新疆地区亲属活体肾移植176例临床疗效分析

目的:总结和分析新疆地区176例活体肾移植的临床疗效和经验。方法:回顾性研究176例活体肾移植受者的术前一般情况、术后急性排斥反应发生率、并发症、人/肾存活率。结果:1999年8月至2008年9月间在新疆本地医院共完成异体肾移植779例,活体肾移植179例(23.0%),但2006年后活体肾移植占同期移植量的69.4%。其中3例失访,资料完整者176例,包括亲属供肾175例,非亲属供肾1例(汉族)。亲属供肾包括直系亲属15例,汉族占66.7%(10/15例);三代旁系157例,少数民族占78.3%(123/157例),夫妻间3例。176例肾移植受者中,少数民族132例,男性144例。1年、3年,5年及5年以上人/肾存活率分别为94.3%/93.2%,92.0%/88.6%,92.0%/88.1%,92.0%/86.9%,急性排斥反应发生率为9.1%,肺部感染18例(10.2%),其中死亡11例(6.3%)。结论:近三年新疆地区活体肾移植呈快速增长,2006年后约占同期肾移植总量的69.4%。患者以少数民族居多(占74.4%),供者多为三代旁系亲属,而汉族患者则以直系亲属供肾为主。本组人/肾短期和中期存活率明显高于尸体肾移植,并与国内、外报道活体肾移植人/肾存活率相近,急性排斥和肺部感染发生率分别为9.1%和10.2%,死亡率为6.3%,其长期存活率有待进一步观察。     

老年肾脏移植的临床特点

目的探讨老年患者肾移植的风险、以及影响肾长期存活的因素。方法对54例≥60岁老年肾移植病例（老年组）进行回顾性分析,并与同期305例〈60岁肾移植病例（对照组）进行对比分析。结果老年患者在术后1年,3年的人/肾存活率分别为92.6%/88.9%、79.6%/75.9%。老年组急性排斥反应发生率为7.4%,与对照组（8.9%）无显著性差异（P〉0.05）。结论老年患者进行肾移植手术,需进行详实有效的术前检查（特别是心脑血管方面的检查）,并积极运用个体化抗排斥药物。     

老年患者肾移植的围手术期治疗

目的 探讨老年患者肾移植的临床特点和围手术期治疗要点，提高老年肾移植患者人／肾存活率。方法 对27例老年肾移植患者的临床资料进行分析总结。结果 21例发生各类并发症，主要有感染和药物性肝功能损害等，治疗后19例恢复正常，治愈率90．5％。1、3年人／肾存活例数分别为25／25，23／21；存活率分别为92．6％／92．6％；85．2％／77．8％。结论 术前全身状态差，术后并发症多时老年肾移植患者的主要临床特点，也是制约其人／肾存活率的主要因素；完善围手术期治疗措施，及时准确检测，合理调整用药是提高老年肾移植患者人／肾长期存活的重要保证。     

雷公藤防治异体肾移植术后急性排斥反应作用的临床研究

目的：通过观察雷公藤防治尸体肾移植术后急性排斥反应的作用，验证雷公藤免疫抑制在抗排斥反应中的疗效。方法：３９例肾移植患者接受雷公藤治疗，根据服用雷公藤剂量的不同分为双倍剂量组（ｎ＝２０，２ｍｇ／ｋｇｄ－１）和常规剂量组（ｎ＝１９，１ｍｇ／ｋｇｄ－１）。以同期未接受雷公藤治疗的肾移植患者作为对照（ｎ＝４０）。所有患者均无合并感染、环孢素肾中毒和手术并发症的情况。三组之间的性别、年龄、冷热缺血时间、淋巴细胞毒性试验、群体反应性抗体水平都非常接近。结果：双倍剂量组患者术后１个月和３个月内无一例急排的发生，其对照组急排发生率分别高达２５％～４５％。常规剂量组术后１个月和３个月内仅各有１例急排的发生。同期对照组急排发生率为１５％～３５％。术后满３年的雷公藤常规剂量组，３年移植肾存活率为８９．５％，显著高于其对照组移植肾６５．０％的３年存活率。此外，长期服用雷公藤未有严重感染等并发症的增加。结论：雷公藤的确具有减少肾移植术后发生急性排斥反应的作用，有助于提高移植肾的长期存活率。     

肾移植术前的心脏准备

肾移植术前的心脏准备曾国彬张创成黄玉林骆苗新杨露郑丽玉（武警福建总队医院福州３５００１９）关键词肾移植术心血管疾病术前准备１９９５年８月，我们成功完成了１例高龄肾移植手术，该例术前曾并发多种心血管疾病。本文报道其术前心脏准备的经验。１资料患者女性，５...     

