老年供肾亲属肾移植疗效和安全性分析

目的:探讨老年供肾亲属肾移植的疗效和安全性. 方法:对我院66例行活体肾移植的供受者资料进行回顾性分析.供者50岁以上24例,其中8例次供者术前检查存在轻度医学异常(包括镜下血尿4例,高血压2例,肥胖1例,结石1例),比较老年供者和非老年供者术前总肾小球滤过率(GFR),手术前后血清肌酐(SCr),留存肾GFR以及并发症等情况.同时对二组受者的手术前后SCr,内生肌酐清除率(Ccr)、并发症、人肾存活率进行比较. 结果:两组供者术后总体肾功能恢复良好,无显著性差异.但50岁以上组术后3月以上留存肾GFR显著低于50岁以下组(P<0.05).两组受者在术后1年内SCr、Ccr、DGF、急性排斥和并发症均无显著性差异. 结论:老年供者选择需十分谨慎.术前全面而彻底评估,严格控制纳入标准,其安全性和疗效良好.     

肾移植活体供肾的现状

自1954年Merrill等实施人类首例同卵双生兄弟间活体亲属供肾移植以来，肾移植技术，现已成为救治终末期肾脏病（ESRD）的最有效手段。特别在西方国家，活体供肾已被广泛应用。美国从2001年以来，活体供肾年移植量显然超过尸肾移植。在伊朗，自从1984年以来已做肾脏移植16000例，约95％以上的肾脏移植来源于活体供肾。与尸肾移植比较，活体供肾移植可获得更好的人／肾存活率，特别在一开始透析时就做活体肾移植的效果更好。透析时间0～6个月移植肾5年存活率78％，透析时间〉24个月者为58％；10年存活率分别为63％和29％。本文主要综述活体供肾移植的现状。     

心脏停跳者供肾的肾移植

本文作者研究的目的在于对比取自心脏停跳者的肾(NHBD)和活体肾(HBD)两者在移植后的存活率和中期功能。从1989年至1998年,马德里San Carlos临床医院共取了144个NHBD肾,95个做了肾移植,此类肾的取出过程是从心跳停止时开始,期间双肾的血供由体外     

肾移植术后移植肾带功死亡原因分析

目的：分析19例肾移植术后移植肾带功死亡原因，为临床防治移植肾带功死亡提供参考。方法：回顾性分析19例移植肾带功死亡者的临床资料。结果：感染死亡12例，其中肺部感染10例(5例混合感染、2例单纯感染、3例不明原因的肺部感染)，术后尿漏引起菌血症2例(均为混合感染)；心脑血管意外死亡5例，均为50岁以上(其中脑出血2例、急性左心衰2例、DIC 1例)；恶性肿瘤死亡2例(均为淋巴瘤)。结论：感染是移植肾带功死亡的最常见原因，与术后免疫状态低下和手术并发症有关，其中肺部感染最重要，移植后肺间质纤维化可能与感染或某些免疫抑制剂有关；心脑血管意外多发生于老年人，术前术后多有难治性高血压及心功能不全；恶性肿瘤的发生与术后免疫力低下有关。防止肾移植术后带功死亡的关键在于预防，对于引起术后带功死亡原因要早发现、早诊断、早治疗，合理调整免疫抑制剂。     

