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。     

合并顽固性高血压的尿毒症患者肾移植前切除双肾对移植肾功 …

目的 探讨尿毒症合并药物难以控制的高血压患者移植前切除双肾对术后血压及移植肾功能的影响。方法 ４２例合并顽固性高血压的尿毒症患者分成２组（每组２１例），一组先行双肾切除，６个月～１年后再行肾移植，另一组不切肾，直接施行肾移植。对比分析２个组肾移植术后的血压及移植肾功能的恢复情况。结果 切肾组在双肾切除后，１３例（６１．９％）的平均舒张压低于９０ｍｍＨｇ或较术前降低１０ｍｍＨｇ以上；６例（２８．６％     

合并顽固性高血压的尿毒症患者肾移植前切除双肾对移植肾功能的影响

目的　探讨尿毒症合并药物难以控制的高血压患者肾移植前切除双肾对术后血压及移植肾功能的影响。方法　 42例合并顽固性高血压的尿毒症患者分成 2组 (每组 2 1例 ) ,一组先行双肾切除 ,6个月～ 1年后再行肾移植 ,另一组不切肾 ,直接施行肾移植。对比分析 2个组肾移植术后的血压及移植肾功能的恢复情况。结果　切肾组在双肾切除后 ,13例 (6 1.9% )的平均舒张压低于 90mmHg或较术前降低 10mmHg以上 ;6例 (2 8.6 % )的平均舒张压较术前降低 15 %以上 ;肾移植术后1年 ,双肾切除组血压正常者 11例 (5 2 .4% ) ,对照组血压正常者 5例 (2 3.8% ) ,两组比较 ,差异有显著性 (P <0 .0 5 ) ;移植肾 1年存活率 ,切肾组为 95 .2 % ,对照组为 81.0 % ,差异有显著性 (P <0 .0 1)。结论　存在顽固性高血压的尿毒症患者若需行肾移植 ,在明确手术指征的情况下可先行自体双肾切除术 ,这有利于肾移植术后血压的控制及移植肾功能的稳定     

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。     

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。     

多囊肾患者肾移植的临床研究

目的 探讨多囊肾患者肾移植的特点、不切除原双侧肾脏的可行性及其对移植效果的影响。方法 总结了２８例多囊肾患者肾移植的临床研究结果。最大年龄６２岁,平均５６．２岁;透析时间３～１８个月。移植术前、术中及术后均未节除原双侧肾脏。移植后观察肾脏体积及血尿的变化,采取积极的防治感染措施。结果 １年人肾存活率均为９５．２％,３年存活率８５．７％,最长存活已９年;急性排斥反应的发生率１０．７％,移植后原肾脏体     

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.     

多囊肾与肾移植相关关系的研究

目的 研究多囊肾尿毒症患者肾移植术前是否需要切除多囊肾。方法 对30例多囊肾尿毒症患者肾移植后进行随访，比较生存率及生活质量。结果 切除多囊肾后肾移植的3、5年生存率分别为100％、70％，肾移植后患者可恢复正常工作。未切除多囊肾的肾移植3、5年生存率为70％、50％，肾移植后生活质量没有提高。结论 多囊肾尿毒症患者，肾移植前应常规切除多囊肾，以提高移植后3、5年生存率和生活质量。     

肾移植术前尿毒症患者合并症的手术治疗体会

目的 总结肾移植术前尿毒症合并症的手术治疗体会。以提高肾移植预后，方法 回顾性分析１９７８年至今尿毒症合并症３９例的手术指征。围手术期治疗以及肾移植预后情况，其中成人性多囊肾９例、药物不可控制性高血压２１例、脾功能亢进４例、胃溃疡５例。结果 ９例多囊肾切除术后１～６个月行肾移植术。随访肾功能正常；２１例高血压患者术后血压不同程度下降，术后６～１２个月行同种肾移植术，肾功能稳定；４例脾脾切除患者肾移     

