Immunosuppressive treatment and radiotherapy in kidney transplant patients:A systematic review

BACKGROUND Immunosuppression(IS)therapy may contribute to cancer development.Some authors have proposed to reduce immunosuppression drugs dose in case of viral infections,in immunosuppression-related diseases,and in patients undergoing radiotherapy.The present analysis reports the results of a systematic review on kidney transplant recipients undergoing immunosuppression and radiotherapy.AIM To define if it is necessary reduce immunosuppression drugs during radiotherapy.METHODS The literature search was based on three electronic databases(Pubmed,Scopus,and Web of Science)using selected keywords linked through the"AND"and"OR"Boolean operators to build specific strings for each electronic search engine.Two researchers independently screened the citations,and disagreement was resolved by discussion or through the intervention of a third author.The review was conducted and reported according to the PRISMA statement.Extracted data were narratively synthesized,and,where possible,frequencies,percentages,and ranges were calculated.RESULTS The literature search resulted in 147 citations.After abstracts screening,21 records were selected for full-text evaluation.Fifteen of these were excluded,leaving six papers considered suitable for analysis.There is still no clear evidence that withdrawing antimetabolites and/or calcineurin inhibitors and/or mammalian target of rapamycin-inhibitors,as opposed to continuing maintenance IS,improves patient survival in kidney transplant recipients with cancer undergoing radiotherapy.Only few retrospective studies on small cancer patient cohorts are available in this setting,but without comparison of different immunosuppression treatments.Even where immunosuppression therapy was described,patient survival seemed to be correlated only with cancer stage and type.CONCLUSION The results of this systematic review do not support the reduction of immunosuppression dose in patients undergoing radiotherapy.

Review and analysis of 1011 cadaveric renal transplantations

renal allograft operations were performed in 969 chronic renal failure patients within 15years,from June 1978 to December 1993.Patients/recipients survival rates were as follows respectively:89.2%/78.7%for 1 year,82.0%/74.7% for 3 years and 67.0%/58.4% fo

Patients Returning to Dialysis after Failed Kidney Transplant: How Do They Fare? A Gulf Perspective

An increasing number of failed transplant patients returning to dialysis (FTRD) have been observed with reported worse survival compared to transplant-naive dialysis (TxN) patients. This study aimed to assess outcomes of FTRD vs. matched TxN controls in a Gulf region multi-center trial of 800 HD patients. Similar mortality was seen, likely due to earlier start and better HD adequacy in FTRD. Younger age, less diabetes and living donor transplantation in majority with 27% graft nephrectomy (Nx) might also confer benefits. Subgroup analysis of Nx patients showed more hospitalizations and prior rejection episodes with lower graft survival. The deaths, however, oc-curred only in nonNx group and are likely explained by older age, longer duration on HD, more prevalence of diabetes and CAD. FTRD showed similar survival to TxN. Early intensive HD might account for the benefit. Whether Nx confers advantage is unclear because of the small sample size.

Efficacy and safety of non-vitamin K antagonist oral anticoagulants post-kidney transplantation

