不同麻醉方法对活体供肾肾移植患者围术期肾功能的影响

目的 探讨选择全静脉全身麻醉(total intravenous anesthesia,TIVA)和腰-硬联合麻醉(combinedspinal-epidural anesthesia,CSEA)不同的麻醉方法对接受亲属活体供肾移植手术患者围术期肾功能的影响是否存在差异.方法 选择择期行亲属活体供肾移植手术的患者60例,均为首次接受肾移植术患者.供受者均为血缘亲属关系,供肾者全部选择在全静脉全身麻醉下经开放术式取肾,供肾热缺血时间50秒～90秒,冷缺血时间60 min～120 min.随机将60例患者分为2组(TIVA组和CSEA组),每组30例,TIVA组术后给予经静脉术后镇痛(patient-controlled intravenous analgesia,PCIA)2d;CSEA组术后给予经硬膜外术后镇痛(patient-controlled epidural analgesia,PCEA)2d.分别记录肾移植手术时间;移植肾开放时平均动脉压(MAP)和心率(HR);移植肾开放后第1、2、3、5、7天的尿量;血肌酐(Cr);血尿素氮(BUN)以及内生肌酐清除率(Ccr)的变化;术后随访患者镇痛满意度.结果 TIVA组手术时间为(171±29)min,CSEA组手术时间为(173±29)min,两组比较无统计学差异(P＞0.05);移植肾血管吻合口开放时TIVA组MAP为(149±10)mm Hg,CSEA组MAP为(139±12)mm Hg,两组比较为差异有统计学意义(P＜0.05);两组移植肾血管吻合口开放时HR组间比较差异无统计学意义(P＞0.05);两组移植肾开放后第1、2、3、5、7天尿量、Cr、BUN和Ccr组间比较差异均无统计学意义(P＞0.05).结论 全静脉全身麻醉与腰-硬联合麻醉对接受亲属活体供肾移植手术患者围术期肾功能的影响无统计学差异,两种麻醉方法都可以安全用于肾移植手术患者.     

Hypertension following renal transplantation in children

The files of 334 consecutive cadaver kidney (CK) and of 27 living related (LR) transplantations (T) in children and adolescents performed from 1973 to 1984 have been reviewed. Following cadaver transplantation, 52 patients (15%) never had hypertension (HT), 41 patients (12%) had only initial HT up to 6 months after transplantation and 18 other patients (5%) exhibited transient HT episodes while on high-dose steroid therapy. Finally, 209 patients (62%) had HT for periods longer than 6 months and 16 patients (5%) until death or graft failure within the first 3 months. Chronic graft rejection was the major cause of HT, but other factors either isolated or in association were also present. Renal artery stenosis (RAS) was diagnosed in 43 cases (13%) 2–17 months post-transplantation; 10 of these were operated upon (5 successfully) and 9 underwent transluminal angioplasty with a single success. Nine cases of RAS resolved spontaneously. HT was attributed to the host kidney in 10 cases (3%) and to recurrence of primary renal disease in 9 (3%). HT observed after CKT was sometimes severe and difficult to control. Acute complications from HT were recorded in 35 cases, with 6 deaths and 2 severe neurological sequelae. Among 25 LRT, 11 cases (40%) had no HT 13 (48%) had HT for longer than 6 months. In this group, no case of RAS was observed and only one complication (without sequelae) was noted. In conclusion, HT is a frequent and sometimes severe complication post-transplantation in children and adolescents.     

