横纹肌溶解合并急性肾损伤供肾移植后受者的临床疗效

目的:探讨横纹肌溶解症合并急性肾损伤(AKI)供者肾移植后受者的临床效果。方法:回顾性分析中山大学附属第一医院2012年1月~2015年12月器官捐献供者中,因横纹肌溶解症导致AKI的供者和肾移植受者临床资料。结果:8例供者因横纹肌溶解症导致AKI,供者血肌酸激酶峰值为10 623±3 692 U/L,血浆肌红蛋白峰值为20 618±7 959μg/L,血清肌酐峰值为483±176μmol/L。其中3例接受血浆置换治疗,2例行持续性肾脏替代治疗(CRRT),1例接受体外膜肺氧合治疗。16例受者,肾移植术后4例移植肾功能延迟恢复,4例移植肾功能缓慢恢复,其余8例受者移植肾功能恢复良好。随访6~46月,人肾均存活。术后6月和12月肾小球滤过率分别为65.4±13.5 ml/(min·1.73m2)和71.2±14.3 ml/(min·1.73m2)。结论:接受横纹肌溶解症合并AKI患者供肾的受者肾移植术后移植肾功能恢复良好。出现AKI的器官捐献供者应该常规行横纹肌溶解症筛查。     

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72.40 ml/(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64.49 mL/(min· 1.73m2)增至80.48 ml/(min·1.73m2),代偿率为24.79％,女性供者平均eGFR由术前的76.72 ml/(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72.82 ml/(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72.18 ml/(min· 1.73m2)增加至91.54ml/min,代偿率为26.82％;术前eGFR 60 ml/(min· 1.73m2)供者平均由术前81.95 mL/(min-1.73m2)增至95.42ml/(min· 1.73m2),代偿率为16.44％,术前eGFR ＜60 mL/(min-1.73m2)供者平均由术前54.90 ml/(min· 1.73m2)增至74.55 ml/(min·1.73m2),代偿率为35.79％;BMI≥23.0 kg/m2供者平均eGFR由术前的67.21ml/(min· 1.73m2)增至84.39 ml/(min· 1.73m2),代偿率为25.56％,BMI＜ 23.0 kg/m2供者平均eGFR由术前的76.50 ml/(min· 1.73m2)增加至90.94 ml/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.     

不同性别、年龄活体供肾代偿能力的比较

目的:检测不同性别、年龄组活体供肾肾移植前后肾小球滤过率(GFR)的变化,比较各组供肾代偿能力。方法:共84例活体肾移植供者,按其年龄分为A组(>50岁)和B组(19～50岁);按供者性别分为女性组和男性组。各组术前用MDRD公式计算总体肾小球滤过率(eGFR),核素分别测定两侧GFR,按比例估算供肾术前的eGFR。计算受者移植后半年内最高eGFR,比较各组供肾eGFR移植前后变化情况。结果:总体供肾手术前后eGFR[(54.78±13.50)ml/(min·1.73m2)vs(76.68±32.23)ml/(min·1.73m2)]差异显著,代偿率32.30%(10.92%～63.89%)。A组术后eGFR明显增加[(47.16±10.43)ml/(min·1.73m2)vs(66.15±17.89)ml/(min·1.73m2)],代偿率44.35%(18.16%～63.22%);B组后eGFR代偿率30.52%(8.96%～63.01%);男性组术后eGFR代偿率33.61%(14.77%～66.96%);女性组术后eGFR代偿率25.66%(1.24%～62.45%);供肾eGFR代偿率与其术前eGFR水平及受体年龄负相关。结论:移植后各组活体供肾eGFR均明显代偿性升高,但个体差异较大。虽然A组eGFR水平在肾移植前后均低于B组,但其总体代偿能力良好。女性活体供肾与男性供体肾移植前后表现相近。术前评估活体供肾代偿能力要考虑其基础eGFR及受者需求。     