BACKGROUND Novel oral anticoagulants(NOACs)were developed as alternatives to vitamin K antagonists,primarily warfarin,as they do not require routine monitoring and have limited drug-drug and drug-food interactions.However,the efficacy and safety of these agents in kidney transplantation are not well studied.AIM To assess the profile and safety of NOACs for patients who had kidney transplantation,and to provide recommendations and guidelines on therapeutic strategies in these patients.METHODS This was a retrospective study carried out among adult patients who were actively on the following NOACs(apixaban,rivaroxaban or dabigatran)in our renal transplantation program from December 2015 to December 2016.The patients were identified primarily through electronic medical record system(patient data linkage).Data on the clinical and laboratory profile of the patients were retrieved and analyzed with SPSS 22.0.RESULTS Complete data on 42 renal transplant patients were retrieved:59.5%males,90.5%were whites and 66.7%were older than 60 years old.The mean duration since renal transplantation of the patients was 8.8±7.4 years.The most common risk factors for the development of end-stage renal disease in the subjects were hypertension(19.0%),polycystic kidney disease(19.0%),followed by diabetic nephropathy(16.7%)and chronic glomerulonephritis(16.7%).The main indications for NOACs use in the cohort were atrial fibrillation in 25 patients(59.5%)and venous thromboembolism in 10 patients(23.8%).Overall,29 patients(69%)were treated with apixaban,10 patients(23.8%)with rivaroxaban and 3 patients(7.14%)with dabigatran.No(0%)thromboembolic events were observed during the one-year period,but 3(7.1%)bleeding events occurred in the cohort consisting of 1 patient treated with rivaroxaban 15 mg daily and 2 patients who received apixaban 2.5 mg twice daily.There were no significant changes in serum tacrolimus level three days after the initiation of NOACs among patients treated with tacrolimus(pre-and post-NOACs tacrolimus levels were 7.2516 and 7.8867 ng/m L,P=0.55,respectively).Also,after one-year of treatment with NOACs there were no significant changes in the pre-and post-NOACs serum creatinine level(P=0.772)and estimated glomerular filtration rates(P=0.232).CONCLUSION No thromboembolic events or significant changes in renal profile were observed in our cohort of kidney transplant recipients who were treated with NOACs for at least a year.However,a few bleeding events were observed.This calls for further well-planned randomized controlled trials to assess the efficacy and safety of NOACs among renal transplant recipients.

Hemodynamics in Transplant Renal Artery Stenosis and its Alteration after Stent Implantation Based on a Patient-specific Computational Fluid Dynamics Model

Background： Accumulating studies on computational fluid dynamics （CFD） support the involvement of hemodynamic factors in artery stenosis. Based on a patient-specific CFD model, the present study aimed to investigate the hemodynamic characteristics of transplant renal artery stenosis （TRAS） and its alteration after stent treatment. Methods： Computed tomography angiography （CTA） data of kidney transplant recipients in a single transplant center from April 2013 to November 2014 were reviewed. The three-dimensional geometry of transplant renal artery （TRA） was reconstructed from the qualified CTA images and categorized into three groups： the normal, stenotic, and stented groups. Hemodynamic parameters including pressure distribution, velocity, wall shear stress （WSS）, and mass flow rate （MFR） were extracted. The data of hemodynamic parameters were expressed as median （interquartile range）, and Mann-Whitney U-test was used for analysis. Results： Totally, 6 normal, 12 stenotic, and 6 stented TRAs were included in the analysis. TRAS presented nonuniform pressure distribution, adverse pressure gradient across stenosis throat, flow vortex, and a separation zone at downstream stenosis. Stenotic arteries had higher maximal velocity and maximal WSS （2.94 [2.14, 3.30] vs. 1.06 /0.89, 1.15] m/s, 256.5 [149.8, 349.4] vs. 41.7 [37.8, 45.3] Pa at end diastole, P - 0.001 ; 3.25 [2.67, 3.56] vs. 1.65 [ 1.18, 1.72] m/s, 281.3 [ 184.3,364.7] vs. 65.8 [61.2, 71.9] Pa at peak systole, P - 0.001 ） and lower minimal WSS and MFRs （0.07 [0.03, 0.13] vs. 0.52 [0.45, 0.67] Pa, 1.5 [1.0, 3.0] vs. 11.0 [8.0, 11.3] g/s at end diastole, P = 0.001 ; 0.08 [0.03, 0.19] vs. 0.70 [0.60, 0.81] Pa, 2.0 [1.3, 3.3] vs. 16.5 [13.0, 20.3] g/s at peak systole, P 0.001） as compared to normal arteries. Stent implantation ameliorated all the alterations of the above hemodynamic factors except low WSS. Conclusions： Hemodynamic factors were significantly changed in severe TRAS. Stent implantation can restore or ameliorate deleterious change of hemodynamic factors except low WSS at stent regions.

