60岁以上尿毒症患者的肾移植临床分析（附151例报告）

目的探讨60岁以上老年尿毒症患者肾移植的特点，总结剧手术期经验。方珐回顾性分析2000年1月至2005年11月我院151例60岁以上肾移植患者的围手术期治疗方案，结合随访结果，对手术适应证、组织配型、免疫抑制剂应用等方面作出评价。结果151例肾移植患者尉手术期无死亡病例，人肾存活率达98．68％，术后平均住院23．86d。术后1年人肾存活率达97．61％。结论严格掌握手术适应证和组织配型，优质的供肾是减少老年‘肾移植患者围手术期并发症的前提；应用免疫诱导，合理使用免疫抑制剂，个体化治疗原则是保障人肾存活率的重要手段。     

老年肾移植的临床特点(附75例报告)

目的：探讨老年患者肾移植的临床特点。方法：回顾性分析了75例老年患者肾移植的临床资料，以同期行肾移植的160例非老年成人患者为对照组。结果：老年组围手术期的并发症发生率（50．7％）和死亡率（4．0％）均显著高于对照组（20.0％和0，P〈0．01）。老年组急性排斥反应发生率为4．0％，显著低于对照组（12．5％，P〈0．05）。老年组1年人存活率为90.6％，显著低于对照组（98．1％，P〈0．05）；1年肾存活率为90．6％，低于对照组（96．3％）但无统计学差异（P〉0．05）。结论：老年患者行肾移植术可以取得良好效果，但围手术期的并发症发生率较高。老年受者术后急性排斥反应发生率低，应使用低剂量的免疫抑制剂。     

尿毒症频发心力衰竭患者肾移植15例

目的：探讨尿毒症频发心力衰竭(心衰)患者肾移植的可行性及安全性。方法：回顾性分析15例继发于尿毒症的顽固性心衰患者肾移植围手术期处理方法及临床效果。结果：14例患者安全度过围手术期，3个月后心脏缩小，心功能明显改善，移植肾功能正常；1例在术后第8天死于心肺功能衰竭。结论：顽固性心衰尿毒症患者可行肾移植，心衰并非肾移植的绝对禁忌证，只要受体选择合适，治疗及时得当，患者可安全度过肾移植围手术期。     

老年尿毒症患者肾移植的围手术期处理（附23例报告）

目的：探讨老年患者肾移植围手术期的处理原则及治疗方案。以提高手术成功率。方法：对23例施行肾移植手术的老年尿毒症患者进行临床分析：术前详细检查，排除手术禁忌证；严格组织配型，采取恰当的手术方式；术后严密观察病情变化；采用合适的免疫抑制治疗方案。结果：23例患者手术全部成功。术后发生肺部感染5例．其中1例并发呼吸衰竭、心功能衰竭抢救无效死亡，1例再次肾移植患者出现移植肾功能延迟恢复（DGF）并出现急性排斥反应、心功能衰竭、肺部感染，经抢救无效死亡；心力衰竭1例，脑出血1例，急性排斥反应3例次，消化道出血1例，CsA、FK506浓度中毒各1例，经治疗后，患者均顺利度过围手术期。绪论：应严格掌握适应证，良好的组织配型、高质量的供体、完备的术前准备、个体化的手术方式及免疫抑制治疗方案、防治并发症是手术成功的重要保证。     

围术期老年胃癌病人精氨酸加压素的变化及临床意义

目的：为探讨老年胃癌根治术围术期的应激反应程度，本研究拟观察其围术期血浆精氨酸加压素（ＡＶＰ）的变化。方法：随机选择ＡＳＡⅠ～Ⅱ级拟行胃癌根治术的患者１０例，年龄６０～７０岁，选择Ｔ８～９硬膜外阻滞，以２％利多卡因及０．５％地卡因混合液维持麻醉。分别于术前１天（基础值）；硬膜外给药后２０分钟；切皮；腹腔探查；肿瘤切除后；手术结束时；术后２４小时、４８小时及７２小时分别抽取肘静脉血样，采用放射免疫分析法测定其血浆ＡＣＰ浓度。结果：与基础值比较，ＡＶＰ水平在麻醉后轻度下降，而切皮至手术结束时明显升高（Ｐ＜０．０１），肿瘤切除后达峰值，术后２４小时、４８小时及７２小时均高于术前水平。结论：老年患者在硬膜外阻滞下行胃癌根治术围术期应激反应明显，因此围术期应使用其它麻醉或镇静药以减轻应激反应，同时还应加强心电监测。     

