亲属肾移植供者术后早期肾功能变化的影响因素

目的:观察亲属肾移植供者所保留肾脏在手术前后肾小球滤过率(GFR)的变化及其影响因素。方法:共入组34例活体亲属肾移植供者,每例供者术前用MDRD公式计算总体GFR(eGFR)。观察供者肾切除后其保留肾脏4月内eGFR变化规律,并观察每例供者术后保留肾脏的代偿率,同时观察性别、年龄、体质量指数(BMI)和术前eGFR水平等因素对代偿率的影响,以术后1月作为观察终点。结果:所有供者肾切除术后保留肾脏的eGFR均逐渐增加,于术后第4天达到高峰,由术前的平均72.40ml/(min·1.73m2)增至平均88.05ml/(min·1.73m2),平均代偿率为21.60%。其中男性供者平均eGFR由术前的64.49ml/(min·1.73m2)增至80.48ml/(min·1.73m2),代偿率为24.79%,女性供者平均eGFR由术前的76.72ml/(min·1.73m2)增加至92.18ml/(min·1.73m2),代偿率为20.15%;≥50岁供者平均eGFR由术前的72.82ml/(min·1.73m2)增加至81.66ml/(min·1.73m2),代偿率为12.14%,<50岁供者平均的eGFR由术前的72.18ml/(min·1.73m2)增加至91.54ml/min,代偿率为26.82%;术前eGFR60ml/(min·1.73m2)供者平均由术前81.95ml/(min·1.73m2)增至95.42ml/(min·1.73m2),代偿率为16.44%,术前eGFR<60ml/(min·1.73m2)供者平均由术前54.90ml/(min·1.73m2)增至74.55ml/(min·1.73m2),代偿率为35.79%;BMI≥23.0kg/m2供者平均eGFR由术前的67.21ml/(min·1.73m2)增至84.39ml/(min·1.73m2),代偿率为25.56%,BMI<23.0kg/m2供者平均eGFR由术前的76.50ml/(min·1.73m2)增加至90.94ml/min,代偿率为18.88%。结论:肾切除术后所有供者保留肾脏的eGFR均明显增加;性别、年龄和术前eGFR水平严重影响肾脏切除术后供者的肾功能恢复;男性和女性供者在肾脏切除术后其保留肾脏的代偿率相似,但男性作为亲属肾移植供者与同龄女性相比术前eGFR水平较低;>50岁供者在术后肾脏的代偿率较低;术前GFR较小和BMI较大的供者,术后其代偿率更高。

移植肾动脉毛霉菌感染2例报告

肾移植术后肾动脉毛霉菌感染比较少见，我单位自1990年至今已行同种异体肾移植1500余例，发现移植肾动脉毛霉菌感染2例，现报告如下。

42例60岁以上尿毒症患者肾移植的评价

目的：探讨６０岁以上尿毒症患者行肾移植手术的可行性。方法：对我院４２例６０岁以上的尿毒症患者接受肾移植术后人／肾存活情况、排斥反应、并发症等进行分析。结果：术后１年人／肾存活率达９０％／７８％。

基于超声弹性成像技术诊断移植肾慢性排斥反应的探索

目的初步探讨超声弹性成像在诊断移植肾慢性排斥反应中的应用价值。方法选用GELOGIQE9对肾移植术后4个月～7年内34例患者，常规及彩色多普勒超声检查后，行移植。肾压迫式超声弹性成像。选定压力质量最佳图像，选取。肾中部测得髓质弹性指数El、皮质弹性指数E2、肾窦弹性指数E3及皮髓质弹性比值E—ratio（E2／E1）。以血肌酐（Scr）男性110μmol／L、女性90μmol／L为界分组，将不同分组弹性结果进行统计学分析。结果移植肾正常组及慢性排斥组弹性指数E均为肾皮质区〉肾髓质区〉肾窦区。