基于肾移植病人全程化药学服务信息管理系统的建立与应用

目的:建立肾移植病人的全程化药学服务信息平台。方法:开发一种基于肾移植病人药学服务的信息管理系统,内容包括病人的基本信息、环孢素浓度测定结果、手术及住院信息、药学服务记录等,并能实现操作方便、信息查询和资料汇总分析等功能。结果:信息管理系统可满足对肾移植病人住院、门诊和家庭随访中的药学服务、用药教育及用药咨询等药学服务的需求,及时为环孢素的剂量调整提供基础数据和依据。结论:该系统有助于药师为肾移植病人提供全程化药学服务。

尸体肾移植1011例次的临床报告

１９７８年６月至１９９３年１２月，我院共为９６９例慢性肾衰患者施行同种异体肾移植１０１１例次。人／肾总存活率：１年期为８９．２％／７８．７％；３年期为８２．０％／７４．７％；５年期为６７．０％／５８．４％；存活１０年以上者已有１２例。１５年的肾移植经验表明：（１）提高肾存活率的因素是多方面的，其中高质量取肾与植肾手术尤为重要；（２）环孢素Ａ等免疫抑制剂虽已普遍应用但仍应坚持ＡＢＯ血型及淋巴细胞毒性试验配型工作；（３）感染仍是移植失败的重要原因，应将预防感染措施贯彻于术前、术中及术后全过程；（４）加强肾移植患者的随访工作，指导患者康复期的治疗，对肾移植后长期存活具有重要意义。

肾移植2508例次临床总结

目的总结肾移植的临床经验,探讨影响移植术后人/肾存活的因素,提高长期存活率。方法回顾性总结1979年1月～2008年6月2508例次肾脏移植资料,分析患者术前状况、组织配型、群体反应性抗体(PRA)、供肾的切取、灌注、热冷缺血时间、植肾技术、术后并发症的发生、不同免疫抑制剂方案、再次移植等因素对移植效果及人/肾存活率的影响。结果①移植效果:总体人/肾存活率81.4%/76.3%;近10年来,1、5、10年人/肾存活率(%)分别为:96.5/93.2、88.6/81.6和74.7/71.3;186例活体亲属供者随访均健康存活,受者1年人/肾健康存活率98.5%/95.5%;②排斥反应:超级排斥反应发生率0.7%,急性排斥反应(AR)发生率13.7%,近十年来急性排斥反应(AR)发生率7.4%;③术后并发症:发生各种感染787例,急性肾小管坏死(ATN)275例,药物毒副作用590例,肾动脉及肾破裂19例;晚期输尿管梗阻39例,恶性肿瘤28例;④死亡原因:前三位的分别是感染占47.3%,心脑血管并发症占34.8%,肝功能衰竭占10.9%。结论充分的术前准备、良好的HLA配型、加强PRA检测是提高存活率的基础;高质量的供肾和娴熟的移植技术是肾移植成功的重要保证;科学、合理、个体化的应用免疫抑制剂是移植后治疗的重点,环孢素A(CsA)或他克莫司(FK506)、霉酚酸酯(MMF)、泼尼松(Pred)三联是目前首选的免疫抑制治疗方案。加强感染的早期监测、预防性治疗是术后早期治疗的另一关键;加强患者的随访,提高患者的依从性,对指导肾移植受者长期存活具有重要价值。

基于5A模式肾移植术后患者自我管理干预方案的构建与应用

针对肾移植术后患者自我管理现状,开展课题研究型品管圈活动。从医院、医联体及家庭三方面挖掘攻坚点,多方拟定方策并予以实施,包括打造肾移植患者自我管理支持团队、构建肾移植患者自我管理四维支持方案、建立肾移植患者“1+N”驿站随访模式等。通过干预,肾移植术后患者自我管理能力和生活质量得以大幅度提升。

国内肾移植术后患者心理体验的质性Meta整合

目的系统评价肾移植患者术后心理体验。方法计算机检索数据库中国知网、万方数据库、维普数据库、中国生物医学文献数据库,搜索关于肾移植患者术后真实体验的质性研究,检索时限从建库至2018年5月。进行文献质量评价后,采用Meta整合方法对研究结果进行归纳、诠释。结果共纳入8篇文献,提炼出52个结果、6个类别和3个整合结果,分别为肾移植术后患者消极心理、肾移植术后患者对未来与生命的心理感受、肾移植术后患者的自身健康需求与期望。结论医护人员应充分了解肾移植术后患者心理体验,做好针对性心理干预,引导患者调整认知和行为方式,提高患者的术后生活质量,并且增强患者对未来生活的心理资本。

