Study on optimized immunosuppression during the period of acute tubular necrosis following cadaveric renal transplantation

我们已经连续进行了152例同种异体肾移植（81例活体相关，71例尸体）。1987 ~ 1989年共施行尸体肾移植32例。在我们的尸体肾移植患者中，术后急性肾小管坏死（ATN）是不可避免的，因为供体来自心脏骤停供体。通过分析我们的病例，我们研究了ATN期间最佳的免疫抑制和适当的患者管理。结果如下。1)ATN期间的免疫抑制：环孢素（Cs）的出现带来了移植物存活率的显着提高。我们的尸体移植成活率为77%后，铯引入。根据Cs血液浓度谷水平和移植物针吸活检组织的组织学发现调整Cs剂量。作为免疫抑制的标志物，淋巴细胞亚群OKT 4/8是有用的;低于0.6的比率意味着过度免疫抑制状态。2）ATN的处理：超声引导下ATN移植肾穿刺活检对排斥反应、ATN和Cs-肾毒性的鉴别诊断有重要意义。标本的免疫细胞化学研究（DNA聚合酶-α）揭示了ATN的恢复阶段。我们新的免疫抑制，淋巴细胞分离，成功地应用于激素抵抗性排斥反应的治疗。我们试图建立一种更安全、更简便的淋巴细胞单采系统。FPIA法测定Cs血药浓度简便、快速，可在床旁进行。Cs-I肾毒性与肾组织中的肾素-醛固酮呈正相关。更昔洛韦治疗CMV感染有效，集落刺激因子治疗白细胞减少有效。结果表明，UW溶液缩短了ATN周期的可能性。

We have carried out consecutive 152 kidney-a-allograftings (81 living-related, 71 cadaveric). A total number of 32 cadaver renal transplantations was Performed in the Period from 1987 to 1989. Postoperative acute tubular necrosis (ATN) was inevitable in our cadaveric kidney transplant patients because of harvesting from cardiac arrest donors. Analyzing our cases, we studied the optimized immunosuppression and appropriate patient management during ATN. The results are following. 1) Immunosuppression during ATN: The advent of cyclosporine (Cs) brought about the remarkable improvement of graft survival rate. Our cadaver graft survival rate became 77% after the Cs introduction. The Cs dose was adjusted according to Cs blood concentration trough levels and histological findings of needle biopsy tissue from the graft. As a marker of immunosuppression, the lymphocyte subset, OKT4/8, was useful; the ratio under 0.6 meant the over-immunosuppressed state. OKT3, a new antirejection agent, was clinically excellent.2) Management of recipients with ATN: Echo-guided needle biopsy of ATN grafts was very useful in the differential diagnosis among rejection, ATN and Cs-nephrotoxicity. Immunocytochemical study (DNA polvmerase- alpha ) of the specimen revealed the stages of recovering from ATN. Our new immunosuppression, lymphocytapheresis, was successfully applied to the treatment of steroid-resistent rejection. We tried to make the more safe and easy lymphocytapheresis system. The measuring of Cs blood concentration using FPIA method was easily and rapidly done at bedside. The positive relationship between Cs-nephrotoxicity and renin-aidosterone was suggested. Ganciclovir for CMV infection and Colony Stimulating Factor for leukopenia were effective. The possibility was shown that UW solution shortened the ATN period.