双源CT在活体肾移植供体术前评估中的应用价值

为了探讨双源CT在活体肾移植术前供体评估中的应用价值,收集55例肾移植供体候选者(男35例,女20例,平均年龄39岁)行双源CT扫描。采用平扫、动脉期及静脉期增强的三相扫描方案,扫描范围从胸11水平至髂嵴水平。对原始数据进行多平面重组(MPR)、最大密度投影(MIP)及容积再现(VR)等后处理。两名放射科医师盲法分析图像,分析肾血管、肾实质及集合系统的解剖结构、有无变异及病变。55例供体均顺利完成检查且图像符合诊断要求。46例双肾血管无变异,6例有副肾动脉,2例肾动脉提前分支,1例肾静脉变异;2例有错构瘤,5例有肾囊肿;无集合系统先天变异和病变。与手术结果对照,CT显示肾血管的准确率为100%。结果证明双源CT能准确显示肾移植供体的肾血管系统、肾实质和集合系统,为活体肾移植供体的筛选及手术方案的制定提供可靠依据。     

Renal transplantation in children. A report of the North American Pediatric Renal Transplant Cooperative Study.

BACKGROUND. Previous studies of renal transplantation in children have focused on the survival of grafts and patients. Little information is available about the cause of renal disease, the sources of donated organs, or children's growth after transplantation. The North American Pediatric Renal Transplant Cooperative Study was organized to identify the diseases that require transplantation and to analyze factors that affect the success of transplantation in children. METHODS. We collected data from 73 pediatric transplantation centers from 1987 through 1990. These data included information about demographic characteristics of patients, graft function, and therapy one month after transplantation and every six months thereafter for each patient 17 years of age or younger. RESULTS. Altogether, 1550 children received 1667 renal allografts during this period; 31 percent of the children were five years of age or younger. Forty-three percent of the transplanted kidneys came from a living related donor, and 57 percent from a cadaver. The two most common causes of renal disease leading to transplantation were congenital malformations of the kidneys and urinary tract (42 percent of the patients) and focal segmental glomerulosclerosis (12 percent). One year after transplantation, the rate of graft survival in recipients of a kidney from a living related donor was 89 percent; it was 80 percent after three years. For recipients of cadaver kidneys, the comparable rates were 74 percent and 62 percent, respectively (P less than 0.001). The best growth was observed in patients who were no more than five years old at the time of transplantation. During follow-up, 79 patients died, and cancer developed in 12 patients. CONCLUSIONS. The most common causes of end-stage renal disease in children and adolescents are congenital malformations of the kidneys and urinary tract and focal segmental glomerulosclerosis. The rates of graft survival at one and three years are better in children and adolescents who receive a kidney from a living related donor than in those who receive a kidney from a cadaver.     

Anomalies of the kidney and urinary tract are common in de Lange syndrome

Sixty-one patients affected by de Lange syndrome underwent a careful renal and urological evaluation including family and personal history, physical examination, urinalysis, renal tract ultrasonography, and serum creatinine. A voiding cystourethrography was performed in patients with urinary tract infections, in patients with renal ectopy, and in patients with small kidneys. Structural anomalies of the kidney and urinary tract were detected either by ultrasound or voiding cystourethrography in 25 patients (41%): absent or poor corticomedullary differentiation (N = 8; 13%), pelvic dilation (N = 6; 10%), vesicoureteral reflux (N = 5; 8%), small kidney (N = 3; 5%), isolated renal cyst (N = 3; 5%), and renal ectopia (N = 2; 3%). Renal function was normal in 52 patients (85%) but reduced in 9 patients (15%) with renal tract abnormalities. Overt proteinuria was disclosed in three patients with impaired renal function.     

Renal arteries: anatomic study for surgical and radiological practice

The renal arterial supply was analyzed in 266 kidneys dissected from 133 fixed adults subjects. The anatomical findings are presented: 1 hilar artery in 53.3% of the cases, 1 hilar artery with 1 superior pole extra-hilar branch in 14.3%, 2 hilar arteries in 7.9%, 3 hilar arteries in 1.9%, superior polar artery in 6.8%, inferior polar artery in 5.3% and other variations in 8.5%. The urological and radiological implications of these findings in kidney transplantation, renovascular hypertension, renal trauma, interventional radiology, conservative surgery and oncologic surgery are discussed.     

