Diagnosis and treatment strategies for vascular complications after kidney transplantation / 器官移植

With persistent progress in donor-recipient evaluation criteria, organ procurement and preservation regimens and surgical techniques, the incidence of vascular complication after kidney transplantation has been declined, whereas it is still one of the most severe surgical complications of kidney transplantation, which may lead to graft loss and recipient death, and seriously affect the efficacy of kidney transplantation. Therefore, the occurrence, clinical manifestations, diagnosis and treatment strategies of common vascular complications after kidney transplantation, including vascular stenosis, arterial dissection, pseudoaneurysm, vascular rupture and thrombosis were reviewed in this article. In combination with the incidence, diagnosis and treatment of vascular complications after kidney transplantation in the First Affiliated Hospital of Xi'an Jiaotong University, diagnosis and treatment strategies for common vascular complications after kidney transplantation were summarized, aiming to provide reference for clinical diagnosis and treatment of vascular complications after kidney transplantation, lower the incidence of vascular complications, and improve clinical efficacy of kidney transplantation and survival rate of recipients.

Cross clamping of the supraceliac aorta is effective for bleeding control in ruptured giant splenic artery pseudoaneurysm when proximal and distal control of the splenic artery is not possible: a case report / O clampeamento da aorta supracelíaca é eficaz no controle de sangramento em pseudoaneurisma gigante roto de artéria esplênica quando o controle proximal e distal da artéria esplênica não é possível - relato de caso

Abstract Splenic artery pseudoaneurysm is the most common of all the visceral artery pseudoaneurysms. Presentation is often variable and the condition demands immediate diagnosis and management because pseudoaneurysm rupture increases morbidity and mortality. It is associated with pancreatitis and other conditions like abdominal trauma, chronic pancreatitis, pseudocyst of the pancreas, liver transplantation, and, rarely, peptic ulcer disease. We present a case of a giant splenic artery pseudoaneurysm measuring 14x8 cm. Proximal and distal control of the vessels could not be achieved during the procedure because of local adhesions and inflammation and it was necessary to cross clamp the supraceliac aorta to control bleeding.

Resumo O pseudoaneurisma de artéria esplênica é o mais comum entre os pseudoaneurismas de artérias viscerais. A apresentação geralmente varia e requer diagnóstico e tratamento imediatos, pois a ruptura do pseudoaneurisma aumenta a morbimortalidade. Esse tipo de pseudoaneurisma está associado à pancreatite e a outras condições, como trauma abdominal, pancreatite crônica, pseudocisto de pâncreas, transplante de fígado e, raramente, úlcera péptica. Apresentamos um caso de pseudoaneurisma gigante de artéria esplênica, com tamanho de 14x8 cm. Durante o procedimento, não foi possível alcançar controle proximal e distal dos vasos devido a aderências locais e inflamação, sendo necessário o clampeamento da aorta supracelíaca para controle do sangramento.

Research progress on the role of exosome in rejection after lung transplantation / 器官移植

Rejection after lung transplantation, including acute rejection (AR) and chronic rejection manifested with chronic lung allograft dysfunction (CLAD), is the main factor affecting the long-term survival of allografts. Exosome, a type of extracellular nanovesicle for intercellular communication among eukaryotic cells, could carry complex biological information and participate in various physiological and pathological processes. Exosome has become a critical immune medium in rejection, regulates the incidence and development of rejection through multiple pathways, and also plays a key role in the monitoring and management of rejection. In this article, the type of rejection after lung transplantation, the mechanism underlying the role of exosome in regulating rejection, exosome acting as biomarkers and the application in rejection treatment were reviewed, aiming to provide a novel direction for comprehensive diagnosis and treatment of rejection following lung transplantation.

