活体亲属供肾移植25例报告

目的 评价活体亲属肾移植的临床效果。方法 总结25例亲属供肾移植的临床资料。结果 25例供者无手术并发症,术后肾功良好。25例受者移植肾全部成活,术后因肾小管坏死和肾动脉吻合口狭窄发生移植肾功延迟恢复各1例,受者和移植肾1年存活率均为100%。结论 活体亲属供肾移植肾存活率明显高于尸体肾移植。     

亲属活体肾移植中父母供肾对移植肾长期存活的影响

目的研究父母供肾对亲属活体肾移植受者移植肾长期存活的影响。方法回顾性分析首都医科大学附属北京友谊医院行父母供肾的亲属活体肾移植并存活5年以上的119例受者临床资料。其中,男性96例,女性23例,平均年龄(28±13)岁。119例供者中,父亲供肾52例,母亲供肾67例,平均年龄(51±13)岁。119例受者均于2010年10月行群体反应性抗体(PRA)检测,并于2014年10月至12月检测肾功能,观察受者抗HLA抗体、供者年龄和性别对移植肾功能的影响。采用χ2检验比较上述指标,P0.05为差异有统计学意义。结果 119例受者中,28例产生抗HLA抗体,其中26例移植肾功能下降,占92.9%;无抗HLA抗体的91例受者中32例移植肾功能下降,占35.2%,差异有统计学意义(χ2=26.26,P0.05)。父亲供肾与母亲供肾移植术后肾功能下降的受者比例分别为38.5%(20/52)和59.7%(40/67),差异有统计学意义(χ2=4.47,P0.05)。119例供者中,81例年龄≥50岁,对应受者中41例肾功能下降(50.6%,41/81);38例供者年龄50岁,对应受者中17例肾功能下降(44.7%,17/38);不同年龄供者供肾移植术后出现肾功能异常的受者比例差异无统计学意义(χ2=0.018,P0.05)。结论父母供肾的亲属活体肾移植中,抗HLA抗体是肾功能下降的重要影响因素,供者性别也可能与术后肾功能下降有关。     

亲属活体供肾动脉轻度狭窄对肾移植受者术后早期肾功能和并发症的影响

目的探讨亲属活体供肾动脉轻度狭窄对肾移植受者术后早期肾功能和并发症的影响。方法回顾性分析14例供肾动脉轻度狭窄的亲属活体肾移植与50例标准亲属活体肾移植供、受者的临床资料。比较两组供者术后血清肌酐(Scr)水平。比较两组受者术后1、3、6个月的Scr水平;比较两组受者移植肾存活率及移植物功能延迟恢复(DGF)、急性排斥反应、肺部感染的发生率。结果两组供者术后Scr水平比较,差异均无统计学意义(均为P0.05)。两组术后1、3、6个月Scr水平比较,差异均无统计学意义(均为P0.05)。两组受者移植肾存活率,DGF、急性排斥反应、肺部感染的发生率比较,差异亦均无统计学意义(均为P0.05)。结论亲属活体供肾动脉轻度狭窄对肾移植受者术后肾功能和并发症的影响不大,可纳入标准供体供肾范围。     

老年活体供肾移植术后供者安全性及受者移植效果的分析

目的 分析老年活体供肾移植术后供者的安全性及受者的移植效果.方法 回顾性分析251例亲属活体供肾移植的临床资料.根据供者年龄,将251例活体供肾移植分为老年供肾组(≥55岁)和中青年供肾组(<55岁),对手术前后两组供、受者的血清肌酐(Cr)、肾小球滤过率(GFR)、内生肌酐清除率(Ccr)、并发症、平均住院时间以及受者的人/肾存活率、急性排斥反应发生率进行比较和分析.结果 老年供肾组和中青年供肾组供者手术前后血Cr水平的差异无统计学意义(P>0.05),而Ccr的差异有统计学意义(P<0.05).老年供肾组与中青年供肾组供者比较,术前总GFR、留存肾GFR及术后10 d留存肾GFR比较,差异均无统计学意义(P>0.05);老年供肾组供者术后10 d与术前的留存肾GFR比较,差异无统计学意义(P>0.05);中青年供肾组供者术后10 d的留存肾GFR较术前明显上升,差异有统计学意义(P<0.05).老年供肾组与中青年供肾组受者比较,手术前后各相应时间点的血Cr水平差异无统计学意义(P>0.05).老年供肾组和中青年供肾组供者平均住院时间分别为(16.67±7.78)d和(16.11±5.89)d(P>0.05),受者平均住院时间分别为(29.61±24.28)d和(28.76±19.27)d(P>0.05).两组受者6个月内急性排斥反应发生率分别为6.50%和5.75%(P>0.05).老年供肾组受者术后死亡1例,中青年供肾组死亡3例,并有1例因急性排斥反应切除移植肾.结论 老年活体供肾移植术前应对供者进行严格的选择,在进行全面系统评估的前提下,可以保证供者术后的安全以及受者的移植效果.     