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     

老年髋部骨折合并糖尿病围手术期治疗探讨

目的探讨老年髋部骨折合并糖尿病治疗的经验。方法从2000年8月～2004年8月，对24例老年髋部骨折合并糖尿病患者进行围手术期处理，其中男13例，女11例，平均年龄72岁（63—85岁）。结果本组病例切口均顺利愈合，术后3—15天出院；全部获得随访，平均随访时间6个月；无一例死亡。骨愈合时间3～10个月。所有病例术后骨折均愈合，髋关节优良满意率为98．4％。结论对于髋部骨折合并糖尿病患者，良好的围手术期康复治疗能够保证老年患者顺利进行手术、切口和骨折快速愈合、恢复良好关节功能、降低并发症及致残率，提高生存质量，延长寿命。     

老年肝癌并存慢性疾病患者肝切除术的围术期护理

目的总结老年肝癌并存慢性疾病患者肝切除术的围术期护理经验。方法对126例老年肝癌并存慢性疾病患者实施肝切除术。术前做好机体功能评估．积极治疗并存疾病，加强功能锻炼，以期达到手术的要求；术后加强监护、并发症的护理及基础护理。结果全组无围术期死亡。术后发生胸腔积液、膈下积液10例，肺部感染4例，腹腔出血3例，胆漏2例，经及时处理均治愈；患者平均住院16．7d。结论老年肝癌并存慢性疾病患者行肝切除手术治疗，配合精心护理，可使患者顺利渡过围手术期，有利于术后顺利康复。     

重视老年胃癌患者的围手术期处理(附370例报告)

目的 总结老年胃癌的临床特点及围手术期处理经验。方法 回顾性分析我院1990年1月至2003年1月间共收治的370例老年胃癌患者的临床资料。结果 370例老年胃癌中290例（78．4％）伴有高血压、心脏病、糖尿病等老年常见病；术后发生并发症110例次，死亡16例；手术前有共存病者术后并发症的发生率（34．5％）明显高于无共存病者（12．5％），P〈0．01。结论 加强围手术期处理是降低老年胃癌患者并发症和死亡率的关键。     

外科治疗老年慢性阻塞性肺病合并自发性气胸57例的体会

目的总结老年慢性阻塞性肺病（COPD）合并自发性气胸（SP）患者的外科诊治经验，探讨治疗策略，以尽可能降低围手术期并发症的发生率。方法回顾性分析57例老年COPD合并自发性气胸患者外科治疗的临床资料，57例患者中45例行胸腔镜手术，12例行开胸手术。结果住院死亡2例（3．5％），均死于肺部感染、呼吸衰竭。术后发生并发症25例（43．9％），主要并发症为肺创面漏气、心律失常、肺部感染等。术后胸腔引流管漏气10例。术后留置胸腔引流管1～21天（平均4．1天）。随访55例，随访时间3～18个月，无气胸复发。结论老年COPD合并自发性气胸患者由于术前基础病症多、肺组织质地和弹性差以及愈合能力差，导致围手术期并发症发生率较高。严格掌握手术指征、有手术条件者尽早选择手术治疗、术中联合采取防止肺创面漏气以及促进胸膜腔粘连的措施是患者术后顺利康复的重要条件。同时应强化呼吸道祛痰、营养支持，采取各种措施促使肺复张，尽早拔除胸腔引流管，早期活动。     

Chronic Kidney Disease After Liver Transplantation for Acute Liver Failure Is Not Associated With Perioperative Renal Dysfunction

