肾移植326例临床分析

目的对1990～2005年间326例次肾移植情况进行临床分析。方法统计肾移植术后受者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抗原/基因配型及群体反应抗体(PRA)检测情况。结果(1)自1990年使用环孢素A(CsA)后1年人、肾存活率(人、肾均存活)为86.33%,3年为80.26%,5年为66..34%;(2)50岁以上肾移植患者102例,1年移植肾存活率83.44%,1年人存活率85.43%;(3)肾移植术后患者心脑血管系统疾病占死亡原因的50.7%,感染占病死率的13.5%;(4)恶性肿瘤的发病率为1.5%。(5)良好的HLA供受者配型可减少术后急性排斥反应的发生率,利于移植肾的长期存活。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56例临床分析

目的：对56例尸体肾移植资料进行分析、总结。方法：统计肾移植术后受者1年人、肾存活率、人类组织相容性抗原(HLA)供—受者配型及群体反应抗体(PRA)检测情况；肾移植术后主要并发症。结果：1年人、肾存活率92．9％／88．1％，加速性排斥1例，急性排斥(AR)8例(14．3％)，环孢素A(CsA)急性肾中毒1例，无1例出现急性肾小管坏死(ATN)。结论：①受者充分的术前准备和高质量的供肾是提高手术成功率的保证；②严格的HLA配型和术后合理用药是提高存活率的关键；③免疫抑制剂的合理应用使感染发生率明显降低。     

PRA配型技术在肾移植中的应用研究

目的探讨群体反应性抗体 (PRA)配型新技术对肾移植近远期的效果。方法 85 4例患者肾移植前运用PRA新技术进行组织配型 ,并行血浆置换 ,未采用PRA组织配型的 42 3例作为对照 ,观察肾移植术后免疫指标变化、近期 (AR)发生率以及对长期存活的影响。结果未采用PRA组织配型组发生超急性排斥反应 (HR) 9例 (2 1% )、急性排斥反应 198例 (47% ) ;1年人/肾存活率 86 7% /76 3%、3年人 /肾存活率 72 5 % /6 7 9%、5年人 /肾存活率 6 9 5 % /4 9 3%。采用PRA配型新技术共 85 4例 ,肾移植术后未发生超急性排斥反应 ,发生急性排斥反应 16 2例 (19 0 % ) ,1年人肾存活率达 97 3% /95 0 %、3年人肾存活率 92 0 % /84 2 %、5年人 /肾存活率 87 0 % /81 6 %。结论PRA阴性配型可杜绝超急性排斥反应发生 ,降低急性排斥反应发生率 ,提高人 /肾长期存活率。     

HLA配型在尸体肾移植中的应用(附100例分析)

分析了行HLA-A、B、DR 配型的100例尸体肾移植资料。结果表明,HLA配型结果较好者,移植后急性排斥反应的发生率为33.3%,移植肾的1年存活率为94.7%;而配型差者,急性排斥反应的发生率达60.0%,移植肾的1年存活率仅78.6%.据此认为,HLA 配型对降低尸体肾移植后排斥反应的发生率,提高移植肾的存活率是非常有益的。     

同种异体肾脏移植20例,胰肾联合移植1例临床报告

目的对19例同种异体肾移植,1例胰肾联合移植资料进行分析、总结。方法统计肾移植术后1年人、肾存活率,人类组织相容性抗原(HLA)供受者之间配型以及群体反应抗体(PRA)检测情况。结果人肾存活率95%/95%,19例恢复工作,1例死亡,未出现外科并发症,术后4例出现加速排斥反应,2例出现急性排斥反应。结论充分的术前准备和高质量的供肾是提高手术成功率的保证;严格的HLA配型和术后合理用药是提高长期存活的关键;免疫抑制剂合理使用可降低感染的发生率。     

PRA配型技术在肾移植中的应用研究

目的 探讨群体反应性抗体（PRA）配型新技术对肾移植近远期的效果。方法 854例患者肾移植前运用PRA新技术进行组织配型,并行血浆置换,未采用PRA组配型的423例作为对照,观察肾移植术后免疫指标变化、近期（AR）发生率以及对长期存活的影响。结果 未采用PRA组织配型组发生超急性排斥反应（HR）9例（2.1%)、急性排斥反应198例（47%）;1年人/肾存活率86.7%/76.3%、3年人/肾存活率725%/67.9%、5年人/肾存活率69.5%/d49.3%。采用PRA配型新技术共854例,肾移植术后未发生超急性排斥反应,发生急性排斥反应162例（19.0%),1年人肾存活率达97.3%/49.3% 。采用PRA配型新技术共854例,肾移植术后未发生超急性排搞清反应,发生急性排斥反应162例（19.0%),1年人肾存活率达97.3%/95.0%、3年人肾存活率92.0%/84.2%、5年人/肾存活率87.0%/81.6%。结论 PRA阴性配型可杜绝超急性排斥反应发生,降低急性排斥反应发生率,提高人/肾长期存活率。     