老龄供肾在青年受者体内的病理学改变

目的研究老龄供肾在青年受者体内的病理学改变,探讨老龄供肾移植的安全性。方法研究对象选择2008年1月至2008年12月期间在广州医科大学附属第二医院移植科实施亲属活体供肾移植的14例老龄供者(年龄55岁)和14例青年受者(年龄30岁)。对每例老龄供肾进行零时活组织检查(活检),对接受老龄供肾的青年受者在移植后6个月进行常规的移植肾活检。观察老龄供肾移植后的肾脏组织病理结构改变。结果老龄供肾移植至青年受者体内6个月后组织病理结构发生改变:肾小动脉病变程度较移植前减轻;肾小动脉硬化指数较移植前减轻(P0.05);肾小球硬化比例移植前后变化不大(P0.05)。纤维连接蛋白(FN)水平较移植术前表达水平降低,但差异无统计学意义(P0.05);层黏连蛋白(LN)表达水平较移植前降低(P0.05)。结论老龄供肾移植到青年受者体内后,其组织病理学结构有所改善。     

关注肾移植术后远期出现移植肾功能丧失的真正原因

自上世纪80年代环孢素A(CsA)进入临床肾移植后,受者及移植肾的近期存活率获得了显著改善,但其长期存活率的改善仍不满意.因此,如何提高受者及移植肾的长期存活是目前临床面临的主要挑战和研究热点.在往期专栏中,我们曾探讨过钙调磷酸酶抑制剂(CNI)的应用与受者长期肾功能的关系,发现远期移植肾损伤并没有所谓的“CNI慢性肾毒性”的特异性组织学表现,因而不能简单归因于CNI治疗.本文将结合近期发表的研究继续剖析撤除或无CNI方案对远期移植肾功能的影响,以及导致晚期移植肾功能丧失的主要原因.     

活体亲属供肾的肾移植5例报告

目的 探讨活体亲属供肾移植及术前特异性输供体血的安全性及可行性,并评价其临床效果。方法 总结5例活体亲属供肾移植的临床效果和供肾者术后的恢复情况。结果 5例活体亲属供肾者经随访10～24月全部健康,正常工作,术后无明显的并发症,5例肾移植受者目前移植肾功能(血肌酐及内生肌酐清除率)均正常,且已恢复正常的学习和工作,术后的免疫抑制剂使用量较同期的尸体肾移植受者低10％～15％。结论 活体亲属供肾是扩大供肾来源的较好途径,移植术后人/肾存活率优于尸体肾移植人/肾存活率。术前特异性输供体血有利于诱导受者产生免疫耐受。     