Double kidney transplantation: initial experience of the Bologna Transplant Center

AIM: Double-kidney transplantation is performed using organs from marginal donors with a histological score not suitable for single kidney transplantation. The aim of the study is to verify the results obtained with double-kidney transplantation in terms of graft and patient survival and complications. METHODS: Between September 2001 and September 2004, 16 double-kidney transplantations were performed in our center. The kidneys were all perfused with Celsior solution and the mean cold ischemia time was 17.6+/-2.7 hours. In all cases a pre-transplant kidney biopsy was performed to evaluate the damage. Immunosuppression was tacrolimus based for all patients. RESULTS: Eight patients had good renal postoperative function while the other eight had acute tubular necrosis. Two of the patients who had severe acute tubular necrosis never recovered renal function. There was only one episode of acute rejection, while the incidence of urinary complications was 31.2%; there were two surgical revisions for intestinal perforation.The graft and recipient survival was 78.1% and 100% and 78.1% and 93.7% at 3 and 36 months. CONCLUSIONS: Double-kidney transplantation is a safe way to face the organ shortage. Moreover the score used in this study is useful to determine whether a kidney should be refused or suitable for single or dual-kidney transplantation. The results of our initial experience are encouraging, but this series is too small in number to consent a conclusive statement.     

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.     

腔内技术处理移植肾上尿路结石

背景：移植肾尿路结石是肾移植一种少见的并发症,因移植肾本身的病理生理的特殊性,临床处理棘手。 目的：总结腔内技术处理移植肾上尿路结石的经验并评估其安全性和有效性。 方法：回顾性分析采用输尿管镜取石和微创经皮肾取石治疗21例移植肾上尿路结石患者的资料。 结果与结论：8例移植肾输尿管结石行输尿管镜取石3例成功,2例取石后出现高热,其中1例需行经皮肾穿刺造瘘引流;5例失败并改行微创经皮肾取石。18例患者行微创经皮肾取石,其中13例患者直接行微创经皮肾取石,5例输尿管镜取石失败后改行微创经皮肾取石。手术均成功且一次性将结石取净,术中术后无并发症发生。说明逆行输尿管镜在处理移植肾上尿路结石的价值有限,微创经皮肾取石处理移植肾上尿路结石安全有效,可作为移植肾上尿路结石的首选治疗方案。     

亲属活体供肾移植中供者肾功能的评估

背景：肾移植前正确有效地评价供者双侧肾脏功能,对于亲属活体肾移植供者及受者的安全十分重要。 目的：探讨亲属活体供肾移植中供者肾功能评估的指标。 方法：173例亲属活体肾移植供者年龄分成老年组(≥55岁)和中青年组(< 55岁),两组供者移植前血清肌酐、总肾小球滤过率、欲保留肾总肾小球滤过率、内生肌酐清除率、血尿素氮反应肾功能指标差异无显著性意义,分析比较移植前后肾功能各指标的变化。 结果与结论：与移植前比较,移植后10 d供者血清肌酐、血尿素氮增高,内生肌酐清除率降低(P < 0.01);移植后1个月留存肾脏总肾小球滤过率增加(P=0.000 0),但与移植前供者双肾比较下降。提示总肾小球滤过率可作为活体亲属肾移植供者肾功能评估的主要指标,但是仍应结合血清肌酐、内生肌酐清除率等指标综合分析。     

活体亲属供肾肾移植的临床分析

目的　总结分析活体亲属供肾肾移植的手术和治疗经验 ,探讨其临床效果 .方法　回顾性分析 33例活体亲属供肾肾移植的临床资料 ,包括手术方法和创新、免疫抑制药物的用药方案及临床效果 .结果　本组全部切取左肾 ,经腹手术 ,手术顺利 ,移植肾在开放血液循环后 1～ 10分钟内分泌尿液 .供体肾功能在 1周内恢复正常 ,未出现严重并发症 .受者仅 2例出现急性排斥反应 .全部受者至今存活 ,肾功能良好 .结论　活体亲属供肾 ,移植效果明显优于尸体供肾肾移植 .排斥反应发生率低 ,恢复顺利     

Tissue-resident mucosal-associated invariant T (MAIT) cells in the human kidney represent a functionally distinct subset

