猫抓病(cat scratch disease)又名良性淋巴网状细胞增多症,是一种通过猫、狗抓或咬伤所致的传染病,由汉赛巴尔通体(Bartonella henselae)感染引起,临床表现以抓、咬伤处皮肤感染及引流区的淋巴结肿大或化脓为特征.由于该病的发生率低,多以散发为主,临床医师对疾病的认识不足,常易造成误诊、误治.广州医科大学附属第二医院肾移植科近期收治1例肾移植术后猫抓病的患者,借助宏基因组二代测序技术(mNGS)明确诊断,现报告如下.

本文介绍1例胰肾联合移植术后急性移植物抗宿主病受者，根据该受者多器官功能受损表现，结合皮肤病理活检报告、血液供者来源游离DNA检测及急性移植物抗宿主病(aGVHD)相关性蛋白因子等检测，诊断aGVHD，并给予相应预防感染、抑制淋巴细胞增殖、抗炎等治疗。该受者治疗效果不佳，最终死于多器官功能衰竭。本病例提示aGVHD在实体器官移植中发生率低，但风险极高，需早期干预治疗。

Objective:To measure serum cell-free DNA (cf-DNA) and donor-derived cell-free DNA (ddcf-DNA) in simultaneous pancreas-kidney transplantation recipients by the next generation sequencing technology and evaluate the relationship between ddcf-DNA and early acute rejection (AR).Methods:A total of 20 recipients who underwent simultaneous pancreas-kidney transplantation in the Department of Organ Transplantation, the Second Affiliated Hospital of Guangzhou Medical University from June 2019 to June 2021 were enrolled. According to whether there was AR after operation, the 20 recipients were divided into two groups: control group (10 cases) and AR group (10 cases). Three recipients in the control group were selected as the observation group by the random number table. The serum levels of ddcf-DNA were measured before transplantation, 2 h after recanalization of blood vessel of transplanted pancreas, and 1, 3, 7, 14, 30, and 60 d after transplantation. The levels of serum ddcf-DNA in the other 7 recipients in the control group were measured before and 14 and 30 d after transplantation. Meanwhile, the testing time points of serum ddcf-DNA in AR group were as follows: before operation, during rejection and after reversal of rejection. The measurement data of normal distribution between the two groups were compared by group t test. Fisher′s exact probability method was used for counting data comparison. P<0.05 means the difference was statistically significant.Results:The length of ddcf-DNA fragment was 110-350 bp. The length of cf-DNA fragment from the recipients was 100-420 bp. Three recipients in the observation group were marked as cases 1, 2 and 3, respectively. The content of ddcf-DNA of the 3 recipients before operation were 0.49%, 0.55% and 0.32%, respectively. The content of ddcf-DNA increased sharply to 12.05%, 10.64% and 11.05% 2 h after recanalization, and reached its peak after blood flow restored. At the first day after transplantation, the level of ddcf-DNA showed a significant downward trend, and reached a stable state about 30 d after transplantation. The content of ddcf-DNA was (0.71%±0.09%) in the control group and (0.66±0.10)% in the AR group. There was no significant difference between the two groups (t=1.126, P>0.05). The time of diagnosis of rejection in AR group was (17±4) d after transplantation, and the content of serum ddcf-DNA was (5.4±2.0)% when AR was confirmed; while the content of serum ddcf-DNA in the control group was (1.70±0.48)% 2 weeks after transplantation, and the difference was statistically significant (t=-5.59, P<0.05). The rejection was reversed and the recipients condition were stable at (27 ± 4) d after transplantation in the AR group, at which time the content of ddcf-DNA was (0.93 ± 0.32)%. The content of ddcf-DNA in the control group was (0.87±0.25)% on the 30th day after transplantation, and the difference was not statistically significant between the 2 groups (t=-0.497, P>0.05).Conclusions:The serum ddcf-DNA in simultaneous pancreas-kidney transplantation recipients increased significantly when AR occurred. When AR was reversed, the content of ddcf-DNA showed a significant downward trend.