肾移植受者妊娠期CNI血药浓度变异性对移植肾功能及妊娠和胎儿的影响

目的观察肾移植受者妊娠期CNI血药浓度变异性对移植肾功能及妊娠和胎儿的影响。 方法回顾性分析1997年1月1日至2019年6月30日在温州医科大学附属第一医院行肾移植手术的育龄期女性受者术后妊娠情况，共有14例肾移植受者术后成功妊娠并分娩15次，均为自然受孕。自怀孕前3个月至分娩后3个月，受者每月随访监测CNI剂量和血药浓度、血清肌酐和估算肾小球滤过率，并根据CNI血药浓度谷值计算变异系数(CV)。观察受者妊娠和胎儿并发症发生情况及新生儿情况，分析CV与移植肾功能和妊娠并发症的相关性。采用重复测量方差分析比较受者妊娠前后各时间点CNI血药浓度、血清肌酐和eGFR水平及CV，进一步两两比较采用LSD法。采用成组t检验或χ²检验比较妊娠晚期高CV和低CV受者妊娠年龄、移植妊娠间期、移植肾功能不全、先兆子痫和胎儿早产情况。P<0.05为差异有统计学意义。 结果14例受者成功妊娠年龄(31±5)岁(21～39岁)，移植妊娠间期平均(71±43)个月(22～157个月)。14例受者CNI血药浓度妊娠后逐渐下降，妊娠中期最低；CV在妊娠早期最高，为(45±30)%，与妊娠前、妊娠中期和晚期相比差异均有统计学意义(P均<0.05)。妊娠过程中，血清肌酐先下降后上升，妊娠中期降至最低，为(62±11)μmol/L，与妊娠前相比差异有统计学意义(P<0.05)。1例受者妊娠过程中出现无症状蛋白尿(尿蛋白＋＋)，分娩后转阴。3例受者分别于分娩后7个月、10个月和9年出现移植肾功能不全。14例肾移植受者妊娠过程中有2例出现先兆子痫，1例在分娩后即缓解，1例在分娩后4个月缓解；4例受者发生泌尿系统感染，予碱化尿液及增加饮水量后均好转。分娩方式包括自然分娩2例，剖宫产13例。15例新生儿中，1例为低体重儿，2例早产儿胎龄分别为32周和36周4天。妊娠晚期CNI血药浓度高CV受者移植肾功能不全及早产发生比例高于低CV受者，差异均有统计学意义(χ²＝5.104和9.231，P均<0.05)。 结论肾移植术后妊娠早期CNI血药浓度CV明显升高，妊娠晚期CNI血药浓度CV>50%的肾移植受者可能更容易发生早产和移植肾功能不全。     

亲属活体肾移植101例分析

目的 总结16年亲属活体肾移植的经验。方法 101例亲属活体肾移植，除3例为夫妻间供肾外，其余为血缘亲属供肾。供、受者为同卵孪生2例，HLA全配24例，HLA单倍体相同69例，HLA有5个抗原错配者4例，HLA完全错配者2例。73例取供者右肾，28例取左肾；100例经开放手术取肾，1例经腹腔镜取肾。术后采用环孢素A（或他克莫司）、硫唑嘌呤（或霉酚酸酯）及泼尼松预防排斥反应。结果 所有供者术后1周内出院，随访6个月，血肌酐正常。术后96例受者存活，存活时间最长者达15年，其中4例移植肾功能丧失，其原因分别为超急性排斥反应（1例，术中切除肾脏）、慢性移植肾肾病与肾病复发（3例）；5例死亡，除1例术后发生移植肾功能恢复延迟，透析期间因肺出血死亡外，另4例死亡与移植肾无关。术后5例发生急性排斥反应，4例Banff分级为Ⅰ级，经甲泼尼龙冲击治疗，4例逆转，1例无效，恢复透析治疗。术后2例发生尿瘘，5例发生移植肾输尿管慢性梗阻，经手术治疗痊愈。结论 术前对供、受者进行全面综合评估是亲属活体肾移植成功的保证；亲属活体肾移植的组织配型好，供肾缺血时间短，排斥反应发生少，免疫抑制剂用量小，移植肾长期存活率高。     

夫妻活体供肾移植的相关问题分析

目的 探讨夫妻供肾移植的临床效果及安全性.方法63例活体供肾移植供者分夫妻供肾组(n=12)和亲属供肾组(n=51)2组.总结夫妻活体供肾肾移植的临床资料,并与同期基础条件相近、免疫抑制剂方案相同、基因相关亲属供肾组的临床资料进行对比.观察指标选择平均住院时间、急性肾小管坏死发生率、1年内急性排斥反应发生率和移植后7、30 d和1年血肌酐(SCr)水平.结果 夫妻供肾组和亲属供肾组受者年龄分别为(39±3)和(37±3)岁,P=0.05;透析时间分别为(4.7±3.2)和(4.4±2.9)个月,P=0.78;平均住院时间分别为(20.9±8.3)和(23.0±7.8)d,P=0.41.2组1年内急性排斥反应发生率分别为33.3%4/12),3.9%(2/51),P=0.01.急性肾小管坏死发生率分别为16.7%(2/12),3.9%(2/51)(P=0.31).夫妻供肾组术后7、30 d SCr值分别为(206.47±47.22)和(163.75±25.91)μmol/L,亲属供肾组分别为(142.79±89.42)和(119.99±15.03)μmol/L,P=0.02,P=0.00.术后1年夫妻供肾组获随访9例,亲属供肾组40例;SCr分别为(133.40±6.11)和(121.00±34.12)μmol/L,P=0.25.结论 术前对夫妻供、受者进行全面综合评估是夫妻供肾移植成功的保证.夫妻供肾移植的近期急性排斥反应发生率略高于亲属活体供肾移植,但术后1年夫妻供肾移植受者的移植肾功能与亲属活体供移植受者比较并无区别.     

