肾移植术后妊娠患者的随访监护及围生期护理

对3例肾移植术后成功妊娠患者进行随访监护和围生期护理,结果均顺利分娩,分娩后随访1年。2例分娩后移植肾功能正常,1例妊娠期肾功能异常,产后3个月恢复正常,但患者产后自行停免疫抑制剂,于产后2年移植肾失功行二次肾移植术,术后肾功能恢复正常。提出根据妊娠不同阶段结合肾移植术后特点进行监护随访、心理护理指导;对患者的妊娠时机选择、日常生活、免疫抑制剂调整进行指导,加强对妊娠后肾功能、血压、血糖、血药浓度进行监测和监护;产后进行健康教育和随访,可保证母婴平安。     

肾移植女性受者妊娠管理的研究进展

综述妊娠对女性肾移植患者的影响,肾移植术后妊娠的管理（妊娠前风险提示、妊娠前风险评估、妊娠期免疫抑制剂的应用、妊娠期产检及移植肾功能随访、分娩及麻醉方式的选择、产后喂养方式）,肾移植术后多胎妊娠受者的现状等。旨在总结近年来国内外对肾移植术后患者妊娠管理的经验,提升移植专科护理人员对术后妊娠群体的关注度,为有妊娠意愿的肾移植术后患者提供支持。     

规律随访对肾移植受者术后生存质量的影响

肾移植技术的飞速发展使终末期肾病患者得到了理想的救治。但是仅追求肾移植手术的成功是不够的,肾移植受者还将面临排斥反应以及长期服用免疫抑制剂所带来的感染、心血管疾病、内分泌代谢异常、造血系统异常、新发肿瘤等问题。来自家庭、经济与社会等方面的压力,也严重影响肾移植受者的生存质量。     

女性肾移植受者术后生育22例报告

目的 探讨女性肾移植受者术后生育对子代、移植肾及自身健康的影响.方法 回顾分析8个器官移植中心自1989年8月至2007年2月的资料,共有22例女性肾移植受者术后妊娠,并各生育子女1名.由专人负责收集、整理受者及其子女的资料,包括受者的年龄、病程、肾移植时间、免疫抑制剂的应用、结婚及孕产时间、妊娠和分娩情况、子女出生情况、喂养方式等,并对其中的18名子女进行了体格检查,记录其身高和体重.结果 22例生育时的年龄为(27.8±2.7)岁,分娩时间为术后(35.1±13.2)个月,孕产期问免疫抑制方案为环孢素A(或他克莫司)、硫唑嘌呤(或霉酚酸酯)和泼尼松联用.其中21例为剖宫产,1例为自然分娩;6名(27.3%)为早产,其余为足月产.22名子女出生时体重为(2944±585)g,均人工喂养,现年龄最大者为18岁,最小者为8个月.3岁、4岁和5岁者的体重分别为(15.2±1.3)kg、(17.0±0.9)kg和(17.8±0.4)kg,身高分别为(99.0±3.6)cm、(106.4±1.3)cm和(109.5±0.7)cm,其他年龄段因样本数太少,未行统计.未发现明显畸形.22例受者在孕产期间并发高血压9例次,肾功能异常和蛋白尿各5例次,肺部感染和心力衰竭各4例次,尿路感染3例次,6例移植肾功能丧失,2例因肺部感染、心力衰竭死亡,1例因慢性排斥反应、移植肾功能丧失、心力衰竭死亡.结论 女性肾移植受者术后若情况允许,可以生育,但有时可对移植肾及自身健康有一定的影响,整个妊娠、生育过程应有产科、移植科以及心内科等医生共同参与指导.     

