Combined pancreas kidney transplantation after isolated kidney transplantation

Simultaneous pancreas kidney transplantation (SPK) is an established therapy for type 1 diabetics with end stage or preterminal renal disease. SPK is superior to isolated kidney transplantation (KTX) in diabetic patients. Even pancreas-re-transplantations are more common in these patients now, mostly after SPK. But Experience with SPK after KTX is rare. Between 1994 and 2003 six Re-SPK 4.5 to 8.5 years after KTX were performed in our department. Average age of the recipients was 40.5 years. They had been suffering from diabetes for an average of 29.3 years. Four recipients were on dialysis again, whereas two had preterminal renal insufficiency. Pancreas transplants were drained through the bladder (n = 1) or into the small intestine (n = 5) with systemic venous anastomosis. After a median observation period of 28 months (8 to 99 months) all six recipients are insulin free. One patient lost his kidney graft due to severe acute rejection. Therefore kidney graft survival is 83 %. Four acute rejections (66 %) were observed in 4 patients. Only one rejection was treated successfully by steroids. Two rejections could be stopped with antibodies. 3 patients had infections in the early postoperative period (sinusitis, urinary tract infection, wound infection). Even after KTX with graft failure, diabetic patients suffering from renal disease can be re-transplanted successfully with SPK.     

Lymphocele and kidney transplantation

The authors report fourteen cases of lymphocele in a series of one thousand consecutive renal transplantations (1.4%). The prevention of these lymphoceles depends on rigorous lymphostasis. The diagnosis is based on ultrasonography. The treatment indicated in cases of voluminous lymphoceles consisted in marsupialization and omentoplasty.     

Hypertension and kidney transplantation

Patients with kidney transplants are often hypertensive. Investigators have described the characteristics of this hypertension in man. Moreover, the hypertension of kidney transplant patients has a higher probability of being responsive to surgical intervention than does hypertension in the general population. Yet the mechanisms of the many varieties of posttransplantation hypertension are not known in detail. Detailed studies that would best be done in animal models are rare. Both medical and surgical management of this transplantation-associated complication needs further study.     

Pregnancy and kidney transplantation

Despite decades of experience with child bearing in women with kidney transplants, these pregnancies remain high risk with an increased prevalence of hypertension and pre-eclampsia. Infertility, common in women with end-stage renal disease, is rapidly restored after transplant although pregnancy rates appear lower in transplant recipients than the general public. Many unanswered questions exist, some old questions such as what is the optimal timing of pregnancy after transplant, whether breast feeding is safe, the long-term impact if any on the offspring, and whether pregnancy negatively affects the kidney graft; and some new questions such as whether to modify immunosuppression in a patient taking a mycophenolic acid-containing drug, whether kidney donation has a deleterious impact on future pregnancies, whether to use erythropoietin-stimulating agents, and the role of BK virus. Counseling about contraception and pregnancy after transplant should be initiated during the pretransplant evaluation process. It is important because of the rapid restoration of fertility that occurs after transplant as well as the many risks and unanswered questions that remain.     

巨噬细胞与肾移植

肾移植是终末期肾病患者的最佳治疗方案,但移植肾远期存活仍是临床上面临的重要难题。肾缺血-再灌注损伤（IRI）和移植肾排斥反应被认为是影响移植肾远期存活的重要因素,受固有免疫和适应性免疫细胞调控。巨噬细胞是固有免疫细胞中一种,可协助启动适应性免疫,分为M1型巨噬细胞、M2型巨噬细胞和调节性巨噬细胞。先前研究揭示M1型巨噬细胞加重肾IRI和急性T细胞介导的排斥反应（TCMR）;而M2型巨噬细胞减轻肾IRI和急性TCMR,但与抗体介导的排斥反应（AMR）呈正相关;调节性巨噬细胞是巨噬细胞一种特殊亚群,可诱导移植免疫耐受,具有极大临床应用前景和基础科研价值。本文述评了巨噬细胞分型、巨噬细胞与肾IRI、移植肾排斥反应及调节性巨噬细胞与免疫耐受的关系,并分析了其可能作用机制,以期诱导巨噬细胞亚型改变或清除特定亚型巨噬细胞,进而改善移植预后及移植肾远期存活。     

Aden kidney transplantation

During the first Yemeni Congress of Uro-Nephrology in Aden, an international team performed the first kidney tranplantations in the region. We report the difficulties encountered and discuss the pros and cons for transplantations in developing countries.     

ABO-incompatible kidney transplantation

Owing to the shortage of deceased donors in Japan, since 1989, we have performed ABO-incompatible kidney transplantation (ABO-IKTx) to expand the indication for living donor kidney transplantation. During the past two decades, about 2000 ABO-IKTxs were performed. Since 2001 the success rate for these kidney transplants has reached 96% for 1-year, 91% for 5-year and 83% for 9-year graft survival, similar to outcomes of ABO-compatible kidney transplantation (ABO-CKTx). This dramatic improvement in results means that ABO-IKTx has become accepted as a therapeutic alternative for end-stage renal failure. Today ABO-IKTx accounts for approximately 30% of all living donor kidney transplantations performed in Japan.We have been making a lot of efforts to elucidate the mechanism of acute antibody-mediated rejection in ABOI-KTx in order to overcome the ABO barrier and to improve the outcome. From careful and precise clinical observations, proteomic analysis of ABO histo-blood group antigens in graft endothelial cells and deep insight into immunology and biology, we have reached the hypothesis that the structural difference of ABO histo-blood group antigens and de novo corresponding antibody production would be the key and keyhole of the development of acute AMR in ABOI-KTx. Preoperative desensitization therapy would be the best solution for the suppression of acute AMR and graft loss, which is now widespread and improves the outcome.     