亲属活体肾移植(附162例报告)

目的探讨亲属活体肾移植的疗效。方法亲属活体肾移植162例,除7例为夫妻间供肾外,其余为血缘亲属供肾。人类白细胞抗原(human leukocyte antigen,HLA)抗原错配5个4例、抗原错配4个6例、抗原错配3个101例、抗原错配2个51例。全部供者经开放手术取肾。受者术后采用环孢素或他克莫司+麦考酚吗乙酯+泼尼松龙三联免疫抑制治疗方案预防排斥反应。结果供者中除2名出现一过性血清肌酐升高外,其余肾功能均在正常范围内。162例受者中,术后早期肾功能恢复正常157例,肾功能延迟恢复5例,急性排斥反应5例,输尿管血栓形成2例,慢性排斥反应3例。1、3、5年人存活率均为96.9%,1、3、5年肾存活率分别为96.3%、95.8%、95.0%。死亡5例,死亡时间为移植后3个月内,均死于重度肺部感染并呼吸衰竭。结论亲属活体肾移植的组织配型好,供者术前准备充分,供肾缺血时间短,受者术前有充足的免疫诱导时间,免疫抑制剂用量小,排斥反应发生率低,移植肾存活率高。     

新疆少数民族亲属活体肾移植供体安全性随访研究(附55例报告)

目的探讨新疆维吾尔族自治区(新疆)少数民族亲属活体肾移植中供肾切除术对供体安全性的影响。方法对55例活体肾移植供体进行随访,复查肾功能、24 h尿蛋白定量等常规检查,并与供者进行沟通,了解其心理状况和生活质量。对供者术前、术后7 d、术后6个月、术后1年、术后3年、术后5年的血清肌酐(Scr)、内生肌酐清除率(Ccr)和血压进行比较。结果 55例供体中,术后出现气胸1例,切口延迟愈合2例,切口血肿4例,经处理后均恢复正常,平均住院时间11 d。随访6～86个月,其中2例供者术后6个月内尿红细胞3～5/HP,2例出现一过性蛋白尿。术后供体各时段的肾功能(Scr和Ccr)和血压(收缩压与舒张压)均在正常范围内,术后7 d、6个月、1年、3年、5年的Scr、Ccr、血压与术前相应指标比较,差异均无统计学意义(均为P>0.05)。在随访期间所有供体家庭生活和日常工作未受到影响。结论新疆少数民族亲属活体供肾是安全可行的,供者在捐肾后肾功能未见减退,且生活质量较好。     

Predictors of improvement in renal function after calcineurin inhibitor withdrawal for post-liver transplant renal dysfunction

BACKGROUND: Renal dysfunction after liver transplantation is a major management problem. Predictors of improvement in renal dysfunction after calcineurin inhibitor therapy (CNI) withdrawal and replacement with either mycophenolate mofetil (MMF) or azathioprine (AZA) have not previously been examined. METHODS: Retrospective analysis of 33 post-transplant patients with creatinine clearance (CrCl) below 50 mL/min who were changed from CNI to either MMF or AZA. Following CNI withdrawal patients were divided into two groups: those with improved CrCl after switching and those without, to identify the variables associated with improved renal function. RESULTS: Variables associated with improved CrCl were: absence of hypertension or diabetes, shorter time between transplantation and switch, deterioration in CrCl in months prior to switch and treatment with MMF (compared with AZA). CONCLUSIONS: Our findings suggest CNI withdrawal should be targeted to a subgroup of patients whose renal function is most likely to improve.     

