他克莫司替换环孢素A延缓慢性移植肾肾病进展的临床研究

目的:探讨他克莫司(FK506)替换环孢素A(CsA)治疗慢性移植肾肾病(CAN)的有效性及安全性.方法:根据是否以FK506替换CsA,将73例CAN患者分成两组,CsA组30例,维持原免疫抑制方案(CsA、霉酚酸酯及泼尼松联用)不变,采用替换方案的FK506组43例,除将CsA转换成FK506外,其他用药同CsA组.两组均随访1年以上,监测血清肌酐(SCr)、肾小球滤过率(GFR)、24 h尿蛋白定量、血脂[包括总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白(LDL)、高密度脂蛋白(HDL)]等生化指标的变化情况,并观察随访期间药物的毒副作用.结果:转换治疗12个月后,FK506组SCr显著低于CsA组[分别为(194.8±42.5)μmol/L vs.(245.4±52.8)μmol/L,P＜0.01],FK506组GFR显著高于CsA组[(50.1 4±3.92)mL/(min·1.73 m2)vs.(40.58±2.49)mL/(min·1.73 m2),P＜0.01];FK506组24 h尿蛋白定量显著低于CsA组[(2.0±0.5)g vs.(3.9±0.7)g,P＜0.01];FK506组除HDL外,TC,TG,LDL均显著低于CsA组[(5.19±0.73)mmol/L vs.(6.94±1.37)mmol/L;(1.86±0.84)mmol/L vs.(3.14±1.38)mmol/L;(3.03±0.71)mmol/L vs.(3.82±0.89)mmol/L,P＜0.01];FK506组震颤发生率较CsA组高(P＜0.01),但高血压发生率显著低于CsA组(P＜0.05).结论:FK506转换治疗后,肾功能减退得到延缓,蛋白尿降低,血脂代谢得到改善,FK506可以有效延缓CAN进展.     

慢性移植肾肾病患者西罗莫司替代钙调磷酸酶抑制剂对肾功能的影响

目的 观察慢性移植肾肾病(CAN)患者采用西罗莫司(SIR)替代钙调磷酸酶抑制剂(CNI)治疗的疗效和安全性.方法 前瞻性、开放性、非随机对照研究,2004年1月至2006年6月浙江大学医学院附属第一医院肾脏病中心诊断CAN患者74例,基线估算的肾小球滤过率(eGFR)为30～60ml·min-1·(1.73 m2)-1.其中36例采用SIR切换治疗(CNI药物停用12 h后开始使用SIR),另外38例继续使用CNI药物维持治疗(环孢素治疗30例;他克莫司治疗8例).所有患者霉酚酸酯适当加量并随访4年,定期观察移植物肾功能和eGFR,记录排斥反应等不良事件的发生情况,监测血常规、血脂、肝功能等指标.结果 SIR切换组和CNI维持组切换前eGFR分别为(40±7)ml·min-1·(1.73 m2)-1和(38±6)ml· min-1· (1.73 m2)-1,差异无统计学意义(P＞0.05).切换后SIR切换组较CNI维持组移植肾功能改善明显,在随访至3、12、24、36和48个月时SIR切换组eGFR均明显高于CNI维持组(均P＜0.05).随访结束时SIR切换组发生急性排斥反应2例,蛋白尿1例,肺部感染1例;CNI维持组发生急性排斥反应2例(P＞0.05).以肌酐翻倍作为终点事件显示SIR切换组的4年存活率(75.0％)显著优于CNI维持组(50.0％)(P=0.03).随访3个月时SIR切换组血总胆固醇和甘油三酯均显著高于切换前;总胆红素显著低于切换前和CNI维持组(均P＜0.05).结论 SIR替代CNI药物治疗CAN患者可以明显改善移植肾肾功能,提高移植肾长期存活,同时并不增加排斥风险.     

