What Is Involved in a Kidney Transplant Procedure?

Conventional kidney transplantation is aliased to conventional kidney transplantation, and complications include bleeding.

Conventional kidney transplant

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Conventional kidney transplantation is aliased to conventional kidney transplantation, and complications include bleeding.

Chinese name

Conventional kidney transplant

Alias

Conventional kidney transplantation

Visiting department

Urology

complication

Bleeding, etc.

Conventional kidney transplant

Conventional kidney transplantation

Urology / Kidney Surgery / Allograft Kidney Transplantation / Kidney Transplantation

Routine kidney transplants are suitable for:

In recent years, cyclosporine A has been widely used in clinical practice and the rapid development of surgical technology; laboratory and special new technology for monitoring of kidney transplantation have relaxed the indications for kidney transplantation. In principle, any end-stage irreversible kidney disease can be considered For kidney transplantation, even multi-organ transplantation can be considered. For example, patients with end-stage diabetes can be treated with combined pancreas and kidney transplantation.

According to Morris (1988) and related data, the indications for kidney transplantation are as follows:

Glomerulonephritis

(1) Crescent nephritis after idiopathic infection;

(2) membranous nephritis;

(3) Mesangial capillary glomerulonephritis (type I);

(4) Mesangial capillary glomerulonephritis (type II, dense deposits);

(5) IgA nephropathy;

(6) anti-glomerular basement membrane nephritis;

(7) focal glomerulosclerosis;

(8) Allergic purpuric glomerulonephritis.

2. Chronic pyelonephritis (reflux nephropathy)

3. Hereditary diseases

(1) Congenital bilateral polycystic kidney disease;

(2) Nephron nephropathy (cystic change of renal medulla);

(3) Hereditary nephritis.

4. Metabolic diseases

(1) Diabetic nephropathy;

(2) oxalate nephropathy;

(3) Hypercystine;

(4) Diffuse body vascular keratinoma (Fabey's disease);

(5) Renal amyloidosis;

(6) Gouty nephropathy.

5. Urinary tract obstructive disease

6. Toxic diseases

(1) Analgesic nephropathy;

(2) opioid abuse nephropathy;

(3) Heavy metal poisoning.

7. Systemic disease

(1) Systemic lupus erythematosus;

(2) Vasculitis;

(3) Progressive systemic sclerosis.

8. Hemolytic uremic syndrome

9. Tumor

(1) Renal embryo tumor (Wilms tumor);

(2) Renal cell carcinoma after bilateral nephrectomy;

(3) Myeloma.

10. Congenital malformation

(1) Congenital renal dysplasia;

(2) Horseshoe kidney.

11. Acute irreversible renal failure

(1) bilateral renal cortical necrosis;

(2) Acute tubular necrosis.

12. Renal trauma.

1. scattered malignant tumors throughout the body.

2. Refractory heart failure.

3. Chronic respiratory failure.

4. Severe vascular disease.

5. Progressive liver disease.

6. Severe infection throughout the body, active TB lesions.

7. Disorders of coagulation mechanism.

8. Psychosis.

9. AIDS.

10. Drug abuse.

In addition, ulcer patients need to be cured before transplantation; old tuberculosis lesions are easy to activate after transplantation, so be careful; HBsAg-positive patients, although not listed as contraindications, have lower survival rates than negative patients after 3 years and die from Patients with liver disease were five times higher than those with negative recipients. Therefore, care should be taken in selecting HBsAg-positive recipients. For patients with uremia caused by lupus nephritis and vasculitis, inactive surgery should be selected. Anti-basal membrane nephritis should be dialyzed for 6 months, and the circulating immune complex should be turned negative before kidney transplantation.

Whether a patient can survive long-term after kidney transplantation and preparation before surgery is a crucial part. Preoperative preparation should pay attention to the following related issues.

1. Postoperative condition observation and laboratory monitoring

In view of the poor physical resistance of patients with advanced uremia, coupled with the trauma of transplantation, the use of a large number of hormones and immunosuppressive drugs, it is easy to cause infection after surgery. Therefore, patients should be admitted to a relatively isolated ward 1 month after surgery, and the indoor air and floor should be disinfected. Workers should wear isolation coats to enter the room, and soak their hands with disinfectant water before and after touching patients.

Close observation of vital signs such as temperature, pulse, respiration, and blood pressure.

Record the hourly volume of urine before removing the indwelling catheter, and record the volume of 24 hours.

Measure body weight once a day.

Blood routine examination was performed every other day.

Routine urine examination and osmotic pressure measurement are performed once a day.

Renal function test is performed once a day.

Liver function tests are performed twice a week.

Blood electrolyte and osmotic pressure were measured once a day.

Trace elements can be determined according to circumstances.

T lymphocyte subsets (T3, T4, T8, T4 / T8) twice a week.

Cyclosporine A blood concentration can be determined according to the medication.

Throat swabs, sputum, and mid-range urine (bacteria, fungi) are cultured once a day.

Wound secretion bacterial culture.

After the incision was removed, the kidney area was routinely subjected to a B-mode ultrasound examination.

Examination of radionuclide nephrogram, color Doppler blood flow imaging, magnetic resonance and other tests can be based on the condition.

