

Prediction of delayed graft function after renal transplantation

Introduction:

Delayed graft function (DGF), defined as the need for dialysis during the first week after renal transplantation, is an important adverse clinical outcome. A previous model relied on 16 variables to quantify the risk of DGF, thereby undermining its clinical usefulness. We explored the possibility of developing a simpler, equally accurate and more user-friendly paradigm for renal transplant recipients from deceased donors.

Methods:

Logistic regression analyses addressed the occurrence of DGF in 532 renal transplant recipients from deceased donors. Predictors consisted of recipient age, gender, race, weight, number of HLA-A, HLA-B and HLA-DR mismatches, maximum and last titre of panel reactive antibodies, donor age and cold ischemia time. Accuracy was quantified with the area under the curve. Two hundred bootstrap resamples were used for internal validation.

Results:

Delayed graft function occurred in 103 patients (19.4%). Recipient weight (p < 0.001), panel of reactive antibodies (p < 0.001), donor age (p < 0.001), cold ischemia time (p = 0.005) and HLA-DR mismatches (p = 0.05) represented independent predictors. The multivariable nomogram relying on 6 predictors was 74.3% accurate in predicting the probability of DGF.

Conclusion:

Our simple and user-friendly model requires 6 variables and is at least equally accurate (74%) to the previous nomogram (71%). We demonstrate that DGF can be accurately predicted in different populations with this new model.     

Long-term changes in left ventricular hypertrophy after renal transplantation

BACKGROUND: Concentric and eccentric left ventricular hypertrophy are common progressive disorders in dialysis patients and are associated with cardiac failure and death. Although partial regression of these abnormalities is known to occur during the first post-transplant year, their long-term evolution is unknown. METHODS: A total of 143 of 433 dialysis patients participating in a long-term prospective cohort study received renal transplants. Laboratory parameters were assessed monthly. Echocardiography was performed annually. Left ventricular mass index (LVMI) and cavity volume index were calculated according to standard formulae. Multiple linear regression was used to model change in LVMI as a function of baseline clinical and laboratory variables. RESULTS: LVMI fell from 161 g/m2 at 1 year to 146 g/m2 (P=0.009) g/m2 after 2 years. No further regression was seen in years 3 and 4. Left ventricular volume index showed similar trends, with a decline from year 1 to year 2 (P=0.05) followed by stabilization in years 3 and 4. Older age, long duration of hypertension, need for more than one antihypertensive, high pulse pressure in normal-size hearts, and low pulse pressure in dilated hearts were significantly associated with failure of regression of LVMI between the first and second years (MLR, P<0.000001, r2=0.57). CONCLUSIONS: Regression of left ventricular hypertrophy continues beyond the first year after renal transplantation, reaching a nadir at 2 years and persisting into the third and fourth posttransplant years. Failure to regress was associated with older age, hypertension, high pulse pressure in normal-size hearts and low pulse pressure in dilated hearts.     

Stent graft of abdominal aortic aneurysm after renal transplantation

The necessity of operative treatment of abdominal aortic aneurysm (AAA) is reported in an increasing number of patients after renal transplantation as a result of improved renal graft long-term survival. In these patients, aortic surgery however, places the allograft at risk for ischemic damage. We present a first case of AAA stenting in a kidney-grafted patient. This procedure helped us avoid ischemia of the graft, which showed excellent function pre- and postoperatively. The patient had an uneventful recovery with no evidence of renal dysfunction and was discharged in good condition 7 days after stenting. This case demonstrates a useful alternative for the repair of AAA in kidney-grafted patients.     

Early renal transplantation after donor renal angiography affects initial graft function

Background

Renal angiography of a living donor is a common radiologic examination before transplantation. However, the contrast agent used during this procedure can cause contrast nephropathy. There are insufficient data regarding whether this radiocontrast exposure detoriates renal function and survival after transplantation. In this study, we analyzed the effects of radiocontrast exposure to donors before transplant surgery on the incidence of delayed graft function (DGF) and on the outcomes of recipients at 1 year posttransplantation.

Methods

We divided 80 living donor transplantations according to the duration between the renal angiography and the transplantation procedure: Group 1 as early transplantation at ≤20 days (n = 42) versus group 2 of late transplantation at ≥20 days (n = 38). We retrospectively collected acute rejection episodes and graft survival at 1 year, monthly serum creatinine values of, DGF, proteinuria at 1 month, GFR at posttransplant day 3 month 1, and 1 year.

Results

There were 10 group 1 recipients (23.8%) and 2 group 2 (5.3%) subjects who experienced ≥1 acute rejection episode in the 1st posttransplant year (P = .02); 1 patient in each group experienced graft loss at 1 year (P = .941). DGF was observed in 9 (22%) versus 1 patient (2.6%) in group 2 (P = .009). Posttransplant day 3 creatinine values were significantly higher (P = .005) with significantly lower GFR values (P = .043) in group 1. However, creatinine and GFR levels were similar at 1 month and 1 year. Month 1 proteinuria levels were significantly higher in group 1 (P = .014). There was a significant negative correlation between renal angiography time and month 1 proteinuria (P = .014).

