硫唑嘌呤或骁悉治疗的肾移植患者术后早期并发症比较

目的:比较硫唑嘌呤(azathioprine,Aza)或霉酚酸酯(mycophenolate mofetil,MMF)联合环孢素 激素两种免疫抑制方案的肾移植患者,在术后并发症方面的差异,探讨较理想的免疫抑制方案。方法:收集两组肾移植患者249例:Aza组(即应用Aza CsA 激素)、MMF组(MMF CsA 激素),统计两组患者在术后1年内各种并发症(包括排斥反应、各种感染、肝损害、白细胞减少等)的发生。结果:Aza组与MMF组术后1年急性排斥反应的发生率差异显著;两组总的感染率、肺部感染率相近,但发生急性呼吸窘迫综合征(ARDS)及肺部感染病死率后者明显高于前者。在肝损害、白细胞减少、糖尿病等方面,两组也无统计学差异。结论:MMF组在减少急性排异方面优于Aza组,但增加重症肺部感染机会,肺部感染的病死率升高,且费用贵,故临床上应根据具体情况选择。     

肾移植术后环孢素A所致药物性牙龈病的治疗

目的 探讨肾移植术后环孢素A所致药物性牙龈病(GDM)的治疗。方法 48例肾移植后发生GDM的患者随机分为3组，分别采用手术治疗、体外培育牛黄糊剂局部治疗及基础治疗，观察治疗1个月后牙龈肿大、疼痛、出血、龈沟出血指数、龄袋深度的变化。结果总的治疗效果，手术治疗组和体外培育牛黄糊剂局部治疗组的效果相仿，但明显优于基础治疗者。结论 体外培育牛黄糊剂治疗GDM疗效较好，不良反应小，尤其适合移植患者。     

肾移植术l053例次总结

目的 对临床肾移植的经验进行总结。方法 回顾分析1053例次肾移植受者的临床资料，从供肾及移植情况、术后并发症及处理、免疫抑制剂的应用、HLA配型及群体反应性抗体检测等对移植效果的影响等几个方面进行分析总结。结果 1988年前免疫抑制治疗采用硫唑嘌呤(Aza)和泼尼松(Pred)二联用药，人／肾1年存活率为69．3％／69．0％，3年为43.0％／42.6％，5年为30．7％／27、8％；1989年后采用环抱素A(CsA)、Aza和Pred三联用药，人／肾1年存活率为93．2％／92．4％，3年为79．3％力8．2％，5年为66、2％／64．2％。术后早期并发症以急性排斥反应为主，晚期主要是移植肾慢性功能丧失，后者是导致受者死亡的主要原因。只要治疗及时，80％的急性排斥反应能够得到逆转。结论 良好的供肾和组织配型，术后免疫抑制药的合理应用，并发症的预防和及时治疗，是提高肾移植术后人、肾存活率的重要保证。     

自身免疫病患者肾移植术后的临床研究

目的　探讨自身免疫病患者肾移植术后原发病复发的高危因素。方法　回顾分析25例接受肾移植的自身免疫病患者的临床资料。结果　25例自身免疫病患者肾移植术后人/肾1、3、5年存活率与同期因其它原因所致的终末期肾功能衰竭而接受肾移植者相比,差异不显著;4例原发病复发者术前平均血液透析时间为（23.6±17.5）个月,21例未复发者的平均血液透析时间为（25.8±20.1）个月（P>0.05）;原发病复发者从发病至肾功能衰竭的时间较未复发者短,发病年龄明显高于未复发者。结论　自身免疫病患者可以接受肾移植术,但应注意原发病的复发。     

肾移植术后直肠结核一例

患者,男,因慢性肾小球肾炎、尿毒症于 2000 年在我院接受同种肾移植术。术后应用环孢素 A(CsA)、硫唑嘌呤(Aza)及泼尼松(Pred)预防排斥反应。术后 20 d 出院。术后7 个月出现尿频、排尿不适感,会阴部坠胀伴发热,体温37.9℃~38.4℃,在外院诊断为慢性前列腺炎,予以抗生素治疗     

骁悉对肾移植术后感染的影响

目的观察骁悉(MMF)对肾移植术后感染的影响。方法将90例肾移植术后患者分为两组．1997年以前手术的56例为硫唑嘌呤(Aza)组,免疫抑制剂为环孢素A(CsA)加Aza加泼尼松;1998～1999年1月手术的34例为MMF组,免疫抑制剂为CsA加MMF加泼尼松。Aza组CsA起始用量为6mg/(kg·d-1),MMF组为5mg/(kg·d-1),以后根据血药浓度进行调整。结果90例肾移植患者术后总的感染率为17.8％,其中Aza组为21.4％(12/56),2例死亡;MMF组为11.8％(4/34),无死亡病例。两者之间感染率差异有显著性意义(P＜0.05)。结论用MMF代替Aza可以减少肾移植术后的感染率,并提高移植肾成活率。     

