Retroperitoneal laparoscopic live donor nephrectomy: Report of 105 cases

Retroperitoneal laparoscopic live donor nephrectomy offers an intrinsic advantage over conventional transperitoneal laparoscopic nephrectomy because of the potentially lower risk for early and late donor intraperitoneal complications.Herein we presented our experience performing retroperitoneal laparoscopic live donor nephrectomy in 105 donors.All donor nephrectomy was successful.There were no donor deaths and no conversion to open surgery.Mean operation time was 112 min(range,70-200 min).Intraoperative blood loss was 10-150 mL with an average of 30 mL.Warm ischemia time was 1.3 to 6 min with an average of 3.1 min.Postoperative retroperitoneal hematoma occurred in only one case and there were no other surgical complications.Donors were discharged from the hospital 5 to 10 days postoperation.Average postoperative hospital stay was 6.4 days.One graft was removed due to acute rejection.Delayed graft function occurred in two recipients but renal function returned to normal within four weeks.The other recipients had normal renal function in two weeks except three recipients in four weeks.We believe that retroperitoneal laparoscopic live donor nephrectomy is safe,reliable,and less invasive.     

Renal function of donors and recipients after living donor kidney transplantation in a Chinese cohort

Background  Living donor kidney transplantation (LKT) has been booming in China. This study aimed to elucidate the renal function of both Chinese donors and recipients after the donation and transplantation.

Methods  One hundred and forty-one pairs of donors and recipients for LKT were randomly selected and followed up for up to seven years. The donors’ and recipients’ renal function was recorded before and after operation.

Results  The donors presented a mean age of (43.9±7.5) years at donation. The female contributed 101/141 (71.6%) in all donors, and no effect was shown between genders on healthy donors’ renal function. The donors’ glomerular filtration rates (GFR) were (119.5±20.4) ml/min, (85.2±17.6) ml/min, (87.2±15.9) ml/min, (82.1±14.6) ml/min and (83.0±13.7) ml/min preoperatively, and for five days, three months, one year and beyond one year after the operation. The donors for the period of 1–3 years, 3–5 years and more than 5 years after donation showed GFR as (83.9±12.7) ml/min, (83.0±17.6) ml/min, and (80.9±20.8) ml/min, respectively, no statistically significant difference was found. Moreover, no significant clinical changes in blood pressure and proteinuria were found among the donors. In the recipients, delayed graft function (DGF) rate was 6.4%, acute rejection rate was 11.3%, and GFR were (66.5±16.4) ml/min, (73.2±19.6) ml/min and (63.9±18.6) ml/min respectively at three months, one year and beyond one year post-transplantation respectively.

Conclusion  The donors/recipients of LKT in Chinese population experience well-functioning remaining/donor kidneys.

     

单中心亲属活体肾移植供受者生活质量调查

目的 调查分析亲属活体肾移植供者和受者术后生活质量。方法 应用自编个人资料调查问卷、SF-36生活质量量表、Zung焦虑自评量表(SAS)和抑郁自评量表(SDS)对169对亲属活体肾移植供受者的一般情况、社会经济情况、捐肾动机和过程、生活质量和心理状况进行调查分析。结果 供者和受者都以初中及以下文化程度 [81.8%(90/110) vs 83.1%(103/124) ]和中低收入者 [85.5%(94/110) vs 54.8%(68/124) ]居多;供者以女性为主(61.8%,68/110),少数供者(5.5%,6/110)因捐肾对婚姻产生不良影响。供者与我国常模相比生活质量无明显差别,术后无焦虑和抑郁状态;受者与血透患者相比生活质量明显改善,极少数患者存在轻度焦虑(1.6%,2/124)和抑郁(5.6%,7/124)。结论 亲属活体肾移植对供者生活质量和心理无明显不良影响,可明显提高受者生活质量,但仍要术前严格筛选供者,加强术后随访和社会支持。     

肾小球滤过率评估方程在亲属肾移植供者评估中的适用性比较

目的以99mTc-DTPA血浆清除率为标准,对24 h内生肌酐清除率（Ccr）、Cockcroft-Gault（CG）方程和简化MDRD方程进行比较,评价三种方程在评估亲属肾移植供者肾功能中的应用价值。方法选择2004—2010年在我院进行评估的40例亲属肾移植供者,所有患者同步检测99mTc-GFR、血、尿肌酐等,将Ccr、C-G方程和简化MDRD方程估算的肾小球滤过率（GFR）用体表面积（BSA）标准化,与BSA标准化的99mTc-DTPA测得的GFR（99m Tc-GFR）进行比较。结果 Ccr、MDRD-GFR、CG-GFR与99mTc-GFR相关系数r分别为：0.74、0.81、0.86;三种方程的GFR估算值与99mTc-GFR差异均有显著统计学意义（P〈0.01）。结论三种方程的GFR估算值与99mTc-GFR均有较好的相关性,其中以C-G方程最好,其次为简化MDRD方程,Ccr最低,但三种方程估算值与99mTc-GFR测定值差异均存在显著统计学意义。C-G方程较适合应用于亲属肾移植供者肾功能的初步评价。     