Protein A immunoadsorption in the treatment of de novo DSA-mediated acute rejection after lung transplantation / 器官移植

Objective To investigate the treatment on de novo donor specific antibody (dnDSA) mediated acute rejection after lung transplantation. Methods Clinical data of 1 recipient with antibody-mediated rejection (AMR) early after lung transplantation was retrospectively analyzed. The process of diagnosis and treatment were assessed. Results The recipient underwent right lung transplantation due to systemic sclerosis-associated end-stage interstitial lung disease. Preoperatively, classⅠ panel reactive antibody (PRA) was positive (11%). No pretreatment was given before transplantation. Antithymocyte globulin induction therapy was delivered on the day of transplantation and postoperatively. The recipient was properly recovered early after transplantation. Chest tightness and shortness of breath occurred at postoperative 13 d, which were progressively worsened and rapidly progressed into type Ⅰ respiratory failure. Class Ⅰ PRA was increased to 58%, and dnDSA was observed at the loci of A24: 02. The mean fluorescence intensity (MFI) was 2 110. According to the guidelines of International Society for Heart and Lung Transplantation, the recipient was diagnosed as possible AMR. After comprehensive treatment including plasmapheresis, protein A immunoadsorption, glucocorticoid pulse, rituximab and immunoglobulin intravenous drip, the PRA and DSA levels were gradually decreased, and the MFI of DSA was 0 at postoperative 20 d. Clinical condition of the recipient was gradually improved. The dyspnea was healed, shortness of breath was eased, respiratory failure was treated, and pulmonary effusion was gradually absorbed. At postoperative 45 d, the recipient was discharged after full recovery. During 1-year follow-up, the recipient was physically stable and obtained normal quality of life. Class Ⅰ PRA was 5%, and class Ⅱ PRA was negative. No DSA was noted. Conclusions Based on traditional drug therapy, supplement of protein A immunoadsorption therapy may effectively eliminate DSA from the circulating blood of the recipient and mitigate the damage of target organs. Ideal short- and long-term prognosis may be achieved. Traditional drug therapy combined with immunoadsorption may yield ideal efficacy in treating AMR after lung transplantation.

Diagnostic criteria and research progress on Banff classification of allograft pathology in composite tissue allotransplantation / 器官移植

Composite tissue allotransplantation (CTA) is a novel transplantation discipline to treat functional tissue or limb defects. Since a majority of CTA grafts were vascularized grafts, it is also known as vascularized composite allotransplantation (VCA). The grafts of CTA/VCA consist of two or more types of allogeneic skin, subcutaneous tissue, bone, muscle, nerve and vessel, etc. Most of CTA/VCA grafts contain skin tissues, which possess the highest antigenicity. Acute rejection after transplantation is the primary obstacle leading to CTA/VCA graft failure and primary graft dysfunction. Hence, histopathological characteristics of skin rejection in CTA/VCA grafts have become the primary hotspot. In this article, pathological features of CTA/VCA rejection, Banff classification in 2007 and related research progress were reviewed, aiming to provide reference for the diagnosis and treatment of rejection and other complications of CTA/VCA.

Clinical application value of contrast-enhanced ultrasound in hepatic artery thrombosis after pediatric liver transplantation / 器官移植

Objective To investigate the clinical application value of contrast-enhanced ultrasound (CEUS) in hepatic artery thrombosis (HAT) after pediatric liver transplantation. Methods Clinical data of 126 pediatric recipients undergoing liver transplantation were retrospectively analyzed. The incidence of HAT after pediatric liver transplantation was summarized. Color Doppler ultrasound and CEUS manifestations of HAT were compared. Results According to color Doppler ultrasound, 17 cases were highly suspected with HAT. Nine cases were highly suspected with HAT by CEUS, who were subsequently confirmed by CT angiography (CTA) or surgery. CEUS manifestations of HAT showed that hepatic artery was not seen surrounding the portal vein during the arterial phase or even portal venous phase. Hepatocyte necrosis occurred in 4 patients with HAT, and no perfusion of intrahepatic contrast agent was observed on CEUS. Conclusions CEUS yields high clinical application value in the diagnosis of HAT after pediatric liver transplantation. It has significant advantages compared with traditional CTA, which could be widely applied in clinical practice.

Diagnostic criteria and research progress on pancreas allograft pathology / 器官移植

Pancreas transplantation and pancreas-kidney transplantation are the optimal treatment for renal failure caused by type 1 diabetes mellitus, partial type 2 diabetes mellitus and their complications. Pancreas transplantation mainly includes simultaneous pancreas-kidney transplantation (SPK), pancreas transplantation after kidney transplantation (PAK) and pancreas transplantation alone (PTA). Among all types of pancreas transplantation, biopsy of pancreas allograft remains the best method for definitively diagnosing rejection and differentiate it from other complications. In this article, biopsy methods of pancreas allograft and related research progress, diagnostic criteria and research progress on rejection of pancreas allograft biopsy, and main complications and pathological manifestations of pancreas allograft were illustrated, aiming to provide reference for guiding the clinical diagnosis of the above mentioned complications and ensuring the long-term survival of pancreas allografts and recipients.

