移植肾功能恢复延迟受者供肾及移植肾活检的意义

目的 分析移植肾功能恢复延迟(DGF)受者进行供肾及移植肾活检对其病因诊断的价值及对治疗的指导意义.方法 回顾性分析144例DGF受者的临床表现、实验室检查特点.获取供肾进行修肾时行供肾活检,在B型超声引导下行经皮肾活检术检查移植肾,分别行组织学、免疫病理和超微病理检查.结果 (1)1994-1997年间DGF的发生率为10.16%,1998-2001年间为7.83%,2002-2005年间为7.48%,2006-2009年降至5.35%;(2)DGF受者的临床表现包括无尿(16.67%)、少尿(16.67%)和高血压(47.22%).123例行移植肾B型超声检查者中肾脏体积增大者占79.67%,血管阻力增高者占45.53%;(3)全部DGF受者均存在血肌酐(SCr)不降或下降缓慢,80例SCr为451～707μmol/L,23例SCr持续＞707μmol/L.70.83%的DGF受者尿N-乙酰-BD-氨基葡萄糖苷酶升高,54.86%的DGF受者尿蛋白定性阳性,53.47%的DGF受者尿沉渣镜检红细胞计数＞50万/ml.(4)144例中,发生急性排斥反应者占45.83%,发生钙调磷酸酶抑制剂肾毒性者占15.28%,IgA肾病者占12.50%,缺血再灌注损伤者占7.64%,移植肾组织学形态正常者占7.64%,急性肾小管坏死者占5.56%,急性间质性肾炎3.47%,移植后复发性疾病占1.39%,肾小球毛细血管内增生性病变占0.69%.(5)60.55%的受者除变更免疫抑制方案外,还进行了肾脏替代治疗.结论 尽管[GF的原因复杂,但供肾质量及移植肾早期病理改变与DGF有直接关系;移植肾活检有助临床更改治疗方案.     

急性肾损伤供肾对肾移植受者预后影响分析

目的分析发生急性肾损伤(AKI)供肾对肾移植受者及移植肾预后的影响。 方法选取2015年1月至2021年9月武汉大学人民医院器官移植科71例供肾捐献前发生AKI供者(AKI 1、2和3期分别为31、16和18例)及78例非AKI供者,AKI组对应受者136例(AKI 1、2和3期供者对应受者分别为70、32和34例),非AKI组对应受者154例。采用成组t检验或单因素方差分析比较正态分布计量资料。计数资料采用卡方检验或Fisher确切概率法比较。采用Kaplan-Meier法绘制受者/移植肾生存曲线并采用log-rank检验进行比较。P<0.05为差异有统计学意义。 结果AKI组供者入院时血清肌酐以及供肾获取时血清肌酐、尿素氮、血红蛋白和尿蛋白阳性比例分别为(91±51)μmol/L、(206±126)μmol/L、(17±16)mmol/L、(121±28)g/L、53.5%(38/71),非AKI组分别为(66±33)μmol/L、(53±24)μmol/L、(9±4)mmol/L、(108±22)g/L和21.8%(17/78),差异均有统计学意义(t＝－3.488、－10.096、－0.432和－3.066,χ²＝16.065,P均<0.05)。AKI 1期、AKI 2期和AKI 3期供者入院时血清肌酐以及供肾获取时血清肌酐和白蛋白差异均有统计学意义(F＝8.275、15.012和3.840,P均<0.05)。非AKI组对应受者术后1个月血清肌酐、术后移植肾功能延迟恢复发生及移植肾存活比例分别为(106±47)μmol/L、9.1%(14/154)和98.1%(151/158),AKI组对应受者分别为(126±82)μmol/L、25.0%(34/136)和86.8%(118/136),差异均有统计学意义(t＝－2.561,χ²＝13.234和9.445,P均<0.05)。AKI与非AKI组供者对应受者移植肾存活率差异有统计学意义(χ²＝9.445,P<0.05);AKI与非AKI组供者对应受者生存率差异无统计学意义(χ²＝3.107,P>0.05)。不同AKI分期供者对应受者移植肾及受者存活率差异均无统计学意义(χ²＝1.643和1.257,P均>0.05)。 结论高分期AKI供者供肾经过积极维护能达到与低分期AKI供者供肾相似的移植效果,高分期AKI供者供肾经专业评估筛选后可作为扩大供肾来源的途径。     