肾移植术后并发大疱性类天疱疮一例

患者为女性 ,34岁 ,6年前诊断为狼疮性肾炎 ,2个月前因肾功能衰竭在我院接受肾移植术 ,术后应用环孢素A(CsA)及硫唑嘌呤 (Aza)预防排斥反应 ,术后 4 0d出院。 1周前无明显诱因全身皮肤出现散在水疱 ,伴瘙痒 ,皮疹逐渐增多 ,收住我院肾内科。体检发现患者全身皮肤散在水疱 ,绿豆至蚕豆大小 ,颜色微红 ,尼氏征阴性。分布以四肢为重 ,部分水疱溃破 ,形成糜烂。双下肢无浮肿 ,无皮下瘀斑及特殊皮疹。取水疱做病理检查 ,可见表皮内及表皮下单房性大疱 ,真皮浅层有少量嗜酸性粒细胞和淋巴细胞浸润。诊断为大疱性类天疱疮。治疗除继续给予CsA及A…     

新剂型环孢素Neoral的肾移植临床研究

肾移植受者１１例服用新剂型环孢素（Ｎｅｏｒａｌ，ＮＯＦ）三天达治疗窗浓度。在一个月可增加最高血浓度（Ｃｍａｘ）平均３０％，曲线下面积（ＡＵＣ）增加２５％，ＮＯＦ剂量可减少２５％。６个月无排斥发生，提示ＮＯＦ吸收快，浓度稳定，抗排斥效果好。副作用主要是肝功能损害４例，多毛、震颤各３例，高血压１例，减药后均能恢复或减轻，不影响治疗。     

肾移植术后服用硫唑嘌呤致粒细胞锐减3例

肾移植术后服用硫唑嘌呤致粒细胞锐减３例温州医学院附属第一医院姜丽萍肾移植术后，患者需终身服用免疫抑制剂以减轻或延缓排异反应。临床上常用药物有：类固醇激素、环孢霉素Ａ（ＣｓＡ）、硫唑嘌呤（ＡＺａ）。其中ＡＺａ有较大毒性，易造成骨髓严重抑制。我院１９８５...     

Randomised open clinical trial of conversion from mycophenolate mofetil to azathioprine in cadaveric renal transplantation

Abstract Mycophenolate mofetil (MMF) is a powerful immunosuppressive drug with established efficacy and safety. The search for a less expensive immunosuppressive protocol has led to an open randomised clinical trial of conversion from MMF to azathioprine (Aza). A total of 28 renal allograft recipients treated with prednisone, cyclosporine, and MMF was randomised into two groups: converted (early conversion) and control (late conversion). Conversion from MMF to Aza was conducted at the end of the 4th post‐transplant month in the converted group and after the 12th month in the control. During the 20‐month observation period, biopsy‐proven acute rejection occurred more frequently in the converted than in the control group, although the difference was not statistically significant. Early conversion from MMF to Aza increased the risk of subsequent rejection in those patients who underwent at least one episode of acute rejection prior to conversion.     

A randomised, prospective study on the conversion from cyclosporine-prednisone to cyclosporine-azathioprine at 6 months after renal transplantation

Abstract In a randomised prospective trial, we studied the effects of replacement of prednisone (Pred) by azathioprine (Aza), 6 months after transplantation, in stable renal allograft recipients on cyclosporine and prednisone (CsA+Pred). Out of 83 patients, 42 started treatment with CsA+Aza and 41 continued therapy with CsA+Pred. CsA was dosed to achieve a level of 150 ng/ml, the Aza dose was 3 mg/kg per day and the Pred dose was 0.15 mg/ kg per day. Eighteen months after randomisation, in the CsA+Aza group 18 of the 42 patients were effectively treated with CsA+Aza. In the main, anaemia, leuco- and thrombocytopenia, and hypocorticism necessitated the reintroduction of Pred in the remaining 24 patients. Compared to the continuation of CsA+Pred, conversion of Pred to Aza resulted in a reduced number of antihypertensive drugs needed, and in lower serum total, LDL and HDL cholesterol levels; the incidence of acute rejections and graft losses was no different. In conclusion, conversion of CsA+Pred to CsA+Aza is a safe option in renal transplant patients with contraindications to long-term corticosteroid treatment.     