生育年龄肾功能不全女性患者月经异常的相关因素分析

目的探讨肾功能不全对女性月经的影响及导致月经异常的相关因素。方法采用横断面研究的方法对2010年9月至11月期间在首都医科大学附属北京朝阳医院及首都医科大学潞河教学医院的222例正在进行血液透析的女性慢性肾衰竭患者进行问卷调查。129例患者纳入研究。结果①129例患者中90例(69.76%)出现月经异常,月经异常相关因素包括合并妇科疾病,子宫内膜增生及既往功能失调性子宫出血病史(P均<0.05)。②月经异常分类:闭经23例(25.56%)、月经过多33例(36.67%)、月经稀发14例(15.56%)、经周期紊乱20例(22.22%)。③血液透析或肾移植后48例患者患者月经改善(53.33%),42例患者月经异常无明显改善(46.67%)。合并妇科疾患及肾功能不全至血液透析的时间间隔延长是月经改善的不利因素(P<0.05)。④肾衰竭与子宫内膜病变的关系:具有诊断性刮宫指征者40例,增殖期子宫内膜20例(50.0%),分泌期子宫内膜7例(17.50%),子宫内膜单纯性增生8例(占20.0%)、子宫内膜复杂增生1例(占2.5%)、子宫内膜非典型增生3例(7.5%)、子宫内膜癌1例(2.5%),肾功能不全至血液透析的时间间隔、开始透析时血肌酐值同子宫内膜病变发生呈显著相关(P均<0.05)。结论生育年龄肾功能不全患者易并发月经异常及子宫内膜病变。与月经改变相关因素包括合并妇科疾病及既往功能性子宫出血病史,与子宫内膜病变发生的相关因素包括肾衰竭至血液透析的间隔时间长及透析开始时血肌酐值高。

Mediating role of inner strength in the relationship between medication literacy and medication adherence among kidney transplant patients

Objective:Compared with long-term renal replacement therapy,kidney transplantation is the ideal treatment for end-stage renal disease(ESRD),significantly extending patient life and improving quality of life.Kidney transplant patients need to adhere to lifelong immunosuppressive medication regimens,but their medication adherence is generally poor compared with other organ transplant recipients.Medication adherence is closely related to medication literacy and psychological status,yet related studies are limited.This study aims to investigate the current status of medication adherence,inner strength,and medication literacy in kidney transplant patients,analyze the relationships among these 3 factors,and explore the mediating role of inner strength in the relationship between medication literacy and medication adherence.Methods:A cross-sectional survey was conducted from March to October 2023 involving 421 patients aged≥18 years who visited kidney transplantation outpatient clinics at 4 tertiary hospitals in Hunan Province.The inner strength,medication literacy,and medication adherence of kidney transplant patients were investigated using the Inner Strength Scale(ISS),the Chinese version of the Medication Literacy Assessment in Spanish and English(MedLitRxSE),and the Chinese version of the Morisky Medication Adherence Scale-8(C-MMAS-8),respectively.Univariate analysis was performed to examine the effects of demographic and clinical data on medication adherence.Correlation analysis was conducted to explore the relationships among medication literacy,medication adherence,and inner strength.Significant variables from univariate and correlation analyses were further analyzed using multiple linear regression,and the mediating effect of inner strength was explored.Results:Among the 421 questionnaires collected,408 were valid,with an effective rate of 96.91%.The scores of C-MMAS-8,MedLitRxSE,and ISS were 6.64±1.16,100.63±14.67,and 8.47±4.03,respectively.Among the 408 patients,only 86(21.08%)patients had a high level of medication adherence,whereas 230(56.37%)patients had a medium level of medication adherence,and 92(22.55%)patients had poor medication adherence.Univariate analysis indicated that the kidney transplant patients’age,marital status,education levels,years since their kidney transplant operation,number of hospitalizations after the kidney transplant,and adverse drug reactions showed significant differences in medication adherence(all P<0.05).Correlation analysis showed that inner strength positively correlated with both medication literacy(r=0.183,P<0.001)and medication adherence(r=0.201,P<0.001).Additionally,there was a positive correlation between medication adherence and medication literacy(r=0.236,P<0.001).Inner strength accounted for 13.22%of the total effect in the mediating role between medication literacy and medication adherence.Conclusion:The level of medication adherence among kidney transplant patients needs improvement,and targeted intervention measures are essential.Inner strength mediates the relationship between medication literacy and medication adherence in these patients.Healthcare professionals should focus on enhancing medication literacy and supporting patients’inner strength to improve medication adherence.