2.Treatment of wound cavity drainage

Although some transplant centers do not advocate the placement of drainage in the wound, it is generally believed that the drainage is safer for the patient. The reasons are as follows: Although most patients undergo dialysis before transplantation, patients with advanced uremia have a bleeding tendency. Surgical trauma and a certain degree of anatomical separation behind the peritoneum lead to an increase in exudates in the interstitial space. Lymph vessels and lymph fluid accumulation were separated around the iliac vessels. Reconstruction of the urinary tract may cause urinary extravasation. Therefore, the placement of drainage is helpful to understand the changes of the wound cavity in time for timely treatment. But be sure to place effective drainage, if the drainage is not smooth, it will be counterproductive.

3.Treatment of urinary drainage tube

At present, most transplant centers use a donor-ureter-extrabladder (recipient) antireflux anastomosis for urinary tract reconstruction of the transplanted kidney. The ureteral stent drainage is rarely used. In special cases, the ureteral stent drainage must be placed, and it is usually removed within 2 to 3 weeks after surgery.

Regardless of whether a ureteral stent is used for drainage or not, a transurethral balloon catheter for drainage of bladder urine is required. If there is no special condition, the catheter is removed within 72 hours after operation. During the placement of the urinary catheter, the urethral secretions should be cleaned daily. After the catheter is removed, the penis should be soaked with disinfectant. Female patients should clean the perineum and routinely take norfloxacin or fluoxacin to prevent urinary tract infections.

4. Maintain water and electrolyte balance

If the quality of the donor kidney is good, urination can usually be done within 3 to 8 minutes after the blood supply to the transplanted kidney is restored. Because patients have different degrees of water and electrolyte retention before surgery, osmotic diuresis caused by an increase in blood urea nitrogen (BUN) value, the use of mannitol and diuretics during the operation, and the renal tubular reabsorption effect due to damage to the donor kidney due to hypothermic preservation Among other factors, most patients developed polyuria within 24 hours after surgery. The urine output per hour can reach more than 800 to 1200ml. Most of the urine electrolyte measurement is increased sodium and potassium ion excretion. If it is not handled properly during this period, it will definitely cause complications such as hypokalemia or hyponatremia, severe dehydration, and even endanger patients' lives.

Renal Transplantation Center of Shanghai Changzheng Hospital, since the late 1970s, has developed a "circulation infusion table for polyuria during renal transplantation (referred to as infusion)" Table, Table 7.2.11.2.1-1). During use, blood and urine electrolytes of 20 postoperative patients were measured. Except for blood Cl-slightly lower, other electrolytes were normal. After more than 700 clinical trials over 12 years In application, only 2 cases developed hyponatremia syndrome, which were corrected by timely intravenous infusion of 3% sodium chloride injection. The precautions for using this table: must be used in the postoperative polyuria situation, oliguria The meter should not be used without urine. The infusion rate should be adjusted according to the amount of urine output per hour, that is, a Murphy dropper is added between the urinary catheter and the urination drainage tube, and the number of intravenous infusion drops and the urination drops per minute are often observed. The number of infusion drops and the number of urination drops are basically synchronized. In this way, the "measures are taken into account" can be basically achieved. Before the patient returns from the operating room to the ward, the nurse can arrange the order according to the "infusion table." "Infusion Table" rehydration It is not necessary to repeatedly issue an infusion doctor's order. In this way, the cooperation between the doctor and the nurse can save time, be busy and not messy, and work well.

5. Management of oliguria and anuria after kidney transplantation

If the patient's urine is less than 30 ml per hour after transplantation, the issue of systemic blood volume should be considered first. Some patients may suffer from excessive dehydration due to preoperative dialysis, coupled with more trauma bleeding during the operation, but fail to make up in time, oliguria or even anuria may often occur after surgery. At this time, the amount of input fluid can be increased in a short period of time. If the urine volume increases, it can be determined that the infusion is insufficient. The infusion rate must be adjusted. After the blood volume is replenished, diuretics such as furosemide can be significantly increased. . If the urine volume does not increase after the above treatment, and the blood pressure has an upward trend, the infusion rate should be slowed down, or even the infusion should be suspended. The cause of oliguria or anemia should be further investigated.

(1) Postrenal obstruction: It may be caused by ureter-bladder anastomotic edema, stenosis, ureteral distortion or compression. Can be diagnosed by radionuclide nephrogram, B-ultrasound or high-dose excretory urography, and take appropriate measures to correct it as soon as possible.

(2) Urinary extravasation: The uretero-bladder anastomosis is not closed or the ureter is too short, the uretero-bladder anastomosis tears due to excessive tension, or the ureter is necrotized due to ureteral blood supply failure, etc. . It can be confirmed through the observation of wound drainage, laboratory examination of local puncture solution, B-ultrasound and excretory urography. Proactive surgical exploration measures should be adopted to avoid more complications.

(3) Renal transplantation arterial and venous embolization: Radionuclide nephrogram, color Doppler blood flow imaging device or percutaneous renal artery angiography are required. If the diagnosis is clear and surgical exploration is handled promptly, the transplanted kidney may be preserved. Otherwise, it will be forced to be removed due to the failure of the transplanted kidney.

(4) Acute tubular necrosis: It is often caused by factors such as mistakes in the technique of removing the donor kidney, poor preservation of the donor kidney, and excessive warming ischemia time. The diagnosis was confirmed by fine needle aspiration (FNAB) or renal biopsy. Once the diagnosis is established, the patient needs to undergo a hemodialysis or peritoneal dialysis transition.

