Objective To evaluate the safety and efficacy of steroid withdrawal in modern triple immunosuppressant (Cycloproine/Tacrolimus, Mycophenolate Mofetil and Steroid) on renal transplantation recipients. Methods We searched MEDLINE (1966-Sep. 2005), OVID (1966-2004), EMBASE (1984-2004), The Cochrane Library (Issue 4, 2005), CBMdisc (1994-2005), and handsearched 7 Chinese Journals. Randomized controlled trials (RCTs) adopting modern triple immunosuppressant, and comparing steroid withdrawal (SW), group and steroid continuing group (SC) were selected. The quality of included studies was evaluated and graded according to Cochrane Reviewer’s Handbook 4.2.5, and meta-analysis was performed by using RevMan 4.2.7 software. Results Nine RCTs including 1 681 patients (845 in SW and 836 in SC) were identified. The average follow-up time was 6-12 months. No significant difference was found in using CsA or Tac in modern triple immunosuppressant. The results of our meta-analysis showed: ① the risk of acute rejection was two times higher in SW than SC (RR 2.05, 95% CI 1.54 to 2.72, P lt;0.000 01), mainly Banff grade I (mild) (RR 1.92, 95% CI 1.16 to 3.17, P =0.01); but no significant differences were found on Banff grade II and III between the two groups. ② the rate of graft and patient survival and chronic rejection were the same between two groups. ③ Steroid withdrawal decreased the incidence of opportunistic infection (mainly caused by simplex herpes virus and Candida) and urinary tract infection. While the incidence of CMV and sepsis infection has no significant difference between two groups. Conclusion Steroid withdrawal within 3 months in modern immunosuppressive regimen ① increases the risk of Banff Grade I rejection reaction, but the moderate and severe rejection are similar between the two groups; ② doesn’t affect the rate of graft, patient survival, and chronic rejection; ③ decreases the incidence of opportunistic and urinary tract infection, but doesn’t improve the CMV infection and sepsis. To prophylaxis serious infection, steroid withdrawal is worth considering under sufficient immunosuppressive regimen. The key point is to balance the benefit and harm for individual recipients.
Objective To improve arterial anastomosis method for rat renal transplantation. Methods Renal transplantations were performed on 72 wistar rats. The donor superior mesenteric artery was end-to-end anastomosed to the recipient left renal artery by using of sleeve anastomosis technique. The external diameters of the vessels anastomosed were 0.60±0.05 mm (left renal artery) or 0.80±0.07 mm (superior mesenteric artery). The procedure consisted of a guidingsuture and two fixing sutures. The guiding suture was used to “telescope” therecipient left renal artery into the donor superior mesenteric artery about 2 millimetre. Two fixing sutures were applied 180°apart from each other and tied. Three sutures passed through all layers of the donor superior mesenteric artery andconstricted the vessel lumen, but only penetrated the adventitia of the recipient left renal artery. Results The time for arterial anastomoses was approximately 6 to 8 minutes. The renal grafts perfused very well after the recipient left renal artery clamp was removed. Complications included anastomotic hemorrhage(1 case) and thrombosis (1 case). Histologic examination of 34 grafts at different postoperative time ranging from 6 to 30 days revealed that renal artery was fully patent, with no evidence of ischemic injury. Conclusion The modified arterial sleeve anastomosis technique is simple and feasible regardless of experimentalcondition and can be easily performed.
Objective To evaluate the safety of mycophenolate mofetil (MMF) versus azathioprine (AZA) for rejection after renal transplantation. Methods We searched MEDLINE (1966 to Jun. 2004), EMBASE (1984 to Jun. 2004), The Cochrane Library (Issue 2, 2004) and Chinese Biomedical Database (CBM, 1979 to Jun. 2004). Randomized controlled trials (RCTs) comparing MMF with AZA for rejection after renal transplantation were included. The quality of included studies such as randomization, blinding, allocation concealment was evaluated and meta-analysis was performed using RevMan 4.1.1 software. Results Twenty-Four RCTs comparing MMF (2 g/day or 3 g/day) with AZA for rejection after renal transplantation were identified. The digest system morbidity of MMF group was higher than that of AZA group. The incidence of vomiting, bellyache and diarrhea of MMF 3 g/day group was statistical by higher than that of AZA group (P＜0.05). The cytom egalovirus (CMV) infection morbidity of MMF 3 g/day group during 6 months, 1 year and 2 years follow-up was higher than AZA group with statistical difference, but for MMF 2 g/day group, this difference was only seen during 1 year follow-up. Leukopenia incidence of MMF 3g/day group was higher than AZA group with statistical difference, but this difference was not seen in MMF 2 g/day group. Thrombocytopenia incidence of MMF 3 g/day group was lower than AZA group with statistical difference. For skin carcinoma morbidity, no statistical difference was found among MMF 3 g/day, MMF 2 g/day and AZA groups. Conclusions Compared with AZA, MMF represents higher digest system side-effects incidence, higher morbidity of leucopenia and CMV infection and lower incidence of thrombocytopenia. The dose-response relationship of adverse drug reaction is found.
