神经干细胞移植的方法选择及其在脊髓损伤中的应用

脊髓损伤是一种创伤性中枢神经系疾病,常伴有脊髓损伤平面以下感觉、运动、自主神经功能丧失,常导致患者终身残疾,且并发症较多,甚至死亡。至今尚无有效的治疗方法从根本上修复已损伤的脊髓功能。神经干细胞具有自我更新、增殖和多向分化等潜能,其移植后可向神经元分化并替代已坏死的神经元,形成新的突触,重建神经通路促进脊髓功能的修复,为脊髓损伤患者的康复带来曙光。近年来许多科学家对神经干细胞进行基因修饰,基因调控,或联合其他细胞、生物材料以及改变移植时间、途径等多方面进行深入研究,来提高移植效率,虽然取得了长足的进展,但仍存在一些不足之处尚待进一步完善,如神经干细胞移植的途径、时机、次数的相关标准,移植细胞的免疫排斥、长期存活、定向分化,神经干细胞的来源及伦理,移植的安全性等。本文拟对神经干细胞移植方法,移植时间,移植途径进行综述,并对神经干细胞移植所存在的问题及应用前景进行展望。     

The global diffusion of organ transplantation: trends,drivers and policy implications

Rising incomes, the spread of personal insurance, lifestyle factors adding to the burden of illness, ageing populations, globalization and skills transfer within the medical community have increased worldwide demand for organ transplantation. The Global Observatory on Donation and Transplantation, which was built in response to World Health Assembly resolution WHA57.18, has conducted ongoing documentation of global transplantation activities since 2007. In this paper, we use the Global Observatory’s data to describe the current distribution of – and trends in – transplantation activities and to evaluate the role of health systems factors and macroeconomics in the diffusion of transplantation technology. We then consider the implications of our results for health policies relating to organ donation and transplantation. Of the World Health Organization’s Member States, most now engage in organ transplantation and more than a third performed deceased donor transplantation in 2011. In general, the Member States that engage in organ transplantation have greater access to physician services and greater total health spending per capita than the Member States where organ transplantation is not performed. The provision of deceased donor transplantation was closely associated with high levels of gross national income per capita. There are several ways in which governments can support the ethical development of organ donation and transplantation programmes. Specifically, they can ensure that appropriate legislation, regulation and oversight are in place, and monitor donation and transplantation activities, practices and outcomes. Moreover, they can allocate resources towards the training of specialist physicians, surgeons and transplant coordinators, and implement a professional donor-procurement network.     

Liver transplantation of living donor adult-to-adult

End-stage liver disease is being treated by liver transplantation since more than 20 years. Despite social and legislative efforts, the number of cadaveric organs suitable for liver transplantation has not grown to match the surplus of patients with end-stage liver disease. With the growing discrepancy between donors and recipients, the median waiting time for liver transplantation has increased dramatically. As a result, the number of patients who die while waiting is increasing. To attempt to meet the growing needs of recipients, surgeons are developing innovative techniques to increase the number of donated livers. These include: split liver transplantation and transplantation of a part of the liver from living donors. This review will focus on adult-to-adult transplantation of the right lobe from a living donor.     

Psychosocial issues in bone marrow transplantation: uncertainty and threat to life

Bone marrow transplantation is a complex medical procedure in which hematopoietic stem and progenitor cells are infused into a patient following high-dose chemotherapy with or without irradiation. Because the allogeneic transplantation is associated with life-threatening physical morbidity, lengthy convalescence, and special isolation, the potential for significant psychosocial uncertainty and psychological morbidity is high in adult patients. This work provides an overview of the medical procedures used in allogeneic transplantation and a review of psychosocial and behavioral issues relevant to transplantation. The discussion is limited to psychosocial issues pertinent to transplant recipients and donors, even though transplantation raises significant psychological issues for medical staff, families and caregivers of recipients.     

Intestinal transplantation

Increasing experience with intestinal transplantation has led to the refinement of techniques to detect and treat rejection and infectious complications. Improved outcome has led to a broadening of the indications for intestinal transplantation, particularly solitary intestinal transplantation.     

Hematopoietic stem cell transplantation in hematologic malignancy

Hematopoietic stem cell transplantation has become increasingly important in the treatment of hematologic malignancies over the past 20 years. While it is associated with significant morbidity, it offers the only chance of cure in many circumstances. Autologous and allogeneic transplantation have been used successfully to treat a variety of hematologic malignancies. These 2 approaches offer different risks and benefits which are discussed in this review. Timing of transplantation and selection of patients are also discussed. New innovations in stem cell transplantation including umbilical cord blood and non-myeloablative transplantation are reviewed.     