Rapamycin instead of mycophenolate mofetil or azathioprine in treatment of post-renal transplantation urothelial carcinoma

Background Malignant tumor is the most common complication occurred in transplant recipients. It is widely recognized that immunosuppressive treatments increase the risk of cancer in transplant recipients. The efficacy and safety of rapamycin （RPM） in combination with low-dose calcineurin inhibitor （CNI） in treating 15 renal allograft recipients which developed urothelial carcinoma were observed.
Methods Immunosuppressive regimen in all recipients was altered with rapamycin to replace mycophenolate mofetil （MMF） or azathioprine （Aza）. The initial loading dosage was 2 mg/d, and the next dosage was 1 mg/d. The dosage of rapamycin was carefully adjusted according to the blood drug level and concentration of the drug was maintained at 4-6 μg/L. In all the 15 patients, the calcineurin inhibitor was reduced down to one third of the original dosage after the rapamycin blood concentration became stable. Surgical treatment and intravesical instillation chemotherapy were carried out in all patients. Recurrence of the tumor was monitored throughout the study. Post-transplant renal function and side effects were also closely monitored.
Results Among the 15 patients, 9 had no tumor recurrence in 2 years, 2 had tumor recurrences twice, and 4 had once. There was no acute rejection observed during RPM treatment. Post-transplant renal function in 11 patients was improved with a decreased creatinine level. Hyperlipoidemia and thrombocytopenia were the most frequent adverse events which responded well to corresponding treatments.
Conclusion Among the renal allograft recipients with urothelial carcinoma, combination of rapamycin and low dose calcineurin inhibitor treatment is effective and safe.     

Effects of renal artery stenting on renal function and blood pressure in patients with atherosclerotic renovascular disease

Objective To study the effects of percutaneous renal artery intervention on renal function and blood pressure in patients with renal artery stenosis. Methods Eighty-seven patients with severe uni- or bi-lateral renal artery stenosis (luminal diameter narrowing ≥70%) and clinical hypertension received renal artery stenting between January 2002 and December 2002. The changes in blood pressure and serum creatinine level and creatinine clearance (CCr) 48 hours after intervention and during 6 months of follow-up were assessed.Results Renal stenting was performed in 98 stenotic arteries of 87 patients, and the procedural success rate was 100%. Serum creatinine level was slightly elevated from (176±21) μmol/L to (179±11) μmol/L (P=0.15) 48 hours after the procedure, but significantly decreased to (149±15) μmol/L at 6 months (P<0.001). CCr was also greatly improved ［(37±11) ml/min before versus (51±8) ml/min at 6 months, P<0.001］. During follow-up, 61% of the patients experienced a normal renal function. Despite conventional medical treatment, systolic and diastolic blood pressures were also significantly decreased after stenting ［(163±23)/(96±13) mm Hg before versus (148±12)/(79±15) mm Hg at 6 months, all P<0.001］, and hypertension was well controlled in 67% of the patients at 6 months’ follow-up.Conclusion Renal artery stenting has a high success rate and is effective in improving renal function and blood pressure for patients with severe renal artery stenosis.     

大鼠原位异体肾移植硬化加快模型的建立

目的 建立大鼠移植肾慢性失功加快动物模型。方法 分别采用雄性SD大鼠和Wistar大鼠作为供受体,进行原位肾移植。术中强化缺血／再灌注损伤,观察术后2、4、6、8及12周各时相血肌酐及移植肾病理变化。结果 经强化缺血／再灌注损伤1h处理的异体原位肾移植大鼠于术后6周起血肌酐开始明显升高,8周出现明显的慢性同种异体移植肾肾病(CAN)的病理改变,与未强化缺血／再灌注损伤对照组相比有明显的统计学差异．结论采用SD→Wistar 大鼠作为供受体,通过强化缺血／再灌注损伤建立原位异体肾移植硬化加快模型简便可行。     