肾移植受者术后生育的临床特点

肾移植受者术后需长期使用免疫抑制剂，因此其生理状况与正常人群有所不同。由于这些不同导致肾移植受者术后生育具有某些特点，但国内外报道甚少。为此，我们自1987年3月～2007年5月对国内5个器官移植中心（解放军第一一七医院；温州医学院附属第一医院；山东大学附属第二医院；上海交通大学附属仁济医院；解放军第一五三医院）的88例男性肾移植受者术后生育情况进行了回顾性调查分析，以探讨男性肾移植受者术后生育的临床特点，现报告如下。     

三例肾移植患者存活20年的随访观察

三例肾移植患者存活２０年的随访观察章咏裳我院自１９７７年１０月～１９７９年１月共施行同种肾移植１２例，经定期随访，迄今尚健存者有３例，存活率达２５％，其中１例存活时间超过２０年，２例存活时间已近２０年。例１，男，５５岁，１９７８年４月１９日因慢性肾炎...     

活体肾移植供者安全性的随访观察

目的探讨活体肾移植对供者安全性的影响。方法研究对象为2003年4月至2007年4月在新疆医科大学第一附属医院完成活体供肾肾移植的62例供者。记录供者手术时间和住院时间,观察术后并发症发生情况和预后情况。术后随访,随访内容包括血清肌酐(Scr)、血尿素氮(BUN)、肾小球滤过率(GFR)、血浆白蛋白、血红蛋白及血压等指标,同时调查供肾对生活工作的影响。结果62例供者供肾手术均获成功。供者中1例开放取肾术中发生气胸,1例发生切口脂肪液化坏死,经对症治疗后痊愈。2例术后并发肺部感染,选用敏感抗生素及雾化吸入治疗后治愈,其余术后均恢复顺利。62例供者平均术后住院时间(8.2±2.6)d,随访时间为(3.2±1.1)年。所有供者均存活,家庭生活和日常工作也未受到明显影响。62例供者术前及术后7 d、3个月、1年、3年、5年的Scr、BUN、GFR、血浆白蛋白、血红蛋白及血压变化情况比较,差异无统计学意义(均为P0.05)。结论活体供肾肾切除手术安全可行。严格完善术前检查,术中仔细操作及术后严密随访对于保障供者的安全有十分重要的意义。     

对27例亲属供肾移植中供者的术后随访

目的探讨活体亲属供肾移植中供者手术的安全性及术后的生活质量。方法总结2001年12月至2005年9月间27例亲属活体供肾的切取方法，其中6例采用开放式经后腹腔切取供肾，21例采用经后腹腔镜下切取供肾。术后对27例供者随访14～60个月，比较供者术前及术后不同时间段的血肌酐（Cr）、尿素氮（BUN）、血糖及血压的变化情况；根据SF-36健康评分调查和25条问卷题目观察供者的生活质量。结果成功地完成了对27例亲属供者的供肾切取。21例经腹腔镜下取肾术无1例中转开放。手术时间为60～180min，术中失血量为20～200ml，术后住院时间为3～7d。27例供者术后近期各项观察指标虽较术前有变化，但差异均无统计学意义（P〉0．05）。健康评分结果显示供者生活质量满意。结论活体供肾切取手术是安全可行的。术前进行详细的检查、术中仔细操作以及术后长期随访对于供者的安全有十分重要的意义。     