Renal dysfunction of acute liver failure (ALF) may have distinct pathophysiological mechanisms to hepatorenal syndrome of cirrhosis. Yet, the impact of perioperative renal function on posttransplant renal outcomes in ALF patients specifically has not been established. The aims of this study were ( 1 ) to describe the incidence and risk factors for chronic renal dysfunction following liver transplantation for ALF and ( 2 ) to compare renal outcomes with age–sex‐matched patients transplanted for chronic liver disease. This was a single‐center study of 101 patients transplanted for ALF. Fifty‐three‐and‐a‐half percent had pretransplant acute kidney injury and 64.9% required perioperative renal replacement therapy. After transplantation the 5‐year cumulative incidence of chronic kidney disease (eGFR <60 mL/min/1.73 m²) was 41.5%. There was no association between perioperative acute kidney injury (p = 0.288) or renal replacement therapy (p = 0.134) and chronic kidney disease. Instead, the independent predictors of chronic kidney disease were older age (p = 0.019), female gender (p = 0.049), hypertension (p = 0.031), cyclosporine (p = 0.027) and nonacetaminophen‐induced ALF (p = 0.039). Despite marked differences in the perioperative clinical condition and survival of patients transplanted for ALF and chronic liver disease, renal outcomes were the same. In conclusion, in patients transplanted for ALF the severity of perioperative renal injury does not predict posttransplant chronic renal dysfunction.     

肝或肾移植术后受者再次行一期肝肾联合移植三例报告

目的 探讨肝或肾移植术后受者再次行一期肝肾联合移植的手术适应证、术后并发症及存活情况.方法 对2003年10月至2008年12月施行的3例肝或肾移植术后再次行一期肝肾联合移植的受者进行随访,并进行文献复习.对其围手术期死亡率、术后并发症及存活情况进行总结.结果 围手术期死亡率为33.3%(1/3).术后并发症:1例因腹腔出血术后第29天死于肺部感染、急性移植肾功能衰竭和多器官功能衰竭;3例患者均发生了肺部感染;无急性排斥反应发生.2例存活患者,从首次移植计算,已经分别存活56个月和228个月;从一期肝肾联合移植计算,已经分别存活40个月和48个月.结论 肝肾联合移植是治疗终末期肝肾疾病的有效方法.肝或肾移植术后受者再次行一期肝肾联合移植是可行的.     

肝肾联合移植13例临床分析

目的 探讨肝肾联合移植的适应证、手术并发症及生存情况.方法 回顾性分析2003年10月至2008年12月施行的13例肝肾联合移植患者的临床资料,分析围手术期死亡率、并发症情况及生存情况.结果 13例肝肾联合移植患者围手术期死亡率30.8%(4/13).术中、术后腹腔出血4例(30.8%);肺部感染7例(53.8%);移植肾急性排斥反应1例(7.7%).本组随访4.4～60个月,中位数40个月.存活1年以上8例,2年以上6例,3年以上5例,4年以上3例,5年以上1例.肝肾联合移植前有1例患者经历肝移植(例2)和2例患者经历肾移植(例3、例4),例4患者于肝肾联合移植术后第29天死于肺部感染、多器官功能衰竭,例2和例3肝肾联合移植术后分别存活40 m、48 m.结论 肝肾联合移植是治疗终未期肝肾疾病的有效方法.肝/肾移植术后再行肝肾联合移植是可行的.

Abstract：

Objective To investigate the indications, complications and survival results of combined liver-kidney transplantation. Methods From Oct 2003 to Dec 2008, the clinical data of 13 patients who underwent combined liver-kidney transplantation (CLKTs) were retrosptiverly analyzed in our institution. The perioperative mortality rate, complications and the result of follow-up were analyzed.Results The perioperative mortality rate (within 30 days) was 30.8% (4/13). Postoperative complications included intrabdominal bleeding in 4 patients ( 30. 8% ); pulmonary infection in 7 patients (53.8%); acute renal rejection in one (7. 7% ). Survivors were followed up from 4.4 to 60 months, with the median time of 40 months. Eight patients have survived more than 1 year; six patients have survived more than 2 years; five of them have survived for more than 3 years; and three of them have survived for more than 4 years, with one surviving for more than 5 years. One patient had undergone liver transplantation ( case 2 ) and two patients had had kidney transplantations ( case 3 and case 4 ) before this CLKTs.Postoperatively case 4 died of pulmonary infection and multiple organ failure at day 29, while case 2 and case 4 survived respectively 40 m, 48 m after CLKTs. Conclusions CLKTs is an effective therapy for end-stage liver and kidney disease. CLKTs for patients with irreversible liver and renal insufficiency after initial liver transplantation or kidney transplantation was feasible.     