6. Immunosuppressant medication plan after kidney transplantation

Various kidney transplant centers at home and abroad have designed their own immunosuppressant medication plans based on their clinical experience, drug configuration conditions, and laboratory testing methods.

In China before the 1980s, the "dual" scheme was used clinically, namely azathioprine + prednisone, and cyclophosphamide for short-term use to enhance the efficacy; CsA began to enter China in October 1984, and it was widely used in clinical practice after 1985. The triple program, CsA + Aza + Pred, was started, and the one-year survival rate of patients with clinical kidney transplantation was increased to more than 95%, which achieved significant results.

Since the 1990's, mycophenolate mofetil (MMF), Prokofux (FK-506), and rapamycin (Rapa) have entered clinical applications. The medication content of the "triple" program has its diversity according to the condition and the patient's economic conditions. It can be: CsA + Aza + Pred; CsA + MMF + Pred; FK-506 + Aza + Pred; FK-506 + MMF + Pred. The efficacy of Rapa in combination with other drugs is being explored. The inducing drug CD25 (Xenipipe) is a humanized monoclonal antibody that specifically suppresses T cell-mediated immune responses. The effect of domestic clinical use remains to be further observed.

It is well known that CsA and FK-506 have liver and kidney toxicity. Therefore, the use of CsA or FK-506 must monitor blood drug concentration and try to avoid empirical drug regimens. In this way, not only can save expensive medication expenses for patients, but also effectively avoid liver and kidney toxicity of CsA and FK-506.

The administration time of CsA and FK-506 is mainly based on the patient's economic situation. At present, most kidney transplant patients in China can persist in using it for about 1 year. "Counceback" (acute rejection manifestation) may occur within 1 to 3 months after CsA is discontinued, and it should be treated in time according to the condition to avoid accidents.

7. Diagnosis and treatment of rejection

Rejection is currently the main cause of kidney transplantation loss of function. In recent years, despite a lot of experience in the diagnosis and treatment of rejection, there has been no new breakthrough so far. Therefore, how to actively prevent, early diagnose and correctly treat rejection is still the main issue to be solved in kidney transplantation.

There are many types of rejection reactions. Commonly used typing methods are shown in Table 7.2.11.1.2.1-2.

(1) Hyperacute rejection: Hyperacute rejection refers to an irreversible humoral rejection that occurs in the transplanted kidney within minutes to hours after blood circulation is restored, or even within 24 to 48 hours.

Hyperacute rejection is considered to be presensitization in the recipient, that is, the pre-existing cytotoxic antibody in the recipient reacts with the HLA antigen or B lymphocytes on the surface of the T lymphocytes of the donor.

In the pathological examination of ultra-rapid rejection, early glomerular capillary plexus and capillaries around tubules showed a large number of neutrophils infiltrating. Over time, it can be seen later that most of the blood vessel walls in the renal parenchyma have cellulosic necrosis. A large amount of fibrin and platelets in the blood vessel lumen aggregate to form thrombi, which causes the lumen to be blocked and blood circulation to be interrupted, leading to extensive necrosis of the renal cortex and loss of the transplanted kidney. Features.

Clinical manifestations can occur on the operating table. A few minutes after the blood circulation of the transplanted kidney is restored, the original transplanted kidney is bright red, pulsating, ureteral peristalsis, and has started urinary. Suddenly, the color becomes dark and red, the texture becomes soft, the pulsation disappears, and the ureteral peristalsis. Vanishing urinary cessation. Later, the transplanted kidney was significantly reduced and became purple-brown and lost its function; or within 1 to 2 days after surgery, oliguria and even anuria suddenly occurred. Surgical exploration of the transplanted kidney is often enlarged, purple-brown, and disabled.

So far, there is no effective treatment for superacute rejection. The only way is to remove the transplanted kidney as soon as possible after diagnosis.

Hyperacute rejection can be prevented by strict matching screening. The PRA test carried out in recent years, especially for kidney transplant waiters, must pay special attention to dynamic examination. Since 1998, Shanghai Changzheng Hospital has failed to detect one case of ultra-rapid rejection in nearly 600 patients with renal transplantation who had a negative PRA test before surgery.

(2) Accelerated rejection: Accelerated rejection often occurs 3 to 5 days after kidney transplantation. The pathogenesis is unknown, and some cases may be associated with mild presensitization. Pathological changes are characterized by small vessel inflammation and fibroid necrosis.

The clinical manifestation is that the transplanted kidney is functional after surgery and even functions well. But sudden rise in body temperature, oliguria, hypertension, swelling and tenderness of the transplanted kidney may occur. The condition was progressive, the condition was serious, and serum creatinine increased, and dialysis treatment was needed immediately. When acute tubular necrosis (ATN) or cyclosporine A nephrotoxicity is present, it is often not recognized and delays diagnosis and treatment.

The radionuclide nephrogram showed a low-level parabolic extension; B-mode ultrasound examination could exclude extravasation of urine, lymphocytic cysts or retrorenal obstruction. DSA or renal angiography showed irregular branching of the blood vessels, and the surrounding branches were significantly reduced or not visualized. A renal biopsy can confirm the diagnosis.

