2005年至2009年上海市第一人民医院共收治肾盂癌患者10例,全部患者均经输尿管软镜及螺旋增强 CT 尿路成像(computed tomography urography,CTU)检查得以诊断,并经手术及病理证实,现分析报告如下。

Objective To evaluate physical and mental health of liver or renal transplant recipients in China to provide evidence for the construction of recipients' health management system.Methods Three hundred and ninety-two liver or kidney transplant recipients from nine cities of China were included in this cross-sectional survey.A questionaire was designed according to the World Health Organization Quality of Life-Bref (QOL-BREF) and Kidney Disease and Quality of LifeTM Short Form(KDQOL-SF).Demographics,quality of life (QOL) and health status over 4 weeks,mental health,and health education needs and satisfaction were recorded during face-to-face interview.Results Of 392 participants,241 underwent liver transplantation,and 151 received kidney transplantive surgery.About 62.2％ patients considered " very good" or "good" QOL,which was significantly affected by age (x2 =6.60,P ＜ 0.05).Nearly 69.4％recipients reported "very good" or "good" health status.Gender,age,post-operation time,medical insurance and work status seemed to play no significant impacts on the health status of the subjects (x2 values were 0.33,3.41,1.85,0.44 and 0.68,respectively; all P ＞ 0.05).Only a small number of the recipients showed long-term negative state of mind.Conclusions Our survey suggests that health status and QOL are considerably improved in majority of solid organ transplant recipients in mainland of China.However,a gap between medical or social satisfaction and mental expectation still exists to some extent among this population.

十、吗替麦考酚酯(MMF)+低剂量钙调磷酸酶抑制剂(CNI)有益于移植肾长期功能 Heemann等以移植时间超过6个月、肾小球滤过率(GFR)＞0.334 ml/s且在移植时即开始使用MMF的肾移植受者为研究对象,评估了MMF+低剂量他克莫司(Tac)方案对移植肾的长期(4年)作用.研究共纳入2040例受者,其中1173例(58%)为移植后1年时入组,接受MMF(1482±511)mg/d+环孢素A(210±88)mg/d或MMF(1270±504)mg/d+Tac(5.3±3.6)mg/d治疗者分别有987例和921例.

由免疫因素和非免疫因素导致的移植物功能丧失、受者带有功能移植物死亡以及免疫抑制治疗的依从性不良，是器官移植近期效果明显提高而远期效果并未同步提高的主要原因，上述因素都与免疫抑制剂是否合理应用相关。由于目前尚无有效的指标来指导用药，用药量往往不足或过度，从而导致免疫损害或免疫抑制剂不良反应的发生。虽不断寻找解决方法，包括剂量最小化或撤除免疫抑制剂，但方案还不一致，结果也不确定或不具说服力，尚无理想结果。长期以来，免疫耐受诱导研究在小动物实验中取得了可喜的结果，在不应用免疫抑制剂的情况下，同种移植物不发生排斥反应，并保持良好的移植物功能，组织学也无免疫损害表现，能再次接受来自同一供者的移植组织，而排斥第三方组织，并证实这些都是主动过程，而不是对同种移植物应答的不足[1]。

由于手术技术的提高,对移植免疫学认识的加深以及强有力免疫抑制剂的问世,器官移植近期效果明显提高.以同种肾移植为例,移植物1年存活率已高达90%以上,但远期效果并未同步提高.为此,更高的长期存活率和更好的生活质量是我们追求的目标.肾移植1年以后,移植肾功能丧失的原因中,受者带肾功能死亡和慢性移植肾功能异常各占50%.心血管疾病、感染和肿瘤是受者带肾功能死亡的最常见原因.感染和肿瘤与免疫抑制过度有关,而心血管疾病也与免疫抑制药物所致之代谢异常相关.

Objective:To evaluate the best means for the treatment of upper ureteral calculi.Methods:The three treatments of 167 cases with upper ureteral calculi including minimally invasive percutaneous nephrolithotomy (MPCNL),ureteroscopic lithotripsy(URL) and retroperitoneoscopic ureterolithotomy(RLU) were compared. Results:82 cases were treated by MPCNL,the rate of one-time gravel was 96.3%.59 cases were treated by URL, and the rate of one-time gravel was 83.1%.26 cases were treated by RLU,and the success rate of stone remove was 100%.2 cases were obliged to accept the second MPCNL because of blood after puncture.1 case was obliged to accept ureteroscopic lithotripsy because the stone went down.5 cases were obliged to accept the open surgery because the ureteroscopic lithotripsy was failure.5 cases were obliged to MPCNL because the stone moved to the renal pelvis.Conclusions:RLU is an efficient minimally invasive surgical technique,but it needs a comprehensive technical training of laparoscopic.MPCNL is becoming the important technology and the best method for upper ureteral calculi because of its good effect.URL was not suitable for upper ureteral calculi.Although with large trauma,ureterolithotomy is the base of all ureteral operation.