肾移植术后妊娠受者34周前分娩危险因素分析

目的分析肾移植术后妊娠受者34周前分娩危险因素。 方法回顾性分析2013年1月至2020年12月期间在浙江大学医学院附属第一医院成功分娩的肾移植受者临床资料。共计有57例受者被纳入研究,按照分娩时妊娠时间是否超过34周将受者分为≤34周分娩组和>34周分娩组,分别为21例和36例。观察肾移植受者原发病、移植妊娠间隔时间、妊娠年龄、孕期免疫抑制剂血药浓度、分娩方式、新生儿出生体重百分位数及Apgar评分等。符合正态分布的计量资料采用成组t检验进行比较,计数资料采用χ²检验进行比较,采用logistic回归分析分娩34周前早产危险因素。P<0.05为差异有统计学意义。 结果57例受者妊娠时平均年龄(31±4)岁(24~42岁),平均移植妊娠间隔时间为(44±23)个月(14~104个月)。均为剖宫产,平均孕周为(34.2±2.2)周(27.7~37.7周),新生儿出生时平均1分钟Apgar评分为(8.4±1.9)分(1.0~10.0分)。>34周分娩组新生儿Apgar评分高于≤34周分娩组,分别为(8.9±1.0)、(7.4±2.6)分,差异有统计学意义(t＝3.17,P<0.05)。两组受者妊娠年龄、移植妊娠间隔时间和新生儿出生体重百分位数差异均无统计学意义(t＝-1.28、0.25和-0.68,P均>0.05)。>34周分娩组肾移植受者妊娠年龄<32岁的比例(77.8%)、移植妊娠间隔时间<48个月的比例(66.7%)与≤34周分娩组(81.0%、71.4%)差异均无统计学意义(χ²＝0.08、0.14,P均>0.05);妊娠期血清肌酐<1.5 mg/dL的比例(94.4%)低于≤34周分娩组(66.7%),差异有统计学意义(χ²＝7.70,P<0.05)。两组受者妊娠前蛋白尿、妊娠前高血压发生比例差异均无统计学意义(χ²＝0.15、1.13,P均>0.05),妊娠期高血压和妊娠期糖尿病发生比例差异均有统计学意义(χ²＝4.51、7.54,P均<0.05)。Logistic回归分析结果显示,妊娠期高血压、妊娠期糖尿病和妊娠期血清肌酐≥1.5 mg/dL是肾移植受者分娩34周前早产儿的危险因素(OR＝8.661、12.684和21.562,P均<0.05)。 结论妊娠期高血压、妊娠期糖尿病和妊娠期血清肌酐升高与肾移植术后妊娠受者34周前分娩有关。     

78例活体肾移植供体安全性的随访观察

目的 探讨亲属活体肾移植供体肾切除对供体的安全性和长期影响.方法 观察78例活体肾移植供体选择、供肾的切除及供体长期随访.结果 78例供体肾切除手术全部成功,其中切取右肾32例,左肾46例.测术前及术后1天、1周的血肌酐(Cr)、尿素氮(BUN)及血压情况,发现手术前后Cr、BUN、血压均有变化,其中Cr的变化较为明显.78例供体术后随访2～5年,发现供体Cr、BUN、血压及尿蛋白均有变化,但各观察指标的变化无显著性差异(P＞0.05).结论 从近5年的随访来看,活体供肾肾切除手术是安全可行的,术前详细地检查供体各项指标,术中仔细操作,以及随访对于保障供者的安全有十分重要的意义.     

Fatigue in kidney transplant recipients

Fatigue is still present in approximately 40%‐50% of kidney transplant recipients (KTR), rates comparable to that of the hemodialysis population. Correlates of fatigue include inflammation, symptoms of depression, sleep disorders, and obesity. Fatigue in KTR determines a significant severe functional impairment, either when globally considered or when analyzed at the level of the single domains such as sleep and rest, homemaking, mobility, social interaction, ambulation, leisure activities, alertness behavior, and work limitations. In addition, fatigue in KTR is significantly associated with a severe deterioration of quality of life. Fatigue is very common among KTR poorly adherent to immunosuppressive therapy. Unfortunately, there is no evidence of studies about the treatments of this symptom in KTR. Efforts to detect and treat fatigue should be a priority in order to improve quality of life of KTR.     

Association between serum resistin level and outcomes in kidney transplant recipients

Resistin is an adipocytokine that is associated with inflammation, coronary artery disease, and other types of cardiovascular disease among patients with normal kidney function. However, little is known about the association of resistin with outcomes in kidney transplant recipients. We collected socio‐demographic and clinical parameters, medical and transplant history, and laboratory data from 988 prevalent kidney transplant recipients enrolled in the Malnutrition‐Inflammation in Transplant—Hungary Study (MINIT‐HU study). Serum resistin levels were measured at baseline. Associations between serum resistin level and death with a functioning graft over a 6‐year follow‐up period were examined in unadjusted and adjusted models. The mean±SD age of the study population was 51 ± 13 years, among whom 57% were men and 21% were diabetics. Median serum resistin concentrations were significantly higher in patients who died with a functioning graft as compared to those who did not die during the follow‐up period (median [IQR]: 22[15–26] vs. 19[14–22] ng/ml, respectively; P < 0.001). Higher serum resistin level was associated with higher mortality risk in both unadjusted and fully adjusted models: HRs (95% CI): 1.33(1.16–1.54) and 1.21(1.01–1.46), respectively. In prevalent kidney transplant recipients, serum resistin was an independent predictor of death with a functioning graft.     