Renal function following kidney transplantation in children treated with cyclosporine

The study was performed to evaluate the longterm renal function of children treated with cyclosporine after kidney transplantation. Renal function was determined with clearances of inulin and aminohippurate sodium for evaluating glomerular filtration rate (GFR) and effective renal plasma flow (ERPF). Thirty-six children aged 0.4–16.2 (median 6.9) years at transplantation were examined within 5 months of transplantation and then yearly over 0.3–7.1 years. Twenty-five children and young adults, 1.5–20 (median 7.7) years of age, with solitary kidneys because of renal agenesis or nephrectomy, served as controls. The GFR and ERPF within 1 year of transplantation were significantly lower than those of controls (65±19 and 345±88 vs 96±12 and 474±91 ml/min per 1.73 m², respectively). GFR remained constant 4 years after transplantation, but ERPF decreased significantly. Significant inverse correlations were found between GFR within 5 months of transplantation and the mean cyclosporine concentration and the number of rejection episodes. The frequency of hypertension decreased from 82% within 5 months of transplantation to 0% after 4 years. The absolute GFR increased during follow-up. In conclusion, kidney transplantation results in a reduced renal function compared with that of solitary native kidneys. The reduction in renal function correlated with the number of rejection episodes and the cyclosporine load. The increase in absolute GFR during follow-up suggests a remaining capacity for growth and/or compensatory hypertrophy.     

Early postoperative renal function following renal transplantation surgery: effect of anesthetic technique

Purpose. The use of continuous epidural anesthesia in patients with chronic renal failure is rare and controversial. In this study, we compared the effects of epidural versus general anesthesia on early postoperative renal function in patients who underwent renal transplantation surgery. Methods. Sixty-eight adult patients were prospectively randomized to two groups. Group 1 (n-37) received epidural anesthesia with bupivacaine and fentanyl, and group 2 (n-31) received general anesthesia with nitrous oxide and isoflurane. The patients' renal function was compared both with qualitative scintigraphic analysis (kidney perfusion, concentration, and excretion capabilities) and biochemically [serum sodium, potassium, creatinine, and blood urea nitrogen) (BUN)] within the first postoperative week. Results. Patient demographics were similar in the two groups, and the scintigraphic and biochemical evaluations were also comparable. The time of the first appearance of Tc-99m diethylene triamine pentaacetic acid (DTPA) was within normal limits in 75.7% of patients in group 1 and 61.3% of those in group 2. The number of patients with normal peak/background activity and 20 min/peak activity were 15 (40.5%) and 19 (51.4%), respectively, in group 1, and 12 (38.7%) and 15 (48.4%) in group 2 (P > 0.05 for both). The levels of serum creatinine and urea in both groups decreased within days postsurgery compared with preoperative levels (P < 0.05), but the changes were similar in the two groups (P > 0.05). A similar number of patients in both groups were treated for acute rejection (P > 0.05). Conclusion. Our results demonstrate the safe use of both anesthetic techniques in renal transplantation surgery. Received: December 25, 2000 / Accepted: November 5, 2001     

The initiation of erythropoiesis following renal transplantation

Erythropoiesis has been examined in relation to kidney function in 38 patients during the 3-month period following successful renal transplantation, using serial determinations of erythropoietin, haemoglobin, and creatinine. Two peaks of serum erythropoietin were observed: an early peak that occurred within 2 days of transplantation and was observed in ten patients, and a late one between 8 and 30 days, observed in 28 patients. The early peak did not produce an increase in haemoglobin and occurred only in the presence of delayed onset of graft excretory function when serum creatinine was greater than 1000 mumols/l. The ineffectiveness of the early peak may be due to the uraemic environment, which is probably a sequel of the tubular damage associated with postoperative acute tubular necrosis. The late peak followed a decrease in serum creatinine to less than 200 mumols/l and was associated with an increase in haemoglobin of 3-4 g/dl during the next 2-6 weeks.     