再次肾移植受者和移植肾长期预后影响因素分析

目的探究再次肾移植受者和移植肾存活情况及长期预后影响因素。 方法回顾性分析1991年1月1日至2017年12月31日于浙江大学医学院附属第一医院肾脏病中心接受肾移植受者临床资料。共纳入再次肾移植受者37例,首次肾移植受者5 374例。根据再次肾移植受者移植肾存活时间长短,将其分为长期存活组(19例,>5年)和短期存活组(18例,≤5年)。采用成组t检验比较长期和短期存活组供受者年龄、首次与再次肾移植间隔时间、HLA错配数和再次移植供肾冷/热缺血时间。采用卡方检验比较长期和短期存活组受者性别、再次移植供肾类型、再次移植前后群体反应性抗体阳性比例、首次移植失功移植肾切除比例、再次移植前免疫诱导比例及再次移植后移植肾功能延迟恢复(DGF)和急性排斥反应发生比例。采用Kaplan-Meier法分析再次和首次肾移植受者/移植肾1、5和10年存活率。采用Cox比例风险模型分析影响再次肾移植术后移植肾长期存活影响因素。P<0.05为差异有统计学意义。 结果截至2018年3月1日,37例再次肾移植受者中位随访时间为152个月(11～323个月),2例死亡,18例发生移植肾失功,17例移植肾功能稳定。5 374例首次肾移植受者中位随访时间为108.9个月(0.1～350.0个月),459例死亡,1 343例发生移植肾失功。再次移植组受者/移植肾1、5和10年存活率分别为86%/81%、86%/62%和82%/36%,首次移植组受者/移植肾1、5和10年存活率分别为99%/98%、93%/89%和88%/80%。再次移植组移植肾1、5和10年存活率均低于首次移植组(χ²＝60.816、25.110和43.900,P均<0.05);再次移植组受者1年存活率低于首次移植组,差异有统计学意义(χ²＝40.409,P<0.05)。长期和短期存活组受者再次移植后移植肾DGF和急性排斥反应发生比例差异均有统计学意义(χ²＝4.039和4.748,P均<0.05)。Cox回归分析结果示DGF和急性排斥反应是影响再次肾移植受者移植肾长期存活的独立危险因素,差异有统计学意义(RR＝4.317和4.571,P均<0.05)。 结论再次肾移植受者移植肾存活率低于首次肾移植受者,DGF和急性排斥反应是影响再次移植受者移植肾存活的独立危险因素。     

移植前活检Remuzzi高评分供肾移植的临床观察

目的初步观察Remuzzi评分高的器官捐献供肾移植给成人受者的近期效果。方法回顾性分析2019年1月至2019年12月间华中科技大学同济医学院附属同济医院接受了移植前活检Remuzzi评分4分及以上心死亡器官捐献供者供肾移植的受者31例, 分为双肾移植组(DKT组, 14例)和单肾移植组(SKT组, 17例)。Remuzzi平均评分为DKT组左肾5.05/右肾5.26, SKT组左肾4.92/右肾4.58。双供肾植入受者同侧髂窝。统计术后1年内的受者/肾存活情况、肾功能状况及急性排斥反应、移植肾功能延迟(DGF)和蛋白尿等并发症情况。结果 DKT组和SKT组的受者男性占比分别为92.9%比52.9%, 体重指数分别为(23.93±2.56)kg/m2比(21.09±2.85)kg/m2, 两组间差异有统计学意义(P<0.05)。DKT组1例术后11个月移植肾功能丧失, 移植肾1年存活率92.9%, 受者存活率100%, SKT组受者/移植肾1年存活率均为100% 。术后12个月的血肌酐(SCr), DKT组为(164±37.7)μmol/L, SKT组(154.92±96.2)μ...     