High-dose methylprednisolone shock is the first choice for treatment, and the first 3 days of intravenous infusion of 0.5g or 1.0g each time. If not, use ALG (ATG) or OKT3 as soon as possible. The use of plasma exchange or immunoadsorption has been envisaged, but few satisfactory cases have been reported. This type of rejection is often unsatisfactory in its final treatment effect, and it is likely to endanger patients with complications such as infection, congestive heart failure, and gastrointestinal bleeding due to the use of a large number of immunosuppressive drugs. At the crossroads of "protecting kidneys" and "saving lives," doctors need to make a decision.

(3) Acute rejection: Acute rejection is the most common, accounting for 40% to 85% of kidney transplantation, and usually occurs within 1 week to 3 months after surgery. Unlike the super-rapid, accelerated rejection mechanism, which is mainly a cellular immune response, antibodies are also involved in this process. Acute rejection can be reversed in more than 90% of patients if immunosuppressive therapy is applied early. Since the 1990s, acute rejection has been significantly reduced with the use of CsA, FK-506, and MMF.

The following factors can induce acute rejection: viral and bacterial infections, and sudden changes in the combination of immunosuppressive methods. In the process of stopping CsA and MMF replacement of azathioprine, improper dose adjustment and surgery, renal vascular and intravenous urography were performed. Sometimes it occurs after the patient intentionally or unintentionally reduces or discontinues immunosuppressants.

Clinical manifestations: increased body temperature, decreased urine output, transplanted kidney enlargement, tenderness, increased blood pressure, and weight gain. Since CsA is used clinically, its symptoms are often atypical. The observations of the symptoms and signs of using different immunosuppressive regimens in the First Affiliated Hospital of West China Medical University are shown in Table 7.2.11.1.2.1-3.

Laboratory inspection:

A. Monitoring of serum creatinine (Scr) and creatinine clearance (Ccr): At present, the increase of Scr and the decrease of Ccr are still considered as the main diagnostic basis. Matas believes that an increase in Scr of more than 25% indicates acute rejection. John Swinney believes that a sudden increase of 30 to 35 mol / L indicates a rejection. It is also doubtful if Scr is increased by 10 mol / L for 2 consecutive days. Continuous clinical observation is meaningful.

B. Hemorheology: Belzer reported in 1988 that hematocrit decreased by 3%, body weight increased by more than 0.9 kg (2 pounds), Scr increased by 30 mol / L, and the accuracy rate of acute rejection diagnosis reached 85.2% with a specificity of 100 %.

C. Exfoliated urine cell test; this test should be done before transplantation, and post-examination can be used as a self-control. Lymphocytes, collecting tubule cells, nuclear residual cell debris, and fibrin deposition increased during acute rejection.

D. Lymphokine monitoring: Interleukin 2 (IL-2) and interleukin 2 receptor measurement. Can be used as a means of monitoring rejection. IL-2 was not found in the urine of normal people, post-transplantation stationary phase, and CsA nephrotoxicity. The CMV infection was mildly elevated and significantly increased during acute rejection. Elevated IL-2 in urine often precedes clinical symptoms and has predictive value for rejection. Immediately after treatment with hormone shock, the urine IL-2 value decreased. Plasma and urine IL-2 and interleukin 2 receptor values reported by Madras in various conditions in 1989 can be referred to (Tables 7.2.11.1.2-4, 7.2.11.1.2.1-5).

E. Donor-specific complement-dependent cytotoxicity test: For kidney extraction, blood is collected or the spleen is excised, and lymphocytes are isolated, and cryopreserved with liquid nitrogen for future use. The method is to take the recipient serum and incubate the donor lymphocytes together, and the dead cells> 10% are positive. Can be used to judge acute rejection and treatment effect.

Monitoring of FT lymphocyte subpopulations: Monitoring the peripheral blood T cell subsets of patients after renal transplantation can be used as a dynamic observation. It has been reported that a CD4 / CD8 ratio of> 1.3 indicates an acute rejection. With CsA, the results may be affected. However, when the ratio is less than 0.5, it indicates that the amount of immunosuppressant is excessive, or there is cytomegalovirus infection.

GT cell rosette test: Active rosettes above 30% or total rosettes above 70% suggest increased immune function. The amount of immunosuppressive agent can be adjusted accordingly.

H. Determination of drug blood concentration: CsA and FK-506 should be used to measure the blood drug concentration regularly. When acute rejection occurs, the blood concentration of these drugs is usually lower than the desired target concentration level. The area under the time drug concentration curve (ACIC) has a very good correlation with rejection and drug poisoning.

Imaging examination

A. Radionuclide examination: Nephron nephrogram of acute rejection shows delayed excretion. Renal scans can be more helpful if two tracers 99mtc DTPA and OIH are used at the same time. It can be found that renal effective plasma flow (ERPF) and excretion index (EI) decrease simultaneously.

BB ultrasound: In recent years, color Doppler ultrasound has been used for the diagnosis of acute rejection. Compared with ordinary B-ultrasound, more data can be obtained, which not only shows the size, shape, peripheral changes, renal cortex, medulla of the transplanted kidney Clarity and abnormal changes in its junction, and can be judged by measuring the resistance index (RI) and blood flow velocity. The images are clear, intuitive, and accurate. The examination is non-invasive and can be used as the first choice.

