肝肾移植受者392例生理和心理健康状况调查

目的了解我国肝、肾移植受者生理和心理健康状况,为卫生管理机构和移植中心建立受者健康管理体系提供依据。方法本研究为全国范围的横断面调查。调查对象为北京、上海、广州等9个地区的392例肝、肾移植受者。采用面对面访谈,问卷问题设计参考WHO生活质量量表（QOL—BREF）及肾脏疾病生活质量简表（KDQOL—SF）。调查内容主要包括：一般人口学信息,过去4周内的生活质量、健康状况及其影响因素,心理状况,受者需求和满意度调查等。结果392例移植受者中,肝移植受者151例,肾移植受者241例。调研结果提示：（1）生活质量调查中,回答“很好”和“好”的受者比例为62．24％,年龄对移植受者生活质量的影响具有统计学意义（X2=6．60,P〈0．05）。（2）健康状况调查中,回答“很好”和“好”的比例占69．39％。移植受者的性别、年龄、移植手术后时间、医疗保障和工作状态5个因素对移植受者的健康状况无显著影响,差异均无统计学意义（X2=0．33、3．41、1．85、0．44、0．68,均P〉0．05）。（3）心理状况调查中,长期处于负性心理状态的受者比例较少。结论我国现阶段多数肝、肾移植受者的健康状况及生活质量较好。但移植受者在生理、心理等方面的满意度与其心理预期还存在一定差距。     

肾移植受者自我管理行为的现状调查

目的调查肾移植受者自我管理行为现状。方法选择2009年9月至2012年6月门诊就诊的97例肾移植受者,按照手术时间分为3组,分别是。肾移植术后≤6个月、6～12个月及≥12个月,采用肾移植受者自我管理行为量表调查其自我管理行为,通过方差分析比较3组受者自我管理行为现状。结果97例肾移植受者中,术后≤6个月组32例,术后6～12个月组31例,术后≥12个月组34例;3组患者的自我管理行为得分分别为（100．1±7．0）分、（99．0±7．3）分、（91．3±5．8）分,组间比较,差异有统计学意义（F=3．53,P=0．03）。饮食方面,术后6～12个月组得分最高,组间比较差异有统计学意义（F=16．41,P=0．00）;躯体活动方面,术后≤6个月组得分最高,3组患者比较差异有统计学意义（F=11．50,P=0．00）。肾移植术后≤6个月、6～12个月及≥12个月3组受者在掌握常用药物作用与副作用得分分别为（2．00±0．00）分、（2．03±0．18）分、（2．41±0．50）分,掌握常规化验值得分分别为（2．00±0．00）分、（2．05±0．16）分、（2．82±0．39）分,保护皮肤防晒方面得分分别为（3．09±0．30）分、（3．03±0．91）分、（2．85±0．36）分。结论肾移植术后≥12个月受者的自我管理行为较差,需要医护人员进行相关的健康教育。     

Experience with Nocardia asteroides in renal transplant recipients

Six cases of Nocardia asteroides infection in renal transplant recipients are described. Respiratory symptoms predominated, complicated in one case by cerebral abscess. General dissemination did not occur in any patient. Environmental testing failed to show source(s) of the organism. Nocardiosis patients should be isolated to prevent airborne spread to renal transplant recipients, who are prone to infection and from whom specimens for culture should be incubated for at least 7 days to exclude Nocardia spp.     

