肾移植术后监测CD4+T淋巴细胞对防治巨细胞病毒肺炎的临床意义

目的 探讨监测CD4+T淋巴细胞对防治肾移植术后巨细胞病毒(cytomcgalovims,CMV)肺炎的临床意义.方法 2005年1月至2008年3月.监测133例肾移植术后受者外周血CD4'细胞计数的动态变化,根据其变化调整免疫抑制剂(Cs～Fl(506+MMF+Pred)的用量,观察调整用药对CMV肺炎发病的影响.结果 共有36例受者CD4'细胞明显下降,发生在术后45～72(61.5～9.31 d.均给予减少或停用免疫抑制剂处理.133例受者有12例出现CMV肺炎,发病在术后5耻118(76.2～11.61d.其中7例伴有急性呼吸窘迫综合征(ARDS).CD4+T细胞下降受者CMV肺炎的发病率(27.8%,10/36)明显高于CD4+细胞稳定受者(2.1%,2/97)(p,0.01),在调整用药期『日J有2例发生急性排斥反应,发生率无明显增加(P>0.05).12例CMV肺炎病人8例(66.7%,8/12)治愈.4例(33.3%,4/12)死亡.24例未发病受者在调整用药后CD4'细胞迅速上升,在14 d恢复到术前水平;8例CMV肺炎治愈者上升较缓慢,在21 d恢复;而4例死亡病人持续保持在低水平.结论 肾移植术后CD4'细胞的变化与CMV肺炎发病有密切相关性,依据其变化在CMV肺炎发病之前减少或停用免疫抑制剂是安全的,为预防和救治CMV肺炎提供一条新的方法.     

尸肾移植术后移植肾动脉狭窄发病原因分析

目的探讨尸体肾移植术后移植肾动脉狭窄(TRAS)的可能发病原因。方法对尸体肾移植术后18例TRAS患者与未发生TRAS的566受者有可能影响TRAS发生的多个因素进行统计分析。结果(1)TRAS患者的肾移植术后急性排斥反应发生率显著高于非TRAS者(66.67% vs5.48% , P<0.01);(2)发生与未发生TRAS的受者在术前透析方式、糖尿病发病、供肾冷缺血时间、供肾动脉数、供肾侧、供肾动脉吻合方式、术后免疫诱导用药、术后口服免疫维持治疗、术后巨细胞病毒感染以及发病时血脂等诸方面均无显著差异。结论肾移植术后TRAS的发生与移植术后急性排斥反应的发生有密切关系。     

前列地尔促进肾移植术后早期恢复的临床研究

目的探讨前列地尔能否促进肾移植患者术后康复。方法2003年1月至2006年8月,对298例肾移植受者术中及术后2周内每天静脉滴注前列地尔50μg,与同期内287例未使用前列地尔的肾移植受者进行对比,比较两组术后尿量、血肌酐(SCr)、肌酐清除率(Ccr)、血压、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、B超下移植肾血流阻力指数以及两组肾功能恢复延迟(DGF)和急性排斥反应的发生率。结果应用前列地尔的患者术后尿量和Ccr均明显大于对照组;高血压、ALT和(或)AST异常升高病例发生率明显低于对照组;SCr浓度、移植肾血流阻力指数亦明显低于对照组;前列地尔组DGF发生率为5.56%,显著低于对照组(10.10%)(P<0.01);两组急性排斥反应发生率差异无统计学意义(分别为10.41%、10.77%;P>0.05)。结论肾移植受者术中及术后早期应用前列地尔可促进移植肾功能的恢复,减少高血压和肝功能异常等常见的并发症。前列地尔对肾移植患者术后早期康复具有促进作用。     

糖尿病终末期肾病肾移植的临床研究

目的探讨糖尿病人行肾移植术的临床处理特点.方法回顾性分析了80例糖尿病尿毒症的肾移植术.结果术后移植肾功能延迟恢复(DGF)发生率为17.5%,显著高于非糖尿病受者,DGF发生原因主要是外周血管硬化和心血管并发症,后者是术后的主要并发症,包括猝死2例、急性心肌梗死1例、急性左心衰2例和室性心率失常2例.结论糖尿病尿毒症病人行肾移植术的主要困难在于潜在的外周动脉硬化和冠状动脉病变,术前应做好冠心病的筛查和外周动脉硬化病变的评估,术后应常规行抗凝治疗.     