供体应用钙调磷酸酶抑制剂预处理减少大鼠肾移植缺血再灌注损伤及机制

目的缺血性预处理被证实能够提高器官对缺血再灌注损伤的耐受性,在肾移植领域具有较大的应用价值。但因其实施过程中还具有一系列问题从而限制了这一技术的临床应用。因此笔者提出使用药物钙调磷酸酶抑制剂（CNIs）对供体进行预处理,以期减少移植后缺血再灌注损伤。方法采用近交系Lewis大鼠肾移植模型,设置环孢素A组（CsA,10mg／kg）、他克莫司组（Tac,1mg／kg）、生理盐水对照组。通过比较肾移植后第3天各实验组与对照组移植肾功能（血清肌酐）、组织病理学改变,以及移植肾组织中肿瘤坏死因子α（TNF-α）、热休克蛋白70（HSP-70）的表达水平,评估移植肾缺血再灌注损伤程度并探讨其发生机制。结果各实验组血清肌酐值均小于对照组,组织病理学改变优于对照组,TNF-α表达水平低于对照组,HSP-70水平高于对照组。结论钙调磷酸酶抑制剂供体预处理能降低移植肾组织TNF-α,增加HSP-70的表达,从而减少肾移植缺血再灌注损伤。     

Renal thrombotic microangiopathies induced by severe hypertension

Renal thrombotic microangiopathy(TMA) is an uncommon vascular complication of severe hypertension.Until now,its clinical-pathological characteristics and renal survival have been unclear.Twenty-one patients with biopsy-proven renal TMA and with severe or malignant hypertension were retrospectively studied.All the patients exhibited severe hypertension,with systolic blood pressure at 200-280 mmHg and diastolic pressure at 110-180 mmHg.No patients had hemorrhagic manifestations.Elevated lactate dehydrogenase and thrombocytopenia were found in 6 and 5 patients,respectively.Significant proteinuria(> 3 g/day) was present in 2 patients and microscopic hematuria in 18 patients.All patients presented with renal insufficiency(creatinine 3.1 +/-2.1 mg/dL).The level of von Willebrand factor:antigen(vWF:Ag) in patients was not significantly higher than that in the healthy subjects,while the ADAMTS13(a disintegrin and metalloprotease,with thrombospondin-1-like domains) activity was not significantly lower than that in the healthy subjects.Renal histology showed a TMA involving preglomerular arterioles and/or interlobular arteries character-ized by fibrin deposits and vascular wall sclerosis.Fibrin glomerular microthrombi were not observed in these patients.Four patients required hemodialysis upon admission for severe acute renal failure.On follow-up,3 patients had recovered normal renal function and 14 had mild renal insufficiency(creatinine 1.8 +/-0.3 mg/dL),while 4 patients still required persistent hemodialysis.In conclusion,compared with patients having hemolytic uremic syndrome/thrombocytopenic purpura,our patients showed a low incidence of throm-bocytopenia and better renal outcome.     

Interstitial pneumonitis is a frequent complication in liver transplant recipients treated with sirolimus

Background

Sirolimus is a powerful immunosuppressive drug which is being used increasingly after liver transplantation because of its renal sparing and anti-tumour effects. It has been associated with uncommon, but potentially fatal, interstitial pneumonitis.

Aim

To determine the frequency and outcome of sirolimus-associated pneumonitis following liver transplantation.

Methods

Retrospective study in an adult liver transplant centre.

Results

We identified five patients with siromimus-associated pneumonitis, three of whom were transplanted at our centre. Between 1999 and 2008 a total of 522 liver transplants were performed, in our unit, and 45 patients were switched from calcineurin inhibitors to sirolimus. Three of these 45 patients subsequently developed pneumonitis (6.7%). The most common presenting symptoms were cough and dyspnea. The duration of use of sirolimus before diagnosis of pneumonitis varied between 4 and 16?months. Trough serum sirolimus levels were elevated in 3/5 patients with pneumonitis. Sirolimus was withdrawn in all five patients with complete resolution of symptoms and radiological findings.