他克莫司个体内高变异度与肾移植受者移植结局的关系探讨

目的探讨他克莫司(tacrolimus,Tac)个体内变异度(intra-patient variability,IPV)是否与肾移植受者慢性移植物失功密切相关。 方法选取2009年1月至2016年12月在四川大学华西医院肾移植中心进行肾移植且在术后长期随访的肾移植受者共1167人,用移植后7~12月期间的Tac全血浓度计算得到Tac IPV。设定的结局(含终点)包括：(1)移植物衰竭,再移植,(再)开始透析,或肾小球滤过率(glomerular filtration rate,eGFR)≤15 ml/min,活检证实的急性排斥反应(biopsy-proven acute rejection,BPAR);(2)组织学确定的移植肾小球病;(3)移植后12个月到最后一次随访期间,血清肌酐浓度加倍;(4)最后一次随访。分析不同IPV组肾移植受者肾脏功能差异,生存时间差异以及出现慢性移植物失功的情况。 结果纳入研究的1167位患者中,有79(6.8%)位到达了移植物失功的终点。肾移植受者移植后7~12月Tac IPV平均值为25.7%;高IPV组移植后第15个月血清肌酐显著高于低IPV组(P<0.05),第15、21、24个月eGFR显著低于低IPV组(P<0.05)。多因素Cox回归分析结果显示：Tac IPV对肾移植预后的预测有一定作用,但并不显著(P=0.051,Harzards ratio：1.015,95%CI：1.000-1.031)。而受者的年龄、性别、移植后6 h的移植物功能,是移植物存活的独立预测因子。 结论高Tac IPV与肾移植受者移植物失功有一定临床相关性,同时高Tac IPV是预测肾移植受者移植后两年内肾脏功能的重要实验室指标。     

肝移植受体医院感染危险因素研究

目的研究肝移植受体医院感染的流行病学特征,探讨其危险因素,采取有效干预措施。方法利用医院信息网络,前瞻性目标监测2007-2008年肝移植术后病例,应用病例对照研究方法,分析肝移植后发生医院感染的危险因素。结果 2007、2008年医院感染率分别为32.58%、19.90%;2008年医院感染率明显低于2007年,差异有统计学意义(P<0.01);2007年排在前5位的感染分别为肺部感染(44.18%)、上呼吸道感染(18.60%)、胆道感染(13.95%)、腹腔感染(9.30%)及Ⅱ类切口感染(4.65%),2008年分别为肺部感染(51.28%)、腹腔感染(15.40%)、上呼吸道感染(10.26%)、胆道感染(7.69%)及Ⅱ类切口感染(7.69%);多因素logistic回归分析结果显示,肝移植术后发生医院感染的主要因素为尿管插管、术前用药和气管切开。结论利用前瞻性目标监测肝移植受体医院感染的发生,可采取有针对性的干预措施,达到预防在先的目的,从而避免肝移植术后医院感染的发生。     

Nosocomial rotavirus infections in adult renal transplant recipients.

We conducted a 24-month survey of hospital-acquired rotavirus infections in 20 renal transplant recipients who received their graft during 1988. Four cases of nosocomial rotavirus infection were diagnosed (20% of patients), 3-34 days after graft. Two patients presented with severe diarrhoea and two with fever alone. The cases occurred mainly during the winter months and remained sporadic. None of our patients was found to have chronic excretion of rotaviruses. Contacts from paediatric cases can be ruled out. We concluded that rotavirus nosocomial infections were frequent in adult renal transplant recipients and suggest that screening for rotavirus is regularly performed in these immunodeficient patients who are very susceptible to hypovolaemia.     

人巨细胞病毒被膜磷蛋白pp65的检测及其应用

目的:建立一种快速简便诊断肾移植受者人巨细胞病毒(HCMV)活动性感染的方法.方法:运用免疫组织化学的催化信号扩增法检测外周血白细胞中的人巨细胞病毒被膜磷蛋白pp65,巨细胞病毒信使核糖核酸(pp67-mRNA)检.测法作比较.结果:检测105例肾移植受者中,HCMVpp65抗原阳性45例,pp67-mRNA检测阳性40例,pp65抗原阳性细胞数为(70±43)个/2×105个WBC,而有症状的CMV病25例,抗原阳性细胞指数为(85±44)个/2×105个WBC.对照组100名健康人,pp65抗原检测全为阴性.pp65的敏感性、特异性分别是100%、88.9%.结论i该法敏感,简便,可作为肾移植术后HCMV病的早期诊断并可指导抗病毒治疗.     