肾移植受者BK病毒感染的临床诊断

目的 探讨肾移植受者BK病毒感染的诊断方法、监测指标.方法 采集234例肾移植受者的血、尿样本,行BKV尿沉渣细胞学计数与实时荧光定量PCR检测方法.结果 234例受者的尿Decoy细胞、BK病毒尿症与病毒血症的阳性率分别为33.3%、33.3%和16.2%.尿Decoy细胞阳性者Decoy细胞中位数水平为6个/10HPF,BKV DNA阳性者尿液和外周血BKV中位数水平分别为7.62×103 copy/ml和7.61×103 copy/ml.尿液BKV阳性率较外周血明显升高(P=0.000).尿液Decoy细胞计数与尿液BKV含量相关(γ=0.59,P=0.000),但尿液和外周血中BKV含量无明显相关性(P=0.14).结论 肾移植受者易发生BKV再活化,定量尿沉渣细胞学检测简单、易行、敏感,可以做为BKV活化的指标,间接反映肾脏病理情况,也可检测血、尿BKV DNA了解病毒活化情况、筛查BKV相关的移植肾肾病.     

肾移植术后环孢素A血药浓度C2监测

目的:探讨术后存活期1 a以上的肾移植患者C2(服用环孢素(CsA)2 h后的血药浓度监测的临床效果.方法:术后存活期1 a以上、接受微乳化CsA(6～8 mg/(kg·d))、硫唑嘌呤和泼尼松三联免疫抑制治疗的患者75例,采用荧光偏振免疫方法进行CsA全血药浓度测定.C2监测至少6个月,CsA治疗窗浓度范围定为(900±120) μg/L.结果:C2监测前,46例(61%)患者CsA全血浓度高于目标浓度范围,13例(17%)低于目标浓度范围.C2监测6个月后,与C2监测前比较患者的尿素氮降低(P＜0.05,而血清肌酐、胆固醇和甘油三酯水平差异无统计学意义(P＞0.05);CsA平均剂量从(241±63 mg 减至(213±50) mg (P＜0.05), 每人每年节省费用约3 500元;C2监测6个月后,CsA暴露量过高患者组的BUN 水平较监测前降低(P＜0.05.结论:稳定期肾移植患者实行C2监测安全、有效.这种方法有利于肾功能的改善并有助于减少药品费用.     

Realtime-PCR动态检测巨细胞病毒在肾移植术后的临床应用

目的探讨巨细胞病毒(C M V)D N A检测在肾移植术后C M V病预防中的作用。方法采用R ealtim e-PC R定量检测肾移植受者外周血白细胞中C M V-D N A,术后4月内每周1次。结果95例患者中有55例检出C M V-D N A阳性(57.9%),初次检出C M V-D N A的平均时间为(25.6±16.3)d,C M V-D N A的平均拷贝数为(1396.4±445.2)/105白细胞。在随访过程中,18例患者的C M V-D N A水平超过警戒线—800copy/105白细胞,经调整免疫抑制剂后,均降至警戒线以下,所需平均时间为(16.3±8.5)d。所有患者均未出现C M V病。结论C M V-D V A检测可用于预防肾移植术后C M V病的发生。     

Effect of pre-transplantation hemoglobin concentration on prognosis of renal transplant recipients

Background  For the renal transplant recipients, anemia is one of the common complications and becomes a major medical issue before transplantation. Haemoglobin (Hb) is used as a prognostic indicator, although the optimal pre-transplantation Hb concentration associated with positive prognosis is still controversial. The aim of this study was to detect the optimal Hb concentration on predicting the graft survival and function.

Methods  A retrospective cohort study was conducted by reviewing the medical records of the patients who received renal transplantations at our center from January 2004 to June 2008. Patients were divided into two groups: high Hb group (≥100 g/L, n=79) and low Hb group (<100 g/L, n=63). There was no significant difference between the two groups regarding sex, age, blood type and tissue types. Renal function among the two groups was measured and compared. Panel reacting antigens (PRA) of all the recipients were negative. The effect of preoperative hemoglobin concentration on the postoperative renal function recovery in both groups was further analyzed.