Multivessel coronary revascularization and outcomes in kidney transplant recipients

Coronary artery disease is a major cause of morbidity and mortality in the kidney transplant population. We compared the long‐term outcomes of coronary artery bypass graft (CABG) surgery with percutaneous coronary intervention (PCI) for multivessel coronary disease in a contemporary cohort of US kidney transplant recipients. From the U.S. Renal Data System, we identified all adult kidney transplant patients with ≥6 months of Medicare A+B undergoing first recorded multivessel coronary revascularization from 1997 to 2009. The associations of CABG versus PCI with death and the composite of death or myocardial infarction (MI) were compared using proportional hazards regression. Of the 2272 patients included in the study, 1594 underwent CABG and 678 underwent PCI. The estimated 5‐year survival rate was 55% [95% confidence interval (CI) 53% to 57%] following coronary revascularization, with no significant association between revascularization type and death [adjusted hazard ratio (aHR) = 1.08; CI 0.94–1.23] or the composite of death or MI (aHR = 1.07; CI 0.96–1.18). Separate propensity score‐matched analyses yielded similar results. In this analysis of kidney transplant recipients undergoing multivessel coronary revascularization, we found no difference between CABG and PCI in terms of survival or the composite of death and MI.     

Management of leukopenia in kidney and pancreas transplant recipients

Abstract: Leukopenia is frequently observed in the setting of solid organ transplantation. The risk factors, natural history, and outcomes associated with leukopenia post‐transplantation have not been well defined. We retrospectively studied 102 adult kidney and/or pancreas transplant recipients over a one‐yr period of time. By defining leukopenia as a white blood cell count ≤3000 cells/mm³ and neutropenia as an absolute neutrophil count ≤2000/mm³, the combined incidence of either leukopenia or neutropenia was 58% (59/102); the first episode occurred at a mean of 91 d post‐transplant. A significant increase in the incidence of leukopenia was found in patients who either received alemtuzumab induction (42% with alemtuzumab vs. 9% with rabbit anti‐thymocyte globulin induction, p < 0.05) and/or had rapid steroid withdrawal in the early post‐transplant period (44% with vs. 16% without steroid withdrawal, p < 0.05). The most common intervention performed for leukopenia was reducing the dose of mycophenolate mofetil and/or valganciclovir. When granulocyte stimulating factors were used, a mean of 3.1 doses were needed to successfully manage the leukopenia. Although leukopenia was a common finding in our study of kidney and/or pancreas transplant recipients, there was no difference in the rates of infection or acute rejection in patients with and without leukopenia.     

Long-term,prolonged-release tacrolimus-based immunosuppression in de novo kidney transplant recipients: 5-year prospective follow-up of the ADHERE study patients

The objectives of this study were to assess long-term graft survival, patient survival, renal function, and acute rejections in de novo kidney transplant recipients, treated with once-daily prolonged-release tacrolimus-based therapy. The study was a 5-year non-interventional prospective follow-up of patients from the ADHERE study, a Phase IV 12-month open-label assessment of patients randomized to receive prolonged-release tacrolimus in combination with mycophenolate mofetil (MMF) (Arm 1) or sirolimus (Arm 2). From 838 patients in the randomized study, 587 were included in the long-term follow-up, of whom 510 completed the study at year 5. At 1 year post-transplant, graft and patient survival rates were 93.0% and 97.8%, respectively, and at 5 years were 84.0% and 90.8%, respectively. Cox proportional hazards analysis showed no association between graft loss, initial randomized treatment arm, donor age, donor type, or sex. The 5-year acute rejection-free survival rate was 77.4%, and biopsy-confirmed acute rejection-free survival rate was 86.0%. Renal function remained stable over the follow-up period: mean ± SD eGFR 4-variable modification diet in renal disease formula (MDRD4) was 52.3 ± 21.6 ml/min/1.73 m² at 6 months and 52.5 ± 23.0 ml/min/1.73 m² at 5 years post-transplant. These findings support the role of long-term once-daily prolonged-release tacrolimus-based immunosuppression, in combination with sirolimus or MMF, for renal transplant recipients in routine clinical practice.     