Natural history and etiology of hyperuricemia following pediatric renal transplantation

A retrospective review was conducted to determine the incidence, etiology, natural history and complications of hyperuricemia after pediatric renal transplantation. Of 81 active transplant recipients aged 10.1±4.8 (mean±SD) years being followed by St. Christoper's Hospital for Children, 57 (70%) were males and 59 (73%) Caucasian. Their immunosuppression consisted of azathioprine, cyclosporine A and prednisone. Mean serum uric acid concentrations peaked at 6 months post transplantation (6.2±2.6 mg/dl), when 39% of the patients had hyperuricemia and 60% were receiving diuretics, and decreased thereafter. At 30 months, 23% of the patients had hyperuricemia and 17% required diuretics. When we compared 42 normouricemic (group A) with 24 hyperuricemic (group B) patients at 18 months post transplantation, we found that patients in group B were older (11.6±4.2 vs. 8.6±5.2 years,P=0.01), had worse renal function (77±25 vs. 96±36 ml/min per 1.73 m²,P=0.03) and required diuretics more frequently (63% vs. 21%,P=0.001), but had identical blood levels of cyclosporine A (82±28 vs. 84±35 ng/ml,P=0.78). A family history of gout did not affect the prevalence of hyperuricemia after transplantation. Asymptomatic hyperuricemia is common following pediatric renal transplantation and is more likely attributable to reduced renal function and diuretic therapy than to the known hyperuricemic effect of cyclosporine A. Of these variables, only diuretic therapy is readily controllable and should be closely regulated following pediatric renal transplantation.     

Non-compliance following renal transplantation in children and adolescents

Reported frequencies of non-compliance in children with end-stage renal disease range from 8% to 70% with a mean around 40%. Sequelae amount to momentous emotional and financial burdens, including the loss of 7% of transplanted organs. Reasons for non-compliance have too often been attributed selectively to the patients (e.g., emotional, mental, social, or communication problems). Compared with general compliance research, this selective attribution appears to be too simplistic. Selective attribution neglects the patients’ experiences within the context of disease and treatment and prevents open communication about non-compliance. Research on personal reasons for non-compliance is scarce. In psychological interviews, a third of our 85 patients with end-stage renal disease (34 boys, 51 girls, mean age 12.7 years, range 7.4–19.3 years) communicated psychologically meaningful reasons for non-compliance, frequently related to interrelational and systemic treatment conditions. Patients indirectly asked for more communication about their subjective reasons for non-compliance. Received July 10, 1997; received in revised form and accepted April 30, 1998     

环孢素新剂型Neoral在肾移植中的应用

对10例肾移植患者作山地明转换Neoral试验进行药效动力学对比研究，30例新移植患者应用Neoral进行临床观察。结果表明，Neoral最高血浓度（Cmax）较山地明高282±84ng／ml，达峰时间（Tmax）短0．79±0．29h，CSA暴露（AUC）大1533±169ng／（h·ml）（P＜0．05）。提示Neoral有较好地抗排斥反应作用，但由于吸收迅速，血药浓度易超过治疗窗水平而引起毒副反应。本组肝中毒达20％。认为Neoral与山地明转换比例应为1：0．8～1：0．9，以避免毒副作用发生；Neoral服药量可较山地明常规剂量减少25％。     

多囊肾患者肾移植的临床研究

目的　分析多囊肾病 (PKD)患者肾移植术后移植效果 ,并探讨影响因素。方法　选取19 78年至 2 0 0 2年 46例PKD肾移植患者 (PKD组 )和 46例其它肾脏病 (非糖尿病肾病 )肾移植患者(对照组 )进行回顾性分析。评估人、肾存活率 (肾移植后 1、3和 5年 ) ,以及术后并发症 ,如感染和心血管疾病等情况。结果　两组患者 1、3、5年人存活率 :PKD组为 95.7%、91.3 %、91.3 % ;对照组为97.8%、95.7%、93 .5% ;肾存活率 :PKD组为 93 .5%、89.1%、87.0 % ;对照组为 95.7%、89.1%、87.0 %。PKD组中 ,女性患者 5年移植人、肾存活率达到 10 0 %、10 0 % ,男性只有 88.2 %、82 .4% ,差异有显著性 (P <0 .0 5)。PKD组患者比对照组更易发生尿路感染 (P <0 .0 5) ;其它部位的感染发生率相似。两组心血管并发症差异无显著性 (PKD组 3例 ,对照组 4例 )。结论　PKD组和对照组总的人、肾存活率差异无显著性。PKD组的女性患者肾移植后存活率高于男性 ,可能与性激素的影响有关。尿路感染和严重的肺部感染可能是PKD患者术后主要的并发症。     

