Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant

BACKGROUND AND METHODS: The extent to which renal allotransplantation - as compared with long-term dialysis - improves survival among patients with end-stage renal disease is controversial, because those selected for transplantation may have a lower base-line risk of death. In an attempt to distinguish the effects of patient selection from those of transplantation itself, we conducted a longitudinal study of mortality in 228,552 patients who were receiving long-term dialysis for end-stage renal disease. Of these patients, 46,164 were placed on a waiting list for transplantation, 23,275 of whom received a first cadaveric transplant between 1991 and 1997. The relative risk of death and survival were assessed with time-dependent nonproportional-hazards analysis, with adjustment for age, race, sex, cause of end-stage renal disease, geographic region, time from first treatment for end-stage renal disease to placement on the waiting list, and year of initial placement on the list. RESULTS: Among the various subgroups, the standardized mortality ratio for the patients on dialysis who were awaiting transplantation (annual death rate, 6.3 per 100 patient-years) was 38 to 58 percent lower than that for all patients on dialysis (annual death rate, 16.1 per 100 patient-years). The relative risk of death during the first 2 weeks after transplantation was 2.8 times as high as that for patients on dialysis who had equal lengths of follow-up since placement on the waiting list, but at 18 months the risk was much lower (relative risk, 0.32; 95 percent confidence interval, 0.30 to 0.35; P<0.001). The likelihood of survival became equal in the two groups within 5 to 673 days after transplantation in all the subgroups of patients we examined. The long-term mortality rate was 48 to 82 percent lower among transplant recipients (annual death rate, 3.8 per 100 patient-years) than patients on the waiting list, with relatively larger benefits among patients who were 20 to 39 years old, white patients, and younger patients with diabetes. CONCLUSIONS: Among patients with end-stage renal disease, healthier patients are placed on the waiting list for transplantation, and long-term survival is better among those on the waiting list who eventually undergo transplantation.     

既往肝外恶性肿瘤病史患者的肝脏移植

 目的 探讨既往有肝外恶性肿瘤病史患者的肝移植手术适应症和疗效。方法 2例术前分别因直肠癌和乳腺癌接受过根治性外科手术的患者，因肝癌或肝硬化接受同种异体原位肝移植术，术后采用个体化免疫抑制治疗方案，并对肝癌患者行术后常规化疗。 结果 2例患者术后恢复顺利，分别随访79个月年及34个月，肝功能良好，既往肝外肿瘤均未见复发。 结论 对既往有肝外恶性肿瘤的患者，肝移植手术并非禁忌，挑选合适的受者并采取个体化免疫抑制和化疗方案，可以取得满意疗效。     

Incompatible kidney transplantation: lessons from a decade of desensitization and paired kidney exchange

Human leukocyte antigen (HLA) sensitization and ABO incompatibility continue to pose significant barriers to further expansion of live donor renal transplantation. However, the recent development of effective desensitization protocols and creative paired donation strategies demonstrates that the presence of circulating donor HLA-specific antibodies and the use of ABO incompatible organs should no longer be considered contraindications for renal transplantation. It is estimated that as many as 6,000 patients on the kidney transplant waiting list have incompatible living donors and could benefit from these treatments. Furthermore, as our understanding of these treatment modalities has improved, it is now possible to predict whether desensitization, kidney paired donation or a combination of both will provide an individual patient with their best chance for successful renal transplantation.     

肾移植患者待肾期间的应对方式调查

背景：对肾移植患者待肾期间的心理学征象进行量化评估,分析该人群应对方式,对其进行相对应的个性化临床心理干预,有利于患者积极面对现实和疾病。 目的：通过对等待肾移植患者的心理应激状态进行调查,分析不同社会因素对患者应对方式的影响,探讨相应的临床心理干预对策。 方法：随机抽取2009年2月至2010年8月在解放军第309医院器官移植中心泌尿二科等待肾移植患者58例及非等待肾移植患者60例进行调查,采用目前通用的医学应对问卷的形式要求患者填写心理调查问卷表,应用多因素Logistic回归方法分析不同社会因素对患者应对方式及其心理应激状态的影响。 结果与结论：调查结果显示等待肾移植患者的“回避”和“屈服”量表得分明显高于非等待肾移植患者(P < 0.05);但两组的“面对”量表得分差异无显著性意义(P > 0.05)。说明等待肾移植患者较非等待肾移植患者所承受的心理压力大,可能与等待肾移植患者病程长、花费大、担心移植后排斥等因素有关。多因素Logistic回归分析发现患者的性别、文化程度、收入、费用支付方式和年龄均可影响等待肾移植患者的“面对”(斗争)、“回避”和“屈服”(接受)量表得分,其中文化程度在大专以上的患者“面对”量表得分高;年收入6万元以下的患者“回避”和“屈服”量表得分高。可见等待肾移植患者的收入与文化程度是影响其应对方式和心理应激状态的主要因素,对患者进行合理的临床个体化护理干预,有利于患者积极面对疾病,可减少移植对患者的心理损害。     