肝肾胰联合移植的围手术期处理

目的总结肝胰肾联合移植围手术期处理的经验。方法报告肝、胰、肾一期联合移植治疗1例乙型肝炎后肝硬化、肝功能不全合并慢性肾功能不全伴慢性胰腺炎导致胰岛素依赖型糖尿病患者的临床特点及治疗体会。对患者围手术期处理及相关资料进行回顾性分析。结果采用胰液空肠内引流及原位背驮式同期尸体肝、胰、肾联合移植。手术顺利，移植肝脏及胰腺功能1周内逐渐恢复，肾功能延迟恢复。术后第16天因移植肾血流下降，切除移植肾脏，于原移植部位行第2次肾移植，肾功能逐渐恢复正常。至2005年11月随访10个月，患者未发生排斥反应及明显感染，移植肝、胰、肾功能均正常，一般情况良好。结论肝胰肾联合移植技术安全，术后因各脏器对功能恢复所需内环境各不相同，矛盾较多，围手术期处理对患者的长期存活至关重要。     

Combined liver and kidney transplantation in a patient with sickle cell disease

Sickle cell intrahepatic cholestasis is a potentially fatal end-organ complication of sickle cell anemia. Renal involvement in sickle cell anemia is common, and in some cases, can present as acute renal failure. Although renal transplants have been performed in patients with sickle cell anemia since the late 1960s and a number of liver transplants have been recently performed for these complications, there has not been experience with dual organ transplantation for sickle cell anemia-related complications. We describe the case of a patient with sickle cell anemia who underwent successful combined liver and kidney transplantation after the development of acute sickle cell intrahepatic cholestasis and renal failure requiring continuous venovenous hemodialysis. The patient underwent a successful combined liver and kidney transplant with limited perioperative complications and preserved allograft function. At 22 months posttransplant, the patient expired as a result of an acute pulmonary embolus in the setting of bilateral hip fractures. Autopsy revealed no evidence of liver or kidney allograft rejection and evidence of chronic sickle cell nephropathy in the native kidney. Combined liver and kidney transplantation is a viable therapeutic option in patients with severe end-organ effects of sickle cell anemia.     

活体亲属肾移植受体围手术期钾离子浓度及肾功能变化分析

目的：总结接受活体亲属肾移植术的患者围手术期。肾功能及钾离子浓度的变化,讨论其意义。方法：回顾性分析近期进行的活体亲属肾移植术患者围手术期肾功能及钾离子浓度的变化,记录术后尿量变化并进行分析。结果l共有60名活体亲属肾移植患者纳入研究。手术前患者血肌酐为（827．7±199．4）mmol／L,高于正常值,血清钾离子经术前透析为（5．228±0．847）mmol／L,接近正常范围;术后连续监测显示血肌酐和血清钾离子浓度逐渐下降,于术后4小时开始血肌酐和血清钾离子浓度的变化差异有统计学意义（P〈0．01）。结论：活体亲属肾移植术术后早期已经出现肾功能及血电解质明显变化,并逐渐趋于正常值,早期监测肾功能及血电解质浓度,及时处理,围手术期处理十分重要。     