Objective:To explore the clinical efficacy of aspirin plus low molecule heparin for pancreatic thrombosis during simultaneous pancreas and kidney transplantation (SPK).Methods:A total of 129 patients aged 18 years or higher underwent SPK between September 2016 and March 2020.They were divided retrospectively into two groups of aspirin ( n=60) and heparin ( n=69) according to different anticoagulant regimens.The aspirin group received only aspirin 100 mg/d at Day 1 post-operation.The heparin group received subcutaneous injection of enoxaparin 2 000 AxaIU daily for 7 days and followed by aspirin and clopidogrel.Outcomes and complication rates were compared between two groups. Results:All operations were successful without any mortality.In aspirin group, there were 5 cases of pancreatic thrombosis and one patient underwent pancreatectomy.There was no pancreatic thrombosis in heparin group ( P=0.014). There were 8 cases of intestinal anastomotic bleeding in aspirin group and 19 cases in heparin group.Statistically significant inter-group difference existed ( P=0.048). However, no significant inter-group difference existed in delayed recovery or rejection. Conclusions:Heparin anticoagulation can significantly lower the incidence of pancreatic thrombosis after SPK.Despite a higher incidence of intestinal anastomotic bleeding, no serious complication occurs after conservative meaures.

Objective:To analyze the association of pre-transplant risk factors with diabetes mellitus after renal transplantation and examine the significance of preventing the occurrence in kidney transplantation recipients.Methods:A total of 290 kidney transplantation recipients were retrospectively reviewed at our transplantation center from August 2018 to May 2020.Diabetes mellitus after renal transplantation was employed as a primary outcome index.Multivariate Logistic regression model was utilized for constructing A (without adjusting for covariates)、B(covariates include: gender, dialysis mode, type of donation)and C(covariates include: gender, dialysis mode, type of donation, calcineurin inhibitor, antiproliferative drugs, primary disease, fasting blood glucose, 1 h postprandial blood glucose, fasting C peptide, 1 h and 2 h postprandial C peptide, fasting C-peptide index, 1 h postprandial C-peptide index, albumin, triglycerides, total cholesterol)to evaluate the relationship between diabetes mellitus after transplantation and age, body mass index, 2 h postprandial blood glucose(2 h-PG), HbA1c, and 2 h postprandial C-peptide index(2 h-CPI).Results:In model A, age [odds ratio(OR)1.1, 95% confidence interval( CI)1.0~1.1], BMI(OR 1.2, 95% CI 1.0~1.3), 2 h PG(OR 1.2, 95% CI 1.1~1.4), HbA1c(OR 2.7, 95% CI 1.5~4.9), 2 h-CPI(OR 0.7, 95% CI 0.5~1.0), model B/C had similar results with A. Age, BMI, 2 h PG and HbA1c were all risk factors for diabetes mellitus after transplantation while 2 h-CPI was a protective factor.Quartile stratification was analyzed by regression model.And trend test was significant( P<0.05). Conclusions:Age, BMI, 2 h PG, HbA1c and 2 h-CPI are correlated with diabetes mellitus after kidney transplantation.

