[A high level of high-density lipoprotein cholesterol is a protective factor against transplant renal artery stenosis].

OBJECTIVE: To investigate the factors associated with the occurrence of transplant renal artery stenosis (TRAS). METHODS: A retrospective analysis was conducted in 26 recipients who developed TRAS and 40 concurrent renal recipients without TRAS. We also conducted a nested case-control study in 14 patients with TRAS (TRAS-SD group) and another 14 non-TRAS recipients who received the allograft from the same donor (non-TRAS-SD group). RESULTS: Compared with those in the concurrent recipients without TRAS, acute rejection (AR) occurred at a significantly higher incidence (P=0.004) and the warm ischemia time (WIT) was significantly longer (P=0.015) and the level of high?density lipoprotein cholesterol (HDL--C) significantly lower (P=0.009) in the recipients with TRAS. Logistic regression analysis suggested that AR (P=0.007) and prolonged WIT (P=0.046) were risk factors of TRAS while HDL-C (P=0.022) was the protective factor against TRAS. In recent years early diagnosis of TRAS had been made in increasing cases, the interval from transplantation to TRAS diagnosis became shortened steadily, and the recipients tended to have higher estimated glomerular filtration rate at the time of TRAS diagnosis. CONCLUSION: Apart from the surgical technique, AR and prolonged WIT are also risk factors of TRAS while a high HDL-C level is the protective factor against TRAS. The improvement of the diagnostic accuracy by ultrasound is the primary factor contributing to the increased rate of early TRAS diagnosis in recent years.

[Early intervention of BK virus replication promotes stabilization of renal graft function].

OBJECTIVE: To investigate the optimal time window for intervention of BK virus (BKV) replication and its effect on the outcomes of kidney transplant recipients (KTRs). METHODS: A retrospective analysis of the clinical data and treatment regimens was conducted among KTRs whose urine BKV load was ≥1.0×104 copies/mL following the operation between April, 2000 and April, 2015. KTRs with urine BKV load <1.0×104 copies/mL matched for transplantation time served as the control group. RESULTS: A total of 54 recipients positive for urine BKV were included in the analysis. According to urine BKV load, the recipients were divided into 3 groups: group A with urine BKV load of 1.0×104-1.0×107 copies/mL (n=22), group B with urine BKV load >1.0×107 copies/mL (n=24), and group C with plasma BKV load ≥1.0×104 copies/mL (n=8); 47 recipients were included in the control group. During the follow-up for 3.2-34.5 months, the urine and plasma BKV load was obviously lowered after intervention in all the 54 BKV-positive recipients (P<0.05). Eighteen (81.82%) of the recipients in group A and 19 (79.17%) in group B showed stable or improved estimated glomerular filtration rate (eGFR) after the intervention; in group C, 4 recipients (50%) showed stable eGFR after the intervention. In the last follow-up, the recipients in groups A and B showed similar eGFR with the control group (P>0.05), but in group C, eGFR was significantly lower than that of the control group (P=0.001). The recipients in group A and the control group had the best allograft outcome with stable or improved eGFR. CONCLUSION: Early intervention of BKV replication (urine BKV load ≥1.0×104 copies/mL) in KTRs with appropriate immunosuppression reduction can be helpful for stabilizing the allograft function and improving the long-term outcomes.

[Pulmonary infection in kidney transplant and liver transplant recipients].

OBJECTIVE: To summarize the features of pulmonary infection (PI) in kidney transplant (Ktx) and liver transplant (Ltx) recipients for effective control measures. METHODS: A retrospective analysis was conducted among Ktx recipients and Ltx recipients with PI during the period from Jan 2004 to Dec 2008. The clinical data concerning the infection was compared. RESULTS: Forty-five Ktx recipients and 23 Ltx recipients developed PI after the transplantation. The incidence of PI was 7.4% and 56.1% in (P<0.001), respectively, with severe PI occurring in 2.6% and 46.3% of the recipients (P<0.001). The median time from PI diagnosis to transplant was 230 days (29-1080 days) and 4 days (2-104 days) (P<0.001), the case-fatality rate for PI was 6.7% and 17.4% (P=NS), and the mortality rate was 0.5% and 9.8% (P<0.001) in Ktx and Ltx recipients, respectively; Gram-negative organisms were the most common in both Ktx and Ltx recipients, but Ltx recipients had significantly higher incidence of multidrug-resistant bacteria (12.9% vs 37.0%, P=0.005). CONCLUSION: The knowledge of PI after the transplantation will benefit appropriate prophylactic and empirical treatment to improve the survival of Ktx and Ltx recipients.

[Long-term survival of high-risk kidney transplant patients].