Pregnancy outcomes in simultaneous pancreas and kidney transplant recipients: a national French survey study

Simultaneous pancreas and kidney transplantation (SPK) is currently the best therapeutic option for patients with type 1 diabetes and terminal renal failure. Renal transplantation restores fertility enabling women to pursue pregnancies. However, scarcity of available data on pregnancy outcomes in SPK impedes fair medical counseling. Medical files of all pregnancies that lasted ≥3 months among recipients of functional SPK performed between 1990 and 2015 in France were retrospectively analyzed. Twenty‐six pregnancies in 22 SPK recipients were identified. Main maternal complications included gestational hypertension (53.8%) and infections (50%). Cesarean section was performed in 73% of cases. Overall fetal survival was 92.6% with a mean gestational age of 34.2 ± 3 weeks. Four children (16.7% of live births) had a birth weight <10th percentile. Endocrine pancreas graft function remained stable during pregnancy. An acute kidney rejection occurred in two patients, one of which resulting in graft loss. Kidney and pancreas graft survival was, respectively, 96% and 100% at 1 year postconception and did not differ from controls. Pregnancy in SPK is feasible, but patients should be informed of the risks for the fetus, the mother, and the grafts. Planning of pregnancy in SPK women is key to allow a personalized multidisciplinary monitoring, which represents the most straightforward approach to optimize outcomes.     

Excellent clinical outcomes in primary kidney transplant recipients treated with steroid-free maintenance immunosuppression

Steroid-free maintenance immunosuppression is desirable to eliminate the side effects of chronic corticosteroid use. Complete steroid avoidance or rapid post-transplant steroid withdrawal has recently been used in renal transplant recipients with encouraging results. The present study evaluated the outcome of a steroid-free maintenance immunosuppressive protocol in kidney transplant recipients with at least one-yr follow up. Between April 2002 and October 2004, a total of 301 primary kidney transplant recipients received steroid-free maintenance immunosuppression. The regimen consisted of induction with thymogobulin and prednisone for the first five d. Patients were maintained on Sirolimus and Neoral. Neoral dose was adjusted to target C2 levels and the Sirolimus dose was adjusted to a target rapamycin trough level. All primary kidney transplants (n = 502) performed in the two yr (starting January 2000) prior to institution of the steroid-free regimen and thus maintained on a steroid-based immunosuppressive protocol were used for comparison. One-year patient and death censored graft survival were 93.1% and 98.1% for the steroid-free group vs. 95.2% and 95.2% for the comparator groups (p = ns). The incidence of biopsy-proven acute rejection was 4.9% in the steroid-free group vs. 9.4% in the comparator group (p < 0.01). Two (0.7%) of 301 patients in the steroid-free group lost their grafts because of acute rejection compared with nine (1.8%) patients in the comparator group (p < 0.05). At one-yr post-transplant the mean serum creatinine level was not different between the two groups. There were no significant differences in mean serum cholesterol and triglycerides levels as well as the percentage of patients on lipid lowering agents between the groups. White blood cell counts, daily doses of Neoral and weight gain were significantly lower in the steroid-free group vs. the comparator group. However, more patients in the steroid-free group required erythropoietin and iron therapy for anemia (p < 0.001). We conclude that excellent graft survival with a significantly lower incidence of acute rejection can be achieved using a steroid-free maintenance immunosuppressive protocol consisting of Neoral and Sirolimus.