Results  A total of 14 acute rejection episodes occurred, including 5 patients in the high Hb group (7.9%) and 9 in the low Hb group (11.4%, P >0.05). The serum creatinine level at one-year post-transplantation of the low Hb group was significantly higher than that of the high Hb group ((117.8±36.3) μmol/L vs. (103.1±35.5) μmol/L, P <0.05). For one-year actuarial patient and graft survival, incidence of delayed graft function (DGF), serum creatinine concentrations at 1, 3, 6 months post-transplantation, the incidence of cytomegalovirus (CMV) infection, post-transplantation anemia (PTA) and post-transplantation diabetes mellitus (PTDM) of both groups, there were no statistically significant differences.

Conclusion  Pre-transplantation Hb concentration has significant effect on one-year creatinine concentration, but can not significantly affect acute rejection episodes, DGF, PTA, CMV infection and PTDM.

     

同种异体肾移植术后肝损害诊断与治疗 (附91例报告)

目的 探讨提高同种异体肾移植术后肝功能损害的诊断与治疗水平。方法 通过对91例(105例次)肾移植术后出现肝功能异常的严重程度进行分类，分别给予不同方法进行综合治疗。针对不同程度、不同病因肝损害，87例次减少CsA(环孢素A等)免疫抑制用量，19例次调整更换为肝功能损害小的免疫抑制剂，所有病例均加用适当的保肝降酶药物。结果 1例因急性肝衰死亡，69例肝功能恢复正常，11例肝功能改善，10例摘除移植肾。结论 由于肝炎病毒感染或药物副作用，肾移植受者易致肝功能损害，对于此类患者，应调整用药方案并加强保肝治疗。     

肾移植患者术后BK病毒感染的检测及危险因素分析

目的:检测肾移植患者术后BK病毒(BKV)感染率,分析BKV感染的危险因素.方法:收集63例肾移植患者术后第1、 2、3、4、6 和8个月的尿液和血液标本,实时荧光定量PCR方法检测标本中BKV DNA含量,并根据检测结果进行分组:尿液、血液BKV DNA均阳性者为UV PV 组,尿液阳性而血液阴性者为UV PV-组,尿液、血液均阴性者为UV-PV-组.尿沉渣涂片寻找含有病毒包涵体的脱落尿路上皮细胞(Decoy细胞),并对Decoy细胞进行细胞免疫学检测;对临床高度怀疑为BK病毒相关性肾病患者(BKVAN)行移植肾活检.比较3组患者的年龄、术前冷缺血时间、术前血透时间、免疫抑制方案、群体反应性抗体(PRA)致敏程度、术后是否合并其他病毒感染等临床指标的差异,应用Logistic回归法分析筛选BKV感染和BKVAN发生的危险因素.结果:UV PV-组19例(30.1%), UV PV 组患者9例(14.3%),UV-PV-组患者35例;前两组首次发现BKV的中位时间分别为术后4个月和3个月.63例患者Decoy细胞检出率为39.7%,Decoy细胞免疫染色阳性率为54.3%.1例移植肾活检未见BKVAN表现.Logistic回归法发现BKV DNA感染与冷缺血时间有显著联系(P=0.048;OR=1.151),与其他指标无显著相关(P=0.069).结论:实时荧光定量PCR能较好地监测术后BKV感染,术后3～4个月是BKV排泄高峰,术前冷缺血时间可能是BKV感染的危险因素之一,而术后免疫抑制方案对BKV感染可能无明显影响.     

Central nervous system complications in renal transplant recipients：Report of 68 cases

Objective: To observe the central nervous system (CNS) complications among 1083 consecutive renal transplant (RT) recipients. Methods: Systemic analyses of the incidence, time of onset and clinical outcome of CNS complications were conducted in 1083 patients receiving cadaveric RT in Nanfang Hospital during Jan 1992 to Dec 1999. Results: Various CNS complications occurred in a total of 68 RT recipients (6. 28%, 68/1083) with a mortality of (1. 29%, 14/1083). Of all the 1 083 recipients enrolled in this study, diffuse encephalopathy occurred in 31 cases (2. 86%), cerebrovascular accidents in 17 (1. 56%), seizure in 11 (1. 02%) and CNS infection in 9 (0. 83%). Immusuppressive agents was the major cause for diffuse encephalopathy (93. 5% , 29/31), and cerebrovascular accidents were associated with a mortality rate of 70. 5% (12/17) and CNS infection with a mortality rate of 22. 22% (2/9). Most of the complications took place within the first month after RT, especially the first 2 weeks, but the majority of     