De novo hemolytic uremic syndrome following renal transplantation

We report a case of complete recovery of renal function in a patient with de novo hemolytic uremic syndrome (HUS) following renal transplantation. This 3-year-old girl had none of the factors known to contribute to the development of HUS in transplant recipients. This case illustrates the usefulness of renal biopsy in the accurate diagnosis and management of dysfunction in the allograft following renal transplantation.     

西罗莫司对肝移植术后肾功能和血脂的影响

目的探讨原发性肝细胞癌（肝癌）肝移植患者术后使用西罗莫司（sirolimus）对肾功能和血脂的影响。方法 56例肝癌肝移植患者分为两组。研究组（33例）采用西罗莫司＋小剂量他克莫司（FK506）＋肾上腺皮质激素（激素）方案,对照组（23例）采用FK506＋激素方案。动态监测两组患者术前,术后1、3、6、9、12个月的血清肌酐（Scr）、血清总胆固醇、甘油三酯及高密度脂蛋白的变化情况,分别行组内不同时点比较和同时点组间比较。结果术前两组患者的Scr水平差异无统计学意义（P〉0.05）,术后9个月时的Scr比较差异有统计学意义（P〈0.05）,研究组的Scr水平低于对照组,且研究组术后Scr呈先升高再降低的变化趋势,对照组Scr呈缓慢上升的趋势。术前两组患者的血脂水平相当（P〉0.05）。两组患者术后1个月的甘油三酯水平,术后6个月时的总胆固醇水平和高密度脂蛋白水平比较差异有统计学意义（P〈0.05）,研究组均高于对照组。两组患者未发现与高脂血症相关的心脑血管疾病。结论西罗莫司是一种低肾毒性的免疫抑制剂,与小剂量的FK506合用时可以减少FK506的肾毒性。西罗莫司的主要的不良反应是高脂血症。     

Long-term follow-up of renal function in recipients and donors following pediatric kidney transplantation

Of 125 children undergoing kidney transplantation (tx), 87 received their grafts from living donors. Renal function of recipients (R) and donors (D) was assessed by glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) determined by clearances of inulin and para-aminohippuric acid. Rs were investigated yearly and Ds on alternate years. Within 5 months of tx, absolute GFR and ERPF (ml/min) were significantly lower in R than in D, and the differences in absolute GFR and ERPF between D and R were directly related to the difference in body surface area (BSA) between the two subjects. R and D pairs were repeatedly followed for 4, 6, and 8 years and the absolute GFR of R did not change during follow-up, while relative GFR decreased. Relative GFR decreased most in R, with the greatest difference in BSA between D and R at tx. In the donors, however, both absolute and relative GFR increased significantly up to 8 years. In conclusion, renal function of the two kidneys from the donor, i.e., the grafted kidney in the R and the single native kidney of the D, differed. The native kidney showed a capacity to increase its absolute and relative function with time. The grafted kidney, however, did not show an increase in absolute GFR, resulting in decrease in relative GFR, and the greater difference in BSA between D and R at tx, the greater fall in relative GFR of the R. Received: 7 June 2001 / Revised: 30 July 2001 / Accepted: 30 July 2001     