To establ ish a simple and stable cervical ectopic renal transplantation rat model that increase surgical successful rate. Methods A total of 208 male inbred Wistar rats (weighing 220-260 g) were randomly served as donors and recipients. The graft consisting of kidney, renal vein (RV) and renal artery (RA) was obtained, and perfused in situ. The donor RA was end-to-end anastomosed to the recipient left common carotid artery (CCA) by using of “sleeve” anastomosis,and the donor RV to the recipient right external jugular vein by using of “cuff” technique. The distal end of the ureter wasbrought out to form cervical cutaneous stomas. Results A total of 104 ectopic renal transplantations were performed in rats, including stages of the pre-experiment (62 operations) and experiment (42 operations). The success rates of the two stages were 80.6% and 95.2%, respectively. The causes of failure in the pre-experimental stage were anesthesia accidents, thrombosis of the arterial anastomosis, massive hemorrhage, air embol ism and phlebemphraxis. In the experimental stage, 2 rats died due to late anastomotic hemorrhage and thrombosis. The remaining 40 transplanted kidney survived more than 6 months. The time for surgery was (40 ± 6) minutes, the average time for donor surgery was (20 ± 5) minutes, the preparation time for the graft was (8 ± 2) minutes, the operative time for the recipient was (18 ± 3) minutes, including the time for the arterial anastomosis (5 ± 2) minutes and venous anastomosis (2 ± 1) minutes, the cold ischemia time of graft was (15 ± 3) minutes. Conclusion The cervical ectopic renal transplantation technique has the advantages of easy-and fast-to-perform, shorter operation and cold ischemia time, higher successful rate.
ObjectiveTo explore the effectiveness of lamividine (LAM) combined with adefovir (ADV) versus entecavir (ETV) for lamivudine-resistant (LAM-R) hepatitis B in renal transplant recipients.
MethodOutpatients and inpatients of lamivudine-resistant kidney graft recipients with chronic hepatitis B admitted to West China Hospital and the People's Hospital of Santai County during Jan 2007 to Mar 2012 were divided into A group (LAM+ADV) and B group (ETV). And the level of alanine aminotransferase (ALT), level of serum creatinine, HBV serological markers and HBV-DNA load were compared by SPSS 16.0 software.
ResultsA total of 15 patients were included. The mean age was 36.7±6.6 years old, the majority of patients were male. After treatment for 4 weeks, 12 weeks, 24 weeks, 48 weeks, 96 weeks, no significant differences were found between two groups in liver function normalization rates, the HBV-DNA negative conversion rates and serum creatinine level.
ConclusionsLAM add-on ADV combination therapy and ETV monotherapy were both safe and effective in LAM-R kidney transplants with CHB, but the load of HBV-DNA in some patients were still positive at the endpoint. Elevated serum creatinine level may occur in some patients who treated with ADV. Consequently, for HBsAg-positive kidney transplantation patients, those anti-HBV drugs that are more effective, safer and less resistant may be better in the beginning of treatment.