Analysis and prospect of platelet compatible transfusion / 中国输血杂志

Platelet compatible transfusion can effectively solve the immune mediated platelet transfusion refractoriness (PTR), save platelet resources and improve blood safety. This paper comments and prospects the compatibility modes of HLA, HPA and CD36, HLA antibody titer, antigen immunogenicity and the development of platelet compatible transfusion. The pattern of HLA compatible platelets involves the matching in the alleles, antigens and epitopes levels, respectively, as well as avoidance donor specificity antibody (DSA) method. While setting the mean fluorescence intensity (MFI) threshold of avoidance DSA needs to be explored when using the DSA prediction method. Allele specific HLA antibodies can be found in the patients with PTR. Therefore, the patients and donors should be genotyped for HLA-A, -B loci at high-resolution level in order to avoid allele specific HLA antibodies. The immunogenicity of various antigens or epitopes at HLA-A and -B loci are different. Selecting donor platelets with low antigen expression or low immunogenicity may be a way of HLA compatible platelets. As the probability and type of HPA antibody production are different in the various populations, the approaching of compatibility HPA involves allele matching and avoidance DSA. As to CD36, the compatibility mode mainly refers to avoidance DSA, which means blood donors with CD36 antigen type Ⅰdeficiency are preferentially selected, and then those with CD36 antigen type Ⅱ deficiency. In the future, more attention should be paid to the scale up of database capacity and update of the information construction. The time waiting for compatible platelets transfusion in clinical could be significantly shortened if the requiring and matching are only conducted within the inventory and candidate platelets.

Application of Ultrasound Combined with DSA-guided Single-incision Technique via Axillary Vein Access in Implantation of Totally Implantable Venous Access Port / 肿瘤防治研究

Objective To evaluate the technical feasibility and safety of a single-incision technique via axillary vein (AV) for placement of totally implantable venous access port (TIVAP) guided by ultrasound combined with DSA in clinical application. Methods We retrospectively analyzed clinical data of 240 patients who received TIVAP by single incision technique via AV access guided by ultrasound combined with DSA. We observed and recorded operation-related information such as AV width, AV puncture success rate, implantation success rate, ultrasound-guided puncture time, operation time and intraoperative and postoperative complications, etc. Results All 240 patients were successfully implanted with TIVAP, and the success rate was 100%. In 229 cases, TIVAP was implanted through single-incision AV puncture under the guidance of ultrasound combined with DSA, and the success rate of AV puncture was 95.42% (229/240). In 11 cases, TIVAP was implanted through the ipsilateral internal jugular vein (IJV) under the guidance of ultrasound combined with DSA due to the failure of AV puncture. In the 240 patients, the average width of AV of the intended puncture segment was (7.56±1.26) mm measured by preoperative ultrasound exploration and positioning, in which 195 cases were successfully punctured once, 26 cases were successfully punctured twice, and 8 cases were successfully punctured three times, with the success rate of 81.25%, 10.83% and 3.34%, respectively. The average puncture time under ultrasound guidance was (0.85±0.52) min, and the average operation time was (25.9±4.8) min. The incidence of intraoperative complications was 1.67% (4/240). No hemothorax, hemopneumothorax or serious fatal complications occurred. The incidence of complications during TIVAP retention was 2.92% (7/240). No complication such as catheter-related bloodstream infection, catheter-related venous thrombosis, catheter rupture/displacement, clipping syndrome or drug extravasation was observed. Conclusion Ultrasound combined with DSA guided single-incision technique via AV access in the implantation of TIVAP is a feasible and safe implantation method with high technical success rate, short operation time and low risk of complications. It can be used as another choice of TIVAP implantation method.