Mucosal-associated invariant T (MAIT) cells are innate-like T-cells that recognize bacterial riboflavin metabolites. They are present in human blood but are abundant at barrier sites, including the liver, lungs, and kidneys, where they possess a CD69⁺/CD103^+/− tissue-resident phenotype. In renal tissue, MAIT cells likely defend against the ascending uropathogens responsible for urinary tract infections (UTIs), which are common, especially among renal transplant recipients (RTRs). Nevertheless, the functional role for MAIT cells in renal tissue and the influence of renal transplantation on MAIT cells remains unclear. Using multiparameter flow cytometry and the MR1-tetramer, we characterized MAIT cell phenotype and function in healthy renal tissue (n = 6), renal transplants explanted after allograft failure (n = 14) and in blood from healthy controls (n = 20) and RTRs before and 1-year after transplantation (n = 21). MAIT cells in renal tissue constitute a distinct CD69⁺CD103^+/− population that displays typical phenotypic features of tissue-resident T-cells and is skewed toward IL-2, GM-CSF, and IL-17A production upon stimulation. The circulating MAIT cell population was not decreased in number in RTRs pre- or post-transplantation. Tissue-resident MAIT cells in the kidney represent a functionally distinct population. This shows how MAIT cells in the kidney may be involved in the protection against microorganisms.     

移植肾血管变异的临床处理

背景：血管吻合技术的好坏直接关系到肾移植的成败。 目的：提高肾移植变异血管吻合的技术方法。 方法：1999年9月至2010年12月广东省第二人民医院器官移植科共完成878例肾移植,对其中供肾存在的动静脉血管变异进行修整、合并、延长等重建处理后进行移植,副肾动脉采用改良支架支撑法同腹壁下动脉吻合。 结果与结论：878例肾移植中,55例供肾动脉变异,肾静脉变异22例,经血管修整重建后均成功与受者髂内或髂外血管吻合。23例直径大于1 mm副肾动脉与腹壁下动脉吻合均取得成功。移植后彩超显示肾动静脉吻合口血流及副肾动脉血流正常。提示移植肾血管变异及副肾动脉只要正确处理,吻合得当,可以安全有效地移植给受者并获良好效果。     

夫妻间活体供肾移植

背景：近几年随着各项移植法规相继出台,中国做为器官移植大国,发展迅速,除了尸体肾移植外,活体肾移植亦得到健康快速发展,夫妻供肾做为没有直接血缘关系的活体移植,在器官移植界占据着重要地位。 目的：观察夫妻间供肾亲属活体肾移植的疗效。 方法：郑州人民医院器官移植科2008-10/2010-09进行夫妻间供肾移植11例,同期尸体供肾肾移植83例为对照组。两组受者均采用供肾静脉与髂外静脉端侧吻合,供肾动脉与髂内动脉端端吻合,输尿管-膀胱乳头式吻合,隧道包埋。免疫抑制诱导方案采用甲基泼尼松龙,基础免疫抑制采用钙调磷酸酶抑制剂(他克莫司或环孢素)、吗替麦考酚酯、肾上腺皮质激素(激素)三联免疫治疗,根据血药谷浓度调整他克莫司或环孢素的用量。移植后6个月内进行随访,评价两组受者移植后的肾功能恢复及早期并发症发生情况。 结果与结论：肾移植后两组急性排斥反应、移植物功能延迟恢复等早期并发症发生率比较,夫妻肾移植组优于尸体肾移植组,差异有显著性意义(P < 0.05)。结果提示夫妻间肾移植由于移植前准备充分,肾脏缺血时间短及夫妻间长期共同生活产生相应的免疫耐受,其疗效优于同样无血缘关系的尸体供肾移植。     

Transplantation of human fetal mesenchymal stem cells improves glomerulopathy in a collagen type I alpha 2-deficient mouse

Fetal mesenchymal stem cell (fetal MSC) therapy has potential to treat genetic diseases with early onset, including those affecting the kidney and urinary tract. A collagen type I alpha 2-deficient mouse has a deletion in the alpha2 chain of the procollagen type I gene, resulting in the synthesis of abnormal alpha1(I)(3) homotrimers, which replace normal alpha 1(I)2 alpha 2(I)1 heterotrimers and a glomerulopathy. We first confirmed that col1 alpha 2-deficient homozygous mice show abnormal collagen deposition in the glomeruli, which increases in frequency and severity with postnatal age. Intrauterine transplantation of human MSCs from first trimester fetal blood led postnatally to a reduction of abnormal homotrimeric collagen type I deposition in the glomeruli of 4-12 week-old col1 alpha 2-deficient mice. Using bioluminescence imaging, in situ hybridization and immunohistochemistry in transplanted col1 alpha 2-deficient mice, we showed that the damaged kidneys preferentially recruited donor cells in glomeruli, around mesangial cells. Real-time RT-PCR demonstrated that this effect was seen at an engraftment level of 1% of total cells in the kidney, albeit higher in glomeruli. We conclude that intrauterine transplantation of human fetal MSCs improves renal glomerulopathy in a collagen type I-deficient mouse model. These data support the feasibility of prenatal treatment for hereditary renal diseases.     

