多囊肾术前不切原肾同种异体尸肾移植11例报告

目的探讨多囊肾尿毒症患者肾移植术前小切多囊肾对肾移植的影响。方法对11例移植术前不切多囊肾尿毒症患者，在成功进行肾脏移植后进行经验总结。追踪术后移棺肾肾功能恢复及术后3年人／移植肾存活率和术后1年原肾体积及血尿变化情况。结果11例移植术前小切多囊肾的尿毒症患者，术后移植肾肾功能均能顺利恢复，占100％。人／移植肾3年存活率100％，移植后原肾体积逐步缩小，12个月内明显缩小20％-45％，血尿逐渐消失。2例术后因原多囊肾严重感染而手术切除（18％）。结论多囊肾尿毒症患者肾移植术前不切原病变肾也能收到满意的移植效果。     

肾移植治疗常染色体显性遗传性多囊肾病患者的临床效果分析（附43例报告）

目的探讨肾移植治疗常染色体显性遗传性多囊肾病（多囊肾）患者的疗效。方法多囊肾患者43例（多囊肾组）,在不切除原双侧肾脏的前提下,进行肾移植,以同期50例原发病为非多囊肾的肾移植患者作为对照组,进行随访研究。比较两组的术后1、3、5年人、肾存活率及排斥反应发生情况,通过肾脏B超检查多囊肾组患者术前与术后移植肾的体积变化,记录多囊肾组的并发症发生情况。结果多囊肾组肾移植术后1、3、5年人存活率分别为95.3%、90.6%、90.6%,术后1、3、5年肾存活率分别为95.3%、88.3%、83.7%。对照组相应为96.0%、92.0%、90.0%,94.0%、92.0%、88.0%,两组比较差异无统计学意义（P〉0.05）。两组的急性排斥反应发生率比较差异亦无统计学意义（P〉0.05）。多囊肾组术后3～6个月原肾明显缩小,1年后体积基本稳定,跟踪观察1～15年肾脏体积变化不明显。移植后血尿逐渐减轻,7～10d后消失。12例在移植后5～10周反复出现肉眼血尿,均经抗感染治疗后消失。多囊肾患者移植后仍需要应用药物控制血压。多囊肾组尿路感染发生率高达40%。32例多囊肾合并多囊肝,术后发生肝功能损害7例。结论多囊肾患者采用不切除原肾的肾移植效果满意,移植后应严密观察患者移植物肾功能、血尿和感染情况,及时对症处理。     

多囊肾患者肾移植术后的临床效果

目的:探讨多囊肾患者肾移植的特点、并发症及其对移植效果的影响。方法:回顾性分析了42例多囊肾患者和80例非多囊肾患者肾移植的临床资料。对两组患者的术后并发症以及1年和5年的人、肾存活率进行比较。同时对多囊肾组术前切除原肾和不切除原肾的患者进行比较。结果:两组患者在术后移植肾功能延迟恢复,急性排斥反应,心脑血管并发症以及肺部感染的发生率上均无显著性差异。多囊肾组患者术后的泌尿系感染的发生率高于对照组(P<0.05)。多囊肾组和对照组患者,1年和5年人存活率分别为95.24%与97.50%和83.81%与88.92%;1年和5年肾存活率分别为90.48%与94.97%和69.55%与66.54%。多囊肾组术前切除原肾和不切除原肾的两组患者间,上述并发症以及人、肾存活率差异均无统计学意义。结论:多囊肾患者接受肾移植是可行的,术后的人肾存活率与对照组比较差异无统计学意义,不切除原病变肾脏能收到满意的移植效果。多囊肾患者肾移植术后易发生泌尿系感染,应积极采取有效的防治措施。     

再次肾移植的临床研究

目的 探讨影响再次肾移植效果的因素。方法 对再次肾移植的４３例患者按术后用药方案的不同分２个组进行回顾性分析。结果 术后急性排斥反应（ＡＲ）的发生率为２７．９％急性肾小管坏死（ＡＴＮ）的发生率为２３．３％，移植后人／肾、１、３、５年存活率分别为８２．４％／６４．７％、７８．３％／６０．９％、６６．７％／５５．５％。环孢素Ａ（ＣｓＡ）组和抗淋巴细胞球蛋白组人／肾１年存活率分别为７７．８％／５５．６％     