ObjectiveTo analyze the clinical characteristics and related prognostic factors of post-renal transplantation pneumonia.MethodsThe clinical data of 89 patients with post-renal transplantation pneumonia in Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital from 1st January 2014 to 31st December 2015 were collected in the study. Kaplan-Meier method was used to calculate overall survival. Cox analysis was used to analyze the related prognostic factors.ResultsPost-renal transplantation pneumonia occurred mainly within 6 months after renal transplantation. The prominent clinical manifestations were cough (95.5%), fever (56.1%), and dyspnea (12.3%). The mortality of post-renal transplantation pneumonia was 11.2% and all death occurred within 5 months after transplantation. The overall survival rate significantly decreased in the patients with C-reactive protein (CRP) ≥40 mg/L (P<0.001), procalcitonin ≥1 ng/ml (P=0.002), brain natriuretic peptide >100 pg/ml (P<0.001), platelet ≤100×109/L (P<0.001), or those with occurrence time of pneumonia <180 days (P=0.013). Platelet ≤100×109/L could increase the risk of death by 66.6 times (RR=0.015, P=0.006), and CRP ≥ 40 mg/L could increase the risk of death by 20 times (RR=0.05, P=0.029).ConclusionsPost-renal transplantation pneumonia has prominent clinical characteristics. Platelet ≤100×109/L or CRP ≥40 mg/L can increase the risk of death and can be used as an independent prognoctic factor of post-renal transplatation pneumonia.
Objective To evaluate the effectiveness of tacrolimus and cyclosporine A on acute rejection, chronic rejection and survival rate of patient and graft after renal transplantation. Methods We searched MEDLINE (1989 to Nov.2004), EMBASE (1989 to Nov.2004), The Chinese Biomedical Database (CBM) (1998 to Nov.2004), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2004) and handsearched 8 Chinese journals. Trials comparing tacrolimus with cyclosporine A after renal transplantation were included. The quality of included studies such as randomization, blinding, allocation concealment was evaluated and meta-analysis was performed using RevMan 4.2.7 software. Results Eighteen studies involving 3 738 patients were included. Tacrolimus was more effective in decreasing the incidence of acute rejection and chronic rejection than that of cyclosporine A with RR 0.65, 95％CI 0.56 to 0.75 at the end of 6 months; with RR 0.70, 95％CI 0.54 to 0.92 at the end of 12 months for number of patients of acute rejection. The pooled RR was 0.65 (95％CI 0.47 to 0.89) for number of patients of chronic rejection. Tacrolimus could reduce the severity of acute rejection. The relative risks of pathologic grade BanffⅠand Banff (Ⅱ＋Ⅲ) were 1.64 (95％CI 1.08 to 2.49) and 0.75 (95％CI 0.63 to 0.89) respectively. But there was no significant difference on the survival rate of patient and graft within 5 years between the two groups. The relative risk of 6, 12, 24, 36 and 60 months were 1.01 (95％CI 0.99 to 1.02), 1.00 (95％CI 0.99 to 1.02), 1.01 (95％CI 0.97 to 1.05), 1.00 (95％CI 0.97 to 1.03) and 0.97 (95％CI 0.88 to 1.07) respectively for the survival rate of patient and 1.04 (95％CI 1.01 to 1.07), 1.03 (95％CI 1.00 to 1.06), 0.99 (95％CI 0.91 to 1.07), 1.04 (95％CI 0.99 to 1.09) and 1.04 (95％CI 0.90 to 1.21) respectively for the survival rate of grafts. Conclusions On acute rejection and chronic rejection, tacrolimus is more effective than cyclosporine A, but there is no difference in the graft or patient survival rate.
