Mechanical versus manual anastomoses for artery in clinical renal transplantation / 重庆医科大学学报

Objective:This study compares titanium ring-pin stapler and hand-sutures in the end-to-end anastomosis between renal artery and internal iliac artery in clinical kidney transplant. Methods:In 75 renal allograft recipients, the arterial reconstruction were randomly assigned to anastomoses with either 6/0 interrupted nylon sutures(39 patients) or titanium ring-pin stapler(36 cases). Results:Arterial anastomosis with ring-pin stapler was significantly faster(17.8 versus 28.1 min). In 2 cases, a lower pole artery was successfully anastomosed to the epigastric artery with 2 mm ring. All 75 renal arteries were patented without episodes of postoperative bleeding, or need for revision of the anastomosis in both groups. Mechanical anastomosis resulted in slightly but not statistically significantly less artery stenosis during 2-5-year follow-up.Conclusion:Renal artery anastomosis with ring-pin stapler is as safe and effective as hand-suture. The time required for mechanical anastomosis is only about 1/2 that required for suture anastomosis.

Posttransplant Lymphoproliferative Disorder: A Report of 4 Cases

Posttransplant lymphoproliferative disorder (PTLD) is a proliferation of B-cells associated with Epstein-Barr virus (EBV) infection as a complication of immunosuppression, especially by FK506. We investigated four cases of PTLD which developed either in allografts or in other organs. Case 1 was a 38-year-old woman, who developed monomorphic PTLD in a kidney 7 years and 7 months after renal transplantation. Case 2 was a 37-year-old man, who developed monomorphic PTLD in the right submandibular lymph node 4 months after liver transplantation. Case 3 was a 60-year-old man, who developed monomorphic PTLD in the liver 8 months after liver transplantation. Case 4 was a 2-year-old female child, who developed polymorphic PTLD in the colon, liver, and mesenteric lymph node 10 months after liver transplantation. FK506 was administered to case 4. EBV was identified in the tissues of all cases by immunohistochemistry and/or in situ hybridization.

Study of Acid-Base in Arterial and Central Venous Blood during / 대한마취과학회지

BACKGROUND: Although pulmonary artery catheters are useful to monitor hydration, these devices may be associated with severe morbidity and are not routinely used in kidney transplantation. A central venous pressure (CVP) catheter is preferred rather than a pulmonary artery catheter. Noninvasive continuous blood pressure monitors may substitute for intraarterial catheters, thereby preserving the radial artery in kidney transplantation patients should it be needed later to create an arteriovenous fistula. If there is a relationship between central venous and radial arterial blood for acid-base (pH, BE, HCO3(-)), we can use the blood sample from a CVP catheter instead of arterial blood from aradial artery catheter for testing acid-base and it can help patients. METHODS: A central venous catheter and radial artery catheter was inserted in 67 patients while undergoing kidney transplantation. To assess arteriovenous differences in acid-base status at operation start, before reperfusion of the transplanted kidney, after reperfusion, we measured the pH, BE and HCO3(-) simultaneously from the arterial and central venous circulation. RESULTS: Aacid-base using arterial and central venous samples at operation start, before reperfusion and after reperfusionb was evaluated. We found the relationship as follows: pH between arterial (pHa) and central venous blood (pHcv) in each: linear regression equation; pHcv = 0.668 + (0.906 X pHa), pHcv = 0.225 + (0.965 X pHa), pHcv = 0.646 + (0.908 X pHa), determination coefficient; 0.908, 0.926, 0.888, P values < 0.001 in each period. Base excess (BE) between BEa and BEcv in each period: linear regression equation; BEcv = 0.483 + (0.952 X BEa), BEcv = 0.032 + (0.939 X BEa), BEcv = 0.008 + (0.954 X BEa), determination coefficient; 0.844, 0.954, 0.962 P values < 0.001 in each period. HCO3(-) concentration between HCO3(-)a and HCO3(-)cv in each period: linear regression equation; HCO3(-)cv = 2.434 + (0.937 X HCO3(-)a), HCO3(-)cv = 2.093 + (0.942 X HCO3(-)a), HCO3(-)cv = 1.755 + (0.954 X HCO3 a), determination coefficient; 0.950, 0.925, 0.932 P values < 0.001 in each period. CONCLUSIONS: The acid base status of arterial blood is similar to that of central venous blood. Central venous blood gas values (pH, BE, HCO3(-)) may be an acceptable alternative to arterial blood gas values in kidney transplantation patients.

Evaluation of sequential monitoring of cytokines in renal allograft recipients / 中国免疫学杂志

Objective:To study the levels of TNF ? in serum and in urine and IL 6 in serum of renal allograft recipients with acute rejection, infection and CsA induced nephrotoxicity.Methods:The sequential monitoring of TNF ? and IL 6 was conducted by ELISA technique in 106 patients before and after renal transplantation.Results:The levels of IL 6 and TNF ? increased in the first day posttransplant, decreased and stabilized after 1 to 2 weeks, and increased 1 to 3 days prior to the clinical diagnosis in acute rejection, then decreased with effective treatment. IL 6 and TNF ? increased in serum in infection and had no difference in urine. TNF ? in serum and in urine and IL 6 in serum had no significant difference in CsA induced nephrotoxicity.Conclusion:It suggests that the sequential monitoring of IL 6 and TNF ? of renal allograft recipients can be used to estimate the function of graft, as markers of the early diagnosis of acute rejection.