老年患者施行肾移植的临床特点

目的 探讨老年患者肾移植的特点、影响移植效果的主要因素及提高移植成功率的措施。方法 对６４例年龄在６０岁以上的老年患者肾移植的资料进行总结。６４例中年龄最大者７３岁，平均６３．６岁。术后环孢素Ａ（ＣｓＡ）的起始量较一般患者低０．５～１．０ｍｇ．ｋｇ＾－１．ｄ＾－１，术后１年内的维持量较同期一般患者低０．２～３．０ｍｇ．ｋｇ＾－１．ｄ＾－１。结果 人、肾１年存活率均为８６．５％，３年存活率为７１．４     

多囊肾患者保留原肾的肾移植疗效分析

目的探讨多囊肾患者保留原肾的肾移植特点、手术方式及疗效。方法回顾性分析25例多囊肾患者肾移植前后原双侧肾脏体积变化以及移植肾功能恢复情况,以25例原发病为慢性肾小球肾炎肾移植患者为对照组。结果25例患者1年人/肾存活率分别为96.0%/92.0%,3年人/肾存活率为90.0%/90.0%;发生急性排斥反应7例(28.0%),移植肾失功2例(8.0%),死亡1例(4.0%);23例患者原肾脏逐渐缩小,左肾长、宽、厚由术前(20.72±4.40)cm、(14.11±2.45)cm、(9.01±1.05)cm缩小至(14.70±2.00)cm、(10.30±1.49)cm、(6.87±0.94)cm,右肾长、宽、厚由术前(20.11±2.64)cm、(15.10±2.14)cm、(9.18±0.96)cm缩小至(15.00±1.84)cm、(10.45±1.28)cm、(6.80±1.15)cm(P<0.05);23例患者移植肾功能稳定,血尿逐渐消失,术前血压(134.20±3.12)/(95.23±2.49)mm Hg(1 mm Hg=0.133 kPa),术后(128.58±2.59)/(92.34±3.40)mm Hg(P>0.05)。对照组1年人/肾存活率分别为100.0%/100.0%,3年人/肾存活率为96.0%/96.0%;发生急性排斥反应6例(24.0%),移植肾失功1例(4.0%),死亡1例(4.0%),与多囊肾组比较均P>0.05,差异无统计学意义。结论多囊肾患者肾移植,不切除原病变肾脏移植效果满意,移植后应严密观察患者移植肾功能、血尿和感染情况。     

老年患者肾移植（附26例报告）

为探讨老年患者肾移植的疗效，对１９８７年１月～１９９６年６月期间６０岁以上肾移植患者２６例进行分析。结果显示，术后发生并发症１６例（６１．５％），死亡５例，分别死于感染３例，心力衰竭１例，脑出血１例。１年及３年人肾存活率分别为８６．４％／８６．４％和６６．７％／６６．７％。认为６０岁以上老年患者可安全成功地接受肾移植术，患者死亡是移植失败的重要原因，感染及心血管并发症是导致患者死亡的主要原因，受者适应证和手术方法的选择及免疫抑制剂的合理应用是提高长期存活的关键。     

淋巴细胞群体反应性抗体检测在肾移植中的应用

自１９９２年１０月～１９９５年１２月对２５２例等待肾移植患者进行淋巴细胞群体反应性抗体（ＰＲＡ）检测，其中３２例患者ＰＲＡ阳性，占１２．７％。２８例患者给予血浆置换２～５次后行肾移植术，术后全部患者均应用甲基泼尼松龙、ＡＴＧ（ＡＬＧ）或ＯＫＴ３治疗。结果：２例发生超急性排斥反应，１例加速排斥反应，均摘除移植肾；３个月内出现急性排斥反应２１例（６５．６％），１４例逆转（６６．７％），５例摘除移植肾恢复血透（２３．８％），２例因肺部严重感染死亡。就ＰＲＡ阳性的原因，ＰＲＡ与肾移植的关系，ＰＲＡ在肾移植中的应用原则进行讨论     