C.CT examination: mainly observe the changes of renal skin, medulla clarity and its junction, because only cross-section imaging, the observation is limited.

D. Magnetic Resonance Imaging (MRI) examination: it has a three-dimensional imaging function, which not only has a cross-sectional display, but also can observe the coronary and sagittal planes. Therefore, the changes in the renal skin, medulla contrast (CMD) and their junctions can be clearly displayed, and comparisons can be made from multiple sections. Acute rejection is mainly manifested by the blurring or disappearance of CMD, the enlargement of the renal pyramid, and the decrease or disappearance of sinus fat. Judgment can also be made for abnormal changes in the kidneys. In recent years, 31P-magnetic resonance spectroscopy has been more accurate in measuring renal vitality, which provides a basis for judgment on renal transplant rejection and subsequent quality changes.

E. Fine Needle Aspiration Aspiration Cytology (FNAB): It is currently being used in clinical practice. It is a safe, fast, reliable, repeatable and highly sensitive and specific monitoring method. The total correction value (TCI) data may be different for each center, but it is believed that a significant increase in TCI in dynamic observation indicates acute rejection. Hayry et al determined that acute rejection was diagnosed when TCI exceeded 2.3. Tang Xiaoda reported that the TCI was 2.0. The kidney transplantation center of Shanghai Changzheng Hospital based on the results of 61 tests in 34 cases: TCI value was 0.91 ± 0.59 in the non-rejection group, 4.25 ± 1.17 in the acute rejection group, and 3.85 ± 2.31 in the chronic rejection group.

F. Histological examination of percutaneous renal puncture: This is a traumatic examination. It can be safely performed under the guidance of B-ultrasound. A definitive diagnosis can be obtained for rejection diagnosis.

Urinary tract complications such as oliguria caused by postrenal obstruction, urinary leakage, and lymph cyst compression; renal vascular complications such as arterial anastomosis stenosis, thrombosis, and sudden anuria caused by renal vein embolism. As surgical techniques continue to improve, its incidence is decreasing. And acute tubular necrosis (ATN), CsA nephrotoxicity and renal damage caused by infection should be diagnosed early and acute rejection.

Kidney transplantation ATN: A. It is related to kidney removal, lavage, and preservation techniques. B. Preimplantation biopsy is predictable. C. Oliguria and anuria begin immediately after kidney transplantation. D. Renal scan, 99mtc DTPA tracer uptake was relatively good, but not excreted. E. Nuclide kidney diagram, typical dome-shaped parabola. FB-type ultrasonography often found no abnormalities. G. FNAB, renal tubular cell edema, vacuolar degeneration, and the appearance of foam cells. H. Renal puncture histological examination, mainly renal tubular changes, little cell infiltration, no changes in small arteries.

CsA nephrotoxicity: A. Blood Cr increased or GPT increased at the same time. When CsA was suspended or reduced, blood Cr and GPT decreased. B. CsA blood concentration monitoring can determine CsA nephrotoxicity. C.FNAB: Renal tubular cell edema is more obvious, vacuole degeneration is more prominent, and most of them are vacuoles of equal size. Some phagocytosed substances, such as red blood cells, can appear in the cytoplasm. Anti-CsA antibody immunoperoxidase Staining enzyme staining can be distinguished from ATN. D. MRI showed no abnormalities in kidney transplantation, renal sinus fat and CMD. E. Renal puncture histological examination, which shows neither ATN nor acute rejection, can be diagnosed based on the CsA medication status.

Infection: The identification of acute rejection and infection by FNAB examination is shown in Table 7.2.11.2.1-6.

For acute rejection, it is necessary to seize the opportunity and provide treatment as soon as possible. Experienced doctors can use medication regimens, and the rejection can be reversed.

Methylprednisolone (MP) intravenous impact therapy is still the first choice. Due to the arbitrariness of the use of MP, the doses used in each center are different. After extensive application of CsA in clinic, the symptoms of acute rejection are variable. It can be comprehensively judged according to the condition, signs, blood Cr level, FNAB, etc., and then given large (800-1000mg), medium (500-800mg), small (200-400mg) doses, 3 to 5 days is a course of treatment, and more reverse.

After the treatment, the condition improved significantly, and continued observation; if the condition improved but not obvious, adjust the MP dose or add CTX at the same time; if the condition does not improve significantly after treatment, polyclonal ALG (ATG) or monoclonal antibody OKT3 should be used as soon as possible.

ALG (ATG): The main target cells of polyclonal ALG and ATG are lymphocytes, platelets and granulocytes. Can be used immediately when an acute rejection is diagnosed. Used when MP shock treatment is ineffective, it can significantly affect its treatment effect. The dose is 5 to 20 mg / (kg · d) intravenously, and 7 to 12 days is a course of treatment. Can reverse 75% to 90% of acute rejection. The use of this drug should pay attention to the following issues: A. Can only be used when the allergy test is negative. B. Dexamethasone is given 5 to 10 mg before each intravenous infusion 3 days before medication to prevent adverse reactions. C. Dissolve ALG (ATG) in 500ml of 0.9% sodium chloride injection, and inject it in the central vein for 4-6 hours. D. Adverse reactions include elevated body temperature, chills, allergic reactions, granulocyte and thrombocytopenia, dyspnea, serum sickness, and chest, lower back, and back pain. E. Monitor granulocytes and platelets during medication.