Objective:To evaluate the value of diagnosis by ultrasonic contrast in small renal carcinoma,and to improve the diagnosis of small renal carcinoma.Methods:35 cases of small renal carcinoma from June 2005 to December 2007 in our hospital were reviewed to analyse the various kinds of imaging characteristic of ultrasonic,CT, IVP,MRI and ultrasonic contrast,and summarize the diagnostic experiences in such disease.Compared the diagnosis consequence between ultrasonic contrast and pathologic diagnosis.Compared the diagnosis consequence between ultrasonic contrast and enhanced CT.Evaluated the diagnosis value of ultrasonic contrast for small renal carcinoma.Results:In all cases the diagnosis accurate rate for small renal carcinoma:ultrasonic 82.9%,CT 91.7%,MRI 90.4%.35 cases of small renal carcinoma were examined by ultrasonic contrast:sensitivity 97.1%, specificity 100%,positive predictive value 100%,negative predictive value 50%,accurate rate 97.2%.Conclusions: The early diagnosis of small renal carcinoma mainly depends on ultrasonic and CT.Ultrasonic is the first-election for screening small renal carcinoma.multislice spiral CT offers the important reference value for the qualitation and level diagnosis of small renal carcinoma.Ultrasonic contrast possess higher sensitivity,specificity,positive predictive value and accurate rate for the diagnosis of small renal carcinoma.Ultrasonic contrast has a excellent diagnostic value in 35 cases of small renal carcinoma.

Objectives: To evaluate the images acquired with a clinical 3.0-T magnetic resonance imaging machine as the quantification of transplanted and surviving islets in vivo. Methods: Polyethyleneimine (PEI) was introduced to increase the labeling efficiency of Feridex, a dextran-coated superparamagnetic iron oxide. Allogeneic (Lewis-to-Wistar) and syngeneic (Wistar-to-Wistar) intraheptatic islet transplantations were performed to study the relationship among magnetic resonance imaging, metabolic monitoring, and pathological examination. Results: After receiving Feridex-PEI-labeled islets, dark voids could be observed in the livers of both groups, accompanied with a significant decrease in liver/muscle intensity ratio from 1.25 ± 0.03 to 1.09 ± 0.05 (P < 0.01). One week after transplantation, islet grafts were rejected in the allogeneic group. Rapid disappearance of dark voids and a significant increase of liver/muscle ratio were observed. No islet grafts could be found in the paraffin sections of livers by that time. Meanwhile, in the syngeneic group, islet grafts survived indefinitely. Dark voids persisted and low liver/muscle ratios retained. The fact that the dark voids represented the labeled islets was confirmed by combined staining of insulin activity and Prussian blue. Conclusions: Either spot counting or signal intensity measurement provides a perfect quantification of transplanted and surviving islets in vivo. Feridex-PEI provides an effective and safe way to label islets.

Objective To evaluate the value of various of kinds of imaging diagnosis in small renal cell carcinoma,and to improve the diagnotic level of small renal carcinoma. Methods 76 cases with small renal cell carcinoma were reviewed to analyse the various kinds of imaging characteristic of ultrasonic,CT,IVP and MRI and summarize the diagnostic experiences in such disease. 35 cases were examined by ultrasonic contrast. The diagnosis consequence between ultrasonic contrast and CT was compared. Results In all cases the diagnosis accurate rate for small renal carcinoma was ultrasonic 81.6%,CT 94.7%,MRI 87.9%,KUB+IVP 23.6%,and ultrasonic contrast 97.2%. It was not significantly different between ultrasonic contrast and CT. Conclusion Ultrasonic is the first-selection for screening small renal carcinoma,while multislice spiral CT offers important reference value for the qualitation and level diagnosis.