2300例次肾移植的临床分析

目的：对1972－2000年10月间2300例次肾移植情况进行临床分析,方法：统计肾移植后受者1、3、5年的人、肾存活率;肾移植主要并发症及其处理原则;影响受者再次移植存活率的因素;HLA－A－抗原／基因配型及群体反应抗体（PRA）检测情况。结果（1）自1985年使用环孢素A（CsA)后1年人、肾存活率（人、肾均存活）为87．33％,3年为80．17％,5年为67．04％。（2）50岁以上肾移植患者353例,1年移植肾存活率83．44％（252／302）,1年人存活率85．43％（258／302）。（3）肾移植术后患者心脑血管系统疾病占死亡原因的50．7％,感染占死亡率的13．5％,（4）恶性肿瘤的发病率为1．46％（23／1580）。（5）良好的HLA供－受者配型型可减少术后急性排斥反应的发生率,利用于移植肾的长期存率。结论良好的组织配型,肾移植术后免疫抑制药物的合理应用,对移植术后并发症的预防和及时治疗是提高肾移植术后 人／肾存活率的重要因素。     

尸体肾移植1 082例次报告

对同种异体肾移植１０５１例１０８２例次进行总结。术后发生超急性排斥反应１２例次，加速性排斥反应３例次，急性排斥反应２８９例次，慢性排斥反应９３例次。人／肾总存活率：１年９４．７％／８７．６％、３年８９．８％／７９．７％、５年８８．３％／７９．１％、１０年５０．０％／３８．６％。最长者存活１６年５个月。１０８２例次的临床研究表明：（１）尸体肾移植是治疗晚期肾脏疾病的有效方法。（２）适应证的选择是保证肾移植成功的关键。（３）良好的ＨＬＡ配型有利于减少移植肾的早期失功和提高肾移植的长期存活率。（４）高质量的供肾、快速的取肾和熟练的植肾手术是保证肾移植成功的重要条件之一。（５）应坚持ＡＢＯ血型、淋巴细胞毒性试验及ＰＲＡ配型工作。（６）合理的应用免疫抑制剂，将激素减到最低量及环孢素血浓度的监测甚为重要。（７）ＡＴＧ或ＯＫＴ３是当前治疗移植肾难治性排斥反应最有效的免疫抑制剂之一。（８）感染是肾移植失败的重要原因，要充分做好预防感染的工作。（９）彩色多普勒超声和ＥＣＴ测定是一种方便、快速、敏捷诊断急性排斥反应的手段。（１０）加强对肾移植患者随访，指导康复期治疗，随时调节免疫抑制剂，这对患者能否长期存活有重要意义。     

多囊肾尿毒症患者肾移植时同期切除多囊肾的临床分析

目的 探讨多囊肾尿毒症患者在接受肾移植时是否同期切除多囊肾以及切肾对肾移植手术、术后并发症及患者预后的影响.方法 对63例接受肾移植治疗的多囊肾患者的临床资料进行回顾性分析.63例中,合并多囊肝者43例,胰腺囊肿者2例.对多囊肾体积较大影响手术操作、术前曾有血尿或泌尿系感染的31例患者,在肾移植的同时切除患者的多囊肾(切肾组),另32例保留多囊肾,仅行肾移植(保留组).术后采用环孢素A(或他克莫司)、霉酚酸酯和泼尼松预防排斥反应,观察比较两组患者的一般情况、移植肾功能恢复延迟(DGF)发生率、急性排斥反应发生率、手术并发症发生率、术后感染情况、患者和移植肾存活率等指标.结果 切肾组的手术耗时为(300±31)min,肾周引流管持续时间为(4.6±1.4)d,明显长于保留组(P＜0.01,P＜0.01),红细胞输注量为(4.31±1.05)U,明显多于保留组(P＜0.01).切肾组手术并发症发生率为29.0%(9/31),明显高于保留组的6.2%(2/32),差异有统计学意义(P＜0.05).保留组泌尿系感染发生率为31.2%(10/32),而切肾组只有6.5%(2/31),二者间比较,差异有统计学意义(P＜0.05),保留组因术后多囊肾感染而须再次手术切除多囊肾者占12.5%(4/32).切肾组和保留组术前各有24例血压偏高,切肾组术后8例(33.3%)血压恢复正常,而保留组只有2例(8.3%)血压恢复正常,两组间的差异有统计学意义(P＜0.05).两组在DGF发生率和急性排斥反应发生率、人/肾1年和5年存活率等方面的差异均无统计学意义.结论 只要操作细致,多囊肾患者接受肾移植时同期切除多囊肾是安全的,但切肾与否与人/肾存活率无关.     