糖尿病髂动脉硬化患者肾移植术51例报告

目的探讨糖尿病髂动脉硬化患者的肾移植手术特点。方法51例糖尿病合并髂动脉硬化的肾移植受者共行肾移植术54例次。其中肾动脉与髂外动脉直接端侧吻合13例次；切除硬化内膜，肾动脉与髂总／髂外动脉端侧吻合19例次；切除硬化内膜，肾动脉与髂内动脉钛环钉法端端吻合22例次。结果发生移植肾血流灌注不足致移植肾原发性无功能3例次，发生移植肾功能延迟恢复9例次（17．6％），其余42例次移植肾功能恢复良好。围手术期死亡2例（均为心跳骤停）。随访11—70个月，1年人／肾存活率为89．8％／87．8％，3年存活率为84．4％／81．3％。结论糖尿病髂动脉硬化患者移植肾动脉吻合困难，为保证移植肾有充足的血流灌注，应根据患者的不同情况选择吻合血管，并行硬化动脉内膜切除术。合并冠心病的患者肾移植术前应先行心肌再血管化手术。     

肝肾联合移植28例临床分析

目的 总结肝肾联合移植治疗终末期肝脏合并肾脏疾病的体会.方法 对28例肝肾联合移植的临床资料进行回顾分析,并对手术适应证的选择、手术方式、免疫制剂方案的应用以及预后情况进行了分析整理和总结.结果 肝肾联合移植各种适应证中,肝肾功能衰竭占78.6 %(22/28),肝肾综合征占14.3 %(4/28),高草酸盐尿症及多囊肾合并多囊肝各占3.6 %(各1/28).所有受者均先行肝移植,再行肾移植.肝移植采用背驮式者4例,采用经典非转流式者24例,供肾植入位置首选右侧髂窝.术后随访5个月至7年8个月,受者1年存活率为92.9 %(26/28),3年存活率为78.3 %(18/23).28例受者中,围手术期发生移植肾功能不良4例,其中3例经保守治疗病情好转,1例死亡.1例因移植肝并发症于术后3个月再次行肝移植治疗,后好转,期间肾功能未受影响.术后发生肺部感染11例,其中1例死亡,其余10例经治疗后痊愈.无一例发生急性排斥反应.结论 肝肾联合移植是治疗终末期肝脏合并肾脏疾病的有效手段,术前应严格控制手术适应证,把握适当的手术时机.

Abstract：

Objective To summarize the experience of treating the end stage of liver disease complicated with renal failure using combined liver-kidney transplantation.Methods The clinical data of 28 cases receiving combined liver-kidney transplantation were retrospectively analyzed, including the inclusion criteria of surgical indications, modus operandi, protocol of immunosuppression and the prognosis post-operation.Results Among these 28 cases in our study, 22 cases suffered from liver and renal failure, accounting for 78.6%; 4 cases were diagnosed as having hepatorenal syndrome, accounting for 14.3%; and 1 case had hyperoxaluria and polycystic liver with polycystic kidney. As for the modus operandi we used, piggy-back procedure was adopted for 4 patients and classic procedure without bypass was used for the rest. Donor kidneys were all put in the right iliac fossa. During the follow-up period of 5 months to 7 years, one-and 3-year survival rate of the recipients was 92.9% and 78.3% respectively. Among these 28 recipients, 4 cases had the graft renal dysfunction early post-operation: One died and 3 recovered through consecutive therapy. One case received re-transplantation of the liver 3 months after the first due to the relevant complications and then recovered. During this period, no impact on the renal function occurred. Eleven cases had pulmonary infection post-operation, and 1 died. No acute rejection occurred.Conclusion Combined liver-kidney transplantation is the effective treatment to the patients with end stage liver disease complicated with renal dysfunction. Suitable case selection and perfect operation timing were the key points to the success of combined liver-kidney transplantation.     

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.     

Polycystic liver and kidney disease: post-transplant kidney function in patients receiving pre-emptive kidney transplantation.