肾移植手术中特殊供肾的处理

目的 总结特殊供肾的外科处理经验。方法 回顾性分析1996年1月-2001年6月间进行的868例尸体肾移植中326只特殊供肾的处理，并与542只普通供肾的移植效果进行比较。结果 326只特殊供肾均得到了利用，血管变异的供肾移植后1个月血肌酐水平，急性肾小管坏死（ATN）发生率及1年移植肾存活率与普通供肾均远见显著差异；其他特殊供肾均未发生与修整术有关的并发症。结论 畸形供肾或损伤供肾，通过合理手术整形，灵活运用等方法保肾，并不影响肾移植的效果。     

肾移植术中受者血压对移植肾的影响

慢性肾功能衰竭移植术者３９例，按手术中移植肾开放血流时受者的平均动脉压分为３组。Ａ组Ｂｐ１６．８－２２．８ｋＰａ；Ｂ组Ｂｐ１０．７－１６．７ｋＰａ；Ｃ组：Ｂｐ７．０－９．８ｋＰａ，观察血流开放后移植肾的情况。     

肾移植中供受者血管变异的处理

在肾移植中,常会遇到供受者动脉病变及多支血管变异,如处理不当,常导致移植肾失败或肾功能不全.本院共施行肾移植350例,其中受者髂内动脉严重粥样斑块硬化、管腔接近闭塞者30例,供肾多支动脉变异36例,供肾动脉与髂内动脉管径悬殊较大8例,均作了合理的处理.术后移植肾血供良好,1年后随访,吻合血管通畅,肾功能正常,现将其处理经验介绍如下.1 处理方法1.1 髂内动脉严重粥样斑块硬化的处理髂内动脉管腔很小,接近闭塞.这种髂内动脉如与肾动脉吻合,开放血流后移植肾常供血不足,肾色虽鲜艳,但充盈张力差,术后常发生急性肾衰及无尿,导致肾移植失败.对此,我们有沉痛的失败教训.后来我们对25例粥样斑块硬化患者采取髂内动脉斑块切除,然后与肾动脉作端端吻合,开放血流后移植肾充盈张力良好.对5例斑块不能切除者,采取肾动脉与髂外动脉端侧吻合,同样取得良好效果.术后随访1年,肾功能正常,肾动脉无血管杂音,B超、彩色多普勒血流图、肾动脉造影(部分患者)未发现异常变化.     

移植肾功能延迟恢复对长期存活的影响

目的 探讨移植肾功能延迟恢复对肾移植受者人／肾长期存活的影响。方法 回顾分析５７３例肾移植中发生的７０例移植肾功能延迟恢复受者的人／肾存活情况及其相关危险因素。结果 ７０例患者总的１、３、５年人存活率分别为７７．１％、４７．６％、３７．５％,肾存活率分别为７１．４％、４０．５％、１５．０％,明显低于同期未发生肾功能延迟恢复的受者,但未合并排斥反应的移植肾功能延迟恢复者存活率并不受影响,合并排斥反应     

供者来源性感染对肾移植受者预后的影响

目的探讨供者来源性感染(DDI)对肾移植受者预后的影响。方法回顾性分析82例公民逝世后器官捐献供者及其148例肾移植受者的临床资料。根据供肾灌洗液培养结果,将受者分为供肾灌洗液培养阳性组(阳性组,92例)和供肾灌洗液培养阴性组(阴性组,56例),根据受者是否发生DDI,分为DDI组(19例)和未发生DDI组(129例)。分析供肾灌洗液培养阳性菌株分布及构成比,总结受者术后感染情况及其他并发症发生情况,比较发生DDI组与未发生DDI组受者围手术期情况,分析DDI受者的治疗及预后情况。结果 148例肾移植受者中,92例供肾灌洗液培养阳性,共分离出病原菌131株,其中革兰阳性球菌占41.2%(54/131),革兰阴性杆菌占48.9%(64/131),真菌占9.9%(13/131)。148例受者中52例发生感染,其中阳性组有45%(41/92)的受者发生感染,阴性组有20%(11/56)的受者发生感染,差异有统计学意义(P=0.002)。52例感染受者最常见的感染部位为手术部位,其次为泌尿系统。共有19例受者发生DDI,发生率为12.8%,病死率为16%,与未发生DDI组受者比较,DDI组受者移植物丢失率和病死率更高、术后住院时间更长,差异均有统计学意义(均为P0.05)。8例发生耐碳青霉烯类肺炎克雷伯菌(CRKP)传播感染受者应用替加环素和(或)多黏菌素、碳青霉烯类药物治疗后有3例死亡,3例行移植肾切除;另外8例发生CRKP传播感染受者中,2例单独应用头孢他啶-阿维巴坦(CAZ-AVI),3例应用CAZ-AVI联合碳青霉烯类药物,3例先应用替加环素联合碳青霉烯类药物,而后应用CAZ-AVI进行挽救性治疗,经过治疗后受者均长期存活。结论 DDI可导致严重的并发症,早期针对性抗菌治疗有着积极作用。     