Conclusions

Pneumonitis is a relatively common side effect of sirolimus in liver transplant patients and can occur despite normal therapeutic blood levels. It is reversible on stopping the medication. Early recognition is important to prevent unnecessary investigations and prolonged morbidity.     

转化生长因子β1对远期移植肾功能影响的临床观察

目的探讨肾移植受者转化生长因子β1(TGF-β1)与远期移植肾功能的关系。方法1999年8月￣2001年6月期间对肾移植术后满1年、肾功能正常的患者检测血、尿TGF-β1浓度,并对上述患者进行3年以上的前瞻性观察,对观察期内肾功不全的患者明确是否为慢性移植肾肾病(CAN)。3年后共有134例患者完成了全程随访,根据术后1年时尿TGF-β1不同的浓度,比较其在3年观察期内肌酐清除率(Ccr)损失量有无差异;其中有16例诊断为CAN的患者,比较CAN患者与非CAN患者在肾移植1年时的血、尿TGF-β1等有无差异。结果上述134例患者术后1年时尿TGF-β1浓度为:135.6￣442.3pg/mg·Cr;尿TGF-β1浓度高的患者在3年观察期内Ccr损失量明显大于尿TGF-β1浓度低的患者;非CAN与CAN患者在肾移植1年时,尿TGF-β1相对浓度分别为(182.7±40.2)和(398±33.5)pg/mg·Cr(P<0.01),血TGF-β1浓度分别为(32.1±4.7)和(31.9±4.8)ng/ml(P>0.05)。结论TGF-β1可能在CAN的发生过程中起着重要作用,CAN患者在肾功能异常前尿TGF-β1已显著升高,肾移植后早期检测尿TGF-β1对远期肾功能具有一定的预测作用。     

EFFECT OF LOSARTAN ON SLOWING PROGRESSION OF CHRONIC ALLOGRAFT NEPHROPATHY

Objective To investigate the effects of losartan, a specific angiotensin Ⅱ receptor blocker, on slowing progression of renal insufficiency in patients with biopsy-proven chronic allograft nephropathy (CAN) and the molecular mechanism of the therapy.Methods Twenty-two renal transplant recipients with biopsy-proven CAN (group A) were treated with losartan within two months after renal dysfunction for at least one year. Losartan was administered at a dose of 50 mg/d. Twenty-four recipients in the same fashion (group B) who never received angiotensin Ⅱ receptor antagonist were studied as control. The investigation time for each patient lasted one year. Renal functions and concentrations of plasma and urine transforming growth factor-beta1 (TGF-beta1) were compared between the two groups at the initiation and end of the study. In group A, expressions of TGF-beta1 mRNA and immunofluorescence intensity of TGF-beta1 protein and pathological alterations in renal biopsy specimens were compared between before losartan therapy and after one year of the therapy.Results At the initiation of the investigation, no significant differences were found between group A and group B in clinical data such as donor age, cold-ischemia time, HLA mismatch, levels of creatinine clearance (Ccr), plasma and urineTGF-beta1 concentrations. One year later, 14 of 22 (63.6%) patients showed stable or improved graft functions in group A,and 4 of 24 (16.7%) in group B. The difference was significant (P＜0.05). At the end of the study, urine TGF-beta1 loss of Ccr was 6.6±5.4 mL/min in group A and 16.2±9.1 mL/min in group B. Both of the differences were significant between the two groups (P＜0.01). No significant differences were found in plasma TGF-beta1 concentrations between the four values determined at the initiation and end of the study in the two groups (F = 2.56, P ＞ 0.05). After one year losartan therapy, group A showed a significant decrease in expressions of TGF-beta1 mRNA and TGF-beta1 protein in renal biopsy specimens [from 1.59±0.35 to 0.96±0.27 and from (10.83 ± 2.33)×106 to (6.41±1.53)×106, respectively; both P＜0.01],but in light microscopy the histological changes were similar to the first renal biopsy. Losartan was excellently tolerated in all patients in group A. No cases with losartan therapy showed too low blood pressure and other side effects.Conclusion This study suggests that losartan have an effect on slowing progression of CAN. Reducing production of intrarenal TGF-betal may play a decisive role in the efficacy of losartan.     