体外膜肺氧合技术对脑心双死亡器官捐献供肝的保护作用

目的探讨体外膜肺氧合(ECMO)技术在公民逝世器官捐献供肝保护中的应用,总结ECMO技术保护供肝的初步体会及经验。方法收集江西省人民医院2015年1月-2018年12月运用ECMO技术完成脑心双死亡器官捐献(DBCD)肝移植供者/受者及常规DBCD肝移植供者/受者的临床资料,对供肝的保护及移植效果进行对比分析。计量资料两组间比较采用t检验;计数资料两组间比较采用χ2检验。结果共纳入一般情况及肝功能接近的供者32例,根据采用的方法将其分为对照组(常规DBCD肝移植)和研究组(运用ECMO技术完成DBCD肝移植),每组各16例;32例肝移植受者分为对应的对照组(n=16)和研究组(n=16)。器官获取前供者对照组与供者研究组比较,心率、收缩压、舒张压、血氧分压、乳酸水平、中心静脉压、TBil、ALT、AST差异均有统计学意义(t值分别为14.121、-17.817、-19.187、-8.927、4.559、-3.495、3.357、4.111、3.553,P值均<0.05)。与受者对照组术后第7天肝功能相比,受者研究组肝移植术后肝功能恢复速度更快,两组TBil、DBil、ALT、AST、ALP、GGT比较,差异均有统计学意义(t值分别为9.309、4.783、5.067、2.203、4.774、5.257,P值均<0.05);受者研究组患者住院时间明显缩短[(12.65±2.86)d vs(20.87±4.98)d,t=5.756,P<0.001]。结论运用ECMO技术获取并实施肝移植临床效果较好,科学合理运用ECMO技术可以有效改善供肝质量,对我国公民逝世器官捐献工作有着积极的作用。     

重组脑利钠肽治疗心肾综合征的临床疗效

目的:回顾性分析重组脑利钠肽(rhBNP)在心肾综合征(CRS)患者中的疗效。方法:本研究纳入2013年11月至2018年11月国家肾脏疾病临床医学研究中心重症监护病房(ICU)收治的CRS患者,按是否使用重组脑利钠肽(rhBNP)分为rhBNP治疗组与对照组,进行倾向性评分匹配研究。入院72h后评估全身症状改变,根据少尿、肝大、腹水、双下肢水肿、肺部啰音、颈静脉怒张共6项异常体征出现的数目评估治疗效果,4项及以上异常体征改善为明显好转。ICU住院期间监测N末端B型利钠肽原(NT-proBNP)较入院时下降≥30%定义为治疗有效,NT-proBNP下降30%定义为治疗无效。结果:259例CRS患者纳入本研究,其中rhBNP治疗组74例,对照组185例。倾向性评分匹配前两组患者基线资料在性别、连续性肾脏替代治疗(CRRT)比例、终末期肾病比例、双肾大小、肺动脉高压比例上存在差异(P0.05)。匹配后二组基线资料均无差异,rhBNP治疗组异常体征明显好转率为66.10%,对照组为30.51%。rhBNP治疗组有效率为72.88%,对照组为47.45%。rhBNP治疗组中CRS 1～3型均治疗有效,CRS 4型、5型治疗有效率分别为74.29%、59.26%,高于对照组。多因素Logistic回归分析提示原发病因为系统性红斑狼疮是rhBNP治疗无效的独立危险因素。rhBNP治疗组中有7例患者治疗期间收缩压下降45(33,62) mmHg,同时监测血清肌酐(SCr)上升超过26.52μmol/L。对照组有9例患者治疗期间监测SCr上升超过26.52μmol/L。两组肾功能损伤率无明显差异。结论:rhBNP治疗CRS能有效降低NT-proBNP,改善心力衰竭症状,提高临床疗效。CRS 1～3型均治疗有效,对部分CRS 4和5型患者效果欠佳。治疗期间需要密切监测血压变化。     

尸体肾移植术后尿液中表皮生长因子的动态变化

目的；研究缺血怀肾损伤后尿表皮生长因子（ＥＧＦ）排泄的变化，与移植肾功能恢复在时相上的关系，以及在肾小管再生中的作用。方法：对１２例尸体肾移植术后肾功能顺利恢复的患者，用放射免疫法检测其术前及术后１－９０天尿ＥＧＦ排出量的动态变化。结果：移植肾术后尿ＥＧＦ的排泄量短期下降，九小时或几天即恢复到正常人一侧健肾的排泄量，其恢复速度与与肾小球滤过率的恢复速度相当，但二者无线性相关，尿ＥＧＦ排出量的恢复邻     