亲属活体肾移植供者围手术期的护理

目的研究亲属活体供肾移植供者围手术期的护理问题,提高亲属活体供肾移植术成功率。方法对活体供肾移植中102名供者进行术前的心理护理,术前、术后的准备,加强对并发症的精心护理。观察手术疗效、供者心理和身体的恢复情况。结果全部102例亲属活体供者左肾摘取术均成功,术后1周内血Cr、BUN均下降至正常值范围,全部顺利度过围手术期,术后9～13天出院,正常生活。3例发生切口愈合不良,经对症处理及行二期清创缝合后,切口完全愈合。1例术后出现短暂的血Cr升高,最高达428μmol/l,一周后下降至108μmol/l。其余98例供者无任何相关并发症。供者术前、术后心理健康,尤其在术后无明显心理问题出现。结论亲属活体供肾摘取术成功率高,通过围手术期的精心护理更能使供肾者减少相关的并发症,使身心早日康复。     

Psychosocial aspects of heart transplantation; 4-year experience

The psychosocial aspects of heart transplantation are described on the basis of the experience gained with these patients in the University Hospital Rotterdam (Dijkzigt) from 1984 to 1988. Quality of life before and after heart transplantation was determined using a comprehensive patient questionnaire. This questionnaire was presented by means of a personal computer. Forty-eight patients completed the pretransplant questionnaire. Data on the quality of life 4 and 13 months after transplantation were available for 33 and 20 patients, respectively, mainly due to the limited observation time. Severe anxiety and depressive mood were the predominant features of patients before transplantation. After transplantation the level of anxiety returns to normal within four months. However, sleep disturbances and depressive feelings may persist. Despite physical recovery, only few return to full or partial employment. Our findings confirm international experience and suggest appropriate psychosocial support in the period following the transplantation procedure.     

TLR4在肾移植急性排斥反应中的预测作用

目的:研究血液中Toll样受体4(TLR4)的含量在大鼠肾移植后发生急性排斥反应中的预测作用。方法:建立大鼠原位肾移植模型。利用流式细胞技术动态监测大鼠血液及移植肾组织中TLR4的含量,以酶联免疫法检测大鼠血液中IL-2的含量。以组织病理学作为急性排斥反应的诊断标准,研究其表达与急性排斥反应的关系。对检测结果进行统计分析。结果:在术后1 d、2 d、3 d、5 d、7 d异基因移植组大鼠移植肾均有急性排斥反应发生,异基因移植组血液中IL-2和TLR4水平明显高于同基因移植组及健康对照组大鼠体内相应指标的水平。在造模后1 d大鼠血液中TLR4含量即开始升高。同时异基因移植组大鼠移植肾组织中的TLR4含量也明显高于同基因移植组及健康对照组。结论:TLR4参与了肾移植术后急性排斥反应的发生,可作为肾移植术后预测急性排斥反应发生的一个敏感指标。     

Imaging techniques for the pre- and postoperative evaluation of recipients with living-donor liver transplantation

Whole-liver transplantation is a worldwide-accepted method for treatment of end-stage liver disease. As a result of the shortage of cadaveric livers, split-liver transplantation and living-donor liver transplantation are becoming more common. Preoperative imaging of the donors and recipients are indispensable for surgery planning, while postoperative imaging highly contributes to the success of transplantation by follow-up the transplanted organ and early diagnosis of possible sequelae. The authors delineate both pre- and postoperative imaging of recipients of living-donor transplantation, including the role of conventional x-ray, ultrasound, CT and MRI techniques, and also the different possibilities in the field of interventional radiology.     

亲属活体肾移植供者围手术期的护理

目的研究亲属活体供肾移植供者围手术期的护理问题,提高亲属活体供肾移植术成功率。方法对活体供肾移植中102名供者进行术前的心理护理,术前、术后的准备,加强对并发症的精心护理。观察手术疗效、供者心理和身体的恢复情况。结果全部102例亲属活体供者左肾摘取术均成功,术后1周内血Cr、BUN均下降至正常值范围,全部顺利度过困手术期。术后9～13天出院,正常生活。3例发生切口愈合不良,经对症处理及行二期清创缝合后,切口完全愈合。1例术后出现短暂的血Cr升高,最高达428μmol／l,一周后下降至108μmol／l。其余98例供者无任何相关并发症。供者术前、术后心理健康,尤其在术后无明显心理问题出现。结论亲属活体供肾摘取术成功率高,通过围手术期的精心护理更能使供肾者减少相关的并发症。使身心早日康复。     

