Introduction: Acute and chronic graft rejection continues to be an important problem after solid organ transplantation. With the introduction of potent immunosuppressive agents such as calcineurin inhibitors, the risk of rejection has been significantly reduced. However, the adverse effects of life-long immunosuppression remain a concern, and there exist a fine balance between over-immunosuppression and risk of rejection.
Areas covered: In this review, the current standard of care in immunosuppressive therapy, including the use of steroids, calcineurin inhibitors, mycophenolate prodrugs and mammalian target of rapamycin inhibitors, will be discussed. Newer immunosuppressive agents showing promising early data after liver and kidney transplantation will also be explored.
Expert Opinion: Currently, calcineurin inhibitors continue to be a vital component of immunosuppressive therapy after solid organ transplantation. Although minimization and avoidance strategies have been developed, the ultimate goal of inducing tolerance remains elusive. Newer emerging agents should have potent and specific immunosuppressive activity, with minimal associated side effects. An individualized approach should be adopted to tailor immunosuppression according to the different needs of recipients. 相似文献
Renal allograft loss from chronic rejection or cyclosporine toxicity (CsAT) is characterized by progressive interstitial fibrosis, yet the protein composition of these lesions is unknown. The normal tubular basement membrane (TBM) contains laminin (LM), collagen IV (containing collagen IV alpha chain 1 [COL4A1] and COL4A2), thrombospondin (TSP), and fibronectin (FN). Only TSP and FN extend beyond the TBM into the interstitial space. Very scanty amounts of interstitial collagens (I and III) are detected in the interstitium. In a pilot study of human renal allograft biopsy specimens, three patterns of extracellular matrix (ECM) composition were identified. Pattern 1 showed no change in ECM composition; pattern 2 showed generalized accumulation of collagens I and III in the interstitium; and pattern 3 showed new expression of COL4A3 and LM-beta2 in the proximal TBM. Criteria were established for the clinicopathological diagnosis of CsAT and rejection. These diagnoses were correlated with the ECM composition in 22 renal allograft biopsy specimens. Control groups were examined in a similar manner and included native kidney biopsy specimens from patients with other allografts (n = 7), renal biopsy specimens from patients with glomerular disease (n = 9), and renal allograft biopsy specimens from patients without clinicopathological evidence of renal disease. These data show that rejection is associated with pattern 3 and CsAT is associated with pattern 2. Thus, detection of ECM composition may be a useful adjunct to standard microscopy in distinguishing rejection from CsAT in renal allograft biopsy specimens. These data suggest that interstitial fibrosis associated with rejection and CsAT result from different pathogenic mechanisms. 相似文献
The study examined parent stress and health‐related quality of life (HRQOL) among families of children with congenital heart disease (CHD) referred for psychological services.
Methods
Parents of 54 children (85% boys) aged 3 to 13 (Mage = 7.48, SD = 2.38) completed measures to assess parenting stress (Parenting Stress Index – Short Form; Pediatric Inventory for Parents) and the PedsQL Family Impact Module. Medical information was retrieved from medical record review.
Results
Half of parents of children with single ventricle anatomy had clinically significant levels of parenting stress. Parents of children with single ventricle anatomy reported more frequent illness‐related stress and more difficulty dealing with illness‐related stress than parents of children with two ventricle anatomy. Younger gestational age at birth and referral for attention or behavior problems were associated with greater likelihood of parent at‐risk psychosocial functioning.
Conclusions
Among children referred for psychological services, many parents report significant stress and significant negative impact of the child's medical condition on the family. Results underscore the need to consider assessing parent psychosocial functioning and providing additional support for parents of children with CHD. 相似文献
Background and Objectives: Children with congenital heart disease (CHD) are at risk
for neurodevelopmental (ND) delays. The purpose of this study is to compare the ND
testing results of children with CHD at 2 and 4 years of age and determine if rates of
ND delays change over time. Methods: Children with CHD completed the Bayley Scales of Infant Development‐III
(BSID‐III) at 2 years of age, and standardized neuropsychological measures at 4 years.
Scores were compared with test norms and were classified as: average (within one
SD of test mean); at risk (1‐2 SDs from the test mean); and delayed (>2 SD from test
mean). Pearson correlations and McNemar’s exact tests were performed to deter‐
mine the relationship between test scores at the two times of assessment. Results: Sixty‐four patients completed evaluations at 24 ± 3 months of age and
4 years of age. BSID‐III cognitive and fine motor scores were correlated with pre‐
school IQ and fine motor scores, r = .75 to .87, P < .0001. Agreement in score catego‐
ries was 79% for cognitive and 61% for fine motor. More patients had at risk or
delayed scores at age 4 vs age 2 (P≤.01). Conclusion(s): Despite significant correlations between 2‐ and 4‐year‐old test scores,
many patients who scored in the average range at age 2 showed deficits at age 4.
BSID‐III scores at age 2 may underestimate delays. Therefore, longitudinal ND as‐
sessment is recommended. 相似文献
AIM: To evaluate the effectiveness and safety of acupuncture for the treatment of obesity by reviewing currently available randomised controlled trials.
METHODS: This review followed the Cochrane Handbook for Systematic Reviews of Interventions. Fifteen English and three Chinese databases were searched from their respective inceptions until July 2014. Key words used in the search consisted of acupuncture, needles, obesity, overweight, randomised trial and their synonyms. The risk of bias of included studies was assessed. The differences in effect size between acupuncture and control (including sham, no treatment, western medicine and dietary therapy/exercise) groups were compared using Cochrane Collaboration’s RevMan 5.3 software.
RESULTS: Two thousand six hundred and twenty-one records were identified; after full-text articles assessed for eligibility, 9 of them met inclusion criteria. Majority of included studies had unclear or high risk of bias across all domains. All included studies had high or unclear risk of bias in randomisation, blinding and outcome data. Meta-analysis showed that acupuncture was more effective for reducing body weight and body mass index than no treatment group. Manual acupuncture was also superior to dietary therapy alone for decreasing body weight. With dietary therapy as co-intervention, combined acupuncture group achieved lower body mass index than combined sham acupuncture group or dietary therapy alone group at the end of treatment period. No severe adverse events from acupuncture group were reported from all included studies.
CONCLUSION: Due to the poor quality of included studies the effectiveness of acupuncture cannot be concluded. Better-designed, large-scale, randomised, sham-controlled clinical trials with long-term follow-up are needed. 相似文献