Bipolar supernumerary renal artery

The variations of renal arteries are considered critical issues that surgeons should have thorough envision and appreciation of the condition. Variations of these vessels may influences urological, renal transplantation and laparoscopic surgeries. We present a case of bilateral accessory renal artery with a striking pre-hilar branching pattern encountered upon digital subtraction angiography (DSA) for imaging of the renal arteries of a healthy 30-year-old man, renal transplant donor. The right kidney received two renal arteries from the aorta including a main hilar and one lower polar. However, the left accessory artery while originated from the aorta, simultaneously, supplied both upper and lower renal poles following its pre-hilar division that replaced upper/apical and lower segmental arteries of the single main renal artery, respectively. The left main renal artery divided into two anterior and posterior segmental arteries. Whether this should be categorized either as an accessory hilar artery or a unique variant of renal arterial supply, the so-called bipolar supernumerary renal artery, is a matter of debate. We discuss possible embryologic origin and clinical aspects of accessory renal artery.     

Fibrin thrombi in deceased donor kidneys: Prevalence and influence on graft function and graft survival in transplanted patients

Fibrin thrombi (FT) are occasionally found in the pre‐implantation biopsy of kidneys from deceased donors. The aim of this study was to monitor the prevalence and answer the question whether FT has any impact on future graft function in a Danish patient cohort. We looked for FT in all donor kidney biopsies taken at the time of renal transplantation in a Danish transplantation unit during a 10‐year period. Every recipient transplanted with a FT donor kidney (n = 15) were matched with up to five control recipients (n = 69), and graft function and graft survival were assessed. FT was present in 3% of the transplanted donor kidneys. Graft function was reduced in the FT group 6 months after transplantation (median estimated glomerular filtration rate (eGFR): 29 mL/min vs 46 mL/min; p = 0.017), but at 12 months, an apparent difference did not reach statistical significance. More patients were on dialysis in the FT group after 12 months compared with the control group (27% vs 6%; p = 0.049). In conclusion, FT in donor kidney biopsies at time of transplantation is a risk factor for the development of reduced renal function during the first year of transplantation.     

肝肾联合移植的适应证及时机

背景：肝肾联合移植以来,肾功能不全甚至肾功能衰竭已不再是肝脏移植的禁忌症。 目的：探寻肝肾联合移植适应证及移植时机,以利合理应用稀缺的实体器官供体。 方法：收集接受肝肾联合移植患者15例,回顾性分析其移植前状态与移植后移植肾及原肾恢复情况间的状态。 结果与结论：入组15例肝肾联合移植患者均手术顺利,至今存活,随访1.5-8(3.6±1.2)年。入组患者中出现移植肾功能延迟恢复1例,行床旁连续性肾脏替代治疗治疗2周后肾功能逐渐恢复;1例移植前行连续性肾脏替代治疗治疗 4周的肝肾综合征患者,移植后2个月行肾图检查提示原肾功能恢复正常;另2例移植前连续性肾脏替代治疗超过6周的肝肾综合征患者,移植后行肾图提示原肾功能未恢复;伴有原发肾病的终末期肝病患者移植前24 h尿蛋白> 500 mg、肾小球滤过率< 30 mL/min或经穿刺活检证实肾小球硬化率> 30%,肝肾联合移植后行肾图提示原肾逐渐失功。移植前行连续性肾脏替代治疗治疗超过6周的肝肾综合征患者,需施行肝肾联合移植;移植前伴有原发肾病的终末期肝病患者,如果24 h尿蛋白> 500 mg、肾小球滤过率< 30 mL/min或经活检证实肾小球硬化率> 30%,需施行肝肾联合移植。     