围手术期处理对低龄、低体质量儿童肾移植效果的影响

目的 探讨完善的围手术期处理对低龄、低体质量（＜ 30 kg）尿毒症患儿肾移植术后效果的影响.方法 2008年12月至2013年11月期间在郑州大学第一附属医院肾移植科接受同种异体肾移植术的16例低体质量尿毒症患儿纳入研究.术前给予患儿充分透析,根据其具体情况制定个体化透析方案,使患儿术前体质量接近干体质量;纠正心肺功能,当患儿心肺功能达标后行肾移植术.术后规律随访患儿身高、体质量、肝肾功能、血尿常规、电解质和他克莫司浓度.结果 1例患儿手术过程中出现心脏骤停,经胸外心脏按压、强心、补充血容量等治疗后恢复心跳;其余15例患儿均顺利完成肾移植手术.围手术期1例患儿出现急性排斥反应,2例出现肺部感染,2例出现肝功能异常,调整免疫抑制剂及对症治疗,16例患儿血肌酐均降至正常并顺利出院.术后均规律随访,平均随访时间（13±7）个月,人/肾存活率为100％.结论 低龄、低体质量尿毒症患儿入院后应严格完善术前检查并充分透析治疗,加强营养,纠正贫血,改善患儿心肺功能,彻底治疗合并症后再行肾移植术,可取得满意的移植效果.     

老年高危患者肾移植手术12例报告

目的：探讨老年高危患者肾移植的临床效果.方法：报告12例60岁以上老年高危肾移植患者的临床资料.结果：12例老年肾移植患者除1例移植肾因急性肾小管坏死于术后第7天切除移植肾外,其余病例均于5～15 d内移植肾功能恢复正常.结论：对老年高危患者行肾移植,只要慎重选择病例,充分的术前准备,术后合理选用免疫抑制剂,积极防治并发症,也可取得满意的临床效果.     

The Evidence of Occult Hypervolemia; Improvement of Cardiac Functions After Kidney Transplantation

The term cardiorenal syndrome (CRS) has been used to define interactions between acute or chronic dysfunction of the heart or kidney. When primary chronic kidney disease contribute to cardiac dysfunction, it is classified as type 4 CRS. Cardiac dilatation, valve regurgitations, and left ventricular dysfunction are observed in end-stage renal failure patients with uremic cardiomyopathy. Because of perioperative risks in these patients, they may not be considered a candidate for kidney transplantation. However, uremic cardiomyopathy can be corrected when volume control is achieved by appropriate dose and duration of ultrafiltration. By presenting two cases with occult hypervolemia in uremic cardiomyopathy whose cardiac functions improved early after kidney transplantation, attention is drawn to the importance of kidney transplantation on cardiac function in such patients primarily and the importance of strict volume control on cardiac function in dialysis patients waiting for kidney transplantation.     

Normal Saline Versus Balanced Crystalloid Solutions for Kidney Transplantation

IntroductionThe ideal crystalloid solution to be used during the perioperative period in patients undergoing kidney transplantation remains unclear. Normal saline (NS), the intravenous fluid commonly using during the perioperative period, contains a high chloride content, which may be associated with hyperchloremic metabolic acidosis and acute kidney injury. Balanced crystalloid (BC) solutions have a lower chloride content. The purpose of the study was to determine if a BC solution prevents the incidence of hyperchloremia and hyperkalemia during renal transplantation.MethodsNS and BC given during kidney transplantation are compared. The primary outcome was hyperchloremia and hyperkalemia within 24 hours after surgery. Secondary outcomes were levels of serum creatinine at preoperative and within 5 days after transplantation, the incidence of acute rejection episodes, graft failure, length of stay at hospital, and mortality.ResultsA total of 60 patients were included in the study (30 in the BC group and 30 in the NS group). The mean postoperative chloride was 103.0 mmol/L (95% CI, 101–105) in the NS group and 100 mmol/L (95% CI, 98–102) in the BC group (P < .05). There were no significant differences in demographic characteristics, serum creatinine values within 5 days, short-term outcomes, and graft survival rates at 28 days postoperatively between groups (P > .05).ConclusionsOur results suggest that a moderate volume (approximately 1500.0 mL) of NS infusion causes hyperchloremia rather than adverse clinical outcomes. A moderate amount of NS infusion can be used safely during uncomplicated living-donor kidney transplantations.