再次肾移植的临床特点及治疗体会

目的 分析影响再次移植肾存活率的各种因素,提高再次移植肾的长期存活率.方法 对39例再次肾移植进行回顾性分析.结果 再次肾移植术后1、3、5年移植肾存活率显著低于初次肾移植(分别为76.5%、64.2%、56.5%和87.1%、75.1%、68.2%, P<0.05);群体反应性抗体(PRA)阳性受者术后急性排斥反应发生率高于PRA阴性受者,使用抗体诱导治疗患者术后急性排斥反应发生率低于未用抗体诱导治疗患者.是否切除失功肾对再次移植肾存活率无明显影响.结论 再次移植肾存活率明显低于首次移植.个体高免疫状态是再次肾移植的危险因素,必须更加严格地进行组织配型,进行抗体诱导治疗有利于再次移植肾的存活.如没有排斥反应及并发症的发生,不主张切除原移植肾.     

近期移植肾排斥反应对长期存活的影响及处理方法

目前同种肾移植的症结所在依然是怎样提高长期存活率和生活质量。由于移植免疫学的迅速发展,同种肾移植近期效果明显提高,移植肾1年存活率超过90％,尸肾移植物半数存活时间(T1/2)亦由原来的6.7年延长至90年代的10.9年,但长期效果还不尽人意。影响长期存活的因素很多,如供肾质量、缺血时间、移植肾功能延迟恢复(GDF)、淋巴毒交叉反应、HLA配型、免疫抑制剂以及急性排斥反应等。近年来,越来越多的证据表明,急性排斥反应是影响移植肾长期存活的重要独立危险因素。     

群体反应性抗体技术及HLA配型在1700例肾移植中的应用研究

目的探讨群体反应性抗体(panel reactive antibody,PRA)、HLA配型技术对肾移植近远期的效果。方法对拟行肾移植的患者运用PRA检测、HLA组织配型,要求HLA抗原3~6个位点相合,PRA阳性(20%以上)给予3~5次血浆置换,共1 700例作为第一组,未采用PRA、HLA组织配型的423例患者为第二组。观察两组肾移植术后免疫指标变化,近期急性排斥反应发生率以及HLA-A、B、DR位点对长期存活的影响。结果第一组肾移植术后环孢素A(cyclosporine A,CsA)用量减至5~7 mg·kg-1·d-1,移植肾功能恢复时间2~16 d,平均5 d,均未发生超急性排斥反应,发生急性排斥反应252例(14.8%),1年人/肾存活率高达98.6%/96.7%,3年人/肾存活率93.1%/87.3%,5年人/肾存活率88.1%/83.6%。第二组肾移植术后CsA用量8~12 mg·kg-1·d-1,移植肾功能恢复时间4~30 d,平均13 d,发生超急性排斥反应者9例(2.1%),急性排斥反应198例(46.8%),1年人/肾存活率86.7%/76.3%,3年人/肾存活率72.5%/67.9%,5年人/肾存活率69.5%/59.3%。结论PRA阴性加良好的HLA配型可杜绝超急性排斥反应的发生,降低急性排斥反应发生率,提高人/肾长期存活率。     

肾移植2 200例次临床分析

目的 总结1908例（2200例次）肾移植手术的临床经验,提高肾移植术后人、肾存活率。方法 总结1985年以后人、肾1年、3年、5年的存活率;肾移植主要并发症及其处理原则;影响患者再移植存活率的因素;HLA－抗原／基因配型及群体反应抗体（PRA）检测。结果 （1）自1985年临床使用环孢素A（CSA）后,其1年人、肾存活率为87.3％,3年人、肾存活率为80.2%,5年人、肾存活率为67.0%.(2)50岁以上肾移植患者302例,术后1年移植肾存活率8.4%(252/302),1年人存活率8534%(258/302).(3)肾移植术后患者死亡原因主要是心血管系统疾病及感染。心血管系统疾病占死亡原因的50.7%,感染占死亡率的13.5％（4）。肾移植术后恶性肿瘤 的发病率为1.5％（23／1580）。（5）肝损害患者有独特的药代动力学特点。（6）良好的HLA供－受者配型可以减少肾移植术后急性排斥反应的发生率,有利于移植肾的长期存活。在HLA抗原不配合的情况下,受者应尽量选择不具有免疫原性抗原／基因的供肾移植。（8）对于慢性排斥应应采取综合方法进行治疗。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及及时治疗是提高肾移植术后人、肾存活率的重要因素。     