Objective To investigate the possibility of monitoring superparamagnetic iron oxide (SPIO) labeled islet grafts in vivo by magnetic resonance imaging (MRI). Methods Islet grafts were labeled with SPIO in vitro and transplanted into the liver of streptomycin-induced diabetic rats. There were 4 groups, including 2 syngeneic groups (Wistar to Wistar transplantation, one group receiving SPIO labeled islets,and the other group unlabeled islets as control) and 2 allogeneic groups (Lewis to Wistar transplantation, one group receiving SPIO labeled islets, and the other group unlabeled islets as control). Poly-L-Lysine (PLL) was used to increase the labeling efficiency of SPIO. After transplantation, MRI was performed regularly, fed glucose level was monitored, and animals were sampled for pathological examination. Results Only SPIO labeled islets could be detected by MRI. The relative number of islets detected by MRI in syngeneic group receiving labeled islets at week 1,2 and 3 following transplantation was (89.6±2.2)%, (87.5±14.4)% and (74.5±19.5)% respectively, and the relative number in allogeneic groups receiving labeled islets at these time points were (43.2±17.2)%, (36.5±13.0)% and (26.5±17.4)% respectively. Statistical significance was observed as the result of a paired student's t test (P<0.05). In the syngeneic groups, hyperglycemia was under well control, and co-localization of insulin activity and Prussian blue staining was observed in the liver sections of the animals receiving labeled islets. Meanwhile, in the allogeneic groups, loss function of islet grafts was determined by fed glucose level > 16.8 mmol/L at first week following transplantation,and no intact islets could be found in liver sections since that time. Conclusion Results of MRI correlate to fed glucose level monitoring and pathological examination. Application of this elegant imaging technique provides a direct, noninvasive and continuous way to monitor the distribution and survival of islet grafts in vivo.

目的:探讨国人接受肾脏-胰岛序贯移植的可行性,分析临床应用免疫抑制方案的安全性和有效性.方法:1 型糖尿病性尿毒症患者1例,在10个月内先后接受1次肾脏移植和2次胰岛输注,肾脏移植于右侧髂窝,胰岛经门静脉系统注入肝脏.术前应用抗胸腺球蛋白(ATG)或Campath-1H诱导治疗,术后联合应用骁悉、雷帕霉素和低剂量普乐可复预防排斥反应.随访期间现察血清肌酐、血糖水平及其排斥反应、感染等并发症.结果:肾移植后移植肾恢复顺利.功能正常,血肌酐维持在66～87 μmol/L,治疗期间未发生急性排斥反应,2次胰岛移植期间移植肾功能稳定.第一次胰岛输注后,胰岛素用量明显减少,由术前54 IU/d降至18 IU/d,C肽水平升高,第二次输注后,胰岛素用量进一步降低,现为12 IU/d,随访16个月血糖、糖化血红蛋白维持在正常水平,未发生低血糖及其相关的严重并发症.结论:初步结果显示国人行肾脏-胰岛序贯移植是可行的,所用免疫治疗方案安全有效,近期效果良好.

BACKGROUND AND PURPOSEAvulsion of the ureteral mucosa is one of the most serious complications of ureteroscopy and considered challenging for urologic surgeons. In this study, we developed two novel methods to reconstruct the impaired ureter.MATERIALS AND METHODSAfter ureteral mucosal avulsion in a canine model, ureteral reconstruction was performed in one of three ways: free tabularized peritoneal grafts (group A, n = 6); bladder mucosal grafts (group B, n = 6); or simple stenting technique (control group [n = 3]). At postoperative week 10, evaluation with intravenous urography (IVU) was followed by harvesting of reconstructed ureter segments for pathologic analysis.RESULTSIVU showed nonvisualization of the collecting system of the affected side and histologic evaluation showed imperforation or stenosis in all animals in the control group. IVU showed good visualization of the reconstructed ureter without stenosis in group A and in most animals in group B. There was a mild dilation but no obvious stenosis in one animal in group B. Microscopically, all the reconstructed ureteral lumens were uniformly lined with transitional epithelium. Extensive neovascularity was evident in the subepithelial layer with a streaming of fibroblasts toward the neomucosa.CONCLUSIONReplacing the avulsed mucosa in the injured ureter with tubularized peritoneal free grafts or bladder mucosal grafts may be an optimal method to manage avulsion of the ureteral mucosa.

由中华医学会《中华医学信息导报》组织、惠氏制药有限公司协办的"提高移植肾长期存活和防治慢性移植肾肾病(cAN)"的专题研讨已历时1年多.在此期间,共举行4次高层学术研讨会,并在《中华医学信息导报》上发表了10余篇相关文章,就CAN的形成原因、最新研究进展和防治经验等方面进行了广泛而深入的讨论.