肾移植后恶性肿瘤16例：临床报告并文献复习

背景：肾移植后发生恶性肿瘤的原因是多方面的,其高发率与大剂量免疫抑制剂的长期应用密切相关。 目的：回顾性分析肾移植后免疫抑制剂应用情况、恶性肿瘤发生率、移植后肿瘤发生时间,发病特征及其相关因素,探讨肿瘤与免疫抑制剂的相关性。 方法：对512例肾移植中并发恶性肿瘤的16例患者的临床资料进行回顾性分析。15例患者肾移植后采用霉酚酸酯 +环孢素A+甲泼尼龙三联预防排异反应,1例患者采用霉酚酸酯+硫唑嘌呤+甲泼尼龙。移植后肿瘤的治疗方法：手术12例,单纯化疗1例,因病情晚期出现多处转移或患者放弃治疗3例。 结果与结论：肾移植后患者肿瘤发生率为3.13%,其中泌尿系肿瘤6例,占37.5%;消化道肿瘤4例(结肠癌2例,直肠癌、胃癌各1例),占25.0%;肝癌3例,占18.75%;皮肤癌、肺癌、卵巢癌各1例,各占6.25%。提示肾移植后患者最常见的恶性肿瘤为泌尿系肿瘤,其次为消化道肿瘤。对移植后患者,减少免疫抑制剂用量是防止移植后肿瘤发生、提高移植后患者长期存活率的主要因素之一。     

The first case of ureteral duplication in a combined liver-kidney transplantation

AIM: Kidney transplantation with ureteral duplication may represent a doubled risk factor in terms of ureteral stenosis or necrosis with urinary leakage usually from the site of ureteroneocystostomy. The incidence of complete duplication is very low at 0.19%. We report a kidney with ureteral duplication in the specific setting of multiorgan transplantation since it could be considered an adjunctive risk factor for urological complications. METHODS: The recipient was a 67-year old man, suffering from terminal renal insufficiency. He was also affected by HCV-related cirrhosis. The patient had been waiting for the combined transplantation for 27 months and in the last two months his hepatic function dramatically worsened. The donor was a 53-year old man who died of non-traumatic subarachnoid hemorrhage. Good HLA compatibility was observed between donor and recipient. During harvest both kidneys presented a complete ureteral duplication. So the ureters were freed together with a wide cuff of periureteral tissue and dissected distally. No vascular abnormalities were noted during the removal of either kidney. The grafts were flushed with University of Wisconsin solution and stored in the same solution. RESULTS: The liver was reperfused after 9 hours of cold ischemia. Subsequently the kidney was vascularized after 15 hours of cold ischemia. Urine production occurred immediately after revascularization. Two separated ureteroneocystostomies with a single antireflux technique were performed. Cyclosporine and steroids were given. Post-operative course was uneventful and liver and kidney function were normal. The 7-day cystography was normal. The 6, 12, 24 month ultrasonographies showed no signs of hydronephrosis or hydroureter. After 28 months renal cancer was diagnosed and the patient underwent a right nephrectomy. The liver-kidney recipient had excellent hepatic and renal function for 84.7 months. He died of malignancy from de novo tumor. CONCLUSIONS: On the basis of this experience, a kidney with an ureteral duplication, while rare, can be satisfactorily used also in combined liver-kidney transplantation.     