Improved outcome with sirolimus-cyclosporine regimen in high-risk renal transplant recipients

AIM: The immunosuppressive agents have a broad spectrum of adverse effects. In the absence of selective and specific drugs the decrease incidence and severity of side effects can be achieved by the combination of synergistic drugs only. Without wise selection and use of the combination of the potent immunosuppressive agents for the immunosuppressive maintenance therapy better results cannot be achieved without or fewer toxicities particularly in high-risk patients who lose their grafts prematurely. Therefore, a good combination will allow not only to reduce individual immunosuppressive drug induced toxicities but will also allow to achieve better graft and patient survival. MATERIAL AND METHODS: To assess the 6-year impact of a sirolimus-based regimen with, modest exposures to cyclosporine among three ethnic groups with different rejection risk, the authors performed a retrospective analysis of 470 renal transplant recipients who were treated contemporaneously: Group 1, high risk African Americans (n = 122); Group 2, moderate risk Hispanics (n = 132); Group 3, mild risk Caucasians (n = 216). Multivariate models were used to compare the outcomes in Group 1 with those of the other two groups. RESULTS: The cumulative incidence of acute rejection episodes over the entire follow-up period was similar among the groups: Group 1, 22.0%, Group 2, 24.2% and Group 3, 23.0%. Although there were no significant differences in overall or individual infection rates, Group 1 and 2 recipients displayed a significantly lower incidence of diarrhea at all times during follow-up compared with Group 3. All recipients showed similar rates of lymphocele formation. However, Group 1 displayed a reduced incidence and decreased severity of hypertriglyceridemia than Group 2 or Group 3 (89.3% vs. 97.2% vs. 93.2%), a similar incidence of hypercholesteremia (94.3% vs. 97.2% vs. 98.5%) was observed. The occurrence of post-transplant diabetes mellitus was greater in Group 1. than Group 3. but similar to Group 2. CONCLUSIONS: A concentration-controlled sirolimus-cyclosporine-prednisone regimen (with steroid withdrawal by 3 months) reduced the incidence of acute rejection episodes and increased 6-year graft survivals among high-risk African Americans to rates similar to other ethnic groups without an augmented toxicity profile.     

Surveillance and treatment of liver transplant recipients for candidiasis and aspergillosis

Between June 1988 and May 1991 88 orthotopic liver transplants and 1 liver and pancreas transplant were performed at the Liver Transplantation Department of the Ospedale Maggiore of Milan. All the patients underwent mycological surveillance and received antifungal prophylaxis with oral amphotericin B (6000 mg/day) or oral or intravenous fluconazole (200 mg/day) from the time of their transplant. The incidence of Candida colonization was 67%. Fluconazole was superior to oral amphotericin B in the treatment of C. albicans colonization (99 vs 15), but less effective in the treatment of colonization by other Candida spp. (03 vs 33). Deep-seated candidiasis developed in 5 patients, caused by C. albicans in 4 cases and C. krusei in 1. C. albicans infection resolved rapidly with fluconazole in 2 subjects, with intravenous amphotericin B alone in 1, and with amphotericin B plus flucytosine in the other. On the contrary, C. krusei infection did not respond to treatment with amphotericin B combined with flucytosine. Aspergillosis was diagnosed in 11 patients, of whom 4 died from invasive aspergillosis, despite 15 and 26 days of amphotericin B treatment in 2. In another patient invasive aspergillosis, diagnosed a few hours before retransplantation, improved with liposomal amphotericin B, but this man died from cytomegalovirus infection one month later. Aspergillosis was eradicated by itraconazole in 4 other patients and by topical amphotericin B in 2 whose infection was localized to surgical wound.     

肾移植患者肺部浸润的病原学分析及支气管镜应用价值

目的 研究肾移植患者肺部浸润的病原学特点及支气管镜检查诊断性应用价值,为临床诊断与治疗提供依据.方法 2006年11月-2011年9月88例肾移植患者因肺部浸润共进行90次支气管镜检查,包括支气管肺泡盥洗和防污染毛刷.结果 55例通过支气管镜获得了明确的病原学诊断,其中单独卡氏肺孢子虫感染23例占41.82％,单独巨细胞病毒感染11例占20.00％,单独细菌感染3例占5.45％,单独结核分枝杆菌感染2例占3.64％;混合感染共16例占29.09％;大多数机会性感染发生在第2阶段,少部分发生在第3阶段.结论 支气管镜检查对评估肾移植患者的肺部浸润是一种极为有效的方法,特别对第2、3阶段的机会性感染的诊断具有极高的价值.     

Healthcare costs in renal transplant recipients using branded versus generic ciclosporin

Background

Generic ciclosporin A modified (CsA) does not have an equivalent pharmacokinetic profile to branded CsA in some transplant populations, potentially leading to negative clinical consequences and increased long-term costs.