活体肾移植供者术前焦虑状况及其影响因素的调查研究

目的评估活体肾移植供者术前焦虑状况并探讨其焦虑影响因素，为供者术前心理护理提供理论依据。方法采用随机抽样的研究方法，抽取100例愿意接受调查的供者，术前进行状态一特质焦虑量表、社会支持评定量表、艾森克人格个性问卷调查，探讨焦虑影响因素。结果100例供者术前焦虑发生率为49％；状态焦虑平均得分为（52．24±10．048）分；影响供者术前焦虑的因素包括对受者手术失败焦虑、特质焦虑、对支持的利用度、对手术本身焦虑、对医疗费用焦虑等。结论供者术前状态焦虑得分高于国内腹部普通手术患者术前水平。了解供者术前焦虑的各种影响因素，将有助于临床制定针对性的护理干预措施，以有效降低供者的焦虑程度，提高手术效果，促进其术后身体恢复。

川芎嗪联合丹参延缓肾移植大鼠慢性移植肾肾病进程的作用

目的研究川芎嗪（TMP）联合丹参延缓肾移植大鼠慢性移植肾肾病进程的作用及机制。方法以Fisher 344大鼠和Lewis大鼠分别作为肾移植的供、受者进行原位肾移植，并建立CAN模型。按随机数字表法将受鼠分为5组：环孢素A（CsA）组（A组）、TMP＋CsA组（B组）、丹参＋csA组（C组）、TMP＋丹参＋CsA组（D组）及空白对照组（E组，未使用任何药物）。分别于术后2、4、6、8和12周，处死每组5只受鼠，取移植肾进行移植肾组织病理学变化，采用免疫组织化学法检测移植肾组织转化生长因子8，（TGF-β1）的表达，采用荧光定量聚合酶链反应法检测移植。肾组织TGF-β1mRNA的表达。结果术后空白对照组受鼠的存活时间均未超过2周。A组于术后4周时最早出现CAN病理改变，B组和C组出现CAN病理改变的时间较A组晚，D组出现CAN病理改变的时间最晚，且病理改变程度最轻。术后各组Banff评分均呈现明显的上升趋势，相同时问点，A组明显高于其他3组（P〈0．05和P〈0．01），D组明显低于与B组和C组（P〈0．05），而B组与C组间无显著差异（P〉0．05）。随着术后时间的推移，各组TGF-β1，表达强度呈逐渐增加的趋势，相同时问点，A组TGF-13，表达强度最高，与其他3组比较，差异均有统计学意义（P〈0．05和P〈0．01），D组明显低于B组和C组（P〈0．05），B组与C组间无明显差异（P〉0．05）。各组TGF-β1mRNA表达的变化趋势及组间差异与TGF-β1，表达强度的情况相一致。结论TMP或丹参均具有通过下调TGF-β1的表达延缓肾移植大鼠CAN进程的作用，当两者联合应用时作用更为明显。

肾移植中丙二醛及超氧化物歧化酶的监测及临床意义

连续动态监测４５例肾移植患者手术前后血浆丙二醛（ＭＤＡ）及超氧化物歧化酶（ＳＯＤ）水平变化，发现急性肾小管坏死（ＡＴＮ）组患者术后第１天血浆ＭＤＡ及ＳＯＤ水平较术前明显升高，分别在术后１０天及７天内维持较高水平（Ｐ＜０．０５）；急性排斥（ＡＲ）及急性感染（ＡＩ）发生时，ＭＤＡ及ＳＯＤ水平亦升高，但不如ＡＴＮ组显著（Ｐ＜０．０５）；术前ＭＤＡ及ＳＯＤ水平明显高于正常对照组（Ｐ＜０．０５）；正常恢复组术后ＭＤＡ及ＳＯＤ水平则逐步下降。结果反映了ＡＴＮ、ＡＲ及ＡＩ发生时脂质过氧化损伤的参与，并表明动态监测ＭＤＡ及ＳＯＤ水平变化有助于ＡＴＮ的早期诊断和鉴别诊断。