横纹肌溶解合并急性肾损伤供肾移植后受者的临床疗效

目的:探讨横纹肌溶解症合并急性肾损伤(AKI)供者肾移植后受者的临床效果。方法:回顾性分析中山大学附属第一医院2012年1月~2015年12月器官捐献供者中,因横纹肌溶解症导致AKI的供者和肾移植受者临床资料。结果:8例供者因横纹肌溶解症导致AKI,供者血肌酸激酶峰值为10 623±3 692 U/L,血浆肌红蛋白峰值为20 618±7 959μg/L,血清肌酐峰值为483±176μmol/L。其中3例接受血浆置换治疗,2例行持续性肾脏替代治疗(CRRT),1例接受体外膜肺氧合治疗。16例受者,肾移植术后4例移植肾功能延迟恢复,4例移植肾功能缓慢恢复,其余8例受者移植肾功能恢复良好。随访6~46月,人肾均存活。术后6月和12月肾小球滤过率分别为65.4±13.5 ml/(min·1.73m2)和71.2±14.3 ml/(min·1.73m2)。结论:接受横纹肌溶解症合并AKI患者供肾的受者肾移植术后移植肾功能恢复良好。出现AKI的器官捐献供者应该常规行横纹肌溶解症筛查。     

尸体肾移植后预防排斥反应时使用激素的观点

本刊从 2 0 0 2年起新辟“临床名家谈”专栏 ,特请国内知名专家就读者普遍关心的或一些有争议的问题发表意见 ,进行切蹉。本栏目的宗旨是“百花齐放 ,百家争鸣” ,强调尊重原作者的观点 ,来稿一律不作更动。笔谈不拘形式 ,有利于充分抒发各家特长或独到的经验。敬希广大读者惠予关注 ,能从各位名家发表的经验、宝贵意见中汲取营养。本刊诚挚地期望本栏目的设立能有利于提高我们的医疗质量 ,更好地为患者服务     

尸体肾移植800例次的回顾与分析

作者报道1978年6月至1992年6月间施行的尸体肾移植768例800次。全组的肾存活率:1年为77.8％3年为73.5;5年为52.6％;存活10年以上者8例。从本组临床资料回顾性分析显示:①提高肾存活率的因素中高质量取肾与植肾手术尤为重要;②在当今环孢素A应用的时代,仍应坚持ABO血型及淋巴细胞毒性试验配型工作;③感染是移植失败的重要原因,应将预防感染贯彻于术前、术中及术后的全过程;④加强对肾移植患者的随访工作,指导患者的康复,这对移植肾能否长期存活有着重要意义。     

Comparing outcomes of donation after cardiac death versus donation after brain death in liver transplant recipients with hepatitis C: A systematic review and meta-analysis

BACKGROUND:

Liver transplantation (LT) using organs donated after cardiac death (DCD) is increasing due, in large part, to a shortage of organs. The outcome of using DCD organs in recipients with hepatits C virus (HCV) infection remains unclear due to the limited experience and number of publications addressing this issue.

OBJECTIVE:

To evaluate the clinical outcomes of DCD versus donation after brain death (DBD) in HCV-positive patients undergoing LT.

METHODS:

Studies comparing DCD versus DBD LT in HCV-positive patients were identified based on systematic searches of seven electronic databases and multiple sources of gray literature.

RESULTS:

The search identified 58 citations, including three studies, with 324 patients meeting eligibility criteria. The use of DCD livers was associated with a significantly higher risk of primary nonfunction (RR 5.49 [95% CI 1.53 to 19.64]; P=0.009; I²=0%), while not associated with a significantly different patient survival (RR 0.89 [95% CI 0.37 to 2.11]; P=0.79; I²=51%), graft survival (RR 0.40 [95% CI 0.14 to 1.11]; P=0.08; I²=34%), rate of recurrence of severe HCV infection (RR 2.74 [95% CI 0.36 to 20.92]; P=0.33; I²=84%), retransplantation or liver disease-related death (RR 1.79 [95% CI 0.66 to 4.84]; P=0.25; I²=44%), and biliary complications.