核素肾动态显像在肾移植亲属供肾功能评估中的作用

目的分析核素肾动态显像在评估活体供肾者肾功能状况中的作用。方法 140例亲属供肾者术前均接受碍标记二乙三胺五乙酸(99Tcm-DTPA)肾动态显像,计算出总肾和分肾肾小球滤过率(GFR)值;根据肾功能图形和GFR值评估供肾功能。结果发现17例肾功能异常,主要表现为排泄缓慢、半排时间延长或GFR值降低。其中3例双肾功能损害,5例右侧单肾功能损害,9例左侧单肾功能损害。结论肾动态显像可用于评估亲属活体供肾者的总肾和分肾功能,有助于筛选供肾和预测移植术后肾功能的状况。     

活体肾移植术对供受者的影响

目的 评价活体肾移植术对供受者健康的影响。方法 对6组活体肾移植术供受者进行随访,动态观察供受者术后并发症及肾功能情况。结果 6名供者,肾切除术后无并发症,术后肾功能正常。6名受者,其中1名PRAl00％,但患者和家属坚决要求手术,尸体肾移植术失败后再行活体肾移植术后发生超排,维持性透析状态。5名均予三联免疫抑制治疗,术后无其他不良并发症,肾功能均恢复至正常范围,其中1名术后发生急性排异,予甲基强的松龙(MP)冲击及抗淋巴细胞球蛋白(ATG)治疗后肾功能恢复正常,另1名发生临界排异,予MP冲击5天缓解。结论 活体肾移植术效果肯定,可延长受者及移植物存活时间,对供者健康影响较小,可以在有一定条件的单位开展,并应重视对供受双方的术前健康评价和术后随访。     

HLA-G expression in the peripheral blood of live kidney transplant recipients

Background The human leukocyte antigen-G (HLA-G) has been considered to be an important tolerogeneic molecule playing an essential role in maternal-fetal tolerance, upregulated in the context of transplantation, malignancy, and inflammation, and has been correlated with various clinical outcomes. The aim of this study was to investigate the clinical relevance of the expression of membrane HLA-G (mHLA-G), intracellular HLA-G (iHLA-G), and soluble HLA-G (sHLA-G) in the peripheral blood of live kidney transplant recipients.

Methods We compared the expression of the three HLA-G isoforms in three groups, healthy donors (n=20), recipients with acute rejection (n=19), and functioning transplants (n=30). Flow cytometry was used to detect the expression of mHLA-G and iHLA-G in the T lymphocytes of peripheral blood from subjects in the three groups. Enzyme-linked immunosorbent assays were used to detect sHLA-G in the plasma from the three groups.

Results There were no significant differences in mHLA-G and intracellular HLA-G among the three groups, but the sHLA-G plasma level was higher in the functioning group than in the acute rejection or healthy group. We found a subset of CD4+HLA-G+ and CD8+HLA-G+ T lymphocytes with low rates of mHLA-G expression in the peripheral blood of kidney transplantation recipients. Intracellular expression of HLA-G was detected in T lymphocytes. However, there was no correlation between acute rejection and the mHLA-G or intracellular HLA-G expression.

Conclusion sHLA-G was the major isoform in the peripheral blood of live kidney transplant recipients and high sHLA-G levels were associated with allograft acceptance.