OBJECTIVE: To summarize the experiences in high-risk renal transplant recipients for ketter long-term survival. METHODS: From April 1991 to December 2008, a total of 921 kidney recipients with high-risk factors were divided into six groups as following: (1) pediatric patients (< 18 years old) (GI, n = 34); (2) retransplant recipients (GII, n = 169); (3) high sensitized patients (PRA> 30% or peak PRA > 50%)(GIII, n = 35); (4) elderly recipients (> 60 years old) (GIV, n = 297); (5) diabetic patients (GV, n = 112); (6) patients with HBV/HCV infection or HBV/HCV carrier (GVI, n = 274). Each group was compared to a control of 807 recipients without any above risk factor for patient and graft survival at 1, 3 and 5 years. Incidences of acute rejection (AR), chronic rejection (CR) and complication were analyzed and compared respectively between the studied subjects and the control group as well. RESULTS: Compared with the control group, patient/graft survivals were lower in GII, GIII and GVI (all P < 0.05), GIV had worse patient survival (P < 0.05); AR and CR incidences were greater in GI and GIII (all P < 0.05); GIV, GV and GVI had more complications. CONCLUSIONS: This study suggests the benefits for long-term outcome in high-immunological risk renal transplant recipients of low acute selection incidence rate, and reduction of complication incidences is the key to long term results for non-immunological high risk recipients.

[Simultaneous liver-kidney transplantation in polycystic kidney and hepatic disease with kidney and liver failure].

OBJECTIVE: To review the clinical experiences concerning simultaneous liver-kidney transplantation in polycystic kidney and hepatic disease with kidney and liver failure. METHODS: This study involved 8 cases of simultaneous liver-kidney transplantation in polycystic kidney and hepatic disease with kidney and liver failure. There were 5 male and 3 female patients, aged from 41 to 67 years old with a mean of 52.8 years old. Six cases transplanted kidney after liver with orthotopic liver transplantation, and 2 cases transplanted liver after kidney with piggy-back liver transplantation. The acute rejections, complications, liver function, kidney functions, and survival rates of patient/liver/kidney were recorded. RESULTS: Within the follow-up of 28 to 65 months, all 8 patients are still alive with normal liver and kidney functions: 2 living more than 5 years, 2 living more than 4 years and 4 living more than 2 years. 2 cases of pleural effusion and 1 case of pneumonia were complications after operation, which had been cured successfully. No acute rejection of allograft was observed. CONCLUSIONS: Simultaneous liver-kidney transplantation is a safe and effective treatment for polycystic kidney and hepatic disease with kidney and liver failure.

[Application of tacrolimus and cyclosporine A in HBV-carrying renal transplant recipients].

OBJECTIVE: To compare the long-term effect and safety of tacrolimus (FK506) and cyclosporine (CsA) in kidney transplant (KT) recipients carrying hepatitis B Virus(HBV). METHODS: A total of 109 patients with HBV were randomized into FK506 group (52 cases) and CsA group (57 cases) after KT, and a 2-year-long follow-up of the patients was conducted to record the patient and graft survival, incidence of acute graft rejection and postoperative liver function. RESULTS: The 2-year patient/graft survival was 86.0%/73.7% and 94.2%/90.3% in CsA and FK506 groups, respectively (P<0.05), with incidence of acute rejection of 10.5% and 9.6% (P>0.05), and rate of abnormal liver function of 26.3% and 15.4% (P<0.05), respectively. Eight patients (14.4%) in CsA group required a drug conversion but none in FK506 group. The drug conversion resulted in significant reduction of ALT/AST level from 255.13+/-31.38/201.88+/-21.25 U/L to 31.25+/-11.50/25.13+/-9.68 U/L (P<0.01). CONCLUSION: For HBV-carrying renal transplant recipients, FK506 as the primary choice of immunosuppressant can be more effective and safer than CsA.

[Clinical observation on long-term surviving patients after combined abdominal organ transplantation].

OBJECTIVE: To summarize the treatment experience of long-term surviving patients after combined abdominal organ transplantation. METHODS: From October 2001 to January 2005, 19 patients received combined abdominal organ transplantation in Nanfang Hospital, including 6 with simultaneous kidney-pancreas transplantation (SKPT), 12 with combined liver-kidney transplantation (CLKT), and 1 with simultaneous liver-pancreas transplantation (SLPT). The periods of follow up were from 6 months to 3 years and 8 months. Summarize primary diseases of the patients, factors which impacted on patients long-term survival rate, and immunological characteristics of combined abdominal organ transplantation. RESULTS: All of 19 transplant cases were performed successfully. Among then, 18 were followed up; 16 survived till now; 2 patients undergoing liver-kidney transplantation were dead, one of which died from myocardial infarction in the 18 months after operation, and one died from cytomegalovirus in infection of lung in 13 months; 1 liver-kidney transplantation patient and 2 pancreas-liver transplantation patients experienced acute rejection once; 2 patients were found nephrotoxicity. Among the 18 patients, 4 patients' survival time were over 3 years, 7 over 2 years, 6 over 1 year, 1 over 10 months. CONCLUSIONS: Combined abdominal organ transplantation is effective for treatment of two abdominal organ failure diseases. Factors which impact on patients long-term surviving include choosing suitable recipient, high quality of donated organ, avoidance of surgical complication, the history of myocardial infarction before operation, immunosuppressive regime and virus infection late after transplantation. Combined abdominal organ transplantation has some different immunological characteristics from single organ transplantation.