亲属肾移植供受者心理问题分析与对策

正随着肾移植相关技术的不断进步,尿毒症患者不需要依靠透析去维持生命,极大地改善了生活质量,尤其是伴随着肾移植和移植免疫学技术的长足发展,肾移植事业已经取得了实质性的进展,但由于肾源的缺乏,肾移植尚未得到广泛的开展,仍有广大的尿毒症患者挣扎在依靠透析来维持生命中。随着亲属供肾肾移植的开展,在一定程度上缓解了肾源缺乏的矛盾,给尿毒症患者带来了福音。手术一旦得到开展并获得成功,患者的生活质量将会得到极大的改善,但作为亲属肾移植的供受方,由于     

Preemptive deceased donor kidney transplant not associated with patient survival benefit in minority kidney transplant recipients

Previous studies have shown an inverse association between pre-transplant dialysis exposure and post-kidney transplant outcomes. Socioeconomic and allocation factors, in contrast to medical factors, play a greater role in dialysis exposure among minorities, and medical causes for delay may impact post-transplant outcomes. This study sought to test whether minorities behaved similarly to Caucasians with regard to the effect of duration of dialysis on post-transplant outcomes. All primary deceased donor kidney transplants between 1997 and 2004 (n = 54,162) were analyzed from the Organ Procurement and Transplant Network database and were categorized as either Caucasian or minority. Adjusted patient and graft survivals were determined in each subgroup based on the duration of pre-transplant dialysis. Caucasians recipients show a clear stepwise increase in risk of graft failure and death with increasing duration of dialysis. The risk of graft failure among minorities increased less without a clear stepwise pattern. The risk of death, however, showed a U-shaped risk profile with the highest risk of death among preemptive transplants and recipients with more than five yr of dialysis. The disparate effect of dialysis on minorities suggests that a selection bias and not a biologic effect may explain the association between dialysis duration and outcomes after kidney transplantation previously reported.     

肾移植术后肾功能延迟恢复的原因及对策

目的：探讨肾移植术后肾功能延迟恢复(DGF)的原因及处理方法。方法：报告我院发生的33例肾移植术后DGF患者的临床资料,发生DGF的原因是急性排斥15例,急性肾小管坏死(ATN)13例,动脉吻合口狭窄2例。输尿管梗阻2例,环孢素中毒1例。经血液透析治疗31例,ATG／ALG或OKT3治疗28例,经皮移植肾动脉吻合口球囊扩张2例,外科手术2例。结果：29例肾移植术后10～93d(平均24．8d)肾功能恢复正常,2例肌酐在200～300μmol／L之间,1例恢复血透,1例于肾功能恢复正常1月后死于肺部感染。结论：急性排斥反应是引起肾移植术后DGF的主要因素,术前严格配型、合理治疗和耐心等待是成功的关键。     

A pilot protocol of a calcineurin-inhibitor free regimen for kidney transplant recipients of marginal donor kidneys or with delayed graft function