肾脏移植术后应用OKT_3治疗难治性排斥反应

对２６例肾脏移植术后出现难治性排斥反应而接受ＯＫＴ３治疗的患者，进行治疗前后ＩＬ－１，ＩＬ－６和ＴＮＦ－α的监测。使用ＯＫＴ３治疗急性加速排斥反应的治愈率８８．９％（８／９），有效率为１００％；急性难治性排斥反应治愈率为６６．７％（１０／１５），有效率为７３．３％（１１／１５）；慢性排斥反应无效。

肾移植患者脑电地形图研究

我院１９８８年以来采用脑电ｔ检验地形图，对３５例尿毒症和２０例肾移植患者手术前后脑电地形图异常分布进行了统计学成象分析。结果发现尿毒症期脑电广泛异常分布是有意义的（Ｐ＜０．０１），慢波功率增加最显著的区域为右顶部，ａ波功率减少最明显为顶区偏右部，表明尿毒症期的脑损害既有广泛性损害的一般性，又有局限性损害的特殊性，且病变最重为某一区域，这种特征随着尿毒症病程延长而加重，一旦接受肾移植，随着移植肾功能恢复，血中代谢性产物清除，脑组织和脑脊液中内环境得以平衡稳定，脑电地形图很快恢复正常。

Liver transplantation for polycystic liver with massive hepatomegaly: A case report

A previous study has shown that liver or combined liver-kidney transplantation can be a valuable surgical technique for the treatment of polycystic liver disease. Herein, we present the case of a 35-year-old woman with polycystic liver disease, who underwent orthotopic liver transplantation (OLT) on November 11, 2008. The whole-size graft was taken from a deceased donor (a 51-year-old man who died of a heart attack). Resection in a patient with massive hepatomegaly is very difficult. Thus, after intercepting the portal hepatic vein, left hepatectomy was performed, then the vena cava was intercepted, the second and third porta hepatic isolated, and fi nally, right hepatectomy was performed. OLT was performed successfully. The recipient did well after transplantation. This case suggested that OLT is an effective therapeutic option for polycystic liver disease and left hepatectomy can be performed fi rst during OLT if the liver is over enlarged.

INFLUENCE OF HEPATITIS B AND HEPATITIS C VIRUS INFECTION ON THE OUTCOME OF KIDNEY TRANSPLANTATION

Objective To investigate the impact of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection on the long-term survival of renal transplantation recipients. Methods A total of 443 patients who received renal allografts from 1992 to 2002 were analyzed. Outcome and survival were compared among four groups retrospectively. Results Twelve patients were positive for both hepatitis B surface antigen (HBsAg) and HCV antibody (anti-HCV) (group 1), 18 were HBsAg-positive and anti-HCV-negative (group 2), 26 were HBsAg-negative and anti-HCV-positive (group 3) and 387 were negative for both markers (group 4). The mean follow-up period was 6.1 ± 2.8 years (range, 0.5-10 years) for all patients. Group 2 had significantly higher liver-related complications (38.9%) and liver-related death (16.7%) than did group 4 (0%, P < 0.01). Among all patients, 4 HBsAg-positive patients had fulminant hepatitis and died within two years of transplantation. Three patients (group 2) who died were seropositive for HBeAg and/or HBV DNA and none had a history of or positive serologic marker to indicate hepatitis of other etiologies. One (group 1), two (group 2), and one patient (group 3) developed liver cirrhosis respectively, and hepatocellular carcinoma occurred in two patients (group 2) and one patient (group 3). Despite high liver-related mortality in HBV-infected patients, no significant differences among the four groups in the long-term graft and patient survivals were demonstrated. The presence of HBsAg or anti-HCV was not associated with poor prognosis as determined by Cox regression analysis. Conclusion HBV or HCV infection is not a contraindiction to kidney transplantation in Chinese patients. However, it should be noted that serious liver-related complications may occur and limit survival in patients infected with HBV and/or HCV after kidney transplantation.