[Relationship between donor renal graft quality and graft rejection].

OBJECTIVE: To evaluate the correlation between the quality of donor renal grafts and graft rejection. METHODS: The cold ischemia time and the pathological findings by biopsies of the donor grafts in 87 cases were analyzed in conjunction with the occurrence of acute or chronic graft rejection after transplantation. RESULTS: After transplantation, acute rejection occurred in 28 cases, in which 5 (17.8%) had adverse changes in the donor grafts; chronic allograft nephropathy developed in 13 cases, in which 6 (46.1%) had adverse changes in the donor grafts. By binary logistic regression analysis, the cold ischemia time and acute renal tubular injury were identified as the factors affecting acute graft rejection, and cold ischemia time and glomeruloserosis as the risk factors for chronic rejection. CONCLUSION: High-quality donor kidney and minimization of the risk factors help reduce the occurrence of graft rejection after kidney transplantation.

[Perioperative management of multiorgan transplantation].

OBJECTIVE: To summarize the experience with perioperative management of multiorgan transplantation. METHODS: From October 2001 to January 2005, 19 patients received multiorgan transplantation in Nanfang Hospital, including 6 with simultaneous kidney-pancreas transplantation (SKPT), 12 with combined liver-kidney transplantation (CLKT), and 1 with simultaneous liver-pancreas transplantation (SLPT). The surgical techniques, application of immunosuppressants, and complication management were reviewed. RESULTS: All transplantation procedures were performed successfully. The transplantation-related complications included tacrolimus-induced renal toxicosis in 1 (5.3%) case, acute graft rejection in 3 (15.8%) cases, intestinal hemorrhage in 2 (10.5%) cases, intra-abdominal hemorrhage in 1 (5.3%) case, and lung infection in 1 (5.3%) case, all of which were cured after proper treatment. CONCLUSIONS: Donor selection, good quality of the donor organ, proper surgical approaches, adequate use of the-mmunosuppressants, and prevention of complications are essential to the success of multiorgan transplantation.

Clinical evaluation of abdominal multiorgan transplantation.

OBJECTIVE: To evaluate the clinical effect of abdominal multiorgan transplantation in patients with multiorgan failure. METHODS: Simultaneous kidney-pancreas transplantation (SKPT) with enteric drainage of pancreatic exocrine secretions was performed in 2 patients with type 1 diabetes and end-stage renal disease. A combined liver-kidney transplantation (CLKT) was done in a 66-year-old patient with alcoholic liver cirrhosis and uremia. Simultaneous orthotopic liver and heterotopic pancreas-duodenum transplantation (SLPT) was performed in a patient with hepatitis B, hepatocirrhosis, hepatic cellular cancer, and type 1 diabetes. RESULTS: The function of kidney grafts became normal 5 days postoperatively and insulin-independent after treatment with low dose insulin for 10 days in the 2 SKPT patients. For the CLKT patient, both transplanted organs rapidly achieved normal functions after operation but suffered-acute liver graft rejection on postoperation day 10 and the rejection was controlled after methylprednisolone pulse therapy. In the SLPT patient, insulin was withdrawn 5 days after operation, liver allograft function recovered well. All the patients are alive with stable allograft function after following-up for 29, 26, 9 and 6 months, respectively. CONCLUSIONS: Abdominal multi organ transplantation was effective therapy to patients with multiple organ failure. SLPT can reduce acute pancreas rejection and promote the recovery of liver allograft.

[Simultaneous orthotopic liver and heterotopic pancreas-duodenum transplantation in a diabetic patient with end-stage liver disease].