     

心脏死亡器官捐献供者肾移植的近期效果评价

目的比较心脏死亡器官捐献(donor after cardiac death,DCD)供肾移植和司法途径标准供者(standard criteria donors,SCD)肾移植的近期存活效果。方法回顾性分析2013年1-9月施行的尸体供肾移植89例,其中DCD供肾移植(DCD组)56例,SCD供肾移植(SCD组)33例。DCD组供肾采用低温机器灌注保存(HMP)25例,单纯低温保存31例;SCD组供肾全部采用单纯静态低温保存。DCD组采用抗体诱导+他克莫司(TAC)+麦考酚酯(MMF)+泼尼松(Pred)四联免疫抑制方案,SCD组采用TAC+MMF+Pred三联用药。随访评价2组移植肾6个月、1年存活率与受者6个月、1年存活率;移植肾功能延迟恢复(delayed graft function,DGF)发生率以及肾功能状况。结果随访6~15个月。DCD组受者因肺部感染死亡1例,因假性肾动脉瘤和急性体液性排斥反应导致移植肾切除各1例,受者6个月存活率98.2%,1年存活率94.4%,移植肾6个月存活率94.6%,1年存活率83.3%;SCD组因肺部感染死亡1例,AMR导致移植肾切除1例,受者6个月存活率97.0%,1年存活率92.9%,移植肾6个月存活率93.9%,1年存活率85.7%。2组受者6个月与1年存活率及移植肾6个月与1年存活率差异均无统计学意义(P>0.05)。DGF发生率DCD组为21.4%,SCD组18.2%,差异无统计学意义(P=0.20)。术后1、3、6、12个月血肌酐值,DCD组均显著高于SCD组(P<0.05),但是2组间估算肾小球滤过率在各时间点差异均无统计学意义(P>0.05)。结论 DCD供肾移植近期存活效果良好,术后肾功能恢复和维持情况与司法途径SCD供肾移植相当,DCD可以成为扩大尸体肾移植供者池的重要来源,其远期存活效果需要继续随访观察。     

亲属活体供肾切取术式选择探讨

目的 探讨亲属活体供肾切取术式选择的策略及不同术式的临床效果.方法 回顾总结我院2004年1月至2007年6月119例亲属供肾切取的4种术式:(1)经腹部开放手术22例;(2)经腹膜后隙腹腔镜下切肾21例;(3)经腹手助式腹腔镜下切肾13例;(4)经腰部腹膜后隙开放手术切肾63例.比较开放手术与腹腔镜手术手取肾的手术时间、供肾热缺血时间、供肾动静脉长度、供肾移植后3 d内血肌酐的下降速度、供者术后平均住院日及住院费、供者术后并发症.结果 开放手术比腔镜手术组:手术时间短(P=0.0033)、供肾热缺血时间短(P=0.0001);供者术后住院时间长(P=0.0000) 住院费用多(P=0.0000);受者术后3 d血肌酐下降速度快(P=0.0001);供肾血管长(左P=0.0000,右P=0.0001).并发症:腔镜组:皮下气肿1例、DGF2例、术中腰静脉大出血改开放手术2例,开放组术后继发肾上腺大出血再手术1例.两组无移植肾丢失及供者生存意外发生.结论 开放手术与腔镜手术切取活体供肾均是安全的术式.亲属活体供肾切取术式的选择应根据供者肾脏血管的形态、供者体形、术侧、术者对术式的熟练程度综合决定.开放手术取肾稳妥、快捷;腔镜手术取肾损伤小,恢复快,供肾血管短、移植早期血肌苷下降速度慢.     

中药辩证施治对血液透析患者营养状态及残余肾功能的影响

目的探讨中药辩证施治对长期血液透析患者营养状态及残余肾功能的影响。方法将56例肾病长期血液透析营养不良的患者分为中药干预治疗组(A组)及单纯透析对照组(B组),治疗组应用中药辩证进行治疗干预,疗程为6个月,两组均于治疗前后,运用主观整体评估法及测量体重指数、肱三头肌皮褶厚度、上臂肌围等指标来了解开始时及6月后的营养状况,并检测其残余肾功能的变化。结果 A组患者整体营养状态较B组有明显改善,而A组残余肾功能在治疗后明显要好于B组,差异均有统计学意义(P<0.05)。结论中药辩证施治可有效改善长期血液透析患者营养状态及延缓残余肾功能的丢失。     

从长期住院研究谈构建“医养结合”照护体系的必要性

长期住院研究对缩短医院平均住院日,正确使用医疗资源,提高医疗系统的效率有一定的意义。通过介绍长期住院的定义以及分类,对长期住院的原因和影响进行了文献综述,最后提出了构建国内“医养结合”的照护体系的设想和相关建议。     

供肾质量和受者体质量与移植肾远期功能的关系

目的探讨肾移植术后供肾质量、受者体质量及二者比值与远期肾功能的关系。方法对108例肾移植手术病人的供肾质量、受者体质量及二者的比值与受者术后3年血肌酐值进行线性相关分析。结果供肾质量与术后3年血肌酐值呈负相关(P<0.05);受者体质量与术后3年血肌酐值呈正相关影响(P<0.01);供肾质量及受者体质量的比值与术后3年血肌酐值呈负相关(P<0.01)。结论供肾质量、受者体质量及二者的比值与远期移植肾功能的关系应引起重视,体质量较大的受者应尽量选择较重的供肾相配。     