Objective To analyze the effect of cyclosporin A(CsA), rapamycin(RPM) and macophenolic acid(MPA) on the co-stimulated lymphocytes, CD28 and CD40, and their production of Th1/Th2 cytokine, IL-2, IFN-γ, IL-4, IL-10 and IL-12. Methods The experimental groups were divided into ①mono-stimulating and co-stimulating groups: CD3 mAb mono-stimulating (group a),CD3 mAb+CD28 mAb co-stimulating (group b), CD3 mAb+CD28 mAb+CD40 L mAb co-stimulating(group c), CD3 mAb+CD28 mAb+CTLA4 mAb co-stimulating (group d). ②CsA groups: 300 ng/ml of CsA was added to group a, b, c and d. ③RPM groups: 300 ng/ml of RPM was added to group a,b, c and d. ④MPA groups:300 ng/ml of MPA was added to group a, b, c and d. The cytokine production was measured by ELISA.Results The co-stimulated CD28 and CD40 Th1/Th2 cytokines production of IFN-γ, IL-2, IL-4 and IL-10 were significantly increased. Compared with group a, IFN-γ increased from (248.91±11.20)ng/ml to (555.08±24.42)ng/ml and (548.19±33.06)ng/ml, IL-2 increased from (29.48±8.61)ng/ml to (1100.82±99.29)ng/ml and (842.23±29.31)ng/ml, IL-4 increased from (32.29±6.76)ng/ml to (116.02±15.03)ng/ml and (147.28±18.07)ng/ml, IL-10 increased from (147.01±10.47)ng/ml to (291.79±12.47)ng/ml and (302.52±35.18)ng/ml,respectively, P＜0. 01. Compared group b with group c, the Th1 cytokines production was decreased.IL-2 and IL-12 decreased (P＜0.05). The Th2 cytokine IL-4 production was increased (P＜0. 05).CTLA4 mAb and three other immunosuppressants, CsA, RPM and MPA, inhibited co-stimulated lymphocyte's both cytokines Th1 and Th2 production. The inhibitory effect of CsA on Th1/Th2 cytokine production was more significant than RPM and MPA did. The co-inhibitory effect of CTLA4 mAb and CsA was observed as well. The increased co-stimulated CD28 and CD40 IL-12 production could be suppressed by MPA. CsA and RPM had no inhibitory effect on the IL-12 production.Conclusions CD28/CD40 co-stimulatory pathway plays the key role in lymphocyte activation and Th1/Th2 cytokine production. CsA, RPM and MPA can inhibit co-stimulated lymphocyte's Th1 and Th2 cytokine production. CsA and CTLA4 mAb have co-inhibitory effect on co-stimulated lymphocyte's Th1/Th2 cytokines production. CD40 L mAb decreases the Th1 cytokines production(including IL-12) and increases the Th2 (mainly IL-4) production, which may be the mechanism of its longevity effect on allograft.

[Objective] To assess the efficacy and announcements of minimally invasive percutaneous nephrolitho-tripsy (MPCNL) for patients with upper ureteral calculi and typeⅡ diabetes mellitus. [Methods] Retrospective investigation was performed on 35 cases suffering from upper ureteral calculi and type Ⅱ diabetes mellitus, who were treated with MPCNL from July 2004 to May 2007 after control of serum glucose and treatment of other medical diseases. [Results] The operation succeeded in 35 cases, immediate phase Ⅰ lithotripsy was performed in 33 cases and delayed phase Ⅱ lithotripsy in 2 cases with single tract in all the cases. Average operation time was 125 minutes, stone-free rate was 86.7%. Hemorrhage was found in 3 cases during and after the operation in which two cases were treated with hemostyptic or clamping the nephrostomy tube and 1 case was supported by blood transfusion. Severe complications did not occur during nephrolithotripsy. 4 cases had fever, and recovered after the intensive use of antibiotics. Average nephrostomy tube stay was 6 days. Average hospitalization stay was 14 days. [Conclusion] Minimally invasive percutaneous nephrolithotomy is safe and effective in treating Skilled operation, control of blood glucose and proper use of antibiotics are the keys for treatment of upper ureteral calculi in patients with type 2 diabetes mellitus.

Objective To investigate the histopathological changes of mucosa avulsed ureters reconstructed with tubularized peritoneal free grafts and bladder mucosa grafts.Methods 18 adult dogs were randomly divided into 3 groups.After the ureteral mucosa was avulsed to about 3-5 cm,the tubularized peritoneal free grafts or peritoneal free grafts and ureteral stents were placed in the injured ureters in the treated groups,while a simple stent was placed in the ureters in the control group.The ureters were examined by histological analysis 10 weeks after operation.Results In the control group,atresia or severe stenosis of injured ureters occurred,and no regenerated mucosa was observed.In the group reconstructed with peritoneum,no obvious stenosis was observed,and histological examination showed the constitutions of the reconstructed parts were similar to the normal appearance.Slight distension occurred in 1 dog in the group reconstructed with bladder mucosa,but no obvious stenosis was observed,and the lumens of all the dogs in this group were uniformly lined with 5-8 lays transitional epithelium.Neovascularization was evident beneath the mucosa and some chronic inflammatory cells and fibroblasts were present in the subepithelial layer.Conclusion The tubularized peritoneal free grafts and the bladder mucosal grafts are optimal substitutes to the avulsed mucosa of the ureter.