Conclusions

Early renal transplantation (within 2 weeks after renal angiography) in living kidney donors can detoriate initial graft function and cause DGF.     

ACE genotype and long-term graft survival after renal transplantation.

Sir, Slowinski et al. [1] report that the angiotensin-convertingenzyme (ACE) (I/D) recipient genotype has no impact on the occurrenceof renal graft dysfunction in 405 Caucasian kidney graft recipients. In their discussion they refer to the Lancet     

Delayed graft function after renal transplantation: an unresolved problem

Unlike other areas in renal transplantation, delayed graft function (DGF) remains an apparently unavoidable complication owing to the characteristics of current donors. The aim of this study was to analyze risk factors for DGF in relation to graft and patient survivals. We retrospectively analyzed 507 renal transplant recipients with a median follow-up of 74.83 ± 45.06 months. DGF, which occurred among 189 patients (36.8%) was defined as requirement for dialysis within the first week after transplantation. Donor (P = .000) and recipient (P = .000) age were greater in the DGF group without differences in recipient or donor gender, HLA sensitization, or dialysis time before transplantation. Donor factors as the cause of death associated with DGF were secondary cerebrovacular stroke (P = .002) and hypertensive history (P = .000). Recipient characteristics associated therewith were higher body mass index (P = .000), smoking habit (P = .003), ischemic cardiopathy (P = .01), and dyslipidemia (P = .05). Moreover, the DGF group showed longer cold ischemia (P = .01) and vascular anastomosis (P = .02) times. On multivariate analysis, recipient age (P = .00) and smoking habit (P = .01) together with a donor history of hypertension (P = .02) were independent risk factors for DGF. No differences were observed in acute rejection incidence (P = .07) with worse renal function during follow-up (P < .05). Graft (81% vs 88%; P = .00) and patient (89% vs 95%; P = .00) survivals at 5 years were lower among the DGF group. In conclusion, DGF which was associated with factors related to the donor, the recipient, and the surgical times, produced worse graft and patient survivals. Shortening the cold ischemia time seems to be a modifiable variable to reduce DGF.     

Weight gain after living-related renal transplantation affects long-term graft function

Weight gain is a common problem in renal transplant recipients. This study investigated whether weight gain after living-related renal transplantation affects long-term graft function. The cohort included 93 patients (28 females, 65 males of mean age, 33.78 +/- 9.78 years who were recipients of kidneys from living-related donors. The data set related risk factors to occurrence of chronic allograft nephropathy (CAN): namely, number of HLA mismatches, PRA levels, delayed graft function, acute rejection, suboptimal immunosuppression, hypertension, hyperlipidemia, and size mismatch. Patients with a 10% increase in body mass index sustained throughout at least 2 years posttransplantation were categorized as group 1 (abnormal weight gain; n = 65) and the others were categorized as group 2 (no or normal weight gain; n = 28). Chronic allograft nephropathy was more frequent among group 1 (P < .03). The mean times to CAN diagnosis in groups 1 and 2 were 1053.41 +/- 461.86 days and 1128.57 +/- 416.09 days, respectively (P > .05). Of all the risk factors for CAN, occurrence of acute rejection was the most important (OR = 5.39, 95% CI: 2.07 to 14.03, P < .001). When this factor was excluded, weight gain emerged as the most important risk factor (OR = 3.04, 95% CI: 1.01 to 9.69, P < .04). There were no significant differences between the groups with respect to the frequencies of immunologic and nonimmunologic risk factors (P > .05 for all). The results suggest that excessive weight gain after living-related renal transplantation may be an additional risk factor for development of CAN. Patients should pay attention to diet and control weight gain after transplantation.     

The role of C-reactive protein in graft dysfunction after renal transplantation

PURPOSE: We investigated whether serial daily measurements of serum C-reactive protein could help differentiate episodes of transplant dysfunction due to rejection, infection, cyclosporin A nephrotoxicity or acute tubular necrosis in renal allograft recipients. MATERIALS AND METHODS: Morning serum was obtained daily from 134 patients during the first 30 days after renal transplantation. All episodes of graft dysfunction were recorded and compared to transplant biopsies. C-reactive protein concentrations were correlated with postoperative graft function and the various causes of graft dysfunction. RESULTS: All patients demonstrated an increase in C-reactive protein in response to surgery and a maximum level was reached on day 2 after transplantation. Mean C-reactive protein concentration was significantly increased for delayed (61.50 microg./ml.) compared to primary (mean 38.01) graft function (p = 0.001, Mann-Whitney U test). There were significant increases in C-reactive protein for bacterial infections other than asymptomatic bacteriuria (33.98 microg./ml), interstitial graft rejection (16.43) and acute tubular necrosis (30.50) compared to uneventful courses. C-reactive protein was unchanged for viral infections or cyclosporin A toxicity. CONCLUSIONS: Serial C-reactive protein measurements help to identify renal transplant dysfunction of different origins. However, rejection, infection and acute tubular necrosis show similar patterns of C-reactive protein increase. Thus, C-reactive protein is unable to discriminate the causes of renal graft dysfunction. Biopsy remains the gold standard for the differential diagnosis of renal allograft dysfunction.     