觉知疗法改善肾移植患者情绪困扰:个案研究

目的:初步探索觉知疗法对肾移植患者情绪困扰的干预效果。方法:1例肾移植患者接受8周觉知治疗。采用抑郁自评量表、焦虑自评量表、睡眠状况量表和注意觉知量表,在干预前、干预后、干预后1个月对患者实施测评,并收集患者的主观报告。结果:患者经过干预后,其抑郁、焦虑水平下降,睡眠状况改善,觉知度提高,其改善在追踪期获得保持。结论:觉知干预对有效帮助国内肾移植患者进行情绪调节存在一定的可能性,但未来需要更多的实证研究。

婴幼儿死亡后器官捐献单侧供肾用于成人肾移植术后的护理

目的探讨婴幼儿死亡后器官捐献(donation after death,DCD)单侧供肾用于成人移植术后的临床特点,总结术后护理要点。方法 2014年1月至2016年6月对36例婴幼儿用于DCD单侧供肾成人受者进行肾移植手术,术后根据患者早期临床特点,给予针对性护理对策。结果 36例婴幼儿DCD单侧供肾用于成人肾移植术后发生肺部感染3例,切口感染2例,移植肾血栓2例,移植肾输尿管尿瘘2例,移植肾功能延迟恢复(delayed graft function,DGF)16例。术后随访1~20个月,36例受者均成活,其中34例受者移植肾功能恢复良好,2例因移植肾动静脉血栓形成而切除移植肾。结论婴幼儿DCD单侧供肾用于成人肾移植手术难度大,术后并发症多,护理难度大。在护理方面应加强术中、术后患者血压的监控,严格控制出入量的管理,做好早期并发症的观察及护理,其对提高移植肾的存活率,减少并发症发生,促进患者早期康复具有重要意义。

蛋白A免疫吸附治疗高致敏肾移植受者1例报告并文献复习

目的 肾脏移植的致敏性是目前临床面临的一大难题，高致敏受者接受移植的机会大大减少，我们对1例高致敏受者肾移植围手术期采用蛋白A免疫吸附疗法配合免疫抑制治疗，观察其临床效果，结合文献评估疗效。方法受者采用蛋白A免疫吸附成功进行肾移植病例，同时回顾通过国内外文献检索得到的蛋白A免疫吸附治疗肾移植高致敏受者的病例。结果结合我们目前的病例，分析已被报道的66例（国内30例，国外36例）蛋白A免疫吸附治疗肾移植高致敏受者的病例，发现大部分患者采用了蛋白A免疫吸附可以明显降低IgG、IgM、IgA等，PRA从术前30％～100％降低到术后30％以下，65例成功进行了肾移植。结论 Protein A免疫吸附可以清除体内免疫球蛋白疗效明显，结合免疫抑制治疗使肾移植高致敏受者成功接受肾移植，提高移植肾远期存活率。

临床药师对肾移植患者实施药物治疗管理的示例

以1例肾移植患者的药物治疗管理(MTM)实践为例,介绍了MTM的规范化流程。通过药物治疗回顾、干预/转诊、制订用药清单和药物相关治疗计划、记录与随访,临床药师解决了药物治疗过程中的潜在药物相互作用,改善了患者的血压控制,并协助医师将他克莫司血药浓度调整至适宜范围。临床药师实施MTM服务对肾移植患者的慢病管理起到了积极有益的作用,可为药学工作者开展MTM服务提供参考。

肾移植术后患者150例重返岗位情况及护理对策

目的了解肾移植术后患者重返岗位的情况,并探讨帮助他们重新融入社会的护理方法,以提高其生活质量。方法回顾性分析2009年9月至2012年9月在第二军医大学长征医院接受肾移植后门诊复查的患者150例的临床资料及随访记录,总结其相应护理方法。结果 150例患者均顺利重返岗位。结论护理人员在工作中不仅要重视生物因素的影响,更要特别重视其社会属性,以提高其生活质量。

重危患者同种异体肾移植麻醉处理

[目的]探讨重危患者同种异体肾移植麻醉处理。[方法]回顾性分析了1995年1月～2005年12月重危患者12例的临床资料。[结果]在12例重危患者中经抢救及麻醉处理得当,10例安全度过围手术期,1例术后5d死亡,1例因严重的排斥反应放弃手术。[结论]正确及时的麻醉处理是重危患者同种异体肾移植手术成功的关键。