颅内出血心脑死亡器官捐献供体的安全性评估

随着器官移植技术的发展,肾移植成为治疗终末期肾病的最有效方法,与透析相比,肾移植受者预期寿命得到延长,生活质量显著提高,总的治疗费用基本持平。然而,器官供应短缺是肾移植的主要障碍,等待移植的患者以及等待中死亡的患者人数却逐年增加,当今心脑死亡供体的器官捐献是我国肾移植的主要来源,扩大标准供体的使用已被提上日程以扩大供体池。实践中,颅内出血导致患者心、脑死亡所占比例大,成为供体器官最重要来源。但是,颅内出血病因众多,因供体评估时间、评估手段、评估经验欠缺等原因,存在供体既存的其他病理性因素未被发现或者认识不足,例如供肾质量差,隐匿的肿瘤性病变等情况。一旦将此类供肾移植给受着,则会带来肿瘤的复发、移植肾功能丧失、甚至危及受体生命的严重后果。反之因过度担心术后并发症,可能将符合标准的移植物弃用,而导致器官的浪费现象。因此通过文献回顾,总结国内外有颅内出血病史供体器官的使用经验和原则。     

Evaluation and selection of candidates for renal transplantation at the Clinical Hospital Center in Rijeka

On December 31, 2001, 2486 patients with terminal renal failure received dialysis treatment in Croatia. Only one third of the patients are registered on the national waiting list for cadaveric kidney transplant. In most of the others, transplantation is impossible because of comorbidity. This is mainly due to the steadily growing age of the dialytic population and therefore a higher incidence of cardiovascular disease and diabetes. Still, evaluation of the potential recipients of cadaveric kidney transplant, registered on the waiting list, often reveals contraindications for transplantation. The aim of this study was to determine the incidence and type of contraindications in transplant candidates, found during immediate preoperative evaluation. Analysis of these data should help in determining how contraindications can be early detected and prevented. Before registering onto the national waiting list transplant candidates need to be thoroughly investigated including detailed history, physical examination, routine diagnostic procedures and additional examinations, if needed, to exclude or evaluate the possibly existing contraindications for transplantation. During the period from January 1997 until June 2002, 145 potential recipients from the national waiting list were referred to the Rijeka University Hospital Center and evaluated for kidney transplantation. Eighty-eight patients underwent transplantation. Preoperative evaluation revealed contraindications for transplantation in 52 (35.9%) candidates. Twenty-two (15.2%) patients had a positive cross-match with donor lymphocytes, 6 (4.1%) patients refused transplantation, and in 24 (16.6%) patients serious comorbidity was the reason for not being accepted for transplantation and for their withdrawal from the national waiting list. Comorbidity was mainly due to cardiovascular disease (12 patients--8.3%) and infection (8 patients--5.5%). These data show a high incidence of contraindications found during the immediate preoperative evaluation of potential kidney recipients. It was the case in more than one third of patients. During the evaluation of potential candidates for kidney transplantation special attention should be addressed to the presence of cardiovascular morbidity and infection. Peripheral vascular occlusive disease, cardiac status and/or cerebrovascular disease should be evaluated. Measures used to treat or reduce the development of complications include an optimal control of blood pressure, serum phosphate, hyperparathyroidism, dyslipidemia, and renal anemia. The sites of infection must be treated and eradicated, because immunosuppressive treatment is a threat to the transplant recipient's life. The second most common cause of refusal of potential candidates was a positive cross-match with donor lymphocytes. Sensitization to human leukocyte antigens can be prevented by the avoiding of blood transfusions and use of erythopoietin in treating renal anemia. To minimize the morbidity and mortality, the potential kidney recipients should undergo rigorous selection and thorough evaluation before including them into the waiting list for kidney transplantation. Afterwards, regular examinations are obligatory to reveal contraindications, proceed to medical interventions and treat concomitant diseases in time, which can influence the patient's survival. In case that contraindications for transplantation arise, the patient must be temporarily or definitely removed from the waiting list.     