公民逝世后器官捐献肾移植546例的预后

目的:探讨公民逝世器官捐献(DCD)肾移植受者的临床预后。方法:回顾性分析2013年6月～2018年7月中国人民解放军总医院第三医院中心肾移植科完成的546例公民逝世器官捐献肾移植供、受者临床资料。供者516例,男性399例、女性117例,年龄42.4±16.1岁(5～68岁);死亡原因以脑卒中和脑外伤为主。5～12岁儿童供肾20例,均做单肾给儿童或低体重成人,60岁以上老年供肾56例。546例受者中,男393例、女153例,平均年龄41.7±11.9岁。分析供肾质量、免疫诱导方案、术后移植肾功能、并发症、人肾生存率,以及特殊供肾和特殊受者的人肾存活情况。结果:本组受者术后无一例原发性移植肾无功能,移植肾功能延迟(DGF)36例(6.6%),急性排斥反应28例(5.1%)。术后42例(7.7%)并发肺部感染,死亡10例。移植肾功能丢失18例。儿童和老年供肾的受者预后较好;14例合并横纹肌溶解综合征相关性急性肾损伤的供肾,DGF发生率较高(42.9%);22例神经系统肿瘤供肾受者随访期间未发生肿瘤。本组受者人、肾存活率为97.2%和93.9%,1年、3年、5年的人、肾生存率分别为98.5%、96.9%、89.3%和96.5%、 92.7%、 85.6%。结论:本组DCD供肾受者人和肾脏预后较好,主要死亡原因是肺部感染;特殊供肾和特殊受者的预后值得关注。     

80岁以上患者腹腔镜胆囊切除围手术期处理

目的探讨高龄（≥80岁）患者腹腔镜胆囊切除术（LC）围手术期处理原则。方法2001年6月至2006年6月解放军第451医院共行LC术13776例,对其中≥80岁的结石性胆囊炎病例共34份进行回顾性分析,对术前评估、降低并发症影响因素并减少其发生提出可行性依据。结果本组平均年龄82.1岁,26例有明确的术前合并症,占76.5%,合并有两种以上疾病者15例,占44.1%,胆囊炎急性发作17例,病理诊断为急性化脓性胆囊炎6例,急性发作患者起病48h内急诊手术7例,内科抗感染并治疗合并症后手术10例,住院时间（13.3±5.3）d,手术时间（28.4±8.6）min,全部病例均完成手术,术后第3天发生快速房颤并急性心衰1例,合并糖尿病切口延迟愈合1例,合并肝硬化急诊手术后出现肺部感染、肝功损害加重1例,其余患者均顺利治愈出院,无手术死亡。结论在高龄患者LC围术期,注意术前评估,慎重确定手术时机,充分术前准备,术中仔细处理,是保证高龄老人顺利度过LC围手术期的必要条件,从而降低高龄患者手术风险。     

提高对肾移植受者心血管危险因素的认识

肾移植术后心血管疾病(CVD)的发生率以每年3.5%～5%的速度递增,已成为肾移植受者带功死亡的首要原因.分析本中心1000例肾移植患者的资料证实,因CVD造成移植受者的带功死亡率约为8.8%.因此,提高对肾移植受者术后CVD的认识,有助于提高肾移植受者的生活质量,延长人/肾存活率.     