Safe conversion from cyclosporine to azathioprine with improved renal function in pediatric renal transplantation

Although cyclosporine has improved allograft survival in renal transplant patients, problems with drug toxicity remain, raising the question whether cyclosporine should be stopped at some point post-transplant. However, the relative safety of converting from cyclosporine to another immunosuppressive agent, or simply stopping cyclosporine remains an issue of debate and has not been evaluated in children. We have developed a protocol to convert children, who are 6 months post-transplant and have stable kidney function, from cyclosporine and prednisone to azathioprine and prednisone. Eleven children have undergone conversion because of suspected/potential nephrotoxicity or because of other difficulties with cyclosporine (expense, hirsutism). These children were compared with a control group of 12 children who met all criteria for conversion at 6 months but remained on cyclosporine. Allograft survival was similar in both groups but the children converted from cyclosporine experienced an improvement in renal function as measured by calculated creatinine clearance. There were no episodes of rejection for a period of 4 months postconversion and all rejection episodes that developed subsequently occurred during or after the change from daily to alternate-day prednisone. We believe that conversion from cyclosporine to azathioprine can be accomplished safely in children with stable allograft function but long-term risks and benefits need further evaluation.     

转换西罗莫司治疗肾移植后高胆红素血症的临床观察

目的：对转换西罗莫司（SRL）并撤除钙调磷酸酶抑制剂（CNI）类药物对高胆红素血症影响及其安全性和可行性进行临床观察。方法：2006年2月～2007年11月对肾移植后伴有高胆红素血症患者37例转换SRL并撤除CNI类药物,观察转换后总胆红素（TB）水平变化、血清肌酐（Scr）变化和不良事件发生情况。结果：TB和直接胆红素（DB）由转换前的30．45μmol／L和10．10μmol／L下降至转换后的12．13μmol／L和3．7μmol／L（P〈0．01）。Scr和血尿酸（Ua）转换后较转换前均有较明显降低,肌酐清除率（Ccr）有所提高。移植肾和患者全部存活。不良事件主要为高脂血症。结论：转换SRI．治疗肾移植后高胆红素血症是有效和安全的。     

小儿肾移植的临床研究(附13例报告)

目的：探讨儿童患者肾移植的术式、术后用药以及术后并发症的处理。方法：分析13例儿童患者肾移植的临床资料。结果：13例儿童患者肾移植1年人／肾存活率均为100％，急性排斥反应发生率为38．4％（5／13），肾小管坏死发生率30．7％（4／13），术后发生肾周积液2例，无其它手术并发症。结论：儿童肾移植的术式应根据受者血管情况选择移植肾动脉与髂内动脉端端或端侧吻合，也可与髂外动脉或髂总动脉端侧吻合。免疫抑制剂用量应比成人稍高。     

Long-term graft survival after conversion from cyclosporin to azathioprine 1 year after renal transplantation. A prospective, randomized study from 1 to 6 years after transplantation

Cyclosporin has improved graft survival after renal transplantation,but cyclosporin nephrotoxicity is a severe clinical problem.Conversion from cyclosporin to azathioprine 1 year after transplantationmight improve long-term graft survival by avoidance of cyclosporinnephrotoxicity. After treatment with cyclosporin and prednisoloneduring the first year after renal transplantation, 106 patientswere consecutively randomized to treatment with either azathiprineand prednisolone or cyclosporin and prednisolone in a prospective,controlled study during the following 5 years, i.e. 6 yearsafter transplantation. Actuarial estimates of graft survivalrates after inclusion in the study were obtained by the product-limitmethod of Kaplan-Meier, and the Mantel-Cox log rank test wasused to compare the two treatment regimens. When the end-pointsin the analyses were cessation of graft function or withdrawalof immunosuppressive treatment due to side-effects, and whenpatients alive with graft function or who had died with a functioninggraft were treated as censored observations, graft survival5 years after inclusion in the study was 57.7±5.2% inthe total material and was the same in both the azathioprinegroup (52.4±7.7%) and the cyclosporin group (63.3±6.7%)(log rank=0.40, P=0.53). When cessation of graft function wasthe only end-point, graft survival 5 years after inclusion inthe study was 73.7±5.2% for the total material with nosignificant differences between the two groups (log rank=0.58,P=0.45). Assuming that cyclosporin and prednisolone were usedduring the first year after renal transplantation, it can beconcluded that conversion to treatment with azathioprine andprednisolone does not deviate from continued treatment withcyclosporin and prednisolone with regard to long-term graftsurvival for the following 5 years.     