大鼠肾移植1 000例经验总结

目的：对大鼠肾移植进行经验总结以指导实验与临床研究。 方法：作者在2004-01/2009-07海德堡大学移植中心期间,采用大鼠肾动、静脉与腹主动脉、腔静脉行端侧吻合。对于急性肾移植模型,输尿管直接植入膀胱内;对于慢性肾移植模型,输尿管采用端端吻合法。术中直接切除对侧肾脏,完成大鼠肾移植1 000例,并对其进行总结。 结果：只要供体肾脏冲洗良好,吻合时暖缺血时间小于30 min,手术时间60 min左右,吻合技术娴熟,移植成功率达98%以上。 结论：该实验模型安全、方便、可行。肾移植成功的关键是手术技术。     

原位肝移植供肝血管及胆道修整

目的探讨原位肝移植供肝血管及胆道系统的修整处理方法。方法回顾性分析31例原位肝移植其供肝动脉变异及胆道内异常情况的处理资料。结果肝动脉变异5例,其中2例肝左动脉来自胃左动脉,2例肝右动脉来自肠系膜上动脉,1例肝总动脉来自肠系膜上动脉。来自肠系膜上动脉的2例肝右动脉,1例吻合到脾动脉的断端;另1例将腹腔干吻合到肠系膜上动脉的近端。供肝的肝内胆管行冲洗时发现有寄生虫2例。结论避免变异的供肝动脉损伤,选择适当的肝动脉吻合方式可以保证移植肝脏的动脉血供。正确的供肝胆道处理,可以减少胆道的并发症。     

Prostacyclin release from endothelial cells, induced by defibrotide treatment, favours the function of grafted rat hearts and kidneys.

Defibrotide, a single-stranded DNA fraction obtained from mammalian lungs and able to increase prostacyclin production by endothelial cells, has been shown to be efficient in protecting rat organs (heart, kidney and liver) from ischaemic damage. We studied the efficacy of the drug in preserving the function of rat heart and kidney submitted to isotransplantation. Defibrotide was administered to donor Wistar rats at the dose of 32 mg/kg in 1.5 ml of saline. Heart and kidney were isolated and cold-preserved in buffered phosphate medium and continuously infused with defibrotide (32 mg/h) through the innominate or renal artery. Recipient Wistar rats were treated with defibrotide before and after transplantation at the dose of 32 mg/kg/day. Controls were treated with the vehicle of the drug. The function of isografted organs was evaluated at 12 and 24 h and at 2, 4 and 7 days from grafting. Heart function was evaluated by studying creatinine phosphokinase (CPK) and lactic dehydrogenase (LDH) activities of myocardial tissue. Renal function was evaluated by studying serum creatinine and urea levels of kidney-grafted rats. CPK and LDH activities were found to be significantly higher in defibrotide-treated rats than in controls. Creatinine and urea levels remained significantly lower in defibrotide-treated rats than in the controls. The results of the present work indicate that defibrotide treatment is useful to maintain the functionality of grafted hearts and kidneys.     

Conditional loss of kidney microRNAs results in congenital anomalies of the kidney and urinary tract (CAKUT)

MicroRNAs have emerged as essential regulators of gene expression and may play important roles in a variety of human disorders. To understand the role of microRNA-mediated gene regulation in the kidney, we deleted the microRNA-processing enzyme Dicer in developing renal tubules and parts of the ureteric bud in mice. Genetic deletion of Dicer resulted in renal failure and death of the animals at 4–6 weeks of age. Interestingly, the kidneys of microRNA-deficient animals were small due to a reduced number of nephrons and showed massive hydronephrosis due to ureteropelvic junction obstruction. This phenotype is reminiscent of congenital anomalies of the kidney and urinary tract (CAKUT), an important group of human disorders characterized by a combination of renal hypoplasia with congenital abnormalities of the urinary tract. We used metanephric kidney cultures to examine the developmental defects underlying these pathologies. Dicer knockout kidneys showed a significant reduction of tubular branching explaining renal hypoplasia. Moreover, the ureters of these kidneys showed an altered morphology and impaired motility. These functional changes went along with altered expression of smooth muscle actin implying a defect in the differentiation of ureteric smooth muscle cells. In addition, we show the polycystic kidney disease gene Pkd1 to be a target of miR-20 implying that this interaction may contribute to the molecular basis for the cystogenesis in our model. In conclusion, these data demonstrate an essential role for microRNA-dependent gene regulation in mammalian kidney development and suggest that deregulation of microRNAs may underlie CAKUT, the most important group of renal disorders in humans.