DSA of the oblique branch of lateral circumflex femoral artery: A morphological study and clinical significance / 中华显微外科杂志

Objective:The morphological characteristics of the oblique branch of lateral circumflex femoral artery (LCFA) were observed by digital subtraction angiography (DSA) in order to provide imaging basis in the application of the ALTF pedicled with the oblique branch of LCFA.Methods:Between February, 2020 and December,2020, for the patients who were requested to repair the wound with ALTF, a DSA radiography was performed before operation. A total of 197 sides of selective DSA were analysed in 113 patients. The occurrence rate, origin and course of the oblique branch of LCFA were observed. Relationships between the oblique branch of LCFA and the upper cutaneous branch, descending branch and transverse branch were analysed. In addition, in order to verify the accuracy of conventional DSA data in describing the morphological characteristics of oblique branches, 10 sites of 10 patients were randomly selected to perform rotational DSA three-dimensional imaging.Results:Femoral artery, deep femoral artery, LCFA and the branches of LCFA were clearly identified on DSA images. The oblique branch appeared in 190 sites, with a occurence rate of 96%. Among them, 1 oblique branch originated from the femoral artery, 2 from the deep femoral artery, and other 187 from LCFA. The oblique branches were found in 10 sites from rotational DSA three-dimensional imaging, which was consistent with conventional DSA imaging.Conclusion:The occurrence rate and morphological characteristics of the oblique branch of LCFA can be directly analysed by DSA. The oblique branch is not a variant branch as reported in the literatures, as it always appears. It may serve the main blood supply artery of the anterolateral thigh flap.

Pathology of antibody-mediated rejection in renal allograft / 器官移植

Antibody-mediated rejection (AMR), also known as humoral rejection, is an immune injury caused by rejection involved with multiple humoral immune effectors, such as antibodies and complements, etc. AMR plays a pivotal role in hyperacute, acute and chronic rejection. In this article, the basic definition of AMR, the research progress and major achievements on AMR pathology according to Banff classification on allograft pathology (Banff classification), and main pathological characteristics of AMR in renal allograft were reviewed, aiming to provide reference for accurate diagnosis and timely treatment of AMR, and guarantee the long-term survival of renal graft and recipients.

Establishment and evaluation of a monkey acute cerebral ischemia model

OBJECTIVES: Cerebral ischemia seriously threatens human health and is characterized by high rates of incidence, disability and death. Developing an ideal animal model of cerebral ischemia that reflects the human clinical features is critical for pathological studies and clinical research. The goal of this study is to establish a local cerebral ischemia model in rhesus macaque, thereby providing an optimal animal model to study cerebral ischemia. METHODS: Eight healthy rhesus monkeys were selected for this study. CT scans were performed before the operation to exclude cerebral vascular and intracranial lesions. Under guidance and monitoring with digital subtraction angiography (DSA), a microcatheter was inserted into the M1 segment of the middle cerebral artery (MCA) via the femoral artery. Then, autologous white thrombi were introduced to block blood flow. Immediately following embolization, multisequence MRI was used to monitor cerebrovascular and brain parenchymal conditions. Twenty-four hours after embolization, 2 monkeys were sacrificed and subjected to perfusion, fixation and pathological examination. RESULTS: The cerebral ischemia model was established in 7 rhesus monkeys; one animal died during intubation. DSA and magnetic resonance angiography (MRA) indicated the presence of an arterial occlusion. MRI showed acute local cerebral ischemia. HE staining revealed infarct lesions formed in the brain tissues, and thrombi were present in the cerebral artery. CONCLUSION: We established a rhesus macaque model of local cerebral ischemia by autologous thrombus placement. This model has important implications for basic and clinical research on cerebral ischemia. MRI and DSA can evaluate the models to ensure accuracy and effectiveness.

Application of chimeric antigen receptor-regulatory T cell immunotherapy in organ transplantation / 器官移植

Regulatory T cell (Treg) is a subset of T cells that negatively regulates immunity and has the function of inhibiting rejection. The specific modification of Treg by chimeric antigen receptor (CAR) technology can successfully chime donor-specific antigen onto the surface of Treg, thus regulating the immune function of the body in a real-time manner. It provides a novel and promising therapeutic option for inducing immune tolerance. In this article, research progresses on Treg in immune related diseases, main difficulties in the realization of CAR-Treg technology and its role in inducing transplantation immune tolerance were reviewed, and the opportunities and challenges of CAR-Treg application in the field of organ transplantation are prospected.