移植肾急性排斥与移植前后血清细胞因子表达的变化

背景：目前异体器官移植后细胞因子变化己经有较多的报道,但有关细胞因子在肾移植患者中的动态变化规律及其与移植急性排斥反应的关系鲜有报道。 目的：观察肾移植受者移植前后血清细胞因子表达变化,并探讨其与移植肾急性排斥的关系。 方法：选择2008年9月至2011年9月武警后勤学院附属医院收治的接受肾移植患者48例,均为首次肾移植,分为肾功能稳定组和急性排斥反应组。另选择健康体检者30人为对照组。 结果与结论：肾功能稳定组、急性排斥反应组移植前1 d血清肿瘤坏死因子α、白细胞介素6、白细胞介素8水平与对照组相比差异无显著性意义(P > 0.05)。肾功能稳定组血清3种细胞因子水平均于移植后第1天即开始逐渐升高,在3 d时显著升高(P < 0.05),5 d时开始下降,7 d下降显著(P < 0.05),14 d左右趋于降至移植前水平,21-28 d表达稳定在移植前水平。急性排斥反应组血清3种细胞因子水平于移植后第1天即显著升高(P < 0.05),7-14 d维持在高水平 (P < 0.05),21-28 d稳定下降,但仍明显高于移植前(P < 0.05)。相同时间段,急性排斥反应组血清3种细胞因子水平均明显高于肾功能稳定组(P < 0.05)。提示移植后血清肿瘤坏死因子α、白细胞介素6、白细胞介素8动态水平变化在一定程度上反映肾移植受者的免疫反应状态,可作为辅助早期诊断急性排斥反应的免疫生物学指标。     

Effect of the ownership of dialysis facilities on patients' survival and referral for transplantation

BACKGROUND: More than 200,000 patients with end-stage renal disease undergo dialysis in the United States each year, about two thirds in for-profit centers. Economic pressures, such as the decline in inflation-adjusted Medicare payments for dialysis, may compromise the quality of care. Facilities may also be reluctant to refer patients to be evaluated for transplantation because of the loss of revenues from dialysis after patients receive transplants. It is unknown whether for-profit facilities respond more aggressively than not-for-profit facilities to these financial pressures. Therefore, we examined the effect of for-profit ownership of dialysis facilities on patients' survival and referral for possible transplantation. METHODS: We used data from the U.S. Renal Data System to assemble a nationally representative cohort of patients with end-stage renal disease of recent onset. We followed patients for a minimum of three years and a maximum of six years, until death, placement on the waiting list for a renal transplant, or loss to follow-up, or until May 31, 1996. We used proportional-hazards models to assess the effect of the profit status of the dialysis facility on patients' outcomes and adjusted for differences in sociodemographic, clinical, and facility-level characteristics. RESULTS: Of the 3681 patients who were eligible for inclusion, we included 3569 in the analysis of mortality and 3441 in the analysis of the waiting list. The crude mortality rate per 100 person-years of end-stage renal disease was 21.2 for patients treated in for-profit facilities and 17.1 for patients treated in not-for-profit centers (adjusted relative hazard, 1.20; 95 percent confidence interval, 1.02 to 1.42). The likelihood of being placed on the waiting list for a renal transplant was lower for patients treated at for-profit centers (adjusted relative hazard, 0.74; 95 percent confidence interval, 0.56 to 0.98). CONCLUSIONS: In the United States, for-profit ownership of dialysis facilities, as compared with not-for-profit ownership, is associated with increased mortality and decreased rates of placement on the waiting list for a renal transplant.     

Continuous venovenous hemofiltration as a bridge to heart transplantation in a patient with congestive heart failure and acute renal failure

Continuous venovenous hemofiltration effectively controls volume overload in cases of severe congestive heart failure accompanied by acute renal failure that could not be medicamentously controlled. A patient with severe ischemic dilated cardiomyopathy who developed acute renal failure while waiting for urgent heart transplantation is described. He was treated with CVVH for three days when the occasion for heart transplantation appeared. At the time of transplantation laboratory markers of renal function were within the normal range with stable hemodynamic parameters. After successful transplantation the patient spontaneously and completely recovered his renal function.     

Is secondary hyperparathyroidism-related myelofibrosis a negative prognostic factor for kidney transplant outcome?

Secondary hyperparathyroidism (HP) presenting with hypocalcemia and subsequent increased parathormone (PTH), is mainly identified in patients with chronic renal failure, which has been associated with variable degrees of bone marrow fibrosis.For suitable patients with end-stage renal disease (ESRD), kidney transplantation is recognized as the therapy of choice, being superior to dialysis in terms of quality of life and long-term mortality risk; in this regard interesting data show that increased time on dialysis prior to kidney transplantation is associated with decreased graft and patient survival.In our opinion an important and until now underestimated determinant of graft survival is the proper activity of bone marrow because of the emerging role of hematopoietic stem cells (HSC) in repair of ischemia/reperfusion (IR) damage. We postulate that in ESRD patients, who usually undergo long dialytic treatment, a myelofibrosis caused by an overt secondary HP could drastically decrease the HSC potential for IR damage repair after kidney transplant; this could irremediably lead to a delay in graft function with all related complicances.If the curative role of bone marrow-derived stem cells was confirmed by more data obtained in experimental animal models, it could be possible to try a cellular-based therapeutic approach in the management of ESRD patients which are in waiting list for a kidney transplant.     

