Impact of Dialysis and Older Age on Survival after Liver Transplantation

Because creatinine is heavily weighed in the MELD (model for end-stage liver disease) score, we sought to determine the impact of MELD-based organ allocation on outcomes after transplantation in the pre- and post-MELD eras, focusing on recipients over age 65 on dialysis prior to transplant. A total of 20 196 patients from the UNOS database were analyzed. Comparing the pre-MELD to MELD era, there was a 41% increase in patients on dialysis (p<0.0001), and a 117% increase in combined liver/kidney transplants (p<0.0001). In the pre-MELD era, 1-year patient survival in recipients greater and less than age 65 on dialysis who received liver transplant alone was 56.8% and 76.4%, respectively (p=0.13). In the MELD era these rates were 50.7% and 77.8% (p=0.04). In the pre-MELD era, 1-year patient survival in recipients greater and less than age 65 on dialysis who underwent combined liver/kidney transplantation was 25.0% and 83.2%, respectively (p=0.0002). In the MELD era, these rates were 67.0% and 82.5% (p=0.18). In conclusion, a greater proportion of patients in the MELD era are on dialysis prior to transplant, and more receive combined liver/kidney transplants compared with the pre-MELD era. Candidates over age 65 who are on dialysis at the time of transplant have decreased survival after isolated liver transplantation.     

碎石术对肾结石患者肾功能损害的观察

目的 探讨肿瘤坏死因子-α（TNF-α）和表皮生长因子（EGF）在经尿道体外冲击波碎石术（ESWL）的变化和规律。方法采用放射免疫分析法，选择性地对50例肾单发结石患者ESWL前后TNF-α和EGF含量进行测定。结果碎石后尿中TNF-α含量在1～4d与术前比较总体水平明显升高（t=2．22，P〈0．05），术后2d TNF-α含量明显高于术后4d（t=2．82，P〈0.01），第5天水平回落，与术前比较差异无统计学意义（P〈0．05）；EGF的含量术后明显高于术前（t=2．28，P〈0．05）。结论TNF-α和EGF水平可能提示肾小管细胞的自身炎症过程及与肾损害的发生机制密切相关。     

肾移植术后并发大腿感觉功能障碍(附28例报告)

目的 提高对肾移植术后并发大腿感觉功能障碍的认识水平。方法 对179例肾移植术后患者进行问诊和大腿皮肤针刺检查。结果 179例中发现28例存在手术侧大腿感觉功能障碍。其中78例移植肾动脉与髂内动脉吻合的患者中有11例，分别为大腿前面7例、外侧面2例、前面和外侧面2例：101例移植肾动脉与髂外动脉吻合的患者中有17例，分别为大腿前面13例、外侧面1例、前面和外侧面3例。除1例为持续性感觉功能障碍外，其余27例均在术后半年内自愈。结论 肾移植术后出现手术侧大腿皮肤感觉功能障碍是较常见的并发症。肾移植术前应告知患者可能出现这种并发症。     

复式脉冲低能量ESWL治疗肾结石769例报告

目的探讨复式脉冲HB-V型低能量体外冲击波碎石机治疗肾结石的治疗效果.方法采用复式脉冲HB-ESWL-VG型低能量碎石机治疗直径<2.0 cm的各类肾结石769例，治疗工作电压3～9 kV，平均冲击次数2 300次.结果肾盏结石总粉碎率为97.4%，其中上中盏结石复打率为13.1%，术后3个月排净率为89.4%，下盏结石复打率为17.3%，排净率为81.5%；肾盂结石粉碎率为98.3%，复打率为6.1%，术后3个月排净率为93.0%.结论复式脉冲低能量ESWL治疗肾结石具有治疗成功率高、复打率低、无严重并发症、副作用少之优点.     

肾结核的CT诊断

目的:探讨肾结核的CT诊断价值。方法:回顾性分析了20例经病理或临床确诊的肾结核CT资料。结果:19例病灶CT表现为多发“花瓣”状囊腔15例、单发囊腔2例、囊实性肿块1例、自截肾1例,其中病灶内伴钙化者有9例;余1例肾内CT阴性。15例肾盂壁增厚,10例输尿管壁环形增厚,一般肾盂不扩张或轻度扩张。2例膀胱壁增厚伴挛缩1例。结论:肾结核具有较特征性的CT表现,CT是目前最有效的影像学诊断方法之一。     