连续性血液净化救治肾移植后重症巨细胞病毒肺炎

肾移植术后感染是危及患者生命的主要并发症，严重影响着肾移植患者的人／肾存活率。随着新型免疫抑制剂临床应用，移植后排斥反应的发生率不断下降。然而，感染，尤其是危及生命的严重肺部感染却有上升趋势。常见的严重感染有肾移植术后3个月左右的巨细胞病毒（CMV）肺炎，患者病情发展迅速，临床经过凶险，文献报道当合并成人急性呼吸窘迫综合征（ARDS）时，死亡率高达65％～90％。近年来，我们应用连续性血液净化（CBP）技术综合救治肾移植术后重症CMV肺炎合并ARDS患者，取得了较好的疗效，抢救成活率有了明显提高，使患者死亡率降低至20％。现将几点粗浅体会介绍如下。     

肾移植术后高血压及处理原则

肾移植术后高血压及处理原则刘红１概述高血压是引发心血管疾病的主要病因，大多数慢性肾功能不全的患者都伴发高血压的发生，即使在肾移植术后，高血压仍是术后常见的并发症之一，并且直接影响肾的长期存活率和患者的寿命。近一年来，肾移植因为术后感染和急性排异所致的...     

Cadaveric renal transplantation in patients older than 60 years of age

The outcome of 105 cadaveric kidney transplants performed in our institution between September 1985 and November 1991 in a non-selected patient population aged 60 to 71 years at the time of transplantation is herewith reported. A total of 11 patients died during the stud period, 8 during the first postransplant year. Infectious (n=4), gastro-intestinal (n=3) and cardiovascular diseases (n=1) accounted for the 8 deaths occurring during the first postransplant year. Thereafter, causes of death were only due to cardiovascular diseases (n=3). The incidence of acute rejection and CMV infectious episodes was respectively 29 and 23%, similar to that from younger transplant recipients. Cyclosporine maintenance therapy was well tolerated in all patients but 1 and 64% of the patients were of steroids at 1 year. As compared to the 615 patients 20–60 years old who were transplanted during the same study period, no statistical significant difference was observed in the 5-year actuarial patient (80 and 90%, respectively in recipients older or younger than 60 years of age) and graft (80 and 72%, respectively in recipients older or younger than 60 years of age) survival rates. However, elderly patients experienced statistically lower survival when compared to patients of 20 to 29 years (p<0.009). It may be concluded that cadaveric kidney transplantation can be performed safely in patients older than 60 years of age. Advanced agedper se is not a contraindication for renal transplantation.     

Renal outcome and evolution of disease activity in Chinese lupus patients after renal transplantation

Lupus nephritis constitutes the major cause of morbidity and mortality in SLE. The long-term outcome of renal transplantation in lupus patients remains controversial, and the recurrence of lupus activity is a major concern. This study aims to determine the long-term outcome of renal transplantation in Chinese lupus patients and the evolution of lupus activity. A total of 23 lupus patients undergoing renal transplantation were enrolled and compared with 94 matched controls. The overall patient and graft survival rates at 10 years post-transplant in lupus group were not different from the control group (95.2% and 57.7% vs. 90.7% and 66.3%). Recurrence of lupus nephritis in renal allograft and flare-ups of lupus activity were not observed in this study. The SLE group had less acute rejection than the control group (20.4% vs. 29.8%, P<0.05). The infection rate between the two groups was similar (39.1% vs. 51.1%, P=0.427), although SLE group had a significantly higher rate of developing avascular necrosis (17.4% vs. 2.1%, P=0.04). In conclusion, patient and graft survival rates and other major complications in Chinese lupus patients are comparable to non-lupus transplant recipients caused by other diseases. Chinese patients with SLE are suitable candidates for renal transplantation.     