Waiting for kidney transplantation from deceased donors: Experiences and support needs during the waiting time -A qualitative study

ObjectivesThe study aimed to explore and describe patients’ experiences of the transplantation process and the support they had received during the waiting time.MethodSemi-structured interviews were conducted with 14 patients currently waiting for kidney transplantation from deceased donors (n = 7) or recently having received kidney transplantation (n = 7). Interviews were transcribed, anonymized and analysed inductively using thematic analysis.ResultsTwo themes and seven sub-themes were identified. The first theme, “Swaying between hope and despair” describes patients’ perceptions of waiting for transplantation as a struggle, their expectations for life after the upcoming transplantation and experienced disappointments. The second theme, “Making your way through the waiting time”, describes support, strategies and behaviours used to manage the waiting time.ConclusionPatients described life while waiting for kidney transplantation as challenging, involving unexpected events, not understanding the transplantation process and having unrealistic expectations on life after transplantation. They also described support, strategies and behaviours used, some of which led to unwanted consequences.Practice implicationsPatients waiting for kidney transplantation from deceased donors need continuous and easily available education, practical and emotional support to manage the waiting time. Transplantation specific education is also needed to facilitate preparation for transplantation and adjustment to life after transplantation.     

Racial disparities in access to renal transplantation--clinically appropriate or due to underuse or overuse?

BACKGROUND: Despite abundant evidence of racial disparities in the use of surgical procedures, it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of inappropriate care. METHODS: We performed a literature review and used an expert panel to develop criteria for determining the appropriateness of renal transplantation for patients with end-stage renal disease. Using data from five states and the District of Columbia on patients who had started to undergo dialysis in 1996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropriateness of patients as data on candidates for transplantation and analyzed rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race. RESULTS: Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness criteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20.9 percent]) and were more likely to have had incomplete evaluations (368 [46.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). Among patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, according to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients classified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transplantation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons). CONCLUSIONS: Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as well as from underuse of transplantation among blacks and overuse among whites. Reducing racial disparities will require efforts to distinguish their specific causes and the development of interventions tailored to address them.     

肾移植后的尿酸性肾石病

背景：高尿酸血症是肾移植后常见的并发症之一,其引起的尿酸性肾石病如果治疗不及时可以造成移植肾肾后性失功。 目的：探讨肾移植后尿酸性肾石病的诊断和治疗方案。 方法：回顾性总结19例肾移植后发生尿酸性肾石病梗阻患者的临床资料,入院时均伴高尿酸血症,8例患者手术切开取石并行输尿管-膀胱再吻合术,11例患者行药物保守治疗。 结果与结论：16例患者为移植输尿管下段结石,2例为移植肾肾盂结石并肾盂积水,1例为移植肾重度积水并输尿管全段结石。18例患者治疗后移植肾功能、尿量恢复正常;1例患者造成移植肾失功能,切除移植肾。提示对于肾移植后血尿酸升高患者应尽早应用药物保守治疗,一旦保守治疗无效应及时采取手术方式,减少肾后性原因引起的移植肾失功。     

Financial incentives to promote prolonged renal graft survival: potential for patients and public health

Non-adherence to immune modulating agents is the single most common cause of renal graft rejection and failure with not only devastating consequences for patients, but also increased dialysis and transplant organ demands causing substantial medical expenses. Financial incentives used to reward and promote patient compliance with immune modulating therapy and post transplantation management could constitute a motivation that might increase renal graft survival, and thereby improve individual patient outcome as well as alleviate public health spending for renal replacement therapy.     