Effect of Renal Transplantation on Sexual Function

This investigation was conducted to determine whether renal transplantation can improve sexual function in male patients with chronic renal failure. The authors retrospectively studied 121 men undergoing renal transplantation who complained of any type or degree of sexual dysfunction pre-operatively. Sexual function was evaluated by questionnaire which included erectile, ejaculative, and orgasmic functions. Pre- and postoperative frequency of sexual intercourse was also recorded. Patient characteristics, laboratory data, and endocrinologic profiles were analyzed to identify factors that might influence sexual function. In patients with hormonal determinations, results essentially normalized after transplantation. However, only 43 patients (35.5%) reported improvement of overall sexual function after renal transplantation, while 34 (28.1%) reported worsening. Although frequency of sexual intercourse was unaffected by transplantation, 15 of 20 patients who had no intercourse before transplantation initiated intercourse afterward. These 15 patients all underwent transplantation before 40 years of age. Comparisons of variables by sexual function showed significant differences for type of immunosuppressive treatment, interval after renal transplantation, and serum concentration of hemoglobin A1c. It is concluded that renal transplantation cannot improve sexual function in allpatients, although hormonal profiles were largely normalized, and that renal transplantation should be encouraged at a younger age.     

冷冻卵巢移植研究进展

哺乳动物的卵巢内有数量众多的卵细胞，是雌性生殖细胞的一个资源库。冷冻保存健康的卵巢组织，快速复苏后再原位移植到盆腔或异位移植至皮下及肾被膜等部位，有望恢复母体的生育力和维持正常激素水平。卵巢组织移植的成功与否取决于移植物的大小、局部缺血持续时间、外源性抗氧化剂和血管生成因子等因素。目前，已有少数关于人类卵巢冷冻移植并成功获得活产儿的报道，也有较多动物实验得到证实。现就冷冻卵巢移植的研究进展进行综述。     

The first successful combined heart-kidney transplantation in Hungary

Combined heart-kidney transplantation has become a new therapeutic solution for patients with coexisting, irreversible heart and kidney failure. Though this combined approach has several theoretical advantages over sequential transplantation, it remains to be established whether it has a jeopardizing impact on patient and graft outcome. The authors report their experience of the first successful combined heart-kidney transplantation in Hungary from a single donor and review the literature in order to clarify this issue. Young male patient candidate for heart transplantation was suffering from concurrent end stage kidney disease. Donor was selected on the basis of weight and size matching, AB0 compatibility and negative T-cell cross-match. The heart was grafted first, and after the hemodynamic stabilization kidney from the same donor was transplanted. The surgical procedure was uneventful. Heart and kidney function recovered quickly, and the patient is doing very well with good cardiac and renal function even a year following the double organ transplantation. The first Hungarian experience showed that combined heart-kidney transplantation is a therapeutic solution for patients with end stage heart and kidney failure. The lower rate of rejection compared to single heart or kidney transplantation, known from the literature as well, supports their current approach to immunosuppression.     

Gastrointestinal surgery and gastroenterology. II. Transplantation of pancreas]

In patients with type I diabetes mellitus, adequate blood glucose control prevents the development or aggravation of late complications. Apart from administration of insulin, transplantation of insulin-producing tissue is also a possibility. Transplantation of Langerhans islets which contain the insulin-producing beta cells is still in its initial phase. Transplantation of the entire pancreas received a boost in the mid-eighties when it became possible to drain the secretion of the exocrine part of the pancreas to the bladder using the duodenum. Other important steps forward were prevention and treatment of rejection and improvement of the preservation fluid. Because pancreas transplantation makes lifelong immunosuppression necessary, it is performed mainly in patients subjected to kidney transplantation because of terminal renal failure. The one-year survival of the patients after simultaneous pancreas and kidney transplantation increased to over 90%, that of the grafted pancreas to 82% and that of the grafted kidney to 86-90%. The one-year survival after transplantation of the pancreas alone increased to 62%. A successful pancreas transplantation leads to independence from insulin treatment and to normal glucose and HbA1c values. Pancreas transplantation also reduces diabetes nephropathy and progression of coronary sclerosis.     