Renal effects of gadopentetate dimeglumine in patients with normal and impaired renal function

Gadolinium chelates are widely used in magnetic resonance imaging as contrast medium in patients with nephropathy. However, only few studies have investigated the effect of gadolinium on serum creatinine concentration and estimated GFR as surrogate markers of renal function. This study was performed to evaluate the effect of gadopentetate dimeglumine in a dose sufficient for diagnostic and interventional purposes on renal function in a large sample of patients. We analyzed serum creatinine and serum-urea levels before and after the administration of gadopentetate dimeglumine in patients with normal and patients with pre-existing impaired renal function. Age, height, body mass, sex, medication and preexisting illnesses such as diabetes, renal artery stenosis and heart disease were monitored. In 181 patients with normal renal function, there was no statistically significant change in serum creatinine concentration after the administration of gadopentetate dimeglumine (at baseline: 0.72 +/- 0.18 mg/dl, after gadolinium: 0.73 +/- 0.22 mg/dl). In contrary, serum creatinine levels decreased significantly after the administration of gadolinium in 198 patients with pre-existing renal impairment (1.82 +/- 1.03 mg/dl before and 1.72 +/- 1.03 mg/dl after gadolinium) (p < 0.01). According to this surrogate marker of renal function, the change of estimated GFR in patients with normal baseline renal function was not significant, while in patients with impaired renal function, GFR increased after the administration of gadolinium (p < 0.001). The high diagnostic value of gadolinium contrast media is associated with a very small risk of adverse reactions. Our findings show that the administration of gadolinium even is associated with a decrease of serum creatinine in patients with pre-existing renal impairment. In conclusion, the use of gadolinium-based contrast media may be considered as a safe alternative in patients with impaired renal function for whom use of iodine-based contrast agents is prone to a high rate of radiocontrast-induced nephropathy.     

Annual intramuscular injection of a megadose of cholecalciferol for treatment of vitamin D deficiency: efficacy and safety data

AIM: To evaluate the efficacy and safety of an annual intramuscular injection of cholecalciferol for vitamin D deficiency. DESIGN: Prospective open-label study. PARTICIPANTS: Five men and 45 women (mean age 66.3 years) with vitamin D deficiency who were given a single therapeutic intramuscular injection of 600 000 IU (15 mg) cholecalciferol (vitamin D(3)). OUTCOME MEASURES: Serum levels of calcium, creatinine, 25-hydroxyvitamin D(3) (25OHD(3)) and parathyroid hormone, as well as early morning 2-hour urine calcium/creatinine excretion index. Specimens were collected at baseline and after 4 and 12 months of therapy. Data are reported as mean +/- 1 SD. RESULTS: Vitamin D deficiency was severe (< 12.5 nmol/L) in one participant, moderate (12.5-24 nmol/L) in 14, and mild (25-49 nmol/L) in 35. Twenty-four participants (48%) had secondary hyperparathyroidism. Following intramuscular cholecalciferol injection, serum 25OHD(3) levels normalised in all participants and remained above 50 nmol/L throughout the study. Serum 25OHD(3) levels were significantly higher at 4 months (114 +/- 35 nmol/L), and 12 months (73 +/- 13 nmol/L) compared with baseline (32 +/- 8 nmol/L) (P < 0.001), increasing by an average of 128% over the 12 months. There was a corresponding decrease in serum parathyroid hormone levels at 4 months (6 +/- 3 pmol/L) and at 12 months (5.2 +/- 3 pmol/L), with a 30% decrease at 12 months from baseline (7.4 +/- 4 pmol/L) (P < 0.01). Primary hyperparathyroidism was unmasked in one participant at 4 months and mild hypercalcaemia (serum calcium, < 2.70 mmol/L) was noted in two participants (4%) at 12 months. Serum creatinine levels remained normal in all participants throughout the study, while increases in 2-hour urine calcium/creatinine excretion index were seen in 10 participants (20%) at 12 months, three of whom had had elevated values at baseline. CONCLUSIONS: Once-yearly intramuscular cholecalciferol injection (600 000 IU) is effective therapy for vitamin D deficiency. While this therapy appears to be safe, the potential for developing hypercalciuria needs to be examined in a large randomised controlled trial.     