CONCLUSIONS:

While the literature and quality of studies assessing DCD versus DBD grafts are limited, there was significantly more primary nonfunction and a trend toward decreased graft survival, but no significant difference in biliary complications or recipient mortality rates between DCD and DBD LT in patients with HCV infection. There is insufficient literature on the topic to draw any definitive conclusions.     

Liver transplantation in the critically ill: donation after cardiac death compared to donation after brain death grafts

Patients with end stage liver disease may become critically ill prior to LT requiring admission to the intensive care unit (ICU). The high acuity patients may be thought too ill to transplant; however, often LT is the only therapeutic option. Choosing the correct liver allograft for these patients is often difficult and it is imperative that the allograft work immediately. Donation after cardiac death (DCD) donors provide an important source of livers, however, DCD graft allocation remains a controversial topic, in critically ill patients. Between January 2003-December 2008, 1215 LTs were performed: 85 patients at the time of LT were in the ICU. Twelve patients received DCD grafts and 73 received donation after brain dead (DBD) grafts. After retransplant cases and multiorgan transplants were excluded, 8 recipients of DCD grafts and 42 recipients of DBD grafts were included in this study. Post-transplant outcomes of DCD and DBD liver grafts were compared. While there were differences in graft and survival between DCD and DBD groups at 4 month and 1 year time points, the differences did not reach statistical significance. The graft and patient survival rates were similar among the groups at 3-year time point. There is need for other large liver transplant programs to report their outcomes using liver grafts from DCD and DBD donors. We believe that the experience of the surgical, medical and critical care team is important for successfully using DCD grafts for critically ill patients.     

A pilot programme of organ donation after cardiac death in China

China's aims are to develop an ethical and sustainable organ transplantation system for the Chinese people and to be accepted as a responsible member of the international transplantation community. In 2007, China implemented the Regulation on Human Organ Transplantation, which was the first step towards the establishment of a voluntary organ donation system. Although progress has been made, several ethical and legal issues associated with transplantation in China remain, including the use of organs from executed prisoners, organ scarcity, the illegal organ trade, and transplantation tourism. In this Health Policy article we outline the standards used to define cardiac death in China and a legal and procedural framework for an organ donation system based on voluntary donation after cardiac death that adheres to both China's social and cultural principles and international transplantation standards.     

A comparison of clinical outcomes between Canadian and American patients after nonurgent coronary stenting

BACKGROUND: Practice patterns for percutaneous coronary interventions (PCIs) may differ between Canada and the United States. Few data are available comparing PCI outcomes between the two countries in the era of coronary stenting and adjunctive glycoprotein IIb/IIIa inhibition. METHODS: In the Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) trial, 2064 patients were randomly assigned to receive eptifibatide or placebo during nonurgent PCI. The 30-day and one-year rates of death, myocardial infarction (MI) and target vessel revascularization (TVR) were compared between Canadian and American patients enrolled in the ESPRIT trial. RESULTS: There were 1531 American patients and 533 Canadian patients enrolled. Americans were older and heavier, and had a higher incidence of cardiac risk factors than Canadians (P<0.05 for all variables). Canadian patients had a lower incidence of death, MI and TVR at 30 days (6.2% versus 10.4%, P=0.004) and at one year (14.8% versus 21.5%, P=0.0006). After adjusting for known baseline differences, enrollment in Canada remained a significant predictor of reduced ischemic complications at 30 days (OR=0.53, c2=9.0, P=0.003). Similar results were observed at one year. Eptifibatide was superior to placebo in both groups of patients. CONCLUSIONS: This analysis is among the first to show Canadian patients to have fewer adverse events than American patients after nonurgent PCI. This effect was independent of known baseline differences between the patients in each country. The relative treatment effect of eptifibatide in Canadian patients paralleled that observed in the main ESPRIT trial and in American patients.