Abstract: Background: The worsening shortage of cadaver donor kidneys has prompted use of expanded or marginal donor kidneys (MDK), i.e. older age or donor history of hypertension or diabetes. MDK may be especially susceptible to calcineurin-inhibitor (CI) mediated vasoconstriction and nephrotoxicity. Similarly, early use of CI in patients with delayed graft function may prolong ischaemic injury. We developed a CI-free protocol of antibody induction, sirolimus, mycophenolate mofetil, and prednisone in recipients with MDK or DGF.
Methods: Adult renal transplant recipients who received MDK or had DGF were treated with a CI-free protocol consisting of antibody induction (basiliximab or thymoglobulin), sirolimus, mycophenolate mofetil, and prednisone. Serial biopsies were performed for persistent DGF. Patients were followed prospectively with the primary endpoints being patient and graft survival, biopsy-proven acute rejection, and sirolimus-related toxicity.
Results: Nineteen recipients were treated. Mean follow-up was 294 days. Actuarial 6- and 12-month patient survival was 100% and 100% and graft survival was 93% and 93%, respectively. The only graft loss was due to primary non-function (PNF). The incidence of AR was 16%. Mean serum creatinine at last follow-up was 1.6 mg/dL. Sirolimus-related toxicity included lymphocele (1), wound infection (2), thrombocytopenia (1) and interstitial pneumonitis (1).
Conclusion: A CI-free protocol with antibody induction and sirolimus results in low rates of AR and PNF and excellent early patient and graft survival in patients with MDK and DGF. CI-free protocols may allow expansion of the kidney donor pool by encouraging utilization of MDK at high risk for DGF or CI-mediated nephrotoxicity.     

Better graft outcomes from offspring donor kidneys among living donor kidney transplant recipients in the United States

A recent study reported that kidney transplant recipients of offspring living donors had higher graft loss and mortality. This seemed counterintuitive, given the excellent HLA matching and younger age of offspring donors; we were concerned about residual confounding and other study design issues. We used Scientific Registry of Transplant Recipients data 2001‐2016 to evaluate death‐censored graft failure (DCGF) and mortality for recipients of offspring versus nonoffspring living donor kidneys, using Cox regression models with interaction terms. Recipients of offspring kidneys had lower DCGF than recipients of nonoffspring kidneys (15‐year cumulative incidence 21.2% vs 26.1%, P < .001). This association remained after adjustment for recipient and transplant factors (adjusted hazard ratio [aHR] = _0.730.77_0.82, P < .001), and was attenuated among African American donors (aHR _0.770.85_0.95; interaction: P = .01) and female recipients (aHR _0.770.84_0.91, P < .001). Although offspring kidney recipients had higher mortality (15‐year mortality 56.4% vs 37.2%, P < .001), this largely disappeared with adjustment for recipient age alone (aHR = _1.021.06_1.10, P = .002) and was nonsignificant after further adjustment for other recipient characteristics (aHR = _0.930.97_1.01, P = .1). Kidneys from offspring donors provided lower graft failure and comparable mortality. An otherwise eligible donor should not be dismissed because they are the offspring of the recipient, and we encourage continued individualized counseling for potential donors.     

Quantifying infection risks in incompatible living donor kidney transplant recipients

Desensitization has enabled incompatible living donor kidney transplantation (ILDKT) across HLA/ABO barriers, but added immunomodulation might put patients at increased risk of infections. We studied 475 recipients from our center from 2010 to 2015, categorized by desensitization intensity: none/compatible (n = 260), low (0-4 plasmaphereses, n = 47), moderate (5-9, n = 74), and high (≥10, n = 94). The 1-year cumulative incidence of infection was 50.1%, 49.8%, 66.0%, and 73.5% for recipients who received none, low, moderate, and high-intensity desensitization (P < .001). The most common infections were UTI (33.5% of ILDKT vs. 21.5% compatible), opportunistic (21.9% vs. 10.8%), and bloodstream (19.1% vs. 5.4%) (P < .001). In weighted models, a trend toward increased risk was seen in low (wIRR = _0.771.40_2.56,P = .3) and moderately (wIRR = _0.881.35_2.06,P = .2) desensitized recipients, with a statistically significant 2.22-fold (wIRR = _1.332.22_3.72,P = .002) increased risk in highly desensitized recipients. Recipients with ≥4 infections were at higher risk of prolonged hospitalization (wIRR = _2.623.57_4.88, P < .001) and death-censored graft loss (wHR = _1.154.01_13.95,P = .03). Post–KT infections are more common in desensitized ILDKT recipients. A subset of highly desensitized patients is at ultra-high risk for infections. Strategies should be designed to protect patients from the morbidity of recurrent infections, and to extend the survival benefit of ILDKT across the spectrum of recipients.     