肾移植术后新生HLA抗体和MICA抗体对移植肾功能的损伤作用

目的研究肾移植术后新生人类白细胞抗原(HLA) 抗体及主要组织相容性I类相关链A抗原（MICA）抗体的产生对移植肾功能的损伤作用。方法采用免疫磁珠流式细胞仪液相芯片技术检测96例肾移植患者HLA及MICA抗体。根据检测结果,将患者分为HLA抗体阳性组（HLA+）、MICA抗体阳性组（MICA+）、以及HLA、MICA抗体阴性组（HLA /MICA ）,观察并比较各组不良免疫事件的发生率。再根据有无急性排斥（AR）,将患者分为排斥组（AR+）和非排斥（AR ）组,观察HLA抗体、MICA抗体对移植肾功能的影响。结果HLA+组急性排 斥反应发生率高于HLA /MICA 组(43．5％ vs 11.7％,P＜0.05);MICA+组急性排斥反应发生率与HLA /MICA 组比较差异无统计学意义(15．3％ vs 11．7％,P＞0．05);AR+组中,HLA+患者术后1、3、6和12个月时血清肌酐水平高于HLA /MICA 患者, MICA+患者在术后1、3月时血肌酐水平高于抗体阴性患者;AR 组中,HLA+患者术后6、12个月血肌酐水平高于HLA /MICA 患者;MICA+组在术后6个月及12个月的尿蛋白定量均值高于150?mg,并随时间逐渐升高。结论HLA抗体对移植肾功能的损伤作用表现为血清肌酐的升高以及与急性排斥反应的发生有关;MICA抗体对移植肾功能的损伤主要表现为尿蛋白定量的升高。     

Homocysteinemia in hypertensive patients with renal target organ damage (mild renal dysfunction)

The prevalence of high plasmatic levels of homocysteine in hypertensive patients with mild renal dysfunction (MRD) defined by 2003 European Hypertension Society Guidelines (men plasmatic creatinine between 1.3 and 1.5; women plasmatic creatinine between 1.2 and 1.4 mg/dl) has not been previously reported. To evaluate this item 18 MRD patients were recruited (54% males, mean age 59.2 +/- 17.3 years, mean plasmatic creatinine 1.30 +/- 0.12 mg/dl). They were compared with a control group of hypertensives with normal renal function (n = 87, 42,9% males, mean age 53.6 +/- 12.3 years, mean plasmatic creatinine 0.83 +/- 0.21 mg/dl) and a group of 29 chronic renal failure patients (51.7% males, mean age 56.9 +/- 15.0 years, mean plasmatic creatinine 2.39 +/- 0.95 mg/dl). Age and sex differences are not significant, plasmatic creatinine levels are different among three groups (p <0.001, t student test). Basal homocysteine levels of CRF (19.3 +/- 7.1 micromol/l) were higher than those of control group (11,0 +/- 4,3 micromol/l) and MRD patients (14.8 +/- 5.5 micromol/l; p = 0.027 vs. CRF and p = 0.007 vs. control, Mann-Whitney test). Mean creatinine clearance was 30.3 +/- 11.5 ml/min for CRF group, significantly lower than MRD patients creatinine clearance (54.5 +/- 9.4 ml/min, p <0.001, t student test) and control ones (88,9 +/- 18,9 ml/min, p <0.001, t student test). Hypertensive patients with mild renal dysfunction showed higher and pathological levels of homocysteinemia as compared with controls, this finding might be related to the higher cardiovascular risk described in this group of patients.     