肾移植术后应用来氟米特的长期效果分析

研究肾移植患者术后长期应用来氟米特(leflunomide,LEF)进行免疫抑制治疗的疗效和不良反应.方法 回顾性研究对象为2001年10月至2012年5月在第二军医大学附属长征医院长期随访(5年以上)的64例首次肾移植术后患者.应用钙神经蛋白抑制剂(CNI)+LEF+泼尼松三联免疫抑制方案的患者32例(LEF组),应用CNI+吗替麦考酚酯(MMF)+泼尼松三联免疫抑制方案的患者32例(MMF组).比较两组患者肾移植后1、3、5年人、肾存活率,肾功能变化、排斥反应、感染及不良反应的发生率.结果 LEF组与MMF组患者术后1、3、5年的人存活率分别为100%、97%、81%和100%、94%、88%;两组术后1、3、5年的肾存活率分别为97%、91%、75%和97%、91%、81%;两组之间比较差异无统计学意义(均为P>0.05).LEF组患者术后1、3、5年的血清肌酐水平和24 h尿蛋白定量分别为(101±14)、(112±21)、(132±26)μmol/L和(896±98)、(1 232±126)、(1 458±110)mg;MMF组分别为(98±16)、(108±23)、(127±21)μmol/L和(912±101)、(1 275±117)mg、(1 483±133)mg(均为P>0.05).LEF组患者中,41%(13/32)出现不同程度的排斥反应,给予抗排斥反应治疗后,逆转5例(38%,5/13),移植肾失功8例;MMF组患者中,34%(11/32)出现不同程度的排斥反应,给予抗排斥反应治疗后,逆转5例(45%,5/11),移植肾失功6例.LEF组和MMF组患者术后感染发生率分别为13%(4/32)和19%(6/32)(P>0.05).两组药物不良反应发生率亦无统计学意义(均为P>0.05).结论 肾移植患者术后长期应用LEF进行免疫抑制治疗是安全、有效的.     

肾移植术后继发性甲状旁腺功能亢进的临床分析

目的研究肾移植术后合并甲状旁腺功能亢进的受者血清钙、磷代谢及免疫反应性甲状旁腺激素(iPTH)水平的变化趋势,探讨治疗方式的选择。 方法回顾性分析2012年1月至2014年6月在解放军第三〇九医院全军器官移植研究所泌尿外科因尿毒症行肾移植、且术前并发继发性甲状旁腺功能亢进(SHPT)、术后移植肾功能恢复至估算肾小球滤过率(eGFR)>60 mL·min^－1·(1.73 m²)^－1的受者资料。共179例受者纳入研究,平均年龄(34±6)岁(18～61岁),术前慢性肾脏病分级均为5级。肾移植术后常规应用骨化三醇治疗(0.25 μg,1次/d),维持正常血清钙、磷水平。记录肾移植前后受者血清钙、磷及iPTH水平。采用单因素重复测量资料方差分析比较肾移植前和移植后1周、1个月、6个月、12个月和24个月受者血清钙、磷、iPTH水平,采用χ²检验比较低磷血症和高钙血症发生率以及iPTH分布情况。 结果肾移植术后1个月受者血清钙上升至稳定期,同时血清磷下降至稳定期;术后6个月高钙血症和低磷血症发生率最高,分别为8.4%(15/179)和9.5%(17/179)。术后1～6个月受者iPTH下降明显,随后无明显变化,术后24个月仅有27%(48/179)的受者iPTH水平降至完全正常。 结论尿毒症患者行肾移植术后,SHPT均有所缓解,但大部分无法恢复至正常水平,术后需要进行积极的针对性治疗。     

The impact of thiopurine S-methyltransferase polymorphisms on azathioprine dose 1 year after renal transplantation

Azathioprine metabolism is influenced by activity of the enzyme thiopurine S-methyltransferase (TPMT), which varies markedly between individuals. In this study we examined the influence of TPMT gene polymorphisms on azathioprine dose 1 year after renal transplantation. TPMT coding and promoter genotypes were determined using PCR-based assays. Azathioprine dose, white cell count, and intercurrent events throughout the first year after renal transplantation were ascertained from contemporaneous clinical notes. All patients analysed (n=172) received an initial azathioprine dose of 1.5 mg/kg per day. Twelve individuals with one variant TPMT coding allele were detected (*3A n=11, *3C n=1). Of these, 58% required azathioprine dose reduction because of leucopenia, compared to only 30% of homozygous wild-type patients (P=0.04). A significant correlation between the presence of 11 variable number tandem repeats (VNTRs) in the TPMT promoter and reduction in azathioprine dose was also identified (P=0.001). We concluded that when azathioprine is administered at an initial dose of 1.5 mg/kg per day, both coding and promoter TPMT polymorphisms influence the dose tolerated.