吡格列酮对慢性肾脏病患者血管内皮功能和肾功能的影响

目的 探讨吡格列酮对慢性肾脏病（CKD）患者血管内皮功能和肾病进展的影响.方法 采用随机、对照的方法选取非糖尿病的慢性肾脏病3～4期约60例,均予常规治疗,处理组27例患者同时加吡格列酮片（30 mg/d）,治疗4个月,观察治疗前及治疗4个月后的肱动脉内皮依赖性舒张功能（FMD）、超敏C反应蛋白（hs-CRP）、血清肌酐（Scr）、尿蛋白定量（Upr）等指标的变化.结果 吡格列酮处理组FMD改善、hs-CRP、Scr、Upr下降,与对照组比较差异有统计学意义（P＜0.05或0.01）,且内皮依赖性血管舒张率升高与hs-CRP水平的降低呈负相关.结论 吡格列酮可以减轻非糖尿病CKD患者炎症,改善血管内皮功能,延缓肾病进展.     

Factors potentially affecting the function of kidney grafts

Background Donor and recipient risk factors on graft function have been well characterized.The contribution of demographic factors,such as age,gender,and other potential factors of donor and recipient at the time of transplantation on the function of a graft is much less well understood.In this study,we analyzed the effects of factors such as age,gender,etc.,on the short-term and long-term graft function in kidney transplant recipients from living donor.Methods A total of 335 living donors and their recipients,who had kidney transplantation in our center from May 2004 to December 2009,were included.Serum creatinine level was used as the assessment criterion (serum creatinine level lower than 115 mmol/L is normal).Factors related to graft function such as age,gender,blood relation by consanguinity,human leukocyte antigen (HLA) mismatch,ABO type,etc.,were analyzed separately.Results Donor age is the key factor affecting both the short-term and long-term function of a grafted kidney from a living donor.The group with donors younger than 48 years showed the best kidney function post transplantation.Match of gender and age is another important factor that influences the function of grafted kidney from a living donor.The older donor to younger recipient group had the worst outcome after kidney transplantation.After 36 months post transplantation,female donor to male recipient group had worse kidney function compared to other groups.We also found that calcinerin inhibitor used in the maintenance period may influence the function of a grafted kidney.No significant statistical differences were found in consanguinity,blood type,and mismatch of HLA.Conclusions Donor age is an important factor affecting the function of a grafted kidney from a living donor.We also recommend taking nephron,immunology factor,infection,and demographic information all into consideration when assessing the outcome of kidney transplantation.     

心脏死亡器官捐献肾移植及顶层设计的初步经验

目的 总结近年来开展的心脏死亡器官捐献(DCD)肾移植的临床经验,探讨终末期肾病患者接受移植的疗效及顶层设计与实施.方法 回顾性分析23例接受DCD肾移植的终末期肾病患者的临床资料.结果 23例患者均顺利完成DCD肾移植术.其中17例患者术后第5～7天肾功能恢复正常;4例患者术后第8～10天肾功能恢复正常;2例患者肾功能延迟恢复,其中1例规律血液透析2周后肾功能恢复正常,另1例(最近1例)血液透析2个月后肌酐维持在190μmoL/L并出院.随访时间为3个月至2年,1例患者术后第5个月死于重症肺部感染.结论 DCD供肾肾移植效果好,是我国尚无脑死亡法的条件下,有效解决肾移植面临的肾源短缺的重要途径;良好的顶层设计及组织实施是DCD肾移植工作开展的有力保障.     

核素肾动态显像法测定肾小球滤过率评价亲属活体供肾功能

目的 探讨核素肾动态显像法测定肾小球滤过率在亲属活体肾移植供肾功能评价中的临床应用价值. 方法 30例亲属活体肾移植供体在手术前及术后3-12个月应用锝一二乙三胺五乙酸(99mTc-DTPA)肾动态显像法测定肾小球滤过率(GFR),对留存肾进行手术前后的比较,观察其代偿性变化. 结果 术后留存肾GFR为(58.4±12.1)ml/min,较术前留存肾(40.1±7.1)ml/min增加45.6%,但与术前双肾GFR(85.4±13.9)ml/min比较则下降31.6%. 结论 核素肾动态显像在亲属活体肾移植供肾功能及供者术后安全性评价等方面均有重要临床价值.     