离体肾动脉瘤修补、肾动脉重建和自体肾移植治疗复杂性孤肾肾动脉瘤一例并文献复习

目的探讨离体肾动脉瘤修补、肾动脉重建和自体肾移植技术治疗复杂性孤肾肾动脉瘤的安全性和可行性。方法CT血管造影（CTA）确诊复杂性孤肾肾动脉瘤1例,病变位于肾动脉主干分叉部,累及节段分支动脉,深入肾门内。肾脏暂时性离体后,在低温和肾脏灌注液灌注保护肾脏的前提下,体外进行肾动脉瘤修补和自体大隐静脉肾动脉重建,然后将肾脏异位移植到右侧髂窝。结果手术成功,围手术期无严重并发症发生。术后血肌酐暂时性升高至约200μmol／L,半个月后逐渐恢复正常;术后2周复查CTA示右髂窝移植肾动脉及其分支血流通畅无狭窄,肾静脉回流通畅,输尿管无狭窄。结论该方法治疗复杂性孤肾肾动脉瘤安全可行,并为以后类似的复杂性肾脏疾病的处理提供了可行方法。     

肾移植后重症肺炎38例临床分析

目的 分析总结38例肾移植术后肺炎重症患者临床特点及救治措施.方法 选择38例2006年至2011年在郑州大学第一附属医院呼吸暨重症监护室收治的肾移植术后肺部感染患者的临床资料进行回顾性分析.结果 38例患者治愈30例,死亡8例.结论 肺炎肾移植患者应用免疫抑制剂的严重并发症,全面综合治疗是救治成功的关键.     

肝移植术后早期急性肾功能衰竭5例临床分析

目的总结肝移植术后早期急性肾功能衰竭的防治经验。方法回顾性分析5例肝移植受者术后早期发生急性肾功能衰竭临床资料,手术方式为改良背驮式肝移植术,其中4例术前即合并肾功能不全。结果5例术后早期急性肾功能衰竭患者3例通过调整免疫抑制方案和改善肾脏灌注及利尿治疗肾功能恢复;2例给予连续性肾脏替代治疗后肾功能恢复。结论肝移植术后免疫抑制剂的个体化应用,积极改善肾脏灌注,必要时选择血液透析治疗,有助于防治肝移植术后早期急性肾功能衰竭。     

肾移植术后并发尿路上皮肿瘤(附25例报告)

目的 探讨肾移植术后并发尿路上皮肿瘤的临床特点及其诊治方法.方法 回顾性分析1998年～2006年间肾移植术后发生尿路上皮肿瘤的临床资料25例.就患者性别、移植时年龄、导致肾功能不全的原发病、移植后肿瘤发生的时间、临床症状、肿瘤发生部位及转归等项目进行临床分析.所有病例移植前均排除肿瘤.肿瘤均经影像学和膀胱镜等检查方法诊断.22例患者行手术治疗,术后所有患者免疫抑制剂用量减少1/3并辅以局部灌注化疗.结果 本组25例患者中男4例,女21例;移植时患者平均年龄55.1岁;原发病为慢性间质性肾炎的患者19例;术后发生肿瘤的时间距肾移植时间平均26个月;临床表现为肉眼血尿或镜下血尿25例,反复泌尿系感染10例,肾盂输尿管积水者12例;肿瘤为多发者22例;移植肾同侧有上尿路肿瘤者16例;3例行姑息性治疗的晚期肿瘤患者分别于发现肿瘤5个月、6个月及8个月后死亡,22例手术治疗患者已随访2～7年,18例肿瘤复发,再行手术治疗;所有患者在免疫抑制剂减量期间均未出现急性排斥,肾功能正常.结论 本组显示慢性间质性肾炎导致肾功能衰竭的肾移植患者和女性肾移植患者易发生移植后尿路上皮肿瘤;血尿、泌尿系感染和肾盂积水是常见的症状,多发性和易复发性是另一临床特点;移植肾同侧上尿路较对侧好发肿瘤.     