活体肝移植与尸肝移植急性细胞排斥反应的比较

目的 比较活体肝移植（LDLT）与尸肝移植（CLT）急性细胞排斥反应（ACR）的发生率及严重程度。方法 将116例病人分为两大组,LDLT组51例（其中供受体有血缘关系者30例）,CLT组65例。收集的临床资料包括肝移植物冷缺血时间、基础免疫抑制剂的应用、ACR发生次数及对激素治疗的反应、供受体HLA配型、肝移植物及病人存活情况。结果 CLT组及LDLT组移植物存活率、病人存活率、ACR发生率、ACR多次发生率、对激素治疗无效率分别是72％和78％、77％和78％、48％和41％、20％和10％、11％和4％（两组比较P＞0．05）。有血缘关系者间的肝移植与尸肝移植比较ACR的发生率差异无显著意义。在发生与不发生ACR的病人间HLA位点不合数差异亦无显著意义。以FK506为主的二联免疫治疗方案能减少ACR的发生（P＜0．01）。结论 活体肝移植与尸肝移植ACR的发生率差异无显著意义。供受体HLA配型及移植物冷缺血时间长短与ACR无关。而FK506预防ACR的效果明显优于环孢霉素A。     

丙型肝炎病毒感染对肾移植术后影响的临床研究

OBJECTIVE: To study the influence of hepatitis C virus (HCV) infection on the clinical outcome of kidney transplantation. METHODS: The recipient/graft survival, the incidence of acute/chronic rejection and cause of death in 86 HCV-infected recipients of renal transplantation were compared with those in another 86 recipients without HCV infection. RESULTS: HCV-infected recipients had significantly shorter 5-year survival (74.4%) than those without HCV infection (87.2%, P<0.01). The 1-year (94.2%/90.7% vs 96.8%/96.0%) and 3-year recipient/graft survival rates (88.4%/79.1% vs 90.7%/87.2%), the incidence of acute/chronic rejection (31.3% vs 21.2%, and 12.5% vs 6.5%) and the 5-year graft survival (73.3%/81.4%) were comparable between the two groups (P>0.05). Hepatic disease was identified as the primary cause of mortality. CONCLUSIONS: HCV infection may affect the long-term survival of the recipients with kidney transplantation, and therefore should be considered as a relative contraindication of kidney transplantation.     

丙型肝炎病毒感染对肾移植术后影响的临床研究

目的 探讨丙型肝炎病毒(Hepatitis C virus,HCV)感染对肾移植术后的影响。方法 比较86名HCV感染和86名非HCV感染病人肾移植术后1,3,5年人/肾存活率和急、慢性排斥反应的发生率,并对死亡病例的原因进行分析。结果 两组病人在肾移植术后不同时间人/肾的存活率分别为:术后1年(94.2%/90.7%和96.8%/96.0%);术后3年(88.4%/79.1%和90.7%/87.2%);术后5年(74.4%/73.3%和87.2%/81.4%)。两组急性排斥反应发生率为31.3%和21.2%,慢性排斥反应发生率为12.5%和6.5%。其中HCV感染组5年人存活率低于非HCV感染组(P<0.05),而其他各项结果无统计学差异(P>0.05)。肝病为感染组的首位死亡原因(36.4%)。结论 HCV感染对肾移植受者术后长期存活存在负面影响,HCV感染应作为肾移植手术的相对禁忌证。     

影响致敏患者移植肾存活的危险因素分析

目的探讨影响致敏患者移植肾存活的危险因素,识别引起移植物失功的高危患者,以提高致敏患者移植肾长期存活率。方法选择102例行肾移植术的致敏患者进行回顾性研究,用Kaplan-Meier计算1、3、5年移植肾存活率,用log-rank进行单因素分析和Cox模型多因素回归分析,计算相对危险度。结果102例致敏患者随访期间移植肾失功16例,其中死亡7例,术后1年内死亡5例,术后2及3年带肾死亡各1例。死亡原因肺部感染5例、心血管疾病2例,失访3例。1、3、5年人存活率为95%、93%和93%,1、3、5年肾存活率为90%、85%和75%,移植肾半生存期为8.9年。单因素及多因素分析表明受者年龄、移植次数、PRA水平、术后PRA水平升高、HLA相配程度、移植肾功能恢复正常时间、移植肾功能延迟恢复、急性排斥反应、血肌酐水平、感染等10个因素对移植肾的存活产生重要或非常重要影响。结论通过控制影响移植肾存活的危险因素,致敏患者移植肾存活同样能取得满意效果。     

Risk factors for graft survival in sensitized recipients of kidney transplantation.