Long-term outcome of kidney transplantation in patients with hepatitis C virus infection

BACKGROUND/AIMS: The impact of HCV (hepatitis C virus) infection on the long-term outcome of kidney transplant patients is controversial. METHODOLOGY: Eighty-four renal allograft recipients who were seronegative for hepatitis B surface antigen and had been screened for antibody to hepatitis C virus (anti-HCV) were included. The outcome and survival were compared between anti-HCV-positive (n = 30, group 1) and anti-HCV-negative (n = 54, group 2) kidney transplant patients. Group 1 patients were further compared to 52 anti-HCV-positive end-stage renal disease patients (group 3) who were on chronic dialysis. RESULTS: Group 1 patients had a higher prevalence of chronic hepatitis than group 2 and group 3 patients did (67% vs. 2% and 31%). Liver-related complications and deaths between group 1 and group 2, and group 1 and group 3 patients were not significantly different. The comparisons of the long-term survival between these groups showed no significant differences, despite group 3 patients had a higher overall mortality rate. Cox regression analysis confirmed that age more than 45 years was the only independent factor that affected survival in anti-HCV-positive end-stage renal disease patients with or without kidney transplantation. CONCLUSIONS: HCV infection is not a contraindication to kidney transplantation. For anti-HCV-positive end stage renal disease patients, survival is better in younger patients, and is not influenced by kidney transplantation or continuing dialysis.     

儿童肾移植多学科管理模式的探讨

目的:本研究旨在探讨改善儿童肾移植长期预后的管理模式,尤其是术前、术后多学科管理在儿童肾移植中的意义。方法:2011年1月至2019年5月,复旦大学附属儿科医院肾脏科与海军军医大学附属长海医院及复旦大学附属中山医院合作开展器官捐献供肾-儿童肾移植,对肾移植患儿采用术前-术中-术后闭环管理模式。本研究通过临床资料分析,探讨该模式的特点和效果,重点讨论术前、术后管理在儿童肾移植中发挥的作用。结果:(1)一般资料:129例终末期肾衰竭患儿接受器官捐献供肾移植,肾移植受者年龄10.6±3.8岁,其中最小移植年龄21月龄,最小移植体重9 kg。供体中104例(80%)为儿童供体,儿童供体中位年龄1.5岁(11月~3岁)。(2)术前管理:原发病诊断方面,儿童肾脏科与泌尿外科、分子诊断中心等多学科合作,使得86%患儿原发病诊断明确,先天性肾脏和尿路畸形(CAKUT)及遗传性肾病为其主要病因,占28.6%和27.9%;移植前肾替代治疗方面:96%患儿移植前接受透析治疗,中位透析时间1.3(0.7~2.0)年;移植前慢性肾脏病相关并发症纠正情况:肾性贫血控制率70%,血钙控制率77%,血磷控制率65%,全段甲状旁腺激素(iPTH)控制率66%,严重左心室肥厚(LVH)控制率80%。(3)术后管理:129例肾移植患儿中位随访时间2.0(1.1~4.8)年。随访期间感染情况:63例(48%)肾移植受者发生感染,病原菌中以细菌感染最多见(54%),其次为病毒感染(42%),病毒感染中半数以上为巨细胞病毒(CMV);排斥情况:14例(10.8%)肾移植术后发生排斥反应;原发病复发情况:1例(0.8%)局灶节段性肾小球硬化原发病复发。(4)肾移植预后:受者1年、3年、5年、7年存活率均为96.6%,移植肾1年、3年、5年、7年存活率均为87%。末次随访时估算肾小球滤过率为81.2±29.8(ml/min/1.73 m^2)。16例移植肾失功,其中13例(81%)移植肾丢失发生在移植后1月内,移植肾血管栓塞是主要失功原因。结论:多学科闭环管理下的儿童肾移植受者预后良好,该模式值得推广。     

Impact of age-related comorbidity on results of colorectal cancer surgery

AIM: To analyze the correlation between preexisting comorbidity and other clinicopathological features, short-term surgical outcome and long-term survival in elderly patients with colorectal cancer (CRC). METHODS: According to age, 403 patients operated on for CRC in our department were divided into group A (< 70 years old) and group B (≥ 70 years old) and analyzed statistically.RESULTS: Rectal localization prevailed in group A (31.6% vs 19.7%, P = 0.027), whereas the percentage of R0 resect ions was 77% in the two groups.Comorbidity rate was 46.2% and 69.1% for group A and B, respectively ( P < 0.001), with a huge difference as regards cardiovascular diseases. Overall, postoperative morbidity was 16.9% and 20.8% in group A and B,respectively ( P = 0.367), whereas mortality was limited to group B (4.5%, P = 0.001). In both groups, patients who suffered from postoperative complications had a higher overall comorbidity rate, with preexisting cardiovascular diseases prevailing in group B ( P = 0.003).Overall 5-year survival rate was significantly better for group A (75.2% vs 55%, P = 0.006), whereas no significant difference was observed considering diseasespecific survival (76.3% vs 76.9%, P = 0.674).CONCLUSION: In spite of an increase in postoperative mortality and a lower overall long-term survival for patients aged ≥ 70 years old, it should be considered that, even in the elderly group, a significant number of patients is alive 5 years after CRC resection.     