OBJECTIVE: To study the effect of combined transplantation of the liver and the pancreas in diabetic patients with end-stage liver disease, and explore the optimal surgical procedure. METHODS: Simultaneous orthotopic liver and heterotopic pancreas-duodenum transplantations were performed in a patient diagnosed as having chronic hepatitis B, hepatocirrhosis, hepatic cellular cancer, and insulin-dependent diabetes. Immunosuppression therapy utilized prednisone, tacrolimus (FK506), mycophenolate mofetil (MMF), and simulect. The function of the liver graft, serum amylase and lipase, blood glucose, and C-peptide were monitored after transplantation. RESULTS: Insulin was withdrawn at the 6th day after operation, good liver allograft functional recovery was achieved, without such complications as pancreatitis, thrombosis, and localized infections. CONCLUSION: End-stage liver disease with concomitant insulin-dependent diabetes is the indication for combined liver-pancreas transplantations, for which simultaneous orthotopic liver and heterotopic pancreas-duodenum transplantations may constitute the optimal surgical approaches as the primary choice.

[Combined liver-kidney transplantation in a senior patient].

OBJECTIVE: To study the surgical techniques, perioperative management, management of infections and graft rejection in patients with combined liver-kidney transplantation (CLKT). METHODS: CLKT was performed in a 66-year-old patient with alcoholic liver cirrhosis and uremia. Lavage in situ with University of Wisconsin (UW) solution of the donor organs and en hoc resection was performed. Orthotopic liver transplantation (OLT) and routine kidney transplantation were respectively carried out. Immunosuppression therapy consisted of tacrolimus (FK506), antithymocyte globulin (ATG), mycophenolate mofetil (CellCept, MMF) and corticosteroid. RESULTS: Both of the transplanted organs rapidly recovered normal functions after operation, and acute rejection of the liver graft occurred on day 10 after operation but was controlled after methylprednisolone pulse therapy. The patient fully recovered and was discharged from hospital on day 29 after operation. CONCLUSIONS: CLKT is effective against both liver and renal function failure. Well-matched HLA tissue typing, proficient surgical skills, adequate application of immunosuppressants and effective management of postoperative complications are crucial for successful CLKT.

[Thirteen-year follow-up in 8 cases of penis reconstruction by ilio-inguinal and umbilical-thoracic compound flaps].

OBJECTIVE: To observe the long-term effect of ilio-inguinal and umbilical-thoracic compound flaps in one-stage reconstruction of the penis. METHODS: Eight patients, who received one-stage reconstruction of the penis using ilio-inguinal and umbilical-thoracic compound flaps, were all followed up regularly at 6 months, 1, 3, 7 and 13 years postoperatively. The color, diameter, length, and sense recovery of the organ, along with urodynamics and satisfaction degree of both patients and their wives were recorded. RESULTS: The reconstructed organ retained the original color all through the follow-up, but had shrunk and shortened to some degree within the first 3 years after the operation, a condition that was stabilized afterwards. The sense of the proximal end of the constructed organ began to recover six months after the operation and almost assumed normal sense. The sense of the distal end also recovered, though relatively slowly. Few long-term complications were observed, and the patients and their wives were reasonably satisfied with the reconstructed organs in terms of their shape and function. CONCLUSION: Good long-term effect of one-stage reconstruction of the penis can be achieved by using illio-inguinal and umbilical-thoracic compound flaps, which can be adopted clinically in cases of penis reconstruction.

[Panel reactive antibody screening and human leukocyte antigen typing in 1 700 cases of renal transplantation].

OBJECTIVE: To evaluate the role of panel reactive antibody (PRA) screening and human leukocyte antigen (HLA) typing in renal transplantation. METHODS: PRA screening and HLA typing were performed in 1 700 patients eligible for the first group of renal transplantation who had 3 to 6 HLA matches in HLA-A, B and DR with the donor, and in cases positive for PRA, plasma exchange was conducted. Another 423 patients who did not receive PRA screening or HLA typing constituted the second group. The changes of immune variables, incidences of acute rejection and the effect of HLA-A, B, DR matching on long-term graft survival were observed. RESULTS: In 1 700 cases of group 1, post-transplantation CsA dose was reduced to 5 to 7 mg*kg(-1)*d(-1) and the graft function recovery time ranged from 2 to 16 d, averaging 5 d. Acute graft rejection occurred in 252 (14.8%) cases, but no hyper-acute rejection was observed. The 1-, 3- and 5-year patient/graft survival rates were 98.6%/96.7%, 93.1%/87.3% and 88.1%/83.6% respectively. In group 2, CsA dose ranged from 8 to 12 mg*kg(-1)*d(-1) and the graft function recovery time was 4 to 30 d, averaging 13 d. Hyper-acute rejection occurred in 9 (2.1%) and acute rejection in 198 (46.8%) cases, and the 1-, 3- and 5-year patient/graft survival rates were 86.7%/76.3%, 72.5%/67.9% and 69.5%/59.3% respectively. CONCLUSIONS: Negative PRA and good HLA matching can eliminate the incidences of hyper-acute rejection, decrease the rate of acute rejection and improve both patient and graft survival rates.