Objective

To assess direct healthcare costs for de novo renal transplant recipients in the US receiving branded versus generic CsA in the first month after transplantation.

Methods

Administrative claims data from eight private US health plans were linked to the Organ Procurement and Transplantation Network data. A total of 227 renal transplant cases between 1996 and 2004 were included: 183 were dispensed branded CsA and 44 received generic CsA. Log transformed multiple linear regression was used to model total first-year healthcare costs after the initial CsA claim, controlling for both patient demographics and clinical characteristics and clustering at the transplant centre level.

Results

After controlling for patient factors and pre-CsA costs, total healthcare costs were significantly higher (p = 0.04) for patients receiving generic CsA versus branded CsA. The main driver for the difference was the cost associated with immunosuppressants other than CsA (p = 0.01).

Conclusions

Despite initial perceived cost savings associated with generic CsA, de novo renal transplant recipients incurred greater total healthcare costs than those treated with branded CsA. Patients receiving generic CsA may need higher doses or other immunosuppressants to maintain the transplanted kidney than patients receiving branded CsA. Providers and payers need to be aware of potential differences in total healthcare costs between formulations of bioequivalent critical-dose drugs to make the best choice for patient care.     

血管紧张素转换酶抑制剂在肾移植中的应用

目的探讨血管紧张素转换酶(ACE)抑制剂依那普利对同种异体肾移植患者移植肾远期功能的保护作用。方法2000-01~2001-06对肾移植术后时间达1年、移植肾功能正常、尿TGF-β1相对浓度≥250.0 pg/mg.Cr的22例患者(A组)连续使用依那普利(5mg/d)1年以上,与同期内、相同条件、未服用依那普利的23例患者(B组)作对比,观察两组肾功能的动态变化;3年后比较两组患者血和尿TGF-β1相对浓度、肌酐清除率(Ccr)减少量和肾功不全的病例数有无差异;比较A组服用依那普利前后,移植肾组织中TGF-β1mRNA表达量有无变化;观察服用依那普利的不良反应。结果B组Ccr进行性降低;在3年随访期内,A组Ccr减少(5.1±4.6)m l/m in,有2例(9.1%)患者肾功能不全,均明显低于B组(P<0.01、0.05),后者分别为(13.7±9.5)m l/m in和9(39.1%)例;3年后A、B两组尿TGF-β1浓度分别为(325.3±46.3、507.7±53.1)pg/mg.Cr,A组明显低于B组(P<0.01);两组血TGF-β1浓度差异无统计学意义(P>0.05);A组服用依那普利1年后,TGF-β1mRNA表达量由(1.57±0.31)降为(0.94±0.27);使用依那普利无不良反应发生;A、B两组中肾功不全者,穿剌活检证实均为慢性移植物肾病。结论依那普利对同种异体肾移植患者移植肾具有保护作用,其作用机理可能与降低移植肾内TGF-β1的分泌有关。     

pp67-mRNA在肾移植术后人巨细胞病毒感染中的诊断价值

目的探讨pp67对。肾移植术后人巨细胞病毒（HCMV）活动性感染及指导抗病毒治疗上的作用。方法采用NASBA测定32例肾移植术后患者外周血中的pp67,同时通过免疫荧光技术（IFA）对早期抗原pp65（CMV-Agpp6S）的检测来判断HCMV活动性,术后第3周,第7周分别用ED-TA管采血5-7rnl,每人每次两管做实验样本,立即送检并将二者结果相比较。其中检测结果有一项阳性的患者,选择更昔洛韦进行对症抗病毒治疗,对pp67-mRNA和pp65抗原检测双阳性患者,在选择更昔洛韦对症治疗时,并随访观察每周采血行pp67检测CMV活动情况,同时CMV抗原血症法检测,将二者结果比较,了解pp67与HCMV活动性感染及CMV病的关系。结果共采集样本128份,其中44份样本CMV-Agpp65阳性,19份样本pp67-mRNA阳性,8例CMV-Agpp65和pp67-mRNA均为阳性。临床诊断为HCMV病患者12例。CMV-Agpp65抗原检测灵敏度（91．7％）高于pp67-mRNA（66．7％）,pp67-mRNA特异性（95．O％）高于CMV．Agpp65（50．0％）抗原检测。而在HCM~临床症状出现感染并治疗后期,随访发现选择以pp67作为抗病毒治疗指标较CMV-Ag更早转阴,可以明显缩短用药时间（P〈0．05）。结论CMV-Agpp65、pp67-mRNA对器官移植术后HCMV感染均具有诊断意义,应用NASBA法能更加快捷准确检测巨细胞病毒,pp67较准确地反映了肾移植术后HCMV的活动性,能更好的指导临床抗病毒治疗并提供了较客观的依据。     