Living-donor kidney transplantation

The number of living donations is increasing in Europe and especially in Germany. The reasons seem to be a continuous shortage of cadaveric organs, better results after living related and living unrelated donation, and a high willingness in the population to donate. Various legal prerequisites have to be fulfilled in different countries. In general, careful donor evaluation is necessary to avoid excessive risk in the donor. Nephrectomy for transplantation can be performed via various approaches; microinvasive surgical techniques have been introduced, but are not yet established. Immunosuppression in living related donation is no different from that in cadaveric transplantations. In conclusion, living donation seems to be an adequate alternative to cadaveric donation. Moreover, results are twice as good as cadaveric donation with regard to long-term function. Received: 25 October 1999 Accepted: 27 October 1999     

Domino kidney transplantation

Kidney transplantation has become a victim of its own success. Despite measures to increase the number of donors, success to date has been limited. At the Western Infirmary, we used an organ that had been transplanted earlier. The patient who received that organ has since been followed up for more than 2 years, and no issues have arisen regarding functioning of the graft. Although it does not increase the donor pool, we believe that domino kidney transplantation ought to be considered when the situation merits it.     

ABO-incompatible kidney transplantation

When a renal transplant candidate's only medically-acceptable living kidney donor is ABO incompatible, the most common practice is to place them on the deceased donor list. Over the past few years, the implementation of paired kidney donor exchange programs and the development of protocols to overcome the ABO blood group barrier have become much more successful and widespread. Here we review the therapeutic options for patients whose only living kidney donor is ABO incompatible, with a specific emphasis on the rationale for and the current outcomes of ABO incompatible living donor kidney transplantation.     

活体肾移植和尸体肾移植术后疗效和安全性比较

近年来随着尸体供肾的日益短缺,国内活体肾移植例数迅速增加,但活体肾移植术后疗效和安全性尚有待进一步探讨.本研究回顾分析我院过去4年多来肾移植资料,比较两组患者术后长期疗效和安全性差异.     

Combined liver and kidney transplantation

Patients with end-stage renal and hepatic failure may be treated with combined liver and kidney transplantation (CLKTx). We reviewed the indications and outcomes of 16 CLKTx performed at the University of Minnesota between 1980 and 1994. The majority of the recipients (87.5%) were young patients affected by congenital hepatic anomalies and concomitant end-stage renal failure. Fourteen were treated with cyclosporin-based immunosuppression and had an excellent outcome: with an average of 6 years of follow-up, patient survival was 85.7%, liver graft survival 85.7%, and kidney graft survival 72%. The incidence of rejection episodes was similar to the rate of rejection in our solitary kidney and liver transplants. In conclusion, our experience supports the value of CLKTx in treating patients with simultaneous failure of both organs or with congenital enzymatic hepatic deficits leading to renal failure.     

ABO-incompatible kidney transplantation and rituximab

We have designed a protocol for ABO-incompatible kidney transplantations based on antigen-specific immunoadsorption rather than plasmapheresis to remove anti-A or anti-B antibodies and with a Prograf/Cellcept/prednisolone protocol using rituximab rather than splenectomy to prevent rebound antibodies. Twelve patients have successfully received transplants with this protocol. The ABO-antibodies were readily removed by the antigen-specific immunoadsorption and maintained at a low-level posttransplantation. There were no side effects. All patients have normal renal transplant function with a follow-up of 1 to 34 months.     

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据国际胰腺移植登记中心 (ＩＰＴＲ)及全美器官分配网络 (ＵＮＯＳ)统计 ,至 2 0 0 0年 10月 ,已经接受胰腺移植超过15 0 0 0例 ,其中 87%为胰肾联合移植。人 /移植胰腺 /肾 1年生存率达 95 % /90 % /84% ,5年生存率达 82 % /70 % /6 6 %。目前胰肾联合移植已成功进入临床应用阶段 ,成为治疗糖尿病合并糖尿病肾病的最佳手段。1　历史回顾早在 1889年Ｍｅｒｉｎｇ和Ｍｉｎｋｏｗｓｋｉ就提出胰腺移植治疗糖尿病的设想 ,1892年开始正式实验研究。 2 0世纪 6 0年代实验基本成熟 ,开始将该技术应用于临床。 196 6年明尼苏达大学的Ｋｅｌｌｙ教授…     

Living donor and kidney transplantation

The medical, immunological and surgical histories of the transplantation of kidneys from a living donor have been developed differently. Living kidney transplantation involves better organ quality and also better kidney function than postmortem kidney transplantation. In Germany, living kidney transplantation is legally based on the transplantation statute of 1997. Traditionally, retroperitoneoscopic open nephrectomy is the gold standard used by most transplantation centers in Germany. The laparoscopic hand-assisted nephrectomy is a very good alternative to other surgical methods, but must be applied by experience surgeons. Digital subtraction angiography gives the best information on the maintenance of the vessels of the kidney, the vessels to the upper or lower poles and the retrocaval course of the venous vessels. The rate of postoperative complications for transplantation from a living kidney donor is lower than that for postmortem kidney transplantation. The formation of a donor organ registry can be very helpful in the evaluation and handling of information on organ donation.