Outcome of renal transplantation in children less than two years of age.

Twenty-two renal transplants were performed in 21 children less than two years of age at Children's Hospital. Fourteen were from living related donors and eight were from cadaveric donors. The five year patient and graft survivals of these recipients were compared to all other pediatric recipients between two and 18 years of age who received renal transplants over the same time period. Five year graft survival for recipients less than two years of age was 86% following living-related donor transplantation and 38% following cadaver donor transplantation. Older pediatric recipients aged between two and 18 years had a five year graft survival of 73% following living-related donor renal transplantation, which was similar to that for recipients less than two years of age. Although older cadaveric recipients had a comparable five year graft survival to younger recipients, at 42%, the patterns of graft loss were different. Graft failures in young recipients occurred within the first seven months post-transplant, whereas the older recipient's grafts failed more gradually. Actuarial five-year patient survival in recipients less than two years of age was 86% following living-related donor renal transplantation and 70% following cadaver-donor renal transplantation. Recipients less than two years of age had a poorer patient survival than older recipients following both living-related donor renal transplantation (P = 0.06) and cadaver-donor renal transplantation (P less than 0.05). These findings suggest that the graft survival of living-related donor renal transplantation in recipients less than two years of age is better than that of cadaver-donor renal transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dual kidney transplantation after liver transplantation: a good option to rescue a patient from dialysis

Abstract:  Chronic renal failure (CRF) due to calcineurin inhibitor (CNI) nephrotoxicity is one of the most serious side effects influencing mortality and morbidity after liver transplantation (LTx). One way to offer a longer survival and better quality of life to LTx recipients who develop CRF is kidney transplantation, though this is not feasible for all candidates due to the shortage of organs. With changes in the characteristics of the global donor pool, which includes increasing number of elderly donors, both kidneys from one older donor are transplanted into the same adult recipient (dual kidney transplantation, DKT) to offset the lower nephron mass. DKT might be an option after LTx to rescue a patient from dialysis, with consequent survival benefits. We report on two cases of DKT after LTx in patients with CRF who were on dialysis due to CNI nephrotoxicity.     

Conversion from a calcineurin inhibitor-based immunosuppressive regimen to everolimus in renal transplant recipients: effect on renal function and proteinuria

New immunosuppressive agents are being actively researched to avoid complications of chronic allograft nephropathy (CAN), calcineurin inhibitor (CNI) nephrotoxicity, and posttransplantation cancer. The family of mTOR inhibitors offers a unique immunosuppressive opportunity to avoid CNI toxicity and reduce the incidence of malignancy. Nevertheless, increasing data have demonstrated that sirolimus (SRL), the first mTOR introduced in the treatment of solid organ transplant recipients, induces proteinuria, an adverse event that could produce deterioration of long-term renal function. In this short-term study of patients followed for 1 to 16 months, we examined changes in renal function and proteinuria among renal transplant recipients converted from a CNI-based regimen to an everolimus (EVL)-based one, a recently introduced mTOR inhibitor. Our data showed that renal function can be optimized after conversion to EVL by up to 42% in recipients showing CAN grade 1 or 2, or CNI nephrotoxicity. Importantly, patients who improved their creatinine clearance did not show increased proteinuria measured in a voided specimen as the ratio of urinary protein and creatinine concentration (P/C). These results, if confirmed with long-term follow-up and a larger number of patients, would allow us to consider EVL as a promising agent for maintenance immunosuppressive regimens in kidney transplantation.     

Effect of Sirolimus Withdrawal in Patients with Deteriorating Renal Function

Sirolimus has been an important addition to immunosuppressive regimens utilized in kidney transplantation. However, sirolimus can potentiate calcineurin inhibitor (CNI) nephrotoxicity by some still uncertain mechanisms. Studies have demonstrated that withdrawal of a CNI under sirolimus immunosuppression can improve renal function. However, it has yet to be demonstrated that withdrawal of sirolimus from such a regimen can also improve renal function and reverse progressive functional deterioration. We studied 17 patients who developed deterioration of renal function while on a CNI and sirolimus. Once an established deterioration in renal function was noted, sirolimus was withdrawn from the regimen and replaced with mycophenolate mofetil. Out of 17 patients with a negative slope in 1/cr, 15 demonstrated a positive treatment effect (change to a positive slope). On aggregate, renal function improved by 18% (creatinine 2.75-2.24 mg/dL), LDL cholesterol improved, as did hematocrit values after withdrawal. The majority of patients on a CNI and sirolimus regimen who experience deterioration in renal function demonstrate improvement in renal function after withdrawal of sirolimus. This strategy may be particularly useful in those patients where CNI withdrawal is considered to be of high immunologic or metabolic risk.     