Objective:To explore the efficacy and safety of simultaneous pancreas and kidney transplantation(SPK)from donors of different ages.Methods:A total of 146 SPK operations were completed at Second Affiliated Hospital of Guangzhou Medical University from September 2016 to June 2020. The donors were divided into three groups: < 18 yrs group(18 cases), 18 to 39 yrs group(85 cases)and 40 yrs and up group(43 cases). The similarities and differences of SPK efficacy were analyzed for different ages.Results:During a follow-up period of (1~45) months, no statistically significant differences existed in postoperative recovery time, transplanted renal function or transplanted pancreatic function. Graft function at 10 days post-operation normalized and no statistical difference existed among three groups. Glycosylated hemoglobin of three groups at 6 month showed no statistical difference among three groups. Medical complication was perioperative infection. And acute rejection was manifested as pancreas duodenum rejection. The incidence of three groups were 0.06, 0.22 and 0.16; the incidence of kidney acute rejection 0.11, 0.05 and 0.09; the incidence of combined acute pancreas and kidney rejection 0.11, 0.05 and 0.09 and three groups showed no statistical difference. Severe surgical complication was poor healing of incision. The incidence of three groups were 0.11, 0.13 and 0.14 and the major serious complications included intestinal leakage, arterial thrombosis and venous thrombosis. The incidence of intestinal leakage in three groups were 0, 0.01 and 0.05, arterial thrombosis 0, 0.01 and 0.05 and venous thrombosis 0, 0 and 0.05 respectively. Thus no statistical difference existed in the incidence of surgical complications. Patient survival rates in 1-year and 3-year post-transplantation in three groups were 85.0%, 95.0% and 90.4%; pancreatic graft survival rates 85%, 91% and 85.8%; despite death, the pancreatic graft survival rates were 100%, 95.8% and 90.6%; kidney graft survival rate 85.0%, 95.0% and 90.4%.Conclusions:After thorough evaluations, detailed surgical procedures and refined surgical skills, SPK from pediatric and elderly donors with certain age limits has similar clinical outcomes to that from adult donors. Besides, elderly donors still need to be carefully evaluated and long-term follow-ups should be further observed.

Objective: To investigate the clinical effect of ipsilateral simultaneous pancreas and kidney transplantation (SPK). Methods: A total of 146 cases of SPK surgeries completed in the Second Affiliated Hospital of Guangzhou Medical University from September 2016 to June 2020 were selected to summarize the outcome, curative effect and complications of the operation. Results: The patients were followed up for 1 to 45 months. Good clinical results were obtained in 146 patients. Renal function indicators suggest that on the 7th day after operation, the serum creatinine returned to normal level [142.4 (108.6, 213.4)μmol/L]. The index of pancreatic function decreased to the normal level as expected. The level of blood amylase was 160.5(109.3, 249.8) U/L within 7 days after operation, and then decreased. The trend of urinary amylase was similar to that of blood amylase, which was 240(121.0, 370.0) U/L 7 days after operation, and glycosylated hemoglobin decreased to the normal level (5.8%±1.4%) 1 month after operation. The main medical complications were infection including pulmonary infection (26.03%, 38/146), urinary tract infection (26.03%,38/146), and abdominal infection (4.79%,7/146), acute rejection including renal graft rejection (5.8%,8/146), pancreas/duodenum rejection (18.49%,27/146), and renal graft combined pancreatic graft rejeciton (6.85%,10/146), as well as gastrointestinal bleeding (30.82%,45/146), of which 5 cases were severe bleeding (3.42%, 5/146). The main surgical complications were poor incision healing (10.27%, 15/146), serious surgical complications including arteriovenous thrombosis of the transplanted pancreas (2.05%, 3/146) and intestinal leakage (0.68%,1/146). The 1-year and 3-year patient, renal and pancreatic survival rates were both 92.5%, 91.5% and 89.5%, respectively, and despite the death, the 1-year, 3-year transplanted kidney survival rate was both 99.3%, and 95% for the the 1-year, 3-year pancreas survival rate. Conclusion: Strict preoperative evaluation of the function of large organs, reasonable surgical methods, perioperative anticoagulation, and prompt diagnosis of complications can achieve good clinical results for patients with SPK.

Objective: To summarize the efficacy and safety of the combination of rituximab and ATG as induction therapy in highly sensitized kidney transplant recipients. Methods: Clinical data of patients who received kidney transplantation from donation after cardiac death(DCD) in Organ Transplant Center of Second Affiliated Hospital of Guangzhou Medical University from January 1st 2015 to December 31th 2016 was retrospectively analyzed. Highly sensitized patients with over 30% active panel reactive antibody (PRA>30%) received rituximab, while non-sensitized recipients as controlled group. All selected patients were observed in the renal function, urine protein, hemogram and the variation of PRA at each time point. Acute rejection, infection required hospitalization, delayed graft function(DGF), primary nonfunction (PNF), graft dysfunction, the mortality rate of patients with good allograft function and the graft survival rate were also observed