Autosomal dominant polycystic kidney disease in a kidney transplant population

AIM: To define specific manifestations of autosomal dominant polycystic kidney disease in kidney transplant patients. METHODS: Of 874 consecutive first renal transplant patients 1985-1993, 114 (13%) had autosomal dominant polycystic kidney disease (ADPKD). Mean age was 53 +/- 8 years, 62% were men, and 83% received cadaveric kidneys. Control patients were matched for sex, age and donor type. Median follow-up time was 63 months. One patient was lost to follow-up. Medical records before and after transplantation were reviewed. RESULTS: Survival of patients and grafts was similar in ADPKD patients and controls. Twenty- five ADPKD patients died, four of causes not seen in the controls; two aortic aneurysms, one urothelial cancer, one colon perforation. Four more ADPKD patients but no control had diverticulitis (P = 0.03), two with perforation. Cardiovascular morbidity was not increased. Eight patients had subarachnoidal haemorrhage before transplantation and two during follow-up. Nineteen patients had undergone nephrectomy before transplantation, 11 because of voluminous kidneys, five for infection, pain or bleeding, two for suspected malignancy, one for hypertension. After transplantation, seven patients underwent nephrectomy, only one related to kidney size. During the first year, need of phlebotomy occurred in 14% of patients versus 4% of controls, P = 0.02. Urinary tract infection rates were not increased. No morbidity was related to liver cysts. CONCLUSION: The specific features of kidney transplantation to patients with ADPKD were few: enlarged kidneys, relevant only before transplantation, erythrocytosis, and as rare but serious events, diverticulitis with perforation.      

Bourneville-Pringle disease for kidney transplantation: a single-center experience

The Bourneville-Pringle disease is an autosomal-dominant disease affecting the kidneys in about 60%, causing end-stage renal disease in about 10% of the cases. Among more than 2800 renal transplant recipients during the last 33 years, we had two patients with this original disease. A third patient who underwent bilateral nephrectomy is currently awaiting a graft. The first patient was diagnosed at the age of 20 years after a few episodes of retroperitoneal bleeding. At the age of 26 years her left kidney was removed after a rupture; it measured 7500 g, and the histology described angiomyolipomatosis. A year later she underwent a cadaveric kidney transplantation. Subsequently her right kidney was removed due to bleeding. She is currently 5 years posttransplant with stable kidney function and good health. Our second patient was nephrectomized at the age of 35 years and 38 years because of angiomyolipomatosis. She underwent a cadaveric kidney transplantation 7 years later. After 5 years of excellent kidney function and a year after her arteriovenous fistula was ligated her upperarm had to be amputated because of uncontrollable bleeding. After another 6 months, she displayed rapid progression of a jejunal tumor and during operation received 54 U of blood transfusion but died at the age of 49 years with a well-functioning graft. Our third patient consecutively underwent two nephrectomies because of angiomyolipomatosis of her kidneys at the ages of 25 and 28 years. She has two children with the same disease. In addition she carries Leyden mutation, which has caused deep venous thromboses and pulmonary emboli. She is currently on our waiting list for kidney transplantation. The Bourneville-Pringle disease is a rare indication for kidney transplantation; the prognosis of the patient is dependent on the original disease.     

Renal transplantation for end-stage polycystic kidney disease

From 1963 to 1984, 56 renal transplants were performed in 51 patients with end-stage renal failure due to autosomal dominant polycystic kidney disease (ADPKD). There were 49 cadaver and 7 living-related transplants. Overall patient and graft survival was 88 per cent and 66 per cent at one year, 59 per cent and 49 per cent at five years, respectively. There was no significant difference in patient or graft outcome with cadaver versus living-related donor kidneys. One-year graft success with and without pretransplant bilateral nephrectomy (BN) was 78 per cent versus 58 per cent, respectively (n.s.). Patient survival after return to dialysis after graft loss was not compromised by the earlier performance of BN. In patients who did not undergo pretransplant BN, there were no complications from the retained native kidneys after transplantation. In cadaver recipients, the two-year graft success rate with and without preliminary blood transfusions was 54 per cent versus 61 per cent, respectively (n.s.). Cadaver graft survival with and without adjunctive antilymphocyte globulin (ALG), excluding 3 recipients managed with cyclosporine, was 88 per cent versus 50 per cent at one year, and 70 per cent versus 32 per cent at five years, respectively (p less than 0.05). This beneficial effect of ALG was still evident when only transfused cadaver recipients were analyzed and was achieved with no resulting compromise in patient survival. Follow-up computerized tomography (CT) scanning of the transplant kidney in 10 recipients with a long-term (1-9 years) functioning allograft showed no evidence of recurrent ADKPKD.     