无创机械通气在肾移植术后重症肺部感染合并急性呼吸衰竭中的应用

目的探讨无创机械通气(NIV)在救治肾移植术后重症肺部感染合并急性呼吸衰竭中的价值。方法收集13例肾移植术后重症肺部感染患者进行NIV的临床资料,回顾性分析NIV前后缺氧的改善情况、并发症及转归等。结果13例患者使用了机械通气,1例仅用有创机械通气(气管插管);12例采用NIV:6例仅用NIV,另6例先采用NIV,后改用有创机械通气。所有患者均能较好耐受。NIV使用1 h后,平均氧合指数较治疗前有明显提高。3例(25%)气体交换获得持续改善,避免了气管插管并最终存活出院,其余病例死亡。1例(8.3%)出现气胸和纵隔气肿。结论NIV可用于肾移植术后重症肺部感染合并急性呼吸衰竭的早期呼吸支持治疗,能有效改善缺氧,耐受性好,并发症少,为原发病的治疗赢得了时间。     

肾移植术后并发原发性肺癌的单中心研究

目的 回顾性分析肾移植术后原发性肺癌的临床特点及预后.方法 自1988年1月~2015年4月期间,2793例患者在我院接受肾移植手术.14例(0.5%)患者随后发展为肺癌,其中10例(71.4%)接受了手术治疗.结果 肾移植时患者的平均年龄为50.2±8.3岁.14例肺癌患者中,10例(71.4%)有吸烟史.9例(64.3%)为偶然发现,而有症状者仅为5例.从移植手术到肺癌诊断的平均时间间隔为65.7±20.1个月.统计结果显示,不同肿瘤分期病人的生存率具有统计学差异(P=0.001).随访期间有11例死于肿瘤转移或器官衰竭,3例存活.肺癌诊断后的总体5年生存率为17.9%.结论 肾移植术后原发性肺癌的危险性可能高于一般人群.肾移植术后常规胸部检查可早期发现原发性肺癌,对于及早施行手术、改善预后很有必要.     

肾移植患者BK病毒感染的诊断和危险因素分析

 目的 研究肾移植术后BK病毒感染的诊断方法和危险因素。方法 对在我院接受同种异体肾移植手术的92例患者进行BK病毒感染的检测,包括:尿沉渣decoy细胞、尿液BKV-DNA、血浆BKV-DNA。对肾移植术后BK病毒感染的流行病学特征和危险因素进行分析。结果 92例肾移植患者中,尿沉渣decoy细胞阳性29例（31.5%）,出现decoy细胞的中位时间为术后18.3月。decoy细胞对诊断BK病毒感染的敏感性和特异性分别为67.7%和86.9%。病毒尿症22例（23.9%）,中位时间为术后16.3月;病毒血症9例（9.8%）,中位时间为术后39.5月。decoy细胞阳性组肾功能异常患者的比例明显高于decoy细胞阴性组（58.6% vs 28.6%,P<0.01）。血浆BKV DNA阳性的9例患者中,8例出现了肾功能异常。Logistic回归分析发现术前免疫诱导和未接受血液透析是术后BK病毒感染的高危因素,而免疫抑制方案、肾脏原发疾病、术后感染等因素无显著性差异。结论 BK病毒感染是肾移植术后常见的并发症。BK病毒的感染将可能导致移植肾功能异常。尿沉渣decoy细胞和尿液BKV-DNA检测能早期发现BK病毒感染。     

胸腺肽a1联合抗病毒药治疗肾移植术后巨细胞病毒肺炎

目的研究胸腺肽a1对肾移植术后巨细胞病毒(CMV)肺炎的治疗效果和不良反应。方法肾移植术后CMV肺炎患者46例分为两组,组Ⅰ单独使用抗病毒药更昔洛韦,组Ⅱ联合应用胸腺肽a1和抗病毒药。结果46例患者总存活率56.52%(26/46),组Ⅱ存活率72.73%(16/22)明显高于组Ⅰ患者的41.67%(10/24)(P<0.05),两组各有1例发生急性排斥反应。结论胸腺肽a1联合抗病毒药可提高CMV肺炎的治愈率,是安全有效的抗CMV病毒肺炎的疗法。     