亲属活体肾移植的伦理学审查:单中心经验总结

目的总结单中心亲属活体肾移植的伦理学审查经验。方法成立北京大学第三医院人体器官移植临床应用与管理伦理委员会(伦理委员会),对130例次在该院拟行亲属活体肾移植的供、受者进行伦理学审查。以国务院《人体器官移植条例》为依据,先对供、受者进行科内初审,然后召开伦理委员会会议进行审查,内容包括移植供、者双方关系是否为亲属,双方术前检查结果是否符合移植要求,供者是否具有完全民事能力,双方是否了解手术风险,供者是否完全自愿捐献,其亲属是否同意,双方是否签署书面知情同意书等。根据审查结果确定能否进行手术。结果 120例次得到批准并顺利完成了肾移植手术,供受双方恢复满意,无发生纠纷。10例次被否决,其中不能确定亲属关系5例次,双方术前检查结果不符合移植要求2例次,供者无完全民事能力1例次,供者配偶不同意移植1例次,非本人真实意愿捐肾1例次。结论成立伦理委员会,严格按照《人体器官移植条例》的要求对拟行亲属活体肾移植的供、受者双方进行伦理学审查可保证器官移植的规范性和医疗安全性。     

The incidence and risk factors of delayed graft function in 689 consecutive living unrelated donor renal transplantation

Due to the severe shortage of deceased donor kidneys, the number of renal transplantation from living-related and living-unrelated donors has increased worldwide. The incidence and risk factors of delayed graft function after deceased donor renal transplantation have been extensively studied. In this analysis, the incidence and predictors of delayed graft function was investigated in 689 living-unrelated kidney recipients. In 53 recipients, dialysis was needed within the first week after renal transplantation (7.7%). The risk factors for delayed graft function upon univariate analysis models were: female gender of kidney donor (P=.027), renal allograft with multiple arteries (P=.005) and previous transplantation (P<.005). Upon multivariate analysis, the only risk factor for development of delayed graft function was retransplantation (P=.001).     

Rapamycin in patients with chronic renal allograft dysfunction

PURPOSE: Nephrotoxicity of calcineurin inhibitors (CNI) complicates the management of chronic renal allograft dysfunction. Rapamycin is a promising immunosuppressive agent free of nephrotoxicity. The effect of conversion from CNI to rapamycin in recipients with chronic allograft dysfunction is still unclear. We investigated the effect of rapamycin in patients with chronic allograft dysfunction. METHODS: We conducted a prospective study on kidney transplant recipients with chronic allograft dysfunction. The patients were under classic CNI, mycophenolate mofetil, and prednisolone triple therapy. They had progressive deterioration of the allograft function. They were converted from CNI to rapamycin directly and observed for 6 months. The CNI serum levels before the conversion were within recommended range. Allograft function, clinical features and adverse effects were evaluated before and after the rapamycin conversion. RESULTS: A total of 16 patients were enrolled. Six of them (37.5%) failed to have a smooth conversion because of deterioration of allograft function and intractable adverse effects. Ten patients (62.5%) went through the 6-month observation period with improved graft function. The average reduction of serum creatinine was 27.7% (p < 0.001) in successful conversion. There were no significant differences on age, gender, lipid profile, sugar control, and rapamycin levels between successful and failed conversion. Anemia and diastolic blood pressure were significantly improved after successful conversion. The failed patients had a longer transplantation period (6.1 +/- 4.1 vs. 11.2 +/- 3.4 yr, p < 0.05). Two of them (12.5%) developed bacteria pneumonia. Self-limited diarrhea developed in three patients (18.8%). CONCLUSION: We suggested that conversion from CNI to rapamycin was beneficial in some kidney transplant recipients with chronic allograft dysfunction.