老年肾移植受者的临床特点与管理分析

目的探讨老年肾移植受者的临床特点及其管理方法。方法选择该院自2006年5月—2014年6月收治的21例接受肾移植的患者的临床资料,全部患者均给予肾移植手术治疗,术前均给予常规检查,取尸体肾,术后给予对症处理。结果全部患者均合并各类系统疾病,其中消化系统疾病5例,心血管疾病8例,呼吸系统6例,泌尿系统疾病2例,术后,合并心血管系统疾病患者发生并发症3例,发生房颤、阵发性室上性心动过速,死亡2例,死亡原因为心衰;合并消化系统系统疾病发生并发症1例,为肝硬化患者发生进展至肝功能衰竭,最终死亡;合并呼吸系统疾病1例,其中支气管炎患者进展至重症肺炎死亡,陈旧性肺结核未见复发;合并泌尿系统疾病1例,为前列腺增生患者行肾移植术后,发生尿路梗阻,经尿道前列腺电切术后解除梗阻,合并泌尿系统疾病患者未见死亡病例,术后,发生AR4例,AR发生率19.0%,其中1例患者先后发生2次AR,3例患者经抗排斥治疗后逆转;术后6例患者发生感染,占比28.6%。全部患者住院时间18~40 d,平均住院时间（27.8±10.4）d。结论肾脏移植是老年终末期肾疾病患者有效的治疗方法,尽管目前仍存在较高的并发症,在治疗过程中,加强术前、术中及术后管理,谨慎选择治疗方案,提高患者及移植物的存活时间。

高龄患者肾移植的体会

目的探讨高龄患者肾移植的治疗问题。方法对９例５０岁以上的高龄患者施行尸体肾移植。结果除１例术后早期死于ＤＩＣ和心衰外，其余８例随访０．５～６年（其中７例已存活＞１．５年），人／肾均存活。结论术前有效地处理原有疾病、合理应用免疫抑制剂、严密的术后护理和实验室监测是高龄患者肾移植成功的关键。

老年肾移植27例临床分析与护理对策

目的:探讨60岁以上老年肾移植患者的临床特点及护理措施。方法:回顾性分析超过60岁肾移植患者27例临床资料,并以同期小于60岁的肾移植患者144例作对照。结果:老年患者透析时间长,低蛋白血症严重,冠心病、糖尿病及心力衰竭发病率高,与对照组比较,差异有显著性(P<0.05)。老年组术后肺部感染、肝功能损害、心力衰竭、心绞痛及糖尿病等的发病率均高于对照组(P<0.05)。结论:老年患者进行肾移植时,术前应慎重选择、充分准备、严格配型,术后合理使用免疫抑制剂,严格消毒隔离制度,加强基础护理,严密观察生命体征,积极处理并发症,以提高移植肾成活率。

高龄肝肾联合移植的基础及临床研究(附1例报告)

目的探讨肝肾联合移植的手术技术、围手术期处理、感染及排斥等并发症的防治措施。方法对1例66岁酒精性肝硬化终末期并慢性肾功能不全尿毒症患者施行一期肝肾联合移植。供体器官采用UW液联合原位灌洗、整块切取,肝移植采用原位非转流移植技术,肾移植采用常规方法置于右髂窝。术后免疫抑制剂采用普乐可复、霉酚酸酯、抗胸腺淋巴细胞球蛋白和皮质类固醇激素联合应用,行免疫指标及移植肝、肾多普勒超声监测。结果移植后肝、肾立即发挥作用,术后24 h胆汁380 ml,尿量8 500 ml,第3天肝、肾功化验指标正常,术后第10天移植肝发生急性排斥反应,经调整普乐可复浓度并行甲基强地松龙冲击治疗后控制。术后第29天康复出院。随访1年肝肾功能正常,日常生活自理。结论肝肾联合移植是治疗肝、肾同时衰竭的有效方法,良好的组织配型、娴熟的技术、免疫抑制剂的合理应用、术后并发症的正确处理是成功的关键。