Overview of international forefront hotspots and new progress on organ transplantation in 2019 ATC / 器官移植

In this paper, forefront hotspots in clinical and applied basis of organ transplantation as well as translational medicine during 2019 American Transplant Congress (ATC) were summarized. It involved transplantation clinical priorities and difficulties which were concerned by transplant surgeons. These hot topics included the immunological mechanisms, risk factors, prognosis evaluation and important biological markers of donor specific antibody (DSA) and antibody-mediated rejection (AMR), desensitization strategy in highly sensitized patients and progress of AMR prevention and treatment, current status and development direction of clinical immune tolerance, hotspots and prevention progress on transplantation-related infection, and brief evaluation of various donor organ mechanical perfusion methods, etc.

Therapeutic dosingtiming and efficacy of bortezomib for antibody-mediated kidney transplant rejection / 中华器官移植杂志

Objective To explore whether therapeutic dosing timing of proteasome inhibitor bortezomib(BZ) would impact its clinical efficacy .Methods From 2012 to 2018 ,35 biopsy-confirmed cases of acute antibody-mediated kidney transplant rejection (AMR) were collected .They received intravenous immunoglobulin (IVIG) plus sirolimus (Sir) plus bortezomib (BZ) .Three groups were assigned according to dosing timing of BZ .After a diagnosis of AMR ,ET (early treatment ) group began BZ dosing within 7 days (n=16) while DT (delayed treatment) group within 8-14 days (n=11) and LT (late treatment) group > 14 days (n= 8).Their clinical parameters and incidence of complications were analyzed .Results DSA reversal rate of ET ,DT and LT groups was 87 .5％ , 45 .5％ and 25 .0％ (P=0 .006) while DSA declining rate 93 .8％ ,90 .9％ and 50％ respectively (P=0 .019);recurrent rate of AMR was lower in ET/DT group than LT group (6 .6％ vs 10％ vs 75％ , P=0 .042) .No significant differences existed in blood perfusion score of allograft at 1 month post-dosing among three groups .In three groups ,creatinine (Cr) of ET group was lower than DT group at month 1/3/12 while DT group was lower than LT group .No significant difference existed in the incidence of adverse reactions among 3 groups .Conclusions More likely to enter the window period , early dosing of BZ is more effective for treating acute AMR .An earlier intervention yields a better efficacy .

Clinical risk stratification ofde novo DSA after kidney transplantation based upon eplet mismatch / 中华器官移植杂志

Objective To compare HLA loci versus eplet match in predicting de novo DSA after renal transplantation and establish a risk stratification scheme based upon eplet mismatch for predicting the risk of de novo DSA .Methods A retrospective analysis of HLA serological versus and eplet mismatch was performed for 141 pairs of donors and recipients .And the predictive power of de novo DSA was evaluated by the follow-up results .Based upon eplet mismatch ,a preliminary scheme of risk stratification was established and experimentally verified .Results No significant difference existed in HLA serological mismatch between de novo DSA and DSA negative groups (10 .40 vs 8 .94 ,P=0 .1224) while there was a significant difference in eplet mismatch (100 .60 vs 70 .37 , P< 0 .0001 ) . The risk stratification scheme based upon HLA serological mismatch could not differentiate de novo DSA-free rates between low/medium/high-risk groups (100％ vs 94 .74％ vs 90 .41％ , P=0 .4485 , P=0 .4506 , P=0 .2060 ) .Instead the novel scheme based upon eplet mismatch revealed significant difference in the prevalence of de novo DSA between low /medium/high-risk groups (100％ vs 91 .04％ vs 66 .67％ ,P=0 .0001 ,P=0 .0001 ,P<0 .0001) .Conclusions As a better tool of predicting de novo DSA ,Eplet match is vital for the risk stratification scheme of de novo DSA .