供肾零点活检病理结果与移植肾功能延迟恢复的相关研究

目的探讨供肾零点活检病理结果与肾移植术后并发移植肾功能延迟恢复(DGF)的关系。 方法回顾性分析西安交通大学第一附属医院肾移植科2018年5月至2019年4月实施的心脏死亡器官捐献(DCD)肾移植供、受者临床资料。采用零点活检病理结果评估供肾质量,并按照Banff 2013标准、Remuzzi评分及马里兰病理指数(MAPI)对供肾进行病理分级和评分。肾小球数量≥7个,小动脉数量≥2支为合格标本。根据受者肾移植术后是否发生DGF,将其分为DGF组和非DGF组。采用Mann-Whitney U检验比较两组供肾肾小球硬化率、小动脉玻璃样变率、Banff 2013标准评分、Remuzzi评分和MAPI评分。采用卡方检验比较两组供肾肾间质纤维化、肾小管萎缩、小动脉内膜纤维化增厚、小动脉管壁透明样变、肾小管损伤/坏死及肾小球内微血栓发生情况。采用logistic回归分析供肾零点活检病理结果与DCD肾移植术后并发DGF的关系。P<0.05为差异有统计学意义。 结果最终纳入133例受者,其中DGF组26例,DGF发生率为19.5%,非DGF组107例。133例合格肾穿刺标本中,平均获得肾小球数量(13±5)个,中位肾小球硬化率5.8%(0～13.3%),中位小动脉数量5支(3～6支),中位小动脉玻璃样变率0(0～11%),肾间质纤维化占47.4%(63/133),肾小管萎缩占48.1%(64/133),小动脉内膜纤维化增厚占58.6%(78/133),小动脉管壁透明样变占36.8%(49/133),未见肾小球内微血栓,所有供肾均合并不同程度肾小管损伤/坏死。两组受者供肾肾间质纤维化、肾小管萎缩、肾小管损伤/坏死以及Remuzzi评分差异有统计学意义(χ²＝7.65、7.92和16.81,Z＝-2.02,P均<0.05)。多因素分析结果显示肾小管损伤/坏死是肾移植术后并发DGF的独立危险因素。 结论供肾零点活检病理学评估对于预测肾移植短期预后具有一定价值,在供者维护和器官保存过程中应尽可能避免造成肾小管缺血/坏死,以降低DGF发生风险。     

Study of the effect of donor source on graft and patient survival in pediatric renal transplant recipients

Evaluation of the impact of live unrelated kidney donor (LURD) source on the outcome of renal transplantation is not adequately studied. We aimed to compare the long-term outcome of kidney transplantation from LURDs to that from living related donors (LRDs) among a pediatric recipient population. This study comprised 235 pediatric recipients who received their kidney grafts between 1976 and 2005 at our center. These patients were further subdivided into two groups according to donor source (211 with LRDs) and (24 with LURDs). All patients’ data were assessed with special emphasis on graft and patient survival as well as posttransplant medical complications. Both groups were comparable regarding graft and patient survival at 1, 5, and 10 years. Despite higher incidence of acute vascular rejection among recipients with LURD (12%) vs. LRD (2.8%) (P = 0.03), there was no difference in the incidence of chronic allograft nephropathy. Moreover, the overall incidence of posttransplant complications was comparable among the two groups. In our series, kidney survival was poorer in LURDs compared with LRDs. However, the number of patients with LURD was small, and the difference in results was also small and justifies LURD in exceptional cases when LRD is not possible.