Monoclonal antibody OKT3: Acts directly on cytotoxic lymphocytes and can quickly reverse rejection. Currently it is mainly used for acute rejection, especially for patients with hormone-resistant acute rejection. When ALG and ATG treatment is not effective, OKT3 dose can be changed to 5mg / d, 10d is a course of treatment. The precautions for the use of this drug are as follows: A. For allergy tests, use when negative. B. Give dexamethasone 5 to 10 mg intravenously before administration to prevent adverse reactions. C. OKT3 was dissolved in 250ml of 0.9% sodium chloride injection, and the drip was completed within 1 hour. D. Adverse reactions are the same as ALG. E. ELISA method for measuring human anti-mouse antibody titer.

For patients with severe acute rejection, the following methods can be used.

A. MP + ALG (or ATG): MP 05 1.0g intravenous drip, 3d; ALG (10mg / kg · d-1) or ATG 5mg / (kg · d-1) intravenous drip, 10d.

B. MP + OKT3: MP 0.5 1.0g intravenously, 3d; OKT3 5mg / (kg · d) intravenously, 10d.

Adjust the immunosuppressive agent in time: increase the amount of CsA, or switch CsA to FK-506, and change Aza to MMF.

Plasma exchange or immunoadsorption: There are not many cases reported in the literature, and the exact effect needs to be further accumulated. At present, due to its high price, it cannot be used in clinical practice.

For acute rejection treatment, due to the use of a large number of hormones, appropriate antibiotics should be given to prevent infection.

If the acute rejection is under treatment control, and it has caused damage to the renal transplantation function, the compound Danshen injection, Chuanxiong injection, Niaoduqing, etc. can be given orally to help restore its function.

(4) Chronic rejection: Chronic rejection usually occurs six months after surgery. It can be the result of repeated acute rejection or it can develop occultly and slowly. Its pathogenesis is unknown. It is believed that it is related to both immune and non-immune factors, so it is more appropriate to rename it chronic allograft nephropathy (CAN). CAN is an important factor affecting the long-term survival of patients.

Clinical manifestations are gradual hypoglycemia, proteinuria, elevated serum creatinine, high blood pressure, progressive anemia, and decreased renal allograft volume. The early pathological changes were mild fibrous proliferation of the renal interstitial tissue, scattered infiltration of lymphocytes and plasma cells, shrinking of the glomerular vessels, and thickening of the basement membrane; late-stage changes were extensive interstitial fibrous proliferation, tubular atrophy, and intimal arteries Fibrous thickening, layered like onion skin, fibers in the inner elastic layer were broken or overlapping, and the blood vessel cavity was narrow.

Renal puncture histology can make a definitive diagnosis of chronic rejection.

There are currently no effective measures for the treatment of chronic rejection. Once the diagnosis is clear, immunosuppressive drugs should be discontinued as soon as possible, diet therapy should be emphasized, and traditional Chinese and western medicine should be used to slow down the development process as much as possible.

Strengthen systemic supportive therapy to avoid complications. If there is no special condition of the disabled kidney, it may not be removed temporarily. Ask the patient to wait for another transplant or restart dialysis.

Routine kidney transplant bleeding

Bleeding after kidney transplantation can be divided into early stages (within 24 to 48 hours after surgery) and late stages (days, months, and even 1 year after surgery).

(1) Causes of bleeding: in the case of uremia in the end stage of renal disease, the coagulation mechanism is impaired and thrombocytopenia; long-term dialysis therapy using anticoagulants; branch arterioles are missed when the donor kidney is removed; anastomosis technique Problems; secondary bleeding caused by infection; diffuse intravascular coagulation; rupture of transplanted kidney.

(2) Clinical manifestations: local pain in the transplanted kidney area and gradually increasing mass. Peritoneal irritation symptoms. Patients with heavy bleeding may have signs of shock such as pale, cold sweats, and decreased blood pressure.

(3) Prevention and treatment methods: adequate dialysis treatment before surgery to improve the poor state of coagulation mechanism; carefully trim the donor kidney and ligation of small arteries; try to avoid extensive separation of the posterior peritoneum during surgery to avoid excessive bleeding; The heart end should be double ligated and sutured to avoid loosening; After the renal blood flow is opened, the renal hilum should be carefully examined to find the small arteries that may be temporarily closed due to cryopreservation and ligated; Improve the technique of vascular anastomosis; Preventive use of antibiotics to avoid infection of the incision; Once acute bleeding is determined, surgical exploration should be performed immediately to remove the hematoma, carefully examine the wound cavity, ligate the bleeding point, control bleeding, and give active supportive therapy; suture blood vessels, choose Reliable and non-destructive sutures. Be careful not to clamp the sutures with tweezers to prevent damage or breakage.

Conventional kidney transplant incision infection

Earlier reports abroad showed that the infection rate of incisions after kidney transplantation was as high as 43%, which has dropped to about 3% in recent years. The factors that cause incision infection are: The patient is under uremia for a long time, and the body is malnourished; The skin is not carefully prepared before surgery, causing minor damage and bacterial accumulation; obese patients; diabetic patients; overall blood volume of patients Insufficient, or hypoxia caused by the use of vasoconstrictive drugs during surgery; Immunosuppressive glucocorticoids can change the process of wound inflammation and delay the process of wound healing; Contamination of the surgical area, hematoma, bladder incision and urine erosion around Tissue; incomplete drainage of the wound cavity.