接受公民逝世后器官捐献肾移植的临床疗效评价

目的:分析接受公民逝世后器官捐献(DCD)肾移植的临床疗效,评价DCD供肾质量与肾移植受者的预后和转归。方法:回顾性研究DCD供者和肾移植受者的临床资料,观察供肾质量评分、肾移植受者肾功能恢复情况、围手术期并发症、移植肾功能延迟恢复(DGF)和移植肾丢失的发生率与长期随访情况。结果:成功实施DCD 114例,供肾热缺血时间(5.6±2.2)min,冷缺血时间(6.5±1.6)h;非边缘性供肾(A级+B级)占92.11%,边缘性供肾(C级+D级)占7.89%;供肾获取、灌注、保存及修复过程顺利。228例终末期肾病患者成功接受DCD供肾肾移植手术,其中211例受者围手术期恢复顺利,术后6～14 d肾功能恢复正常;术后DGF的发生率为3.54%(8/228),术后20～45 d肾功能逐渐恢复;1例受者移植肾原发性无功能和3例受者移植肾动脉破裂出血切除了移植肾,围手术期移植肾丢失率为1.75%(4/228);无一例受者围手术期死亡。随访过程中, 213例受者肾功能稳定,8例受者发生移植肾功能衰竭,3例受者死亡。结论:DCD供肾肾移植的总体临床疗效良好,但仍存在潜在风险和并发症。     

老龄亲属活体供肾移植疗效观察

目的:探讨老龄亲属活体供肾移植的疗效. 方法:我院自2006年1月至2006年12月共施行亲属活体肾移植74例,收集该74例活体供肾移植的临床资料,按供者年龄大小分为2组:老龄组(≥55岁)11例,低龄组(＜55岁)63例.分别对两组受体术后不同时间点临床资料和两组供体术前术后的临床资料进行分析比较,探讨老龄活体供肾移植的疗效. 结果:(1)受者情况:老龄组有1例术后发生移植肾功能延迟恢复,低龄组有7例,组间比较无差别(P>0.05),两组受者移植术后肾功能恢复情况比较无差异,1年人/肾存活率均为100%.供者情况:两组供者术后一周血肌酐均明显升高,老龄组术前血肌酐(85.6±13.7)μmol/L,术后1周升高至(106.4±15.6)μmol/L,而低龄供者术前血肌酐(73.7±6.8)μmol/L,术后1周升高至(101.8±13.1)μmol/L.但术后1年随访,两组供者血肌酐恢复术前水平. 结论:在严格供体筛查的前提下,老龄供肾(55～65岁)对供者是安全的;而对受者,接受老龄供肾术后近期肾功能恢复情况良好,远期效果有待进一步观察.华中科技大学同济医学院附属同济医院器官移植研究所,教育部/卫生部器官移植重点实验室 (武汉,430030)     

同种异体原位肾移植的临床分析

探讨原位肾移植的手术适应证、手术技巧及临床效果.方法:对5例临床同种异体原位肾移植受者进行回顾性分析,其中男3例,女2例,年龄28～55岁,平均45岁,多囊肾1例,三次肾移植2例,二次肾移植髂血管粥样硬化2例,均先行左肾切除,再行原位肾移植,尿路重建采用肾盂-肾盂端端吻合,术后常规三联免疫抑制治疗.结果:手术经过均顺利,术后2例再次移植受者发生移植肾功能延迟恢复(DGF).术后1月平均血清肌酐(SCr) 124 μmol/L.术后随访6月～7年均带肾存活,4例受者移植肾肾功能正常,1例受者术后7年出现慢性移植肾肾病,SCr波动于340 ～462 μmol/L.结论:原位肾移植对于第二、三次肾移植,双侧髂血管条件不好的受者,原位肾移植能达到良好的治疗效果.     

