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例异体肾移植（81例与活人有关，71例与尸体有关）。1987年至1989年共施行尸体肾移植32例。术后急性肾小管坏死（ATN）在我们的尸体肾移植患者中是不可避免的，因为从心脏骤停供体中采集肾。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期间免疫抑制：环孢素（cyclosporine, Cs）的出现使移植物存活率显著提高。引入c后，我们的尸体移植成活率达到77%。根据Cs血药浓度谷值和移植物穿刺组织组织学结果调整Cs剂量。作为免疫抑制的标志物，淋巴细胞亚群OKT4/8是有用的；比值小于0.6表示免疫过度抑制状态。新型抗排斥药物OKT3临床表现优异。2) ATN受者的处理：超声引导下ATN移植物穿刺活检在排斥反应、ATN和cs肾毒性的鉴别诊断中非常有用。免疫细胞化学研究（DNA聚合酶- α）显示了ATN的恢复阶段。我们的新免疫抑制，淋巴细胞摘除术，已成功应用于治疗类固醇抵抗性排斥反应。我们试图使淋巴细胞分离系统更安全、更容易。采用FPIA法在床边简便、快速地测定血Cs浓度。提示肾素醛固酮与肾毒性呈正相关。更昔洛韦治疗巨细胞病毒感染，集落刺激因子治疗白细胞减少有效。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.