Hepatitis C therapy with long term remission after renal transplantation

Hepatitis C virus infection (HCV) is common in patients with end-stage renal disease (ESRD) and long observation periods have shown the detrimental effect of HCV infection on patient and graft survival after renal transplantation. At present, interferon is the most important agent for the treatment of hepatitis C in ESRD; however, limited information exists concerning the long-term response of patients who undergo renal transplantation after successful antiviral therapy. We describe the evolution of HCV infection in a dialysis patient with hepatitis C who was successfully treated with interferon alpha and then underwent renal transplantation. He received aggressive immunosuppression during the induction phase and for allograft rejection; however, regular screening showed complete absence of biochemical and virological relapse of HCV over a 6-year post-transplantation period. We conclude that interferon can offer excellent response in selected dialysis patients with hepatitis C. Alternative strategies with newer antiviral agents are currently under active investigation.     

Spontaneous acute tumor lysis syndrome with advanced gastric cancer

Acute tumor lysis syndrome (TLS) occurs frequently in hematologic malignancies such as high-grade lymphomas and acute leukemia, which are rapidly proliferating and chemosensitive tumors. It occurs rarely in solid tumors and has never been reported in gastric adenocarcinoma. Typical biochemical findings of acute tumor lysis syndrome are hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia in patients with a malignancy. Rapid changes of these electrolytes may cause cardiac arrhythmia, seizure, acute renal failure and sudden death. Therefore, as soon as it is detected, it should be taken care of immediately. Until now almost all cases of TLS associated with solid tumor have developed after cytoreductive therapy in chemosensitive tumors. We report here a case of spontaneous acute tumor lysis in a patient of advanced gastric cancer with hepatic metastases and multiple lymphadenopathy. The biochemical finding of TLS improved with the management and tumor burden also showed slight response to the one cycled combination chemotherapy but the patient died of progressive pneumonia.     

肾移植后他克莫司与五酯胶囊合用致高血钾症1例

背景：肾移植患者由于免疫抑制剂的药物肝毒性,肝功能异常发生率高,对临床出现肝功能异常者,需护肝治疗。但合用护肝药必须监测免疫抑制剂浓度。 目的：探讨肾移植患者他克莫司与五酯胶囊合用对他克莫司浓度及血生化的的影响。 方法：回顾性分析1例以他克莫司为免疫抑制剂的肾移植患者加服及停用五酯胶囊时他克莫司浓度及肾功能、血生化变化。患者因“慢性肾小球肾炎,慢性肾功能不全”于1998-06起行血液透析治疗。2000-08行同种异体尸体肾移植,移植后免服他克莫司+吗替麦考酚酯+泼尼松。移植后4个月患者出现肝功能异常,加用联苯双酯。2010-07-25患者停用联苯双酯,改服五酯胶囊。2010-07-29患者停用五酯胶囊。 结果与结论：服用他克莫司的肾移植受者,合用五酯胶囊,他克莫司血浓度显著升高。由5.3 ng/L升至24.7 ng/L,并合并高血钾症,停用五酯胶囊1周,他克莫司浓度由24.7 ng/L降至6.1 ng/L,血钾由6.4 mmol/L降至4.6 mmol/L。提示移植肾功能稳定的肾移植受者,在加用五酯胶囊,必须严密监测他克莫司血浓度及肝肾功能、电解质,及时调整他克莫司用量,保护移植肾功能。     

Erratum to 'The management of chronic hepatitis B in the immunocompromised patient: recommendations from a single topic meeting' [J. Clin. Virol. 41 (4) 2008 243-254]

Patients with chronic hepatitis B virus (HBV) infection have a substantial risk of reactivation and jaundice following the use of immunosuppressant therapy. A single topic conference was convened to discuss the management of HBV patients undergoing chemotherapy for haematological malignancy, liver and renal transplantation and with HIV co-infection. In advance of the meeting a draft guideline was prepared and circulated to a participating expert panel. Presentations and consensus views were obtained on the day of conference to allow pragmatic algorithms to be established on each of these topics.Use of lamivudine prophylaxis for HBV patients undergoing chemotherapy and renal transplantation is strongly supported with good evidence. Patients with HBV cirrhosis who are candidates for transplantation should be started on nucleos(t)ide therapy prior to surgery and, in addition, hepatitis B immune globulin given from the time of transplantation onward. Co-infection with HBV and HIV offers unique challenges. If the patient is a candidate for highly active retroviral therapy then dual nucleos(t)ide analogues which are also active against HBV must be used to prevent immune reconstitution hepatitis. In all these conditions, awareness of possible HBV resistance to therapy must be kept in mind and HBV DNA levels monitored.