Outcome of allogeneic stem cell transplantation in patients older than 50 years of age

Because of progress in supportive therapies, the upper limit of age for conventional allogenic stem cell transplantation (allo-SCT) is rising. We retrospectively evaluated the impact of age on transplant outcomes in patients older than 50 years of age who underwent conventional allo-SCT in 8 institutions in Japan. The median age was 52-years old (range 50 to 65). The underlying diseases included severe aplastic anemia (n = 3), acute myelogenous leukemia (n = 20), acute lymphoblastic leukemia (n = 10), chronic myelogenous leukemia (n = 11), myelodysplastic syndrome (n = 18), and non-Hodgkin lymphoma (n = 3). Forty two patients (67%) with hematological malignancies received allo-SCT in an advanced disease stage at the time of transplant. The two-year overall survival and disease-free survival rate were 50.1% and 43.6%, respectively. In patients with hematological malignancies, the two-year probability rates of survival were 54.3% with standard risk patients, and 45.9% with poor risk patients. The severity of acute GVHD, the kind of grafts, and age (> or = 55) were related to poor prognosis. Our data suggest that prophylaxis of acute GVHD and selection of the graft is more important for older patients, and that patients less than 55-years old can be candidates for conventional allo-SCT.     

Kidney transplantation in the elderly

The outcome of renal transplantation in older patients has been improving steadily over the past decade such that advanced age alone is no longer an independent contraindication to this procedure. Review of this center's experience with kidney transplantation in patients older than 60 yr of age revealed an overall 1 year patient and graft survival of 82%. Low risk patients, defined as those without diabetes or cardiovascular disease, had markedly improved patient (91%) and graft (84%) survival rates. Review of the literature revealed 1 year patient and graft survivals of 60–77% and 48–74% respectively for patients transplanted in the pre-cyclosporine era. Under cyclosporine immunosuppression, kidney transplant outcomes were generally improved with patient and graft survival ranges of 79–97% and 67–93%, respectively. Although medical complications such as myocardial infarction, pneumonia; and steroid induced diabetes are more frequent in the elderly, irreversible allograft rejection appears to occur less frequently than in younger patients. Consequently, rigorous pretransplant screening for comorbidity is very important and posttransplant strategies of reduced immunosuppression may be prudent. With increasing numbers of older patients awaiting kidney transplantation, advanced age is now being reevaluated as a contraindication to kidney donation.     

Systemic lupus erythematosus after renal transplantation: patient and graft survival and disease activity. The Dutch Working Party on Systemic Lupus Erythematosus

OBJECTIVE: To determine the outcome of renal transplantation in patients with systemic lupus erythematosus and end-stage renal failure and to compare disease activity after transplantation with disease activity before transplantation. DESIGN: Retrospective case finding using data for an 8-year period from the central registry for renal replacement therapy in The Netherlands. SETTING: Tertiary care hospitals with facilities for renal transplantation in the Netherlands. PATIENTS: Twenty-eight patients who fulfilled at least four of the American Rheumatology Association's criteria for the classification of systemic lupus erythematosus and who received a renal transplant. MEASUREMENTS: Actuarial survival rates for grafts and patients after transplantation, maximal nonrenal scores on the Systemic Lupus Erythematosus Disease Activity Index, and time-adjusted disease exacerbation rates in all patients before and after transplantation. RESULTS: The actuarial graft survival rate at 1 year and 5 years was 68% (95% CI, 47% to 82%) and 54% (CI, 25% to 77%), respectively, whereas the actuarial patient survival rate was 87% (CI, 69% to 96%) at 1 and 5 years. High disease activity was not found to affect graft survival adversely before the start of renal replacement therapy or during dialysis. After transplantation, disease activity per patient and the overall incidence of disease exacerbations decreased. One case of recurrent lupus nephritis was seen. CONCLUSIONS: Patients with systemic lupus erythematosus and end-stage renal failure are excellent candidates for renal transplantation; disease activity after transplantation is sporadic and low, and the recurrence of lupus nephritis is rare.     