Renin-angiotensin system polymorphisms and renal graft function in renal transplant recipients

OBJECTIVE: To analyze the role of 3 polymorphisms of the renin-angiotensin system (RAS) in renal transplant recipients (RTRs) and correlate them with graft function. METHODS: The present study was performed in the Drug Applied Research Center, Tabriz Medical University, Tabriz, Iran from September 2003 to December 2005 on 108 RTRs (66 males and 42 females, with a mean age of 37.34 +/- 4.97 years) with stable allograft function (creatinine < or =2.2 mg/dl). Following the DNA extraction from the blood leukocytes, the genotypes of the angiotensin converting enzyme (ACE I/D), angiotensinogen (ANG M235T), and angiotensin II type 1 receptor (ATR1 A1166C) were determined by polymerase chain reaction. The magnitude of clearance of creatinine (ClCr) in the setting of each of the above RAS polymorphisms was determined. The ClCr was measured by modification of diet in renal disease formula. Values were expressed as mean +/- SD; p< or =0.05 was considered to indicate statistical significance. RESULTS: There was no association of each genotype of the RAS alone with ClCr, serum urea, cyclosporine through level and the degree of urinary protein excretion rate. However, patients with the DD genotype of angiotensin converting enzyme + CC genotype of angiotensin II type I receptor polymorphisms had lower ClCr (p=0.05) and a higher urinary protein excretion rate (p=0.03). Other combination genotypes of RAS had no effect on allograft function. Interestingly, the percent of hypertensive patients in the C allele (70%) was more than the A allele (30%) of ATR1 polymorphism (p=0.04). CONCLUSION: Although none of the single gene polymorphisms of the RAS affected renal allograft function, combinations of these genotypes were associated with the outcome of allograft function.     

EFFECTS OF PROSTAGLANDIN E1 ON THE PROGRESSION OF ARISTOLOCHIC ACID NEPHROPATHY

IT hasbeen confirmedthataristolochi acidnephropathy (AAN ) has renalvascularlesionsand isone of thein- terstitialnephritis.Recent studiessuggestthatrenalbl-ood vesselchangesoccurintheearlystageofAAN .1Renalvascularlesionswillreducerenalblood flow and make ki-dney hypoxiaand ischemia,which resultindeteriorationfrenalfunction.Inthekidney,prostaglandinE1 (PGE1 )playsa roleinkeepingtheblood-flowand intrarenaldistributionofblood.PGE1 caninhibiteffectorT cellinductionand tissuedamage inexperim…     

Long term outcome of renal allografts in patients with immunoglobulin A nephropathy

Recurrent glomerular disease is an important cause of late allograft loss in renal transplant recipients. Immunoglobulin A nephropathy (IgAN) is a leading cause of end-stage renal disease (ESRD) worldwide and its recurrence has been reported in allografts. The present study examined outcomes following renal transplantation (RTX) in 101 patients with ESRD due to biopsy-proven IgAN, in comparison to non-IgA patients, and evaluated the incidence of recurrence. The study population (mean age 34.8 +/- 7.7 years; males 62.2%; Chinese 88.3%) underwent RTX under CsA immunosuppression between November 1984 and December 2004; as two patients underwent retransplantation during the study period, 103 allografts (56.3% cadaveric) were included for retrospective analysis. At time of analysis on 1 January 2005, 78 (75.7%) renal allografts (IgAN RTX) were functioning, of which 51 (49.5%) had normal serum creatinine, 27 (26.2%) had chronic allograft dysfunction, while 25 had graft losses, either due to patient death with functioning grafts (5.8%) or withdrawal to dialysis (18.5%). Persistent microscopic haematuria, not attributable to other causes or proteinuria > 1 g/day occurred in 42.7% and 13.6% of allografts respectively. Of 29 allografts biopsied for evaluation of proteinuria and/or renal dysfunction post-RTX, 8 (27.6%) had IgAN (overall histological recurrence, 7.8%). Of these, three had graft loss due to recurrent IgAN, three had elevated serum creatinine, while two had normal serum creatinine. Overall five and ten year patient survivals for IgAN RTX were 95.3% and 82.2%, and five and ten year actuarial graft survivals were 82.3% and 67.8% respectively. Five and ten year patient and graft survivals for IgAN RTX were not significantly different from that for non-IgAN RTX. In summary, RTX patients with IgAN have a low incidence of documented histological recurrence and recurrence contributing to graft loss occurs in only 2.9%. These results suggest that RTX is an excellent modality of renal replacement therapy in this population.     