Renal artery reconstruction for harvesting injuries in kidney transplantation with particular reference to the use of vascular allografts

At the University of Pittsburgh during the calendar year 1986, an arterial injury occurred during harvesting in 20 (7.5%) of the 270 grafts used to perform kidney transplantation (KTx). Four cases required reconstruction, using extension iliac arterial allografts from cadaveric donors of the same blood type; 6 patients, remodelling of the aortic patch in multiple arteries; 4 cases, repairs for injuries to the smaller segmental/polar arteries; 6 cases, a combination of the above techniques. These ex vivo arterial reconstructions are described and the use of donor arterial homografts is emphasized. No deaths have occurred at an average follow-up of 19 months. The postoperative acute tubular necrosis (ATN) rate was significantly higher (90%) compared with non-reconstructed kidneys during the same year (30%). The 1-year graft survival of kidneys undergoing arterial reconstruction (75%) was statistically no different than the overall kidneytransplant survival. Whenever extension iliac allografts were utilized, the cyclosporin-steroid immunosuppression required to control the kidney rejection contributed to the long-term patency rate of the graft. Since the number of organs available for grafting is limited, reconstruction of injured renal vessels has become justified, allowing valuable kidneys to be used that would otherwise be lost     

Selective, concurrent bilateral nephrectomies at renal transplantation for autosomal dominant polycystic kidney disease

PURPOSE: An algorithm was developed for performing bilateral nephrectomies for specific indications before or at renal transplantation in patients with autosomal dominant polycystic kidney disease. Outcomes for the living donor arm of the algorithm are reported. MATERIALS AND METHODS: Patients with autosomal dominant polycystic kidney disease and end stage renal disease were evaluated for transplantation. Patients with recurrent pyelonephritis, hemorrhage, pain, early satiety or kidneys that extended into the true pelvis underwent bilateral nephrectomies. Bilateral nephrectomies with concurrent renal transplantation were performed if a living renal donor was identified. If no living donor was identified, pre-transplantation bilateral nephrectomies were done and the patients were listed for cadaveric donor renal transplantation. The living renal donor arm of the algorithm was evaluated by comparing certain parameters for 15 and 17 patients with autosomal dominant polycystic kidney disease who underwent pre-transplantation and concurrent bilateral nephrectomies, respectively, including patient and graft survival, delayed graft function, graft function, length of stay for each surgery, transfusions and complications. RESULTS: No deaths, graft failures or delayed graft function occurred. In the delayed renal transplant group median time from nephrectomy to living donor transplantation was 124 days. Serum creatinine at discharge home and 1 year after transplantation for the pre-transplantation nephrectomy cohort was 2.0 and 1.3 mg/dl, respectively. Seven of the 17 patients with concurrent nephrectomy underwent transplantation before starting renal replacement therapy. A longer mean total hospital stay in the pre-transplantation nephrectomy cohort was the only statistically significance outcome variable. CONCLUSIONS: Selective bilateral nephrectomies at living donor renal transplantation results in decreased total length of stay without compromising patient or graft outcomes and it allows preemptive renal transplantation. Concurrent nephrectomy is safe and it further validates the algorithm for selective, concurrent bilateral nephrectomies for patients with autosomal dominant polycystic kidney disease who undergo living donor renal transplantation.     

Living related kidney donors over 60 years old

The lack of available cadaveric organs for transplantation has resulted in an increased number of kidney transplants from living donors. During a period of 6 years, 149 kidney transplantations were performed from living related donors in our institute, 33.5% of whom were older than 60 years of age. In this study we examined the survival of patients and grafts as well as the graft function in 50 patients with transplants from donors over 60 years (mean age 65 years) as compared with those of 99 patients with transplants from donors younger than 60 years (mean age 47 years). There were no significant differences in the course of donor nephrectomy, postoperative complications, or remnant kidney function. However, delayed graft function occurred more frequently in recipients of transplants from older donors. Improvement in graft function was also slower in recipients of kidneys from older donors, with significant differences in serum creatinine levels observed during the first 12 months after transplantation. More frequent acute complications and more progressive chronic graft failure, irrespective of the causes, occurred during the 1st post-transplant year in recipients with grafts from older donors. Five-year patient survival (77% vs 92%) and kidney graft survival differed significantly for the same period with worse results for patients receiving grafts from older donors. It may be concluded that kidney grafts from donors older than 60 years — and especially those older than 70 years — may be used for living related kidney transplantation, but with precautions.