Combined Heart-Kidney Transplant Versus Sequential Kidney Transplant in Heart Transplant Recipients

ObjectivesIn patients with reduced kidney function there are no established guidelines to suggest combined heart-kidney transplant (HKTx) versus sequential kidney transplant (SKTx) using preoperative value of estimated glomerular filtration (eGFR).MethodsThe United Network for Organ Sharing database was queried from 2000 to 2015 to evaluate survival of HKTx and SKTx population stratified by preoperative eGFR rate <45 mL/min. Aim of the study was to assess the eGFR rate that is most beneficial to perform a concomitant or a SKTx at time of transplant evaluation.ResultsIn our analysis, patients who required SKTx are recipients that, after heart transplantation, developed or worsened kidney insufficiency due to calcineurin inhibitor nephrotoxicity. In recipients with eGFR <30 or dialysis, a total of 545 received HKTx and 80 received SKTx. The median waiting time between heart and kidney transplant in SKTx group was 6 years. The overall post-transplant survival was 81% and 80% and 75% and 59% at 5 and 1 years for the HKTx and SKTx groups, respectively (P = .04). In recipients with eGFR from 30 to 44, a total of 107 received HKTx and 112 received SKTx. The median waiting time between heart and kidney transplant in SKTx group was 4 years. Overall post-transplant survival showed no statistically significant differences in HKTx group (n=107) compared with SKTx group (n=112) and was 90% and 95% at 1 year and 74% and 52% at 5 years, respectively (P = .4) .ConclusionsTo optimize organ and patient survival, eGFR value can be utilized to discern between HKTx versus SKTx in patients with decreased renal function at the time of heart transplantation. Patients with eGFR<30 or in dialysis presented better survival with HKTx, while both SKTx and HKTx are suitable for patients with eGFR between 30 and 45.     

Renal transplantation in scleroderma

Although the outcome of renal transplantation in patients with systemic lupus erythematosus (SLE) has been studied, there are few reports about the outcome of patients with systemic sclerosis who have undergone renal transplantation. We retrospectively collected data from the United Network for Organ Sharing (UNOS) Scientific Renal Transplant Registry from a 10-year period. From 1987 to 1997, 86 patients with systemic sclerosis who had renal transplantation were identified. Of these 86 patients, 70% were women, 86% were Caucasian, and the mean age at transplantation was 50.4 years. The overall mortality was 24% of the patient group; 44% (38/86) of renal grafts failed. First- through fifth-year graft survival rates were 62%, 60%, 57%, 50%, and 47%, respectively. The causes of graft failure could not be ascertained in 24 of 38 patients (63%). Among the known causes, 5 had acute rejection, 4 had chronic rejection, 3 had recurrence of scleroderma, and 1 each had infection and graft thrombosis. Immunosuppressive regimens used in the patients with systemic sclerosis consisted of antilymphocyte globulin in at least 25%. Sixty percent received a combination of steroids, azathioprine, and cyclosporine. The use of cyclosporine was not associated with either improvement of graft survival or an increased rate of graft failure. Graft survival at 5 years in patients with systemic sclerosis was comparable to that of patients with SLE who received renal transplantation, according to existent medical literature. Based upon these data, renal transplantation is as effective a treatment for restoring renal function in patients with systemic sclerosis as it is in patients with SLE. Those patients with systemic sclerosis whose renal function did not improve with angiotensin-converting enzyme (ACE)-inhibitor treatments after scleroderma renal crisis should be considered as transplant candidates. Although the data are incomplete, the use of cyclosporine may not confer the advantage of improving graft survival in patients with systemic sclerosis as compared with SLE patients.