EXPRESSION OF ICAM-1 AND LFA-1 MOLECULES IN RELATION TO RENAL ALLOGRAFT REJECTION IN RATS

Objective.The purpose of this study was to assess the renal graft expression of ICAM 1(intercellular adhesion molecule 1) and LFA 1(lymphocyte function associated antigen 1)molecule with relation to graft rejection. Methods.Rat kidney transplantation was performed according to the procedure of Kamada with some modification.Experimental rats were divided into 5 groups.The survival time of recipient rats and function of grafts after renal transplantation were observed.The sections of renal graft were stained for monoclonal antibody ICAM 1 and LFA 1, and then quantification of ICAM 1 and LFA 1 expression was accomplished by computer image analysis. Results.ICAM 1 and LFA 1 increased significantly in the renal allograft rejection group as compared with the non rejection groups(P<0 05). Conclusion.Both biopsy of renal graft and monitoring of ICAM 1 and LFA 1 are useful tools in diagnosing and treating acute rejection.

PREVENTION AND TREATMENT OF REJECTION AFTER SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTATION

Objective To explore methods of preventing and reversing rejection after simultaneous pancreas-kidney （SPK） transplantation. Methods Seventeen patients underwent SPK transplantation from September 1999 to September 2003 were reviewed retrospectively. Immunosuppression was achieved by a triple drug regimen consisting of cyclosporine, mycophenolate mofleil （MMF）, and steroids. Three patients were treated with anti-CD3 monoclone antibody （OKT3, 5 mg·d^-1） for induction therapy for a mean period of 5-7 days. One patients received IL-2 receptor antibodies （daclizumab） in a dose of I mg·kg^-1 on the day of transplant and the 5th day posttransplant. One patient was treated with both OKT3 and daclizumab for induction. Results No primary non-functionality of either kidney or pancreas occurred in this series of transplantations. Function of all the kidney grafts recovered within 2 to 4 days after transplantation. The level of serum creatinine was 94 ± 11 μmol/L on the 7th day posttransplant. One patient experienced the accelerated rejection, resulting in the resection of the pancreas and kidney grafts because of the failure of conservative therapy. The incidence of the first rejection episodes at 3 months was 47.1% （8/17）. Only the kidney was involved in 35.3% （6/17）; and both the pancreas and kidney were involved in 11.8% （2/17）. All these patients received a high-dose pulse of methylprednisone （0.5 g·d^-1） for 3 days. OKT3 （0.5 mg·d^-1） was administered for 7-10 days in two patients with both renal and pancreas rejection. All the grafts were successfully rescued. Conclusion Rejection, particularly acute rejection, is the major cause influencing graft function in SPK transplantation. Monitoring renal function and pancreas exocrine secretion, and reasonable application of immunosuppressants play important roles in the diagnosis and treatment of rejection.

Unplanned hospital readmissions after kidney transplantation among patients in Hefei,China:Incidence,causes and risk factors

Objectives:Unplanned readmissions severely affect a patient's physical and mental well-being after kidney transplantation(KT),which is also independently associated with morbidity.A retrospective study was conducted to identify the incidence,causes and risk factors for unplanned readmission after KT among Chinese patients.Methods:Patients who underwent KT were admitted to the organ transplant center of the Affiliated Hospital of University of Science and Technology of China(2017-2018).Medical records for these patients were obtained through the hospital information system(HIS).Results:In 518 patients,the incidence of unplanned readmissions within 30 days(n=9)was 1.74%,and 90 days(n=64)was 12.35%.The one-year unplanned readmission rate was 22.59%(n=122).Overall,122 patients were readmitted because of infection,renal events,metabolic disturbances,surgical complications,etc.Hemodialysis(OR=10.462,95%CI:1.355-80.748),peritoneal dialysis(OR=8.746,95%CI:1.074-71.238)and length of stay(OR=1.023,95%CI:1.006-1.040)were independent risk factors for unplanned readmissions.Conclusion:Unplanned readmission rates increased with time after KT.Certain risk factors related to unplanned readmissions should be deeply excavated.Targeted interventions for controllable factors to alleviate the rate of unplanned readmissions should be identified.

Treatment of advanced rectal cancer after renal transplantation

Renal transplantation is a standard procedure for endstage renal disease today. Due to immunosuppressive drugs and increasing survival time after renal transplantation, patients with transplanted kidneys carry an increased risk of developing malignant tumors. In this case report, 3 patients with advanced rectal cancer after renal transplantation for renal failure were treated with anterior resection or abdominoperineal resection plus total mesorectal excision, followed by adjuvant chemotherapy. One patient eventually died of metastasized cancer 31 mo after therapy, although his organ grafts functioned well until his death. The other 2 patients were well during the 8 and 21 mo followup periods after rectal resection. We therefore strongly argue that patients with advanced rectal cancer should receive standard oncology treatment, including operation and adjuvant treatment after renal transplantation. Colorectal cancer screening in such patients appears justified.