[Objective] To assess the efficacy and safety of mini-percutaneous nephrolithotomy(M-PCNL)with holmium laser(Ho:YAG)in treatment of staghorn kidney calculi.[Methods] From December 2004 to October 2006,50 cases of partial-staghorn stone and 36 cases of complete-staghorn stone underwent M-PCNL at our institute,and the clinical data was retrospectively analysed.[Results] In 86 cases,they were treated with one-stage operation in 68 cases(79.1%),two-stage in 18 cases(20.9%),of which single channel was used in 80 cases(93%),and dual-channel in 6 cases(7%).Complete stone clearance was achieved in 74 renal units,giving an overall clearance rate of 86%.The average operative time was 114 minutes.The duration of hospitalization was 5~10 days with an average of 6.4 days in one-stage stone-free clearance patients.Urinry tract infection(>38.5℃,>2 days)after operation was seen in 8 patients;Only 1 patient required 400 ml blood transfusion after operation.There were no other several complications.[Conclusions] Mini-percutaneous nephrolithotomy(M-PCNL)with holmium laser(Ho:YAG)can fragment staghorn kidney calculi quickly and reduce the length of time of operation.It is an effective and safe technique for staghorn kidney calculi.

Objective To evaluate the occourance of complication in minimally invasive percutaneous nephrolithotomy (MPCNL) and effective management to deal with complication. Methods From April 2002 to December 2006, 412 patients underwent MPCNL in treatment of upper urinary calculi at our institute, and the clinical data was retrospectively collected, occourance and management to deal with complication were retrospectively analysed. Results Among 412 patients with 458 cases of operation, complication was found in 61 cases(13.3%). 4 cases (0.87%)complicated with injury of pleura and aeropleura. 3 patients (0.66%) found severe hemorrhage in operation, and were cured conservatively. 8 patients(1.75%) were unable to put double-J tube in operation due to visual ambiguity. Urinry tract infection( >38.5℃, >2 days) after operation was seen in 16 patients(3.49%);Double-J tube location was dysfunction after operation in 5 patients(1.09%) through KUB. The pain of PCN tunnel after operatin was found in 14 patients(3.06%). Shedding of nephrostomy tube after operation was found in 9 patients. 2 patients(0.44%) complicated with severe hemorrhage after operation were successfully treated with blood transfusion and super-selective arterial embolization. There were no severe hemorrhage needing nephrectomy and abdominal organ injure. Conclusions The rate of complication in MPCNL is lower by improvement and innovation of this technique, renal severe hemorrhage in operation, delayed hemorrhage and infection after MPCNL is the several complication and must take active prevention and cure measure.

The different effects of cyclosporine and rapamycin on tumor progress and metastasis and their mechanisms were investigated. BTT-T739-gfp cell line stably expressed green fluorescence protein was intracutaneously inoculated into 24 mice. One week later, the mice were randomly divided into 3 groups and treated intraperitoneally by normal saline (as control), cyclosporine and rapamycin respectively. Survival rate and tumor volume were measured. The tumor metastasis, pathological angiogenesis and expression of angiogenesis-associated genes were analyzed. The metastasis analysis in lung and liver were also accomplished under the fluorescent microscope. Compared with the normal saline and cyclosporine, the general immunosuppressive dosage of rapamycin effectively inhibited the progress and metastasis of the established tumors. It was the rapamycin that improved the survival rate of tumor-beared mice and decreased the developmental velocity of tumor volume, to which was significantly different from the control and cyclosporine groups on the 12th day and 14th day. Experimentally, rapamycin inhibited tumor growth through angiogenesis and metastases repression in the established mouse model. From a mechanistic perspective, rapamycin showed anti-angiogenetic activities related to decrease of VEGF-A production which was a result of the down-regulation on the transcriptional level of VEGF-A and its transcription activator HIF-1 alpha. It implied that conventional immunosuppressants showed different therapeutic roles on established tumors. Rapamycin, not cyclosporine could inhibit the tumor growth and metastasis of which was referred to anti-angiogenesis.