A study of HLA matching in donors and highly sensitized recipients of renal transplantation / 中华泌尿外科杂志

Objective To investigate the significance of human leukocyte antigen (HLA) matching in highly sensitized recipients of renal transplantation. Methods 18 highly sensitized recipients preexisting panel reactive antibody IgG (PRA IgG) and their specificities were detected by enzyme linked immunosorbent assay (ELISA) with lambda antigen tray (LAT and LATM). Donors and recipients HLA class I typing was performed using complement dependent cytotoxicity (CDC) test with special monoclonal tray (SMT) and HLA class II gene typing by micro sequence specific primers polymerase chain reaction (Micro PCR SSP). Results PRA IgG positive rate in 18 highly sensitized recipients was between 40%～96% with an average of 56%, patients with 0～1 or 2～3 mismatch (MM) of HLA A,B,DR antigen were 28%(5/18) and 72% (13/18) respectively according to the standard of conventional HLA antigen matching.Whereas cases with 0～1 or 2～3 MM of HLA crossreactive antigen groups (CREGs) were 11 (61%) and 7 (39%) respectively by the rule of CREGs matching and the cases with 0～1 MM increased 33%. Only 4 (22%) cases of posttransplantation developed acute rejection and was reversed by OKT 3 treatment. Conclusions The allocation based on CREGs matching should result in a significantly higher percentage of well matched between donors and recipients. Good HLA matching plays an important role in reducing the incidence of acute rejection and in improving the survival of grafts.

Combined kidney and islet cell transplantation in the treatment of 4 patients with type I diabetes agsociated with end-stage renal failure / 中华器官移植杂志

Objective To observe the clinical effects of combined islet cell and kidney transplantation in the treatment of insulin-dependent diabetes mellitus associated with end-stage renal failure.Methods Four patients with type I diabetes and ESRD received combined renal and islet cells transplantation.Clinical and metabolic data were studied during the follow-up.Results The cultured human adults islet cells were infused into the portal vein system of the 4 patients.Immunosuppression included CsA.azathioprine and prednisone.Metabolic follow-up comprised assessment of daily fasting and non-fasting blood glucose,basal C-peptide secretion,HbAIc,renal function and blood cell counts.Islet isolation yielded 25 000～48 000 equivalents(single or multiple donors).No adverse effects were seen subsequent to islet transplantation.Basal C-peptide secretion maintained at normal levels.and blood glucose and HbAIc levels were normalized throughout the observation period.The dosage of insulin were decreased by over 25% in all 4 patients after transplantation.Conclusions Combined adult islet cells and renal transplantation has a good effect in the treatment of the patients with type Ⅰ diabetes and ESRD and can be used as an effective way for treating ESRD secondary to the type Ⅰ diabetes.Postoperative efficacy is related not only to the quantlty and quality of the islet cells,but also to the rejection of the grafts.

Non-invasive Positive Pressure Ventilation for Pulmonary Edema in Kidney Transplanted Patient / 대한마취과학회지

Non-invasive positive pressure ventilation (NIPPV) was mainly applied to acute respiratory failure in chronic obstructive pulmonary disease (COPD) and to intrinsic lung disease such as neuromuscular disorders. It has been reported that this maneuver reduces morbidity, mortality and hospital stay in patients in the intensive care unit. We observed a 32-year-old female renal transplantation patient who developed pulmonary edema during the perioperative state. The mainteance of an endotracheal tube in intubated patients who were on immunosuppresive therapy might increase nosocomial pneumonia significantly. In this case, the mortality increase was expected, therefore we considered that early extubation and mask continuous positive airway pressure (mask CPAP) could help. By using mask CPAP, the patient showed a good response and the pulmonary edema was improved. We report a case about the benefits of NIPPV in the treatment of pulmonary edema in an immunosuppressed patient of which the result was very satisfactory.

Anesthesia for Renal Transplantation in Children: 4 cases / 대한마취과학회지

Despite significant advances in dialysis technology, kidney transplantation is accepted today as the optimal available treatment for end-stage renal disease (ESRD) in children and adolescents. Children undergoing renal transplantation pose many challenges to the anesthesiologist because ESRD has such adversely affects on the entire vital organ system as hypotension, hypovolemia, acidosis, atelectasis and pulmonary edema. Most importantly, hypotension and hypovolemia as results of large kidney transplantation should be corrected for normal renal function. In addition, ESRD alters the effects of various drugs used in anesthetic practice. We experienced 4 cases of general anesthesia for renal transplantation in children. Careful preoperative evaluation and preparation of the patients, as well as a knowledge of altered dry responses are essential in planning and managing anesthesia.

HAND ASSISTED LAPAROSCOPIC LIVE-DONOR NEPHRECTOMY / 解放军医学杂志

The laparoscopic technique for live donor nephrectomy is a technically difficult procedure that has not yet gained widespread acceptance in the transplantation community in our country. The procedure would be more acceptable if alterations be added to the technique to make it easier to perform and decrease operation time.In Dec.2001,we performed a hand assisted laparoscopic live donor nephrectomy (HLDN) including the use of a device allowing hand assistance.HLDN, was peformed with Hand System,Auto Sonix,Endo Clip,Hem o lok, Endo GIA, and with pheumoperitoneum the left kidney was removed through the upper midline incision.The incision was 6 0cm long.The operating time was 118min,warm ischemia time was 3 3min,and cold ischemia time 92 min. The renal artery was 2 0cm long and 0 5cm in diameter, the renal vein was 2 2cm long and 1 2cm in diameter, and the length of the ureter was 12 0cm.Both the donor and recipient recovered very well post operatively without any complication.The donor was discharged form the hospital on the day 7 after operation,and the recipient on the day 21 with normal renal functions. The advantages of the hand assisted technique include the ability to use tactile sensation to facilitate dissection,retraction and exposure.In addition,the final stages of vascular stapling and kidney removal are more as sured and rapid.The modifications in the laparoscopic technique presented here provide measurable and subjective improvements to laparoscopic live donor nephrectomy.