Contraceptive awareness and birth control selection in female kidney and liver transplant recipients

Objective(s)

Interest has increased regarding the issue of contraception in transplant recipients. The purpose of this study was to assess birth control selection and the role of contraceptive counseling sessions in female kidney transplant (KT) and liver transplant (LT) recipients.

Study Design

A cross-sectional single-center survey study of 217 female organ recipients (KT, 137 and LT, 80), aged 18–45 years, met the study criteria. Patients were asked 43 questions regarding their pre- and posttransplantation use of contraceptive methods, birth control awareness, contraception counseling and the factors determining the selection of effective contraception (hormonal contraception, intrauterine devices and female sterilization).

Results

Thirty-three percent (5/15) of patients who had undergone the transplantation within 1 year prior to study inclusion were unaware of the necessity to use contraception. Both of the groups studied did not differ significantly in terms of the rates of pre- and posttransplantation consultations on effective contraception (KT: 26% vs. 34%; p=0.153 and LT 38% vs. 35%; p=0.729). Effective posttransplantation contraception was used by one in three patients, as indicated by posttransplantation consultations (KT: 30% vs. LT: 29%; p=0.910). The following factors affected the posttransplantation use of effective contraception: the presence of posttransplantation counseling on effective contraception [odds ratio (OR): 6.67; 95% confidence interval (CI): 2.12–20.1] and infrequent sexual activity prior to transplantation (OR: 0.56; 95% CI: 0.35–0.89).

Conclusion(s)

The selection of effective contraception in KT and LT recipients remain suboptimal. Despite the low numbers of women who received contraceptive counseling in this study, consultation was nonetheless associated with choosing an effective method of contraception.

Implication

Current literature and data regarding contraception among female organ transplant recipients remain limited and are predominantly limited to a single population. The purpose of the study was to assess the level of satisfaction and the reasons underlying birth control selection in female kidney and LT recipients.     

Prevalence of antibodies to hepatitis C virus in hemodialysis patients and renal transplant recipients

This work was carried out to study the prevalence of hepatitis C virus (HCV) infection, its associated risk factors and possible routes of transmission in hemodialysis patients and renal transplant recipients. Ninety five patients and 15 normal controls were included in this study. Patients were classified into 3 groups: Group I (64 hemodialysis patients), Group II (16 renal transplant recipients) and Group III (15 patients with chronic renal insufficiency on conservative treatments). Each individual was subjected to full clinical examination, estimation of serum alanine aminotransferase (ALT), testing for antibodies to hepatitis C virus (anti-HCV), screening for hepatitis B surface antigen (HBsAg), antibodies to hepatitis B surface antigen (anti-HBs) and core antigen (anti-HBc) by modified ELISA technique. Anti-HCV was found in 87.5% of hemodialysis patients, 81.25% of renal transplant patients, 53.3% of the conservative group and in 13.3% of the control group. There was a significant correlation between the presence of anti-HCV and the duration on dialysis in groups I and II (p < 0.05), while no significant correlation was detected between HCV positive cases and the number of units of transfused blood in groups I and II (p > 0.05). Serum ALT was elevated in patients with HCV infection, but there was no significant correlation between the presence of anti-HCV and elevated ALT level among the examined groups of patients (p > 0.05). The prevalence of HCV infection was not correlated with the duration of renal transplantation and the type of immunosuppressive therapy (p > 0.05). Coinfection with HBV and HCV could occur, as previous infection with HBV was demonstrated. Anti-HBc was found in 51.8%, 66.7%, 37.5% of anti-HCV positive patients in groups I, II, II respectively. Anti-HBs was detected in 24.1% and 15.4% of anti-HCV positive in groups I and II. HBsAg was found only in 4.7% of anti-HCV positive hemodialysis.