Prospective study of pulmonary function for cyclomegalovirus infection after renal transplantation

Abstract Pulmonary involvement remains the main complication of cytomegalovirus (CMV) infection in renal transplantation (RT). Early diagnosis is required for the best management of patients, and preemptive therapy could be a successful approach. In order to define the predictive value of lung alveolocapillary abnormalities. We prospectively studied 26 renal transplant recipients for their diffusing capacity of carbon monoxide (DLCO) and their pulmonary clearance of a ^99mTc-DTPA aerosol. Patients were studied before transplantation and then every 2 weeks up to the end of the 3rd month following RT. Viral blood cultures and serological determinations were performed every week during these first 3 months. Bronchoalveolar lavage (BAL) was done in case of CMV disease. Statistic analysis was done using Student's t -test and Pearson's chi-quare test. During the 3-month follow-up, 13 patients remained free of CMV infection. Three non-infected and 8 infected patients showed DTPA clearance abnormalities (P < 0.05). Six non-infected and 7 infected patients showed DLCO disturbance (P > 0.50). DTPA clearance were significantly modified on days 45 and 60 in the infected group. Serial DTPA scanning, in association with viral blood cultures, could be a useful test to avoid unnecessary BAL in a preemptive therapy strategy.     

肾移植术后肺部感染状态下免疫抑制剂的调整

目的 探讨肾移植术后肺部感染患者免疫抑制剂的应用与预后的关系.方法 对肾移植术后合并肺部感染的98例患者临床资料进行回顾性分析.将患者分为维持应用免疫抑制剂组(维持剂量组,45例)与免疫抑制剂减量或停用组(调整剂量组,53例).按与感染相关的器官衰竭估计评分(SOFA)标准,在肾移植术后肺部感染较重(SOFA≥12分)和感染较轻(SOFA＜12分)的情况下,分别分析两组患者的死亡率、感染恢复时间和排斥反应发生率的差异.结果 当SOFA≥12分时,调整剂量组死亡率和感染恢复时间明显低于维持剂量组(P＜0.05),而排斥反应发生率在两组之间的差异则无统计学意义(P＞0.05);当SOFA＜12分时,死亡率和感染恢复时间在两组之间差异无统计学意义(P＞0.05),但调整剂量组患者排斥反应发生率明显高于维持剂量组(P＜0.05).结论 在肾移植术后肺部感染较重(SOFA≥12分)时,减量和停用免疫抑制剂有利于降低患者的死亡率和缩短抗感染疗程;但感染较轻(SOFA＜12分)时,建议维持免疫抑制剂原剂量不变.     

亲属活体供者供肾前后肾功能的变化

目的 观察亲属活体供者供肾前后肾功能的变化.方法 102名供者均经过严格的术前筛选及评估,其中男性32名,女性70名,供肾时年龄为34～62岁,平均为51.7岁.采用腹腔镜切取供肾74例,开放手术切取供肾28例;其中取左肾90例,取右肾12例.术后对供者进行长期随访,收集术后1 d、7 d、14 d、1个月、3个月、6个月及每年的随访检测资料,检测内容包括血常规、尿常规、血清肌酐(Cr)和尿素氮(BUN)及肾小球滤过率(GFR)等,观察术后不同时期肾功能的变化情况,并与术前进行比较.结果 102例亲属活体供肾切取术均获得成功,术后随访时间为3～99个月,平均37.85个月,供者均健在.供肾术后早期供者的血红蛋白和红细胞计数有所下降,但分别在术后1周和2周后恢复至术前水平;供者的血清Cr水平均有不同程度的升高(P<0.05),但未超出正常范围;除术后第1天供者的血清BUN水平较术前有所升高外(P<0.05),其他随访时间血清BUN水平与术前比较,差异均无统计学意义(P>0.05);术后供者的GFR较术前均有不同程度的升高,从术后2周开始,与术前比较,差异均有统计学意义(P<0.05),其中以术后3个月时的增幅最大;术后各随访时间均未检测出尿蛋白定性呈阳性的供者.结论 活体供肾后,供者的血清Cr水平虽较术前有不同程度的升高,但未超出正常范围,GFR呈代偿性增高,活体供肾是安全的.