OBJECTIVE: To investigate the independent prognostic factors for graft survival in sensitized recipients undergoing kidney transplantation, so as to identify the individuals at high risk of graft loss before transplantation. METHODS: A retrospective investigation was conducted in 102 sensitized kidney transplant recipients and 31 relative variables were analyzed with SPSS10.0 software. Using log-rank method, the influence of these variables on short- and long-term graft survivals was evaluated, and Kaplan-Meier analysis was performed to estimate the 1-, 3- and 5-year graft survival rates and half-life. Proportional hazards regression analysis (Cox model) was used to assess the relative risks of the potential variables. RESULTS: In the recipients with a mean half-life of 8.9 years, the 1-, 3- and 5-year graft survival rates were 90%, 85%, and 75%, respectively. By log-rank analysis, the factors affecting short- and long-term graft survivals were identified, namely the recipient age, times of transplantation, levels of panel reactive antibody and the post-operative anti-HLA-IgG antibody, HLA mismatch, renal function, time needing for graft function recovery, presence of acute rejection, delay of graft function recovery and infection, which affected the graft survival demonstrated by Cox model multivariate analysis. CONCLUSION: High-quality donor kidney and minimization of the risk factors for graft survival may insure successful kidney transplantation in sensitized recipients.     

41例再次肾移植的临床分析

目的：总结再次肾移植的临床经验,提高移植肾的长期存活率。方法：回顾分析1999年1月～2005年12月41例再次肾移植的临床资料,统计移植后受者1、3、5年的移植肾存活率及影响存活率的因素。 结果：再次移植后1、3、5年移植肾存活率分别为85.4％、76.2％、65.8％;再次移植前切除原移植肾患者1、3、5年移植肾存活率分别为88.9％、74.7％、62.2％,术后急性排斥反应的发生率为33.3％;再次移植前未切除原移植肾患者1、3、5年移植肾存活率分别为82.6％、77.1％、68.5％,术后急性排斥反应的发生率为30.4％,二者存活率及急性排斥反应发生率差异均无统计学意义。PRA阳性患者术后急性排斥反应的发生率高于PRA阴性患者,应用抗体诱导治疗的患者术后急性排斥反应的发生率低于未诱导治疗的患者。结论：再次移植前切除原移植肾不能提高再次移植的远期存活率,采用良好的HLA配型及抗体诱导治疗有利于移植肾的存活。     

A retrospective comparison of the efficacy and safety in kidney transplant recipients with basiliximab and anti-thymocyte globulin

Background  Induction therapy are utilized to achieve an adequate immunosuppression at the time of transplantation. The use of basiliximab or anti-thymocyte globulin (ATG) for induction therapy has significantly reduced the incidence of acute rejection episodes post-transplantation. The purpose of this study was to compare the efficacy and safety of the basiliximab in patients with immuno-induction therapy after kidney transplantation with the ATG.

Methods  A retrospective analysis was carried out in kidney transplant recipients including 146 patients with the basiliximab and 116 cases with the ATG and the acute rejection, graft function, infective complications and 1-year and 5-year actuarial patient and graft survival after renal transplantation were compared between the two treatment groups.

Results  There were no statistically significant difference between groups regarding age, sex, cold ischemic time, warm ischemic time, human leukocyte antigen (HLA) matching type between the donor and recipient, lymphotoxin test and the use of immunosuppressive agents. There was no statistical significance regarding the incidence of the acute rejection (9.59% vs. 8.62%, P=0.481) and delayed graft function (10.27% vs. 9.48%, P=0.501) between groups. There were significantly lower lung infection incidence (5.48% vs. 12.93%, P=0.029) in the basiliximab-treated group in comparison with the ATG-treated group. One-year patient and graft survival rates were 98%, 97% for the basiliximab-treated group, and 95%, 73% for the ATG-treated group, respectively. Five-year patient and graft survival rates were 92%, 86% for the basiliximab-treated group and 93%, 72% for the ATG-treated group, respectively. Log rank test showed statistically significant difference with P=0.038 for patients and P=0.033 for grafts, respectively. There were significantly lower the incidence of granulocytopenia (8.22% vs. 17.24%, P=0.022) and thrombocytopenia (4.11% vs. 19.83%, P=0.000) after transplantation in the basiliximab-treated group in comparison with the ATG-treated group. There was no statistical significance regarding the incidence of the heart dysfunction after transplantation between the two groups (6.16% vs. 6.90%, P=0.502).