Development of DSA Information Management and Image Analysis System Based on Java Web / 中国医疗器械杂志

OBJECTIVE@#To establish a digital subtraction angiography (DSA) information management and image analysis system to realize scientific management of DSA image information and efficient processing of image data.@*METHODS@#Based on Java Web under Windows 7 environment, a dynamic Browser/Server mode system was constructed by JSP and Servlet on the network. Eclipse and MySQL were used as development tool and database development platform. Tomcat network information service was used as application server. Matlab codes were embedded to analyze DSA image.@*RESULTS@#The system consists of five modules:image information management, image processing, image analysis, advanced retrieval and clinical data management. It may complete such process as storing, deleting, saving, analyzing of DSA image and basic information of patients.@*CONCLUSIONS@#The main interface of the system is user-friendly and easy to operate. The system will be helpful to the clinical, teaching and scientific research work related to DSA.

Study on the application of CCQ-DSA in the evaluation of microvascular of liver carcinoma / 中国医学装备

Objective: To evaluate the clinical value of color coded quantitative-digital subtraction angiography(CCQ-DSA)in microvascular of liver carcinoma.Methods: 40 patients with hepatocellular carcinoma(HCC)who received treatment in hospital were selected in this research and they were divided into observation group(20 cases)and control group(20 cases).The CCQ-DSA was applied in observation group to observe microvascular of liver carcinoma and DSA imaging was applied in control group.And the applied effects of two groups in the display evaluation of new vessels of liver carcinoma were compared.Results: The differences of collateral circulation vessel and collateral circulation of small lesion of liver carcinoma between the two groups were significant(x2=5.584,x2=18.142,P＜0.05),respectively.And the difference of capillary type of liver carcinoma by diagnosis of angiography was significant(x2=10.039,P＜0.05).Conclusion: The diagnostic effect of CCQ-DSA for microvascular of liver carcinoma is better than that of DSA imaging,and it has significant advantage of display on image detail.

Exploration on the configuration of air conditioner and ventilating system of large medical equipment / 中国医学装备

Objective:To explore the configuration of air conditioner and ventilating system of large medical equipment in comprehensive hospital so as to meet the normal operation of various large medical equipment of hospital.Methods: Facing to the characteristics, that the requirements of large medical equipment on air conditioner and ventilating system were higher than that of common equipment and the configuration requirements of different large medical equipment on air conditioner and ventilating system were different, the allocation according to the demands was adopted.Results:Depended on the equipment parameter and requirement of actual operation of linear acceleration, magnetic resonance imaging (MRI), computed tomography (CT) and the machine room of digital subtraction angiography (DSA) in the items of new medical technique building of hospital to design the configuration plan of air conditioner and ventilating system of large medical equipment so as to ensure their normal operation. Conclusion: In the planning programming and construction management of air conditioner and ventilating system of large medical equipment, the different characteristics of them should be considered so as to establish better basis for installation, debugging and operation of equipment in later period. At the same time, these can provide better medical environment for patients and medical staff.

Application of electromyography in the treatment of multiple segment intervertebral disc herniation with ozone injection / 介入放射学杂志

Objective To investigate the application of lower limb electromyography in guiding preoperative localization for multiple segment intervertebral disc herniation treated with ozone injection and in predicting the curative efficacy.Methods A total of 51 patients with MRI-proved multiple segment lumbar intervertebral disc herniation,who were admitted to authors' hospital during the period from January 2012 to December 2013 and who had complete clinical materials,were included in this study.Guided by DSA,intradiscal injection of ozone together with the injection of ozone plus compound betamethasone and bupivacaine into the space around the spinal nerve was carried out in all patients.The degree of lower lumbago was evaluated with M-JOA score,and Oswestry disability index (ODI) was adopted to assess the curative effect.Results Preoperative electromyography showed that 43 patients had nerve root injury,the positive rate was 84.3％.The positive HIZ sign was detected in 30 patients,with the positive rate being 58.8％.The positive Modic sign was observed in 24 patients,the positive rate was 47.1％.Postoperative MJOA scores indicated that one-,3-and 6-month effective rates were 90.1％,86.2％ and 78.5％ respectively;and postoperative ODI values showed that one-,3-and 6-month effective rates were 87.3％,79.5％ and 74.6％ respectively.Conclusion In treating multiple segment intervertebral disc hemiation with ozone injection,lower limb electromyography is very valuable in accurately making preoperative localization as well as in precisely predicting the curative efficacy,thus this technique is worth popularizing in clinical practice.