妊娠中晚期合并输尿管结石的急诊腔内技术处理

目的探讨妊娠中晚期合并输尿管结石急诊腔内技术处理的安全性和有效性。方法1998年6月至2005年3月,对17例妊娠中晚期合并输尿管结石急症的患者行急诊腔内技术治疗。患者年龄21～35岁,平均27岁,孕周20～36周,平均29周。表现为肾绞痛反复发作11例,发热4例,急性梗阻性无尿2例。结石位于左侧5例、右侧10例、双侧2例；结石位于输尿管上段8例、中段5例、下段2例,双侧下段2例。结石大小6mm×7mm～13mm×21mm。患侧轻度肾积水6例,中度11例。行经尿道输尿管镜下气压弹道碎石14例；输尿管上段结石推至肾盂1例；因无法进镜而单纯留置双J管2例。结果17例患者的肾绞痛、发热等症状经治疗后完全消失。结石一次取净者14例(82.4%)。残留结石者3例,留置双J管至分娩后,其中1例每3个月更换双J管。未发生先兆流产或早产等情况,无输尿管穿孔及其他并发症。留置双J管后出现排尿后腰部不适1例,3d后缓解；术后肉眼血尿1例,6d后自行消失。17例均顺利生产,婴儿健康。结论经尿道输尿管镜腔内技术治疗妊娠中晚期合并输尿管结石急性发作安全、有效。     

Laparoscopic enucleation of a renal cell carcinoma

The purpose of this study was to report on the feasibility of laparoscopic excision of renal cell carcinoma. An 81-year-old female with renovascular disease underwent a laparoscopic excisional operation for a 2-cm tumor localized in the left kidney.Pathological evaluation showed a low-grade tumor without any extension through the renal capsule (grade I Hand Broder, stage I Robson). The postoperative course was uneventful; there was minimal postoperative pain. The patient was discharged home on the sixth day. Laparoscopic excision would appear to be a safe and effective technique in selected cases.     

APPRAISAL OF SURGICAL AND ENDOSCOPIC MANAGEMENT OF CHOLEDOCHOLITHIASIS

One hundred and ten patients with common bile duct (CBD) stones were treated in the Department of Surgical Gastroenterology at SGPGIMS, Lucknow, India between January 1989 and December 1992. The primary modality of treatment was surgery in 62 patients (group I) and endoscopic sphincterotomy (ES) in 48 (group II). The two groups were well matched with respect to clinical features and presence of medical risk factors. Surgical clearance of CBD stones was achieved in 58 patients (93.5%; group Ia). Four patients (7%) had retained stones following surgery (group Ib). In group II, the CBD was cleared by endoscopic means in 20 out of 48 patients (42%) and was categorized into group IIa. In the remaining patients ES was followed by CBD exploration (group IIb). Significantly higher morbidity was seen in patients needing CBD surgery following attempted endoscopic clearance, because of ES-related complications, such as bleeding, cholangitis, septicaemia and numerous others. Use of ES to treat CBD stones on a routine basis was therefore not found to be any better than one-time surgical exploration.     

Profile of cytokine production in mixed kidney lymphocyte culture

Abstract Kidney cells are an important source of immunoregulatory molecules that regulate cell-to-cell interactions, which is the key step in the generation of the immunoresponse to alloantigens. In this study we identified the cytokines that are produced by both lymphoid cells and kidney cells when coincubated in mixed kidney lymphocyte cultures (MKLC). The capacity of kidney cells to stimulate the proliferation of effector allogeneic lymphocytes was assayed by incubating irradiated kidney cells and lymphocyte. The cytokine secretion profile in MKLC was investigated by incubating monolayers of kidney cells with effector peripheral blood mononuclear cells (PBMC). The culture supernatants were harvested on days 1, 2, 3, 4, 5, 6, 7, and 8 and assayed for IL-1β, IL-2, IL-6, and TNF alpha using an ELISA. Kidney cells, in comparison to PBMC stimulator cells were poor stimulators of the allo-proliferation even when HLA expression was increased by IFN gamma treatment. Compared to lymphocyte or kidney cells incubated alone, MKLC induced a considerable stimulation of cytokine production. This increase in cytokine production was observed essentially for IL-2 and IL-6 (at day 3, a 10-fold increase in IL-2 and a 5-fold increase in IL-6). This study provided evidence that target kidney cells and effector lymphocyte interactions generate a number of cytokines such as IL-11, IL-2, IL-6, or TNF alpha. These cytokines are known to modulate alloproliferation and generation of cytotoxic J lymphocytes (CTL).     

Association Between Waiting Times for Kidney Transplantation and Rates of Live Donation

A deceased donor (DD) allocation system incorporating net life survival benefit has been proposed. In this system, many kidneys will be shifted to younger recipients, thereby decreasing their waiting times. The goal of this study was to determine the potential effects of altering waiting times on the likelihood of live donor kidney transplantation (LDKT). We analyzed 93,727 waiting list candidates to determine the association of various patient factors with likelihood of LDKT. The proportion of patients receiving LDKT was compared by the median DD waiting time at that patient's transplant center for someone of that patient's age category and race. LDKT was consistently higher as waiting times became longer. After adjusting for all other factors associated with likelihood of LDKT, waiting time remained a significant, independent predictor. Patients with the longest DD waiting times had 2.3-fold higher odds of LDKT (95% CI 2.11-2.58, p < 0.001). In planning the new DD allocation policy, we must account for resulting alterations in LDKT. It is possible that shifting DD kidneys to younger recipients may decrease LDKT or shift it to older recipients, net effects not consistent with the goal of net life survival benefit.