老年亲属供肾肾移植临床效果分析

目的 了解老年人供肾亲属肾移植临床效果. 方法 回顾性分析我院肾移植科2005年11月至2011年6月亲属活体肾移植的临床资料,按供者情况分为老年亲属供肾组36例(老年组),非老年亲属供肾组208例(非老年组).比较两组受者术后3d、7d、1个月、3个月、6个月、12个月、24个月、36个月血肌酐(SCr)水平和外科并发症、急性排斥、钙调磷酸酶抑制剂(CNI)肾毒性、移植肾功能延迟(DGF)发生率,并观察1年、3年人和(或)肾存活率. 结果 老年组受者SCr术后3d为(245.2±135.2)μmol/L、7d为(150.5±86.8)μmol/L、1个月为(140.6±42.5)μmol/L,高于非老年组的(185.6±148.4)μmol/L、(122.2±136.8)μmol/L、(117.8±33.2)μmol/L(分别为t=84.07、31.90、21.54,均P=0.000);CNI肾毒性发生率分别为22.2％(8/36)、1.9％(4/208),差异有统计学意义(x2=27.04,P=0.000);但两组受者术后3个月、6个月、12个月、24个月、36个月SCr水平和外科并发症、急性排斥、DGF发生率及1年、3年人和(或)肾存活率比较,差异无统计学意义(均P＞0.05). 结论 术前对老年供者进行严格筛选和综合评估,健康老年人亲属供者不应作为供者禁忌;但对老年人供肾亲属肾移植受者应注意CNI肾毒性.     

心脏死亡器官捐献供肾术前病理改变对肾移植预后的影响

目的:应用Pirani评分系统评估心脏死亡后器官捐献(DCD)供肾的组织病变程度,追踪不同程度病变的供肾对肾移植患者短期预后的影响。方法:(1)研究对象于2015-02-01～2017-02-01在郑州人民医院行DCD供肾移植患者,供肾获取后移植术前行活检病理,即经快速切片后行苏木素-伊红(HE)染色,采用Pirani评分系统评估供肾组织病变程度。(2)根据供肾Pirani病理评分分为两组,低分组(0～3分),高分组(4～6分)。(3)观察指标:比较两组肾移植患者的预后,包括移植肾功能延迟恢复(DGF)、术后1月、12月和24月血清肌酐(SCr)及12～36月累计移植肾存活率。结果:供肾及相应受者共92例纳入本研究,低分组68例(73. 9%),高分组24例(26. 1%)。受体总体DGF发生率为15. 2%,高分组与低分组DGF发生率分别为37. 5%(9/24)和7. 0%(5/68)(P=0. 028)。受者术后1月、12月、24月低分组SCr值分别为(104. 9±16. 8)μmol/L、(94. 9±16. 7)μmol/L、(91. 8±9. 3)μmol/L,高分组分别为(116. 2±34. 4)μmol/L、(116. 5±14. 9)μmol/L、(111. 7±10. 2)μmol/L。低分组SCr两年内各个时间点SCr值均低于高分组(P=0. 041,P=0. 044,P=0. 038,P0. 05)。随访12～36个月,Kaplan-meier分析结果表明高分组与低分组移植肾存活率无明显差异(log-Rank检验,p=0. 499)。结论:DCD供肾病理Pirani评分越高,受者肾移植术后DGF发生率越高,短期移植肾功能越差,但短期内存活率无明显差异。     

老年心房颤动患者慢性肾功能受损对血栓栓塞事件的影响

目的探讨老年心房颤动(房颤)患者慢性肾功能受损对血栓栓塞事件的影响。方法选择无抗凝治疗的老年房颤患者265例,根据慢性肾脏疾病分级分为估算肾小球滤过率(eGFR)≥60ml/(min·1.73m2)152例、eGFR45⁵9ml/(min·1.73m2)69例、eGFR<45ml/(min·1.73m2)44例,通过eGFR和尿蛋白的评估,观察其随访期间是否出现血栓栓塞事件。结果房颤血栓栓塞的发生与eGFR下降(RR=4.183,95%CI:2.57159ml/(min·1.73m2)69例、eGFR<45ml/(min·1.73m2)44例,通过eGFR和尿蛋白的评估,观察其随访期间是否出现血栓栓塞事件。结果房颤血栓栓塞的发生与eGFR下降(RR=4.183,95%CI:2.571⁶.805,P<0.01)和尿蛋白(RR=3.692,95%CI:2.7316.805,P<0.01)和尿蛋白(RR=3.692,95%CI:2.731⁵.105,P<0.01)相关。多因素分析显示,尿蛋白使血栓栓塞的危险性增加46.2%(HR=1.462,95%CI:1.2155.105,P<0.01)相关。多因素分析显示,尿蛋白使血栓栓塞的危险性增加46.2%(HR=1.462,95%CI:1.215¹.904,P<0.01);将eGFR≥60ml/(min·1.73m2)作为参照,eGFR在451.904,P<0.01);将eGFR≥60ml/(min·1.73m2)作为参照,eGFR在45⁵9ml/(min·1.73m2)出现血栓栓塞事件增加17.2%(HR=1.172,95%CI:0.91559ml/(min·1.73m2)出现血栓栓塞事件增加17.2%(HR=1.172,95%CI:0.915¹.402,P<0.01),eGFR<45ml/(min·1.73m2)则增加42.1%(HR=1.421,95%CI:1.2111.402,P<0.01),eGFR<45ml/(min·1.73m2)则增加42.1%(HR=1.421,95%CI:1.211¹.816,P<0.01)。结论慢性肾功能受损增加了不用抗凝药物的老年房颤患者血栓栓塞的危险性。     