Prevention and treatment measures: adequate dialysis before surgery to improve the nutritional status of the whole body and correct anemia; check and actively treat the infected lesions of the recipient; try to avoid contamination during the removal of the donor kidney; strictly perform aseptic operation during the operation to completely stop bleeding To avoid the formation of hematomas; use local antibiotics in the incision; use effective negative pressure drainage in the wound cavity; use systemic antibiotics 5 to 7 days after surgery; once local infection forms an abscess, open the drainage as soon as possible, and adjust the use of immunosuppression accordingly. Medications and dosages; Active systemic supportive therapies.

Renal artery thrombosis

(1) Cause: It is rare in the clinic. The reasons are: damage to the renal artery intima; improper vascular anastomosis technique; caused by rejection; local hematoma, infection, etc.

(2) Clinical diagnosis: severe pain in the transplanted kidney area, sudden absence of urine, and reduced renal transplantation volume; radionuclide nephrogram examination, lack of excretion of vascular segments of the transplanted kidney, and renal failure; color Doppler imaging (color (B ultrasound) examination, obstruction of the transplanted renal artery; intravenous urography examination, the transplanted kidney is not developed; magnetic resonance angiography or percutaneous puncture of the renal artery angiography can be definitive diagnosis.

(3) Treatment method: Once the renal artery embolism is diagnosed, it should be surgically explored immediately. People hope to open the artery, remove the thrombus, lavage the kidney again, and reconnect the blood vessel in order to get functional recovery. However, in clinical practice, from the onset of symptoms to the diagnosis, often due to time delay, the function of the transplanted kidney has been lost, the kidneys cannot be saved, and most of them are forced to undergo early transplantation nephrectomy.

Renal vein thrombosis

(1) Reasons: Endometrial injury of donor kidney; narrow anastomotic stoma; distorted anastomotic vein; thrombus formation and spread in the iliac vein system; compression of hematoma or lymph cyst around the transplanted kidney.

(2) Clinical diagnosis: swelling, tenderness, proteinuria, hematuria, and anuria in the transplanted kidney area; swelling of the ipsilateral lower limb; radionuclide nephrogram and intravenous urography confirmed that the transplanted kidney is not functional; And magnetic resonance angiography can confirm the diagnosis.

(3) Treatment method: anticoagulant drugs such as heparin and urokinase can be tried in the early stage; surgical exploration, incision of the vein to remove the thrombus, the surgical technical problems are not big, but most of them are too late, the transplanted kidney appears purple and has lost its function . At this time, the transplanted kidney needs to be removed.

Renal artery stenosis

Renal artery stenosis is a common complication after renal transplantation, and its incidence is 3% to 11.8%.

(1) Reasons: During the extraction and lavage of the donor kidney, the endometrium of the blood vessel was damaged due to pulling the renal pedicle or intubation by force; the anastomosis of the vascular anastomosis technique; repeated rejection occurred.

(2) Clinical diagnosis: clinical manifestations are persistent hypertension, hair-like murmurs are heard in the transplanted kidney area; renin activity of the transplanted renal vein is increased; digital subtraction imaging (DSA) or magnetic resonance angiography , Can not only clear diagnosis, but also understand the narrow area.

(3) Treatment method: The surgical indications are: hypertension that cannot be controlled by drugs; renin activity of the transplanted renal vein is increased; renal function is only slightly or moderately impaired. The surgical methods are: resection of the stenosed vessels and re-anastomosis; incision of the stenosis and "patch" (autologous saphenous vein, treated allogeneic blood vessel or artificial blood vessel); percutaneous puncture, balloon catheter dilation angioplasty (PTA ), Can achieve the desired effect.

Conventional kidney transplantation lymph cyst

It usually occurs 2 weeks to 2 months after surgery, and its incidence is 0.6% to 18.1%.

(1) Reasons: from the lymphatic vessels of the donor kidney that are not ligated; most people think that it is from the lymphatic vessels of the recipient's palate.

In the early days of kidney transplantation abroad, the incidence of lymphocytic cysts was high, which may be related to the extensive separation of the iliac vessels that Hume advocated in his early years. The units that carry out kidney transplantation in China have not paid much attention to the operation of separating the sacral blood vessels and can ligate the sacral lymphatic vessels more carefully. Therefore, the incidence of complications related to lymphatic cysts in China is low. Only individual cases have been reported.

(2) Clinical manifestations and examination results: there is a local cystic mass in the transplanted kidney or edema in the ipsilateral lower extremity; B-ultrasound, local effusion around the transplanted kidney; urography, which can show hydronephrosis, transplantation The kidney is compressed and displaced. secondary hypertension with hypo-transplanted kidney function; local puncture aspirate ether test is mostly positive; through the dorsal foot lymphangiography examination, the contrast agent can leak in the sacral lymphatic vessels.

The clinical diagnosis of lymphocytic cysts is not difficult, but it needs to be differentiated from local hematomas and urinary leaks, because their treatment methods are very different.