Conclusion  The immuno-induction therapy with the basiliximab in kidney transplant recipients is efficient and safe with less complication compared with the ATG.

     

群体反应性抗体技术及HLA配型在1700例肾移植中的应用研究

OBJECTIVE: To evaluate the role of panel reactive antibody (PRA) screening and human leukocyte antigen (HLA) typing in renal transplantation. METHODS: PRA screening and HLA typing were performed in 1 700 patients eligible for the first group of renal transplantation who had 3 to 6 HLA matches in HLA-A, B and DR with the donor, and in cases positive for PRA, plasma exchange was conducted. Another 423 patients who did not receive PRA screening or HLA typing constituted the second group. The changes of immune variables, incidences of acute rejection and the effect of HLA-A, B, DR matching on long-term graft survival were observed. RESULTS: In 1 700 cases of group 1, post-transplantation CsA dose was reduced to 5 to 7 mg*kg(-1)*d(-1) and the graft function recovery time ranged from 2 to 16 d, averaging 5 d. Acute graft rejection occurred in 252 (14.8%) cases, but no hyper-acute rejection was observed. The 1-, 3- and 5-year patient/graft survival rates were 98.6%/96.7%, 93.1%/87.3% and 88.1%/83.6% respectively. In group 2, CsA dose ranged from 8 to 12 mg*kg(-1)*d(-1) and the graft function recovery time was 4 to 30 d, averaging 13 d. Hyper-acute rejection occurred in 9 (2.1%) and acute rejection in 198 (46.8%) cases, and the 1-, 3- and 5-year patient/graft survival rates were 86.7%/76.3%, 72.5%/67.9% and 69.5%/59.3% respectively. CONCLUSIONS: Negative PRA and good HLA matching can eliminate the incidences of hyper-acute rejection, decrease the rate of acute rejection and improve both patient and graft survival rates.     

KIR及苴HLA配体与肾移植急性排斥反应的关系

目的 探讨供受者对杀伤细胞免疫球蛋白样受体(KIR)及其人类白细胞抗原(HLA)配体所介导信号传导通路在肾移植受者术后发生急性排斥反应(AR)中可能的作用.方法 回顾性分析53对肾移植供受者对HLA和KIR基因型,受者按照术后肾功能状态分为急性排斥组(n=19)和肾功能稳定组(n=34),探讨供者HLA、受者KIR基因型以及受者KIR/供者HLA配体组合型与肾移植急性排斥反应发生的相关性.结果 供者HLA、受者KIR基因表现型频率在急排组和稳定组的分布:供者HLA基因型HLA-CI/2、HLA-A3、HLA-A11、HLA-Bw4在两组间分布无显著统计学差异(P>0.05).受者KIR2DL2/2DS2在急排组表达低于稳定组(26.3% vs 55.9%,P=0.038),受者KIR基因组合型AA类型在急排组表达低于稳定组(31.6% vs 67.6%,P=0.011).供者HLA-Cw、受者KIR基因组合型术后急性排斥反应发生率:供者HLA-C1/C1类型低于非HLA-C1/C1类型(31.6% vs 46.7%,P>0.05).受者KIR基因组合型AA类型低于非AA类型(20.7% vs 52.2%.P=0.011).受者KIR/供者HLA配体组合型匹配情况:肾功能稳定组中KIR2DL2/HLA-C1和KIR2DL2/HLA-C1信号匹配率较急性排斥组高(P=0.030,P=0.028).结论特定的KIR/HLA配体组合型(如KIR2DL2/HLA-C1、KIR2DL2/HLA-C1)可以降低肾移植术后急性排斥反应的发生率.良好的供者HLA和受者KIR配型选择有利于同种异体肾移植的预后.     

IMPORTANCE OF DONOR SELECTION IN RENAL TRANSPLANTATION

Renal transplantation has become a treatment of choice for patients with end stage renal disease. A successful transplant is the result of a combination of several factors acting synergistically, such as the degree of HLA compatibility between donor and the recipient, pretransplant blood transfusions, the recipient''s state of immunoreactivity and sensitization, immunosuppressive therapy given in post operative period etc. Donor selection appears to be the most critical factor for the long term success of the organ graft. In this brief review, some of the important parameters of donor selection in renal transplantation are highlighted.KEY WORDS: Histocompatibility (HLA) matching, Cross match, Sensitization