Navigating the new,transplanted self: how recipients manage the cognitive risks of organ transplantation

The physiological risks of organ transplantation are well documented, but more poorly understood are the sociological ways in which organ recipients redefine themselves in reaction to physiological risks and social changes accompanying transplantation. This article analyses transplantation as a procedure that is not only physiologically risky but also poses risk to the social identity of the recipient, and explores how transplant recipients cognitively navigate transplantation surgery from waiting for to recovering after a transplant. It builds on previous sociological exploration of risk as a socially constructed process mediating experiences of health and illness with a focused contribution on explaining how individuals navigate risks posed to their social identities by major biophysical transformations. This article pointedly analyses narratives of fourteen organ recipients and the four dominant phases of identity management that emerged to create what we have coined as the new ‘transplanted self’, indicating the varied ways the individual social self emerges in response to the social risks of transplantation. We conclude that a better understanding of the recipient experience will contribute to improved care in the transplantation field.     

器官移植患者的营养支持

器官移植患者的营养支持关系到移植器官的功能。近年来，本所将营养支持已应用于肝移植、肾移植、胰腺移植、小肠移植、骨髓移植、联合器官移植和多器官移植的患者身上，提高了手术成功率，治愈了术后严重并发症。营养支持分为移植前期、围手术期和移植后期进行。各期应按病情特点进行合理的肠外与肠内营养支持，做到个体化。谷氨酰胺、生长激素等特殊营养素对危重器官移植患者具有代谢调理和免疫调理作用。     

The Varna-Thessaloniki telemedical collaboration in setting up a regional transborder transplantation network

In most Balkan countries, with the exception of Greece, transplantation is very rare and equality of access does not exist. In 2003, a Balkan partnership was established called SETNET (South-Eastern European Transplantation Network) for the promotion of transplantation. The objectives are to bring about the diffusion of transplantation techniques and practices in the Balkans, to increase public support for and participation in transplantation, and to eliminate the disparities in access to good health-care. SETNET is already beginning to generate data for an analysis of transplantation-related needs in the Balkans and to accelerate cross-border data exchange in transplantation-related emergencies. In the next few years, a regional training programme will be introduced for all health-care staff involved in transplantation. A regional organ procurement and transplantation network will be set up to utilize the existing telemedicine infrastructure. If successful, it will also prove that telemedicine infrastructures, however modest, can be the backbone for other, far-reaching human networks.     

Bone marrow transplantation in adolescents

This paper reviews bone marrow transplantation in adolescents. The primary indications for bone marrow transplantation are malignancies, usually relapsed lymphomas or acute/chronic leukemias. Autologous bone marrow transplantation is used as a high-dose consolidation therapy in some solid tumor patients with varied success. Peripheral blood stem cells are a feasible source of autologous stem cells in adolescents. The process of stem cell transplantation and the complications are the same in adolescents as in younger children and adults. Adolescents face the same biologic barriers to allogeneic transplant (minimal residual disease, availability of donor), but may also face more problems with their insurance status. The psychological and social aspects of bone marrow transplantation during adolescence are unique to their developmental stage. With appropriate medical, nursing, and psychosocial support, bone marrow transplantation offers cure for the adolescent with high-risk disease.     

The first 12 years of Hungarian lung transplantation

12 years have passed since the first Hungarian patient went through lung transplantation. A small but dedicated group of clinicians work to make lung transplantation an easily accessible, accepted therapy for Hungarian patients. Transplantation is recommended for patients suffering from end stage vascular or parenchymal diseases of the lung after conservative therapies are proven unsuccessful. Lung transplantation as a surgical intervention is currently not available in Hungary. In the past 12 years 64 Hungarian patients were transplanted at the Department of Cardiothoracic Surgery, Medical University of Vienna, in Austria by the Vienna Lung Transplant Group led by Prof. Walter Klepetko. Our patients went through lung transplantation for the following indications: cystic fibrosis (22), idiopathic lung fibrosis (18), primer pulmonary hypertonia (8), lymphangioleimyomatosis (5), emphysema (4) and other (7). The 64 patients altogether went through 68 transplantation procedures. In 4 cases re-transplantation was necessary. The surgery techniques employed were as follows: bilateral lung transplantation (33), bilateral lobar transplantation (18), single lung transplantation (13), heart-lung transplantation (2) and split-lung transplantation (2). Bilateral living-donor lung lobar transplantation was performed in one case. The mean age of patients at the time of surgery was 33.3 years (between age 14 and 58). 48 of the 64 patients are still alive.