The aim of the study is to evaluate the changes in kidney function after pre-emptive kidney transplantation in patients with polycystic liver and kidney disease (PLKD) and to establish whether pre-emptive kidney transplantation is warranted. Between 1998 and 2006, five patients with severe anatomical changes in both native kidneys but only mild alteration of the clearance function received combined liver and kidney transplantation. Preoperatively, Technetium-99m mercaptoacetyltriglycine (Tc99m MAG3) scintigraphy was used to evaluate separately the function of each native kidney. This examination was repeated six months after transplantation, additionally measuring the function of the transplanted kidney. Pretransplant creatinine levels were 77-115 mumol/l and Tc99m MAG3 clearance was 141-163 ml/min/1.73 sqm (74 +/- 8% of minimum-for-age values). Six months after transplant, creatinine values were not significantly different. Minimum-for-age clearance decreased by 12.5 +/- 11.5% in four patients, and increased by 26% in one patient. In four patients, the transplanted and the native kidneys assumed each about one third of total tracer clearance. In one patient, the transplanted kidney assumed 92% of the clearance function. Kidney function decreases despite pre-emptive kidney transplantation. Native kidneys are not functionally excluded and the clearance seems to be divided between native and transplanted organs. Kidney transplantation in nonuremic PLKD patients does not improve the overall kidney function and should be performed only in exceptional cases.     

Strategies for compensating for the declining numbers of cadaver donor kidney transplants.

BACKGROUND: The living-donor and dual kidney transplantation programmes were initiated in the transplantation centre of Münster (TCM) as two approaches to compensate for the declining numbers of cadaver donor kidney transplants after the implementation of the new Eurotransplant Kidney Allocation System (ETKAS). We analysed the outcome of cadaver, living-donor and dual kidney transplantation and their effects on the waiting list in the TCM. METHODS: Between January 1990 and December 2000, 1184 kidney transplants were performed in the TCM. They were subdivided into cadaver, living-donor and dual kidney transplants and retrospectively analysed in terms of the number of kidney transplants performed, waiting time and waiting coefficient. In addition four representative groups were formed to reflect donor origin (I: cadaver kidney transplants allocated by the old ETKAS, n = 180; II: cadaver kidney transplants allocated by the new ETKAS, n = 139; III: living-donor kidney transplantation, n = 59; IV: dual kidney transplantation, n = 31) and compared according to graft function (initial diuresis, creatinine, 3-year graft function), patient survival and median waiting time. RESULTS: After the implementation of the new ETKAS, the number of cadaver donor kidney transplants at the TCM almost halved, but the proportion of living-donor kidney transplantations increased significantly by 12.8% and of dual kidney transplantations by 8.5%. Patients who had received kidneys from cadaver donors allocated by the new ETKAS (group II) had a better survival rate, short- and long-term function but a longer waiting time than in group I (old ETKAS). Patients with dual kidney transplants (group IV) showed the lowest survival and short-term function rate, but had long-term function equivalent to that of cadaver kidney transplants (groups I and II). Patients who had received kidneys from living donors (group III) had the best survival, and short- and long-term function rate as well as the shortest mean waiting time. CONCLUSIONS: Living-donor and dual kidney transplantation proved to be functionally equivalent alternatives and successful strategies for compensating the declining numbers of cadaver donor kidney transplants.     

公民逝世后器官捐献供肾移植临床分析

目的探讨公民逝世后器官捐献供肾移植的近期临床效果。方法公民逝世后器官捐献供肾移植73例,供者43例,其中本院器官获取组织42例,外院器官获取组织分享1例。分析肾移植术后人/肾存活率和并发症的发生情况。结果 73例受者随访9~38个月,术后6个月、1年的人/肾存活率分别为97.3%/94.5%、94.5%/91.8%。10例(13.7%)受者发生移植肾功能恢复延迟,15例(20.5%)受者术后发生急性排斥反应,21例(28.8%)受者发生肺部感染。2例受者移植肾丢失,4例受者移植肾带功死亡。结论公民逝世后器官捐献供肾移植近期疗效较好,是解决供肾来源的有效途径。