Diagnosis and treatment of bacterial pneumonia in liver transplantation recipients: report of 33 cases

Background Bacterial pneumonia in the recipients of liver transplantation (LTX) is a common postoperative complication influencing the prognosis greatly. In this article, the diagnosis and treatment of bacterial pneumonia in 33 LTX recipients are reported. Methods From February 1999 to January 2003, a total of 103 patients underwent allogeneic LTX at our center; afterwards, a retrospective analysis was made on their postoperative clinical manifestations, including symptoms (expectoration, panting and fever), sign (rale), results of laboratory examinations (white blood cell count and sputum culture of tracheal secretions or pleural fluid culture), and chest X-ray films. The following data of the pneumonia and non-pneumonia groups were collected, and the rank sum test (SPSS 11.0, Wilcoxon’s method） was used to analyze the duration of postoperative respirator utilization and the volume of pleural effusion through pleurocentesis or pleural drainage. Results In the 103 patients, 33 experienced 53 episodes of bacterial pneumonia during their hospital stay after transplantation, 14 of them (42.42%) had more than three manifestations of the seven mentioned above. The pathogens causing bacterial pneumonia included Pseudomonas aeruginosa (17.48%), Klebsiella pneumoniae (15.53%), Acinetobacter baumannii (10.68%), and Staphylococcus aureus (7.77%). Amilkacin, tienam, ciprofloxacin, vancomycin, etc. were the antibiotics of choice against those bacteria. Acute rejection occurred during the treatment of bacterial pneumonia in 16 patients, and 5 of them died. Wilcoxon’s rank sum test of the data indicated that the pneumonia group had longer duration of postoperative ventilator treatment and larger volume of pleural effusion than the non-pneumonia group (P&lt;0.05). Conclusions The clinical manifestations of pneumonia after LTX might be atypical,and special attention should be paid to the respiratory symptoms and signs within 2 months after LTX. Whenever the diagnosis of bacterial pneumonia is confirmed, consideration should be given to reasonable use of antibiotics and regulation of immunity in addition to other routine therapies. Chin Med J 2005; 118(22):1879-1885     

Effects of Bailing capsules for renal transplant recipients: a retrospective clinical study

Background The administration of immunosuppressive agents is always an important factor affecting the long-term survival of organ transplantation recipients.The best therapeutic regimen which either decreases the side effects of immune inhibitors or enhances the immunosuppressive efficacy is the goal of transplantation surgeons continue to search.This study investigated the effects of Bailing (Cordyceps sinensis) capsules on renal function and other systems of the body after renal transplantation.Methods Clinical data of 80 renal transplant recipients who were administered Bailing capsules and 100 renal transplant recipients in the control group were retrospectively analyzed to compare the incidences of graft rejection and infection after transplantation.The results of routine blood and urine tests,liver and kidney functions,uric acid (UA),24-hour urine protein (24 h-Upro),as well as 1-and 5-year patient renal allograft survival rates were compared between the two groups.Results The follow-up was 3-5 years.The two groups were not shown to have statistically significant differences in age,gender,cold ischemia time,donor-recipient human leukocyte antigen typing,panel reactive antibodies,lymphocytotoxicity tests,and the application of immunosuppressive agents at the baseline.The two groups were also not significantly different in the incidence of acute injection after transplantation,recovery of renal function,and blood glucose level.The Bailing group was significantly lower than the control in the incidence of infection,serum aspartate aminotransferase/alanine aminotransferase,total bilirubin,UA,and 24-hour Upro,but significantly higher than the control group in peripheral red blood cell count and white blood cell count (P＜0.05).One-year and 5-year patient survival rates were 98.7％ and 98.0％,respectively in the Bailing group,95.0％ and 93.0％,respectively,in the control group.One-year and 5-year renal allograft survival rates were 97.5％ and 95.0％,respectively,in the Bailing group,and 92.5％ and 84.0％,respectively,in the control group.The comparison of patient and renal allograft survival rates between the two groups using Kaplan-Meier survival curves and log-rank test showed that only the differences in renal allograft survival rates were statistically significant (Log-rank:5 years:patient survival P=-0.420; renal allograft survival P=0.049).Conclusion Bailing capsules were effective in preventing allograft rejection,protecting liver and kidney functions,stimulating hematopoiesis,and reducing the incidence of infection and thus are ideal immunoregulators.     