供者尿液肾损伤标志物检测与肾移植预后的关系

目的:通过前瞻性研究心脏死亡器官捐献(DCD)供者脑死亡期间尿液肾损伤标志物与术后移植肾功能恢复延迟(DGF)及肾功能恢复的关系,阐明肾脏损伤标志物对移植肾预后的评估作用。方法:收集从2015年10月～2017年5月于天津市第一中心医院行DCD供肾肾移植术的101例患者资料,所有患者术后随访期为半年。结果:101例受者中出现DGF 9例(8.9%),平均术后6月肌酐为118.0±35.2μmol/L。单因素方差分析发现DGF影响因素包括供者肌酐(P=0.02)、尿中性粒细胞明胶酶相关脂质运载蛋白(NGAL)(P0.001)、尿肾损伤分子1(KIM-1)(P0.001)、尿白细胞介素18(IL-18)(P0.001)、受者体质量指数(BMI)(P=0.024)及受者原发病(P=0.025)。多因素回归分析发现,供者年龄和尿NGAL是DGF发生的独立危险因素。术后6个月肾功能的影响因素包括:供者BMI(P=0.01)、供者年龄(0.001)、供者高血压(P=0.001)、尿KIM-1(P=0.008)、尿NGAL(P=0.001)、受者BMI(P=0.012)、受者性别(P=0.015)。进行多因素线性回归分析后显示,供者尿NGAL、BMI和年龄是影响术后6个月肾功能的独立影响因素。结论:尿NGAL与DGF发生相关,且对于早期肾功能评估具有一定价值。     

Three layer functional model and energy exchange concept of aging process

Relying on a certain degree of abstraction, we can propose that no particular distinction exists between animate or living matter and inanimate matter. While focusing attention on some specifics, the dividing line between the two can be drawn. The most apparent distinction is in the level of structural and functional organization with the dissimilar streams of ‘energy flow’ between the observed entity and the surrounding environment. In essence, living matter is created from inanimate matter which is organized to contain internal intense energy processes and maintain lower intensity energy exchange processes with the environment. Taking internal and external energy processes into account, we contend in this paper that living matter can be referred to as matter of dissipative structure, with this structure assumed to be a common quality of all living creatures and living matter in general. Interruption of internal energy conversion processes and terminating the controlled energy exchange with the environment leads to degeneration of dissipative structure and reduction of the same to inanimate matter, (gas, liquid and/or solid inanimate substances), and ultimately what can be called ‘death.’ This concept of what we call dissipative nature can be extended from living organisms to social groups of animals, to mankind. An analogy based on the organization of matter provides a basis for a functional model of living entities. The models relies on the parallels among the three central structures of any cell (nucleus, cytoplasm and outer membrane) and the human body (central organs, body fluids along with the connective tissues, and external skin integument). This three-part structural organization may be observed almost universally in nature. It can be observed from the atomic structure to the planetary and intergalactic organizations. This similarity is corroborated by the membrane theory applied to living organisms. According to the energy nature of living matter and the proposed functional model, the decreased integrity of a human body's external envelope membrane is a first cause of the structural degradation and aging of the entire organism. The aging process than progresses externally to internally, as in single cell organisms, suggesting that much of the efforts towards the restoration and maintenance of the mechanisms responsible for structural development should be focused accordingly, on the membrane, i.e., the skin. Numerous reports indicate that all parts of the human body, like: bones, blood with blood vessels, muscles, skin, and so on, have some ability for restoration. Therefore, actual revival of not only aging tissue of the human body's membrane, but the entire human body enclosed within, with all internal organs, might be expected. We assess several aging theories within the context of our model and provide suggestions on how to activate the body's own anti-aging mechanisms and increase longevity. This paper presents some analogies and some distinctions that exist between the living dissipative structure matter and inanimate matter, discusses the aging process and proposes certain aging reversal solutions.     