大剂量ARB对肾移植后蛋白尿治疗作用的临床研究

目的观察大剂量ARB对肾移植后蛋白尿的疗效及安全性。方法83例肾移植后蛋白尿患者,分为治疗组50例(采用2~4倍剂量ARB治疗)和对照组33例(不使用ARB治疗),观察不同治疗时间两组患者24h尿蛋白、血肌酐、血生化、血压、远期人/肾生存率及药物不良反应。结果治疗组24h尿蛋白排出显著低于对照组;治疗组血肌酐倍增时间、进展到移植肾功能衰竭或死亡的时间显著高于对照组〔(34.42±12.56)个月与(17.51±10.26)个月,(38.12±22.51)个月与(24.25±13.56)个月〕;治疗组出现2例血钾升高,4例低血压。结论大剂量ARB可有效控制肾移植后蛋白尿,提高移植患者人/肾远期存活率,使用安全有效。     

Pregnancy in patients with chronic renal disease.

Pregnancy is not invariably contra-indicated in patients with pre-existing renal disease. Clinical data now exist that permit the clinician to distinguish such patients who are likely to experience difficulty during pregnancy from those in whom pregnancy can be undertaken with high expectation of success. Patients suffering from systemic lupus erythematosus, active or inactive, with or without lupus nephritis, should avoid pregnancy. Patients with other forms of chronic renal disease in whom the serum creatinine concentration prior to pregnancy is less than 1.5 mg/dL are not exposed to increased maternal or fetal risk. On the other hand, patients with serum creatinine values exceeding 1.6 mg/dL experience a high incidence of maternal and fetal complications and should avoid pregnancy. The life expectancy of recipients of a renal transplant is uncertain, and these patients should receive counselling as to the advisability of undertaking pregnancy. The maternal risk in such patients is not inordinately high, but the fetal risk is considerable.     

Serum C-reactive protein on the prognosis of oncology patients with acute renal failure: an observational cohort study

BACKGROUND: We undertook this study to evaluate the significance of the C-reactive protein level (CRP) as a prognostic factor in oncology patients with acute renal failure (ARF) during nephrology consultation. METHODS: The study was comprised of a cohort of 375 consecutive oncology patients who had been admitted to a university-affiliated hospital between March 1998 and April 2006 and had been diagnosed with ARF. One hundred and fifty nine patients with ARF who matched at least one of the RIFLE criteria on increased serum creatinine were included for subsequent analysis. We used a Cox proportional hazard model. RESULTS: Clinical pathological variables were compared among patients with serum CRP levels > or =8 mg/dL (exposed group; cut-off point: median) and patients with serum CRP level <8 mg/dL (control group). In-hospital mortality rates associated with CRP levels were 53.8% for > or =8 mg/dL and 21.5% for <8 mg/dL (p <0.001). After adjusted analysis, the presence of a CRP level > or =8 mg/dL was significantly associated with an increased in-hospital mortality (HR 2.10; 95% CI: 1.17-3.78) than in those patients with similar Liano scoring, the same RIFLE classes, and the same treatment for ARF. In addition, each increment of 1 mg/dL of serum CRP was associated with an adjusted 4% increment of in-hospital mortality (HR 1.04, 95% CI: 1.01-1.06). CONCLUSIONS: CRP levels at nephrology consultation were an independent predictor of death in this cohort of oncology patients with ARF. Patients with levels > or =8 mg/dL may be considered at higher risk of death.