(3) Treatment method: The focus is on prevention. The main reason is to avoid extensive separation of retroperitoneal tissue and iliac vessels. The adipose fibrous tissue in front of the blood vessels contains lymphatic vessels, which should be "limitedly separated", and ligated and then cut off. In this way, leakage of broken lymphatic vessels can be avoided, which can lead to the formation of lymphatic cysts. If a lymph cyst has formed, puncture and aspirate under strict aseptic operation. And can inject an appropriate amount of medical absolute ethanol, rinse repeatedly and then withdraw. If so, better results are expected. If the cystic cavity is large, the effusion is more than 200ml, or it is difficult to obtain good results after repeated suction, peritoneal "open window" drainage can be performed. Avoid incision and drainage as much as possible, because it is easy to cause secondary infection and will bring unpredictable adverse consequences to patients. Early lymphatic leakage can be surgically explored again, and lagged or sutured damaged lymph vessels.

Ruptured kidney

Renal graft rupture is one of the serious complications in the early postoperative period. Its incidence is 0.3% to 8.5%, and it is more common for cadaver donor kidney. It can occur within 3 weeks after surgery, but it is more common within 1 week after surgery. Rupture usually occurs at the flange of the long axis of the kidney, but can also occur at other sites.

The cause of spontaneous rupture of the transplanted kidney is generally considered to be related to rejection. It can also be induced by renal puncture biopsy, damage during kidney extraction and lavage, urinary tract obstruction, severe cough, sudden increase in abdominal pressure by forced stool, and accidental falls occur.

(1) Clinical diagnosis: Sudden pain and tenderness in the transplanted kidney area, with gradually increasing mass, and decreased blood pressure. It is easy to be confused with acute abdomen at the beginning of onset, and can be identified by local puncture and B-ultrasound. If a typical "triple disease" occurs clinically, that is, severe pain, hypotension, and oliguria in the transplanted kidney area, surgical exploration should be considered.

(2) Treatment method: surgical exploration for rupture of transplanted kidney. The experience of each family is very different. Retention of the kidney: limited to the superficial fissure, the scope is limited, and the renal function is still good. Hematoma can be removed. Use autologous muscle mass, omentum or hemostatic sponge to fill the fissure and suture to stop bleeding. However, 28.5% of the recipients may rupture again. Resection of the kidney: If the fissure is deep, multiple sites are ruptured, bleeding does not stop, kidney function is lost, or irreversible damage is confirmed by biopsy, it should be removed.

Urinary tract obstruction

It is mainly ureteral obstruction, and its incidence is 1% to 9.7%.

(1) Reasons: ureteral bladder anastomosis is edema and stenosis; ureter is too long and twisted; ureter is angled by adhesion; ureter is oppressed by spermatic cord, blood clot, lymph cyst, etc .; surgical technique error; The found kidney stones dropped to the ureter.

(2) Diagnosis: The patient gradually or suddenly appeared oliguria, anuria and pain in the kidney transplant area; serum creatinine and urea nitrogen increased; B-ultrasound can find different degrees of hydronephrosis with ureteral dilatation; Urography can confirm the location and extent of obstruction.

(3) Treatment method: Surgery should be performed as soon as possible after the diagnosis is clear. Remove the cause of obstruction and rebuild the unobstructed urinary tract; balloon dilatation or ureteral dilation devices can also be used, which can have certain effects in some cases.

Conventional renal transplant urinary fistula

Urinary fistula is a serious complication after kidney transplantation. It includes ureter, bladder, pyelonephric fistula. Urinary fistula occurred mostly within 3 weeks after surgery. The morbidity rate reported abroad is 3% to 23%, and the mortality rate is 14% to 60%. From January 1980 to June 1987, a total of 641 cases of renal transplantation occurred, 56 cases of urinary fistula occurred (8.7%), and 17 cases of death (30.3%).

(1) Reasons: Damage to the ureteral blood supply when the kidney is removed or repaired; The ureter is cut and failed to find in time; distal (segmental) necrosis of the ureter; ureteral and bladder anastomosis technique is poor; Technical errors; Compression and necrosis of the ureter by drainage, spermatic cord, and hematoma; Ureteral rejection; Ligation of the superior or inferior accessory arteries of the kidney, ischemic necrosis caused by renal calico fistula.

(2) Clinical manifestations and examination results: The patient gradually oliguria, or suddenly no urine, local tenderness, increasing mass, wound exudation, and elevated body temperature; Ultrasound examination to understand the scope of local effusion; puncture examination Hematomas and lymphatic cysts can be ruled out; intravenous indigo rouge or bladder injection of methylene blue solution can be determined as urinary fistula; intravenous urography examination can understand the scope and extent of urinary fistula.

(3) Preventive measures: Keep the ureteral mesentery when removing and repairing the donor kidney to ensure blood supply. If the urine leaks only from the bladder cleft, try inserting a urinary catheter first and continue to drain the urine. If the symptoms cannot be changed after a short observation, surgical exploration and treatment should be performed in time. The necrosis of the distal end of the ureter should be removed, and then the ureteral bladder is anastomosis. After resection of the distal ureter necrosis, the recipient's ureter can be anastomosed with the donor ureter; or the recipient's bladder flap can be anastomosed with the donor ureter. After the full-length necrosis of the ureter is removed, the ureter of the recipient can be used to anastomize the donor kidney and pelvis; Renal fistula can be partially excised. Effective drainage should be placed in the wound cavity, and sensitive antibiotics should be used to actively support the whole body.