Donor-specific HLA antibodies and graft function in children after renal transplantation

Background  

The presence of circulating donor-specific human leukocyte antigen antibodies (HLA-DSA) has been associated with chronic antibody-mediated rejection, leading to progressive graft dysfunction and poor graft survival. The aim of this study was to investigate the incidence and significance of HLA-DSA in paediatric renal transplantation (RTx) patients.     

Adverse effect of donor arteriolosclerosis on graft outcome after renal transplantation.

INTRODUCTION: In recent years less strict criteria for renal graft donors have been applied. Our study was designed to investigate whether the histological picture, with special reference to vascular changes of the donor kidney, has an effect on the development and level of graft function, and on 48-month graft survival. METHODS: Three morphologically distinct groups were formed from 150 consecutive cadaveric kidneys donors transplanted into 290 recipients. A control group (C) consisted of kidneys with a completely normal histological picture. Group M1 included kidneys with mild arteriolosclerosis and group M2 (n=122) was comprised of kidneys showing significant arteriolosclerosis. The onset of graft function was assessed by the need for dialysis treatment post-transplantation and the levels of serum creatinine and creatinine clearance at 6, 12, 24 and 36 months post transplant. RESULTS: The proportion of sclerotic glomeruli (P<0.001) and the incidence and severity of interstitial fibrosis was greater in groups M1 and M2 than in the control group (M1, P<0.01; M2, P<0.001). The incidence of vascular fibrinoid necrosis in M2 was greater than in controls (P<0.001). The onset of graft function did not differ significantly between the groups. Group M2 showed a significantly lower level of graft function (P<0.001). The 4-year graft survival rate of group M2 was 74.2%, significantly lower than in the combined group C+M1 (P=0.03). CONCLUSION: Significant vascular lesions in the donor kidney should be taken into account when predicting graft function and survival.     

Delayed graft function in renal transplantation

Delayed graft function (DGF) has gained interest with the increased use of marginal donors to overcome donor shortage. We review the literature on DGF in renal transplantation. We describe items concerning its etiology and its impact on short- and long-term graft survival. DGF is a phenomenon that is supposed to be caused by ischemia and reperfusion injury. We propose that the lack of consistency of studies on the impact of DGF on short- and long-term graft outcome is caused by inconsistent definitions. Therefore, we use a functional definition of DGF, excluding acute rejection episodes and calcineurin inhibitor toxicity as a possible attributable factor. We state that, using this functional definition, DGF has no direct impact on long-term graft survival and that it is merely the expression of poor graft quality rather than an independent risk factor for graft outcome. We propose that poor graft quality is the explanation for the correlation between the occurrence of DGF and poor long-term graft outcome. In clinical practice this means that parameters for graft quality should be found and defined so that the allocation of grafts can be more tailor-made.     

供体亚低温状态对公民逝世后器官捐献移植肾功能的影响

目的  探讨供体亚低温状态对公民逝世后器官捐献肾移植早期肾功能影响。方法  将符合入选条件的36例公民逝世后器官捐献供体根据处理方式随机分为常温组（体温36.5~37.5℃,19例）和亚低温组（体温34.0~35.0℃,17例）。对应供体分组的肾移植受体包括常温组（38例）和亚低温组（34例）。比较两组供体、受体的围手术期情况和两组受体术后移植肾功能恢复情况,包括移植物功能延迟恢复（DGF）和原发性无功能（PNF）发生率。结果  两组供体围手术期的尿量、血清肌酐（Scr）、收缩压、血氧饱和度、热缺血时间和冷缺血时间比较,均无统计学意义（均为P < 0.05）。两组受体的手术时间、术中平均血糖、术中平均动脉压比较,差异均无统计学意义（均为P < 0.05）。亚低温组和常温组受体术后DGF发生率分别为6%和24%,两组受体DGF发生率比较,差异有统计学意义（χ²=4.393,P=0.036）。亚低温组和常温组受体术后PNF发生率均为3%,两组受体PNF发生率比较,差异无统计学意义（χ²=0.000,P=1）。结论  供体亚低温状态可以显著降低受体DGF的发生率,对PNF的发生率则无明显影响。     

早期移植肾功能异常的相关因素及其预后

目的 探讨早期移植肾功能异常的相关因素及其对移植肾长期存活的影响。方法 根据术后６个月内有无发生急性排斥反应和６个月时的血肌酐水平（ＳＣｒ６月）,将２５１例肾移植患者分为４组：Ａ、Ｂ组未发生急性排斥反应,前者ＳＣｒ６月〈１３０μｍｏｌ／Ｌ,后者ＳＣｒ６月≥１３０μｍｏｌ／Ｌ;Ｃ、Ｄ组为４组：Ａ、Ｂ且未发生急性排斥反应,前者ＳＣｒ６月〈１３０μｍｏｌ／Ｌ,后者ＳＣｒ≥１３０μｍｏｌ／Ｌ。术后各组的免