Unusual responses of nocturnal pineal melatonin synthesis and secretion to swimming: Attempts to define mechanisms

Abstract: The effect of swimming at night on rat pineal melatonin synthesis was compared with that of light exposure at night. Rats were forced to swim at 0030 hr (lights out at 2000 hr) and sacrificed by decapitation 15 and 30 min later, immediately after swimming. Other groups of animals were exposed to white light (650μW/cm²) for 15 and 30 min at same time. Swimming caused a rapid and highly significant drop in the melatonin content in the pineal gland; however, the activity of N-acetyltransferase (NAT), the supposed rate limiting enzyme in the melatonin production, was not changed. Despite the drop in pineal melatonin levels, serum concentrations of the indole remained elevated in the rats that swam. In contrast, melatonin levels in the pineal and serum of light exposed rats fell precipitously, accompanied by a significant suppression of NAT activity. Since we anticipated that the strenuous exercise associated with swimming may induce release of artrial natriuretic peptide (ANP) from the heart, which in turn could cause the release of pineal melatonin, in a second study we injected physiological saline intravenously to stretch the cardiac muscle and release ANP. Three milliliters of normal saline was injected during the day into the jugular vein of anesthetized rats that were pretreated with isoproterenol to stimulate pineal melatonin production. Animals were killed 15 min after the saline injection, and pineal NAT activity and pineal melatonin levels were measured. The saline injections caused no alteration in the elevated levels of either NAT or melatonin. These data suggest that the disparity in pineal NAT activity (which was high) and pineal melatonin (which was low), in animals swum at night, may not be caused by ANP which is released during strenuous exercise such as swimming.     

Melatonin and photoperiodic time measurement: Seasonal breeding in the sheep

Abstract: Well-established circadian physiology supports the view that photoperiodic time measurement utilizes the coincidence between the presence of light and a photosensitive phase of a 'biological clock' to alter reproductive status—the so-called external coincidence model of seasonal breeding. In this review, we examine the mechanism whereby photoperiod interacts with presumed suprachiasmatic nuclei activity to allow endogenous melatonin to normally synchronize reproductive activity to the optimal time of year. The Romney Marsh sheep is particularly explored as an experimental model. It is suggested that the on/off activity of seasonal reproduction may be a robust mechanism able to be predictably manipulated by the judicious use of the light/dark cycle and exogenous melatonin, but firmly based on circadian principles.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Serological survey of HIV and syphilis in pregnant women in Madagascar

Objectives Peripartal transmission of human immunodeficiency virus (HIV) and Treponema pallidum, the causative agent of syphilis, leads to severe consequences for newborns. Preventive measures require awareness of the maternal infection. Although HIV and syphilis testing in Madagascar could be theoretically carried out within the framework of the national pregnancy follow‐up scheme, the required test kits are rarely available at peripheral health centres. In this study, we screened blood samples of pregnant Madagascan women for HIV and syphilis seroprevalence to estimate the demand for systemic screening in pregnancy. Methods Retrospective anonymous serological analysis for HIV and syphilis was performed in plasma samples from 1232 pregnant women that were taken between May and July 2010 in Ambositra, Ifanadiana, Manakara, Mananjary, Moramanga and Tsiroanomandidy (Madagascar) during pregnancy follow‐up. Screening was based on Treponema pallidum haemagglutination tests for syphilis and rapid tests for HIV, with confirmation of positive screening results on line assays. Results Out of 1232 pregnant women, none were seropositive for HIV and 37 (3%) were seropositive for Treponema pallidum. Conclusions Our findings are in line with previous studies that describe considerable syphilis prevalence in the rural Madagascan population. The results suggest a need for screening to prevent peripartal Treponema pallidum transmission, while HIV is still rare. If they are known, Treponema pallidum infections can be easily, safely and inexpensively treated even in pregnancy to reduce the risk of transmission.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.