慢性铍病12例肺功能6年随访观察

目的通过对12例慢性铍病患者6年的随访,观察其肺功能的改变。方法选择12例明确诊断为慢性铍病的男性患者,平均年龄为(52±11)岁,进行各项呼吸功能指标的测定。此后每两年随访1次,共随访6年。结果与初次就诊时比较,随访6年中的用力肺活量、第一秒用力呼气容积、第一秒用力呼气容积与用力肺活量百分比、最大通气量、肺活量、肺一氧化碳弥散量、每升肺泡容积肺一氧化碳弥散量和动脉血氧分压均逐年下降,6年后分别降低27．0％、34．5%、18．1%、19．9％、30．7％、37．1%、37．0％和15．5%;残气量、残气量与肺总量百分比、动脉血二氧化碳分压和肺泡气-动脉血氧分压差逐年上升,6年后分别增高88．9％,39.8%、32．4％和43．6%。结论氧化铍明显影响肺功能,尤其是损害肺换气功能。     

国产雷帕霉素洗脱支架和进口紫杉醇洗脱支架的3年临床随访

目的 比较国产雷帕霉素洗脱支架(Firebird)和紫杉醇洗脱支架(Taxus)的长期临床效果.方法 回顾性分析从2004年4月至2005年4月阜外医院连续置入Firebird支架(F组:88例)和Taxus支架(T组226例)共314例患者.结果 基线上T组包括的复杂病变比率、病变狭窄程度、球囊预扩张的比率以及置入支架的长度均明显大于F组,两组介入成功率均为100%.主要心脏不良事件(MACE)发生率F组明显低于T组(8.O%、21.7%,P=0.005),其中心源性死亡、非致死性心肌梗死(MI)两组差异无统计学意义;(O%、1.8%)和(1.1%、3.5%);(P=0.580,P=0.453),靶血管重建率(TVR)F组明显低于T组(6.8%、16.4%,P=0.028).支架内血栓发生率两组差异无统计学意义(1.1%、3.5%,P=0.453),早、晚期和晚晚期支架内血栓发生率两组差异无统计学意义.造影随访F组支架内和血管段再狭窄率均明显低于T组(0%、21%;P=0.002和0%、24%,P=0.001).F组支架内和血管段的晚期丢失均明显小于T组[(0.11±0.07)mm、(0.53±0.38)mm,P=0.000和(0.05±0.03)mm、(0.38±0.19)mm,P=0.000)].结论 Taxas和Firebird支架有良好的长期临床效果,Firebird在降低再狭窄方面有优势.     

长期住院对男性精神分裂症患者认知功能的影响

目的 研究长期住院对男性精神分裂症患者认知功能的影响。方法 采用威斯康星卡片分类测验(WCST)、空间广度测验、数字序列测验和伦敦塔测验分别对30例男性长期住院的精神分裂症患者(住院组)、32例男性长期随访门诊治疗的精神分裂症患者(门诊组)以及26名健康对照者(对照组)进行认知功能评估。结果 与正常对照组相比,住院组和门诊组在4项神经心理学测验中的所有评估分数较差,差异均具有统计学意义。住院组除空间广度测验中的正序得分外,其它测验中的指标均低于正常对照组,差异具有统计学意义。结论 长期住院加重男性精神分裂症患者认知功能的损害。     

Outcome of kidney transplantation between controlled cardiac death and brain death donors: a meta-analysis

Background Our goal was to evaluate the outcomes of kidney transplants from controlled cardiac death donors compared with brain death donors by conducting a meta-analysis of cohort studies.Methods The PubMed database and EMBASE were searched from January 1980 to July 2013 to identify studies that met pre-stated inclusion criteria.Reference lists of retrieved articles were also reviewed.Two authors independently extracted information on the designs of the studies,the characteristics of the study participants,and outcome assessments.Results Nine cohort studies involving 84 398 participants were included in this meta-analysis; 3 014 received kidneys from controlled cardiac death donors and 80 684 from brain death donors.Warm ischemia time was significantly longer for the controlled cardiac death donor group.The incidence of delayed graft function was 2.74 times （P 〈0.001） greater in the controlled cardiac death donor group.The results are in favor of the brain death donor group on short-term patient and graft survival while this difference became nonsignificant at mid-term and long term.Sensitivity analysis yielded similar results.No evidence of publication bias was observed.Conclusion This meta-analysis of retrospective cohort studies suggests that the outcome after controlled cardiac death donors is comparable with that obtained using kidneys from brain death donors.