ObjectiveTo explore the effect of rehabilitation training focusing on early exercise on the time of first getting out of bed after surgery, pain during early activities, postoperative infection rate and the length of hospital stay for renal transplant recipients.MethodsThe clinical data of patients undergoing allogeneic renal transplantation in West China Hospital of Sichuan University from June to August 2020 were analyzed retrospectively. According to the time of multidisciplinary postoperative management and the time of early rehabilitation intervention, the patients were divided into the conventional group (from June 2020 to the beginning of multidisciplinary postoperative management) and the rehabilitation group (after multidisciplinary postoperative management). The time to get out of bed for the first time after surgery, the Visual Analogue Score (VAS) during weight monitoring on the second day post operation, the number of days required to complete an independent walk of 100 meters, postoperative complications, the incidence of postoperative infection and the length of hospital stay were compared between the two groups.ResultsA total of 79 patients were included. There were 46 cases in the conventional group and 33 cases in the rehabilitation group. Among the included patients, 14 patients had postoperative infection, 1 patients in the conventional group developed thrombosis, no catheter shedding or bleeding after exercise occurred. The differences between the rehabilitation group and the conventional group in the time to get out of bed for the first time after surgery [(1.1±0.2) vs. (2.2±0.4) d; t=13.224, P<0.001], the VAS during weight monitoring on the day post operation (2.5±0.9 vs. 3.4±1.4; t=3.267, P<0.001), the number of days required to complete an independent walk of 100 meters [(2.2±0.4) vs. (4.0±0.8) d; t=11.312, P<0.001], and the incidence of postoperative infection (6.1% vs. 26.1%; χ2=5.285, P=0.022) were statistically significant. There was no significant difference in the length of stay between the rehabilitation group and the conventional group [(19.8±5.8) vs. (20.7±7.4) d; t=0.584, P=0.561].ConclusionEarly postoperative rehabilitation training reduces the time required for renal transplant recipients to get out of bed for the first time post operation and to walk 100 meters independently, reduce the pain response during early activities, and reduce the incidence of postoperative infection.
ObjectiveTo systematically evaluate the efficacy and safety of enteric-coated mycophenolate sodium (EC-MPS) versus mycophenolate mofetil (MMF) in kidney transplant recipients.
MethodsWe searched MEDLINE, EMbase, PubMed, the Cochrane Library (Issue 9, 2013), CBM, CNKI, VIP and WanFang Data from their inception to November 2013, to collect randomized controlled trials (RCTs) of EC-MPS versus MMF in kidney transplant recipients. References of included studies were also retrieved. Two reviewers independently screened studies according to the exclusion and inclusion criteria, extracted data, and assessed the risk of bias of included studies. Then, meta-analysis was performed using RevMan 5.1 software.
ResultsA total of 8 RCTs involving 2 400 patients were included. The results of meta-analysis indicated that there were no significant differences between the two groups at the end of 4-week, 6-month, 12-month and 48-month follow-up in the acute rejection rate (4-weeks:RR=0.33, 95%CI 0.01 to 8.05; 6 months:RR=0.94, 95%CI 0.73 to 1.22; 12 months:RR=0.88, 95%CI 0.63 to 1.24; 4 years:RR=0.93, 95%CI 0.47 to 1.84). There were no significant differences between the two groups at the end of 6-month and 12-month follow-up in the chronic rejection rate (6 month:RR=0.66, 95%CI 0.27 to 1.58; 12 month:RR=0.57, 95%CI 0.29 to 1.15). There were no significant differences between the two groups at the end of 6-month, 12-month and 48-month follow-up in the graft loss or death rate (6-month:RR=0.79, 95%CI 0.41 to 1.50; 12-month:RR=0.76, 95%CI 0.40 to 1.43; 48-month:RR=1.38, 95%CI 0.59 to 3.23). As to the side effect, EC-MPS could significantly reduce the risk of pneumonia compared with MMF (RR=0.32, 95%CI 0.13 to 0.79).
ConclusionBased on current evidences, EC-MPS is comparable with MMF for renal transplant patients in short-term effectiveness, and the incidence of pneumonia in the EC-MPS group is lower than the MMF group. Due to the limited quantity and quality of the studies, the conclusions should be validated by more high quality studies.
Objective To evaluate the efficacy of mycophenolate Mofetil (MMF) and azathioprine (AZA) after renal transplantation. Method Searching: Medline, Embase, Cochrane library and Chinese Biomedicine database (CBM); identified the randomized controlled trials (RCTs) and applied Revman 4.11 for statistical analyses. Results Twenty-two RCTs were identified, involving MMF and AZA for anti-rejection after renal transplantation. The data shown that MMF (2 g/d) was more beneficial than AZA in improving the graft survival rate of short periods and the long-term patient survival rate, but there was no statistical differences between MMF (3 g/d) with AZA. Whether in 6 months or in 1 year after renal transplantation, the use of MMF (2 g/d) or MMF (3 g/d) could markedly reduce the incidence of biopsy-proven rejection. Conclusions Comparing with AZA, MMF is a more potent immunosuppressive drug, and more efficient in reducing the acute rejection after renal transplantation. MMF can improve the graft and patient survival rate. The 2 gram per day is more acceptable.