肾移植术后感染巨细胞病毒性肺炎的多因素分析

目的 探讨肾移植术后感染巨细胞病毒性(CMV)肺炎的多种高危因素,提出早期预防措施.方法 回顾2005年1月～2007年12月间曾在我院接受同种异体肾脏移植术并因发生CMV肺炎而再次入院患者28例,采用卡方检验及多元logistie回归分析方法分别对影响CMV肺炎的一些凶素进行逐步分析.结果 与CMV肺炎感染密切相关的独立因素包括:受者年龄、急性排斥反应、术前透析时间、移植肾功能延迟恢复、受者PRA水平、供体CMV血清学、麦考酚酸酯的应用;logistic回归分析认为供体CMV血清学IgG(+)、术后急性排斥反应及术前长期血透时间为高危因素.结论 肾移植术后为减少巨细胞病毒性肺炎的发生发展,抑制早期急性排斥反应非常重要,同时尽量选择血清学阴性供体,缩短肾移植术前血透时间也能减少其发病率.     

肾移植受者合并肺孢子菌肺炎的CT和肺功能观察

目的 探讨肾移植受者合并肺孢子菌肺炎(PCP)的CT和肺功能的动态变化.方法 对2002至2006年期间确诊的肾移植术后合并肺孢子菌肺炎的16例患者,进行胸部CT、血气分析和肺功能动态变化的回顾性研究.结果 16例患者确诊为PCP病例,年龄(36±11)岁,肾移植术后时间(4.3±2.1)个月,院外病程(4.5±1.9)d.入院后胸部CT均表现为两肺渗出、实变为主,比病程刚起时明显进展.部分还表现为渗出性病灶内多发的局灶性肺气肿样改变.治疗后肺部阴影开始吸收,病程2个月CT上遗留少许纤维灶.肺功能异常急性期表现为限制性通气功能障碍和弥散功能降低,第3周时通气功能异常即逐渐恢复正常,第4周弥散功能明显好转,病程第3个月内肺功能完全恢复.结论 肾移植合并PCP患者胸部CT以肺泡病变(渗出和实变为主)为特点,可有局部肺气肿样改变.肺功能异常急性期以限制性通气功能障碍和弥散功能下降为主;治疗若有效,病程第3个月内肺功能异常可完全恢复.     

免疫吸附在高致敏肾移植受者中的应用

目的 探讨蛋白A免疫吸附(IA)治疗在预防高致敏肾移植受者急性排斥反应中的效果和安全性.方法 回顾性分析2008年3月至2009年10月首都医科大学附属北京朝阳医院收治的12例群体反应性抗体(PRA)高的肾移植患者在术前应用IA治疗的临床资料.比较治疗前后血免疫球蛋白IgG、IgM、IgA及PRA水平.观察患者术后急性排斥反应发生情况及不良反应.结果 12例患者IA治疗次数为3～8次.治疗后PRA Ⅰ和Ⅱ类抗体均较治疗前明显下降[14%(4%,27%)比86%(73%,98%),6%(0,23%)比68%(34%,88%),均P＜0.01];血清总IgG水平较治疗前明显下降[(550±341)g/L比(1301±393)g/L,P＜0.01];IgA和IgM也较治疗前降低[(144±78)g/L比(185±93)g/L,(103±48)g/L比(131±66)g/L,P＜0.01].5例患者在术后发生了急性排斥反应,给予抗胸腺细胞球蛋白(ATG)或联合IA(2例)治疗后均逆转.术后6个月内,1例患者发生烟曲霉菌肺炎,2例出现卡氏肺囊虫肺炎,均治愈.结论 IA治疗可降低高致敏患者体内预存抗体水平.辅以诱导治疗对预防和减轻肾移植术后排斥反应疗效确切.