Jejunoileal bypass:A surgery of the past and a review of its complications

Jejunoileal bypass(JIB),popular in the 1960s and 1970s,had remarkable success in achieving weight loss by creating a surgical short bowel syndrome.Our patient had an unusual case of liver disease and provided no history of prior bariatric surgery.Later,it was recognized that he had a JIB in the 1970s,which was also responsible for the gamut of his illnesses.Patients with JIB are often not recognized,as they died of complications,or underwent reversal of their surgery or a liver-kidney transplant.Early identification with prompt reversal,and the recognition and treatment of the life-threatening consequences play a critical role in the management of such patients.

Efficiency and safety of lamivudine therapy in patients with chronic HBV infection, dialysis or after kidney transplantation

AIM: To analyze the effectiveness and safety of lamivudine treatment in patients with chronic HBV infection undergoing hemodialysis or after kidney transplantation, and to study the frequency of tyrosine - methionine - aspartate - aspartate (YMDD) mutation occurrence after lamivudine treatment. METHODS: We analyzed 91 patients with chronic hepatitis B, among whom, 16 patients underwent hemodialysis, 7 patients had kidney transplantation and 68 patients had normal function of kidney. The hemodialysis patients were treated by lamivudine 300 mg/wk. patients after kidney transplantation and patiente with normal function of kidney were treated with lamivudine 100 mg/d. Therapy lasted for 12 mo. HBV-DNA, HBsAg, HBeAg and anti-HBe, and anti-HCV antibodies were assessed in sera of patients. The analysis was performed before and 6 mo after the end of lamivudine treatment. Before, during and after the lamivudine therapy, the number of erythrocytes, leukocytes, platelets and hemoglobin concentration, ALT and AST activity, as well as bilirubin, urea and creatinine concentrations were analyzed in sera from patients. RESULTS: After the 12-mo lamivudine treatment, elimination of HBV - DNA was observed in 56% patients undergoing hemodialysis and in 53% patients with normal kidney function. Only 1 from 7 (14%) kidney-transplanted patients eliminated HBV-DNA. Furthermore, HBeAg elimination was observed in 36% hemodialysis patients, in 51% patients with normal function of kidneys and in 43% kidney transplanted patients. Among the patients undergoing dialysis, no YMDD mutation was found after 12 mo of therapy, while it was detected in 9 patients (13%) with normal function of kidney and in 2 kidney-transplanted patients (29%, P<0.006). We did not observe significant side effecte of lamivudine treatment in studied patiente. CONCLUSION: Effectiveness of lamivudine therapy in dialysis patients is comparable with that in patiente with normal function of kidney. Lamivudine treatment is well tolerated and safe in patiente with renal insufficiency undergoing hemodialysis and kidney-transplantation. However, in the latter group, high incidence of YMDD mutation after lamivudine treatment was observed.

Management of patients with a failed kidney transplant: Dialysis reinitiation, immunosuppression weaning, and transplantectomy

The number of patients reinitiating dialysis after a failed transplant increases over time and has more than doubled between the year 1988 and 2010 （an increase from 2463 to 5588）. More importantly, patients returning to dialysis have been shown to have a greater thanthree-fold increase in the annual adjusted mortality rates compared with those with a functioning graft. Continuation of immunosuppression to preserve residual graft function has been implicated to be a contributing factor, seemingly due to immunosuppression-ass-ociated cardiovascular and infectious complications and malignancy risk, among others. Nonetheless, maintenance low-dose immunosuppression has been suggested to confer survival beneft in patients returning to peritoneal dialysis. Whether early vs late reinitiation of dialysis or whether transplantectomy has an impact on patient survival remains poorly defined. Consensus guidelines for the management of a failed allograft are lacking. In this article, we present a literature overview on the ideal timing of dialysis reinitiation after graft loss, the management of immunosuppression after graft failure, and the risks and benefits of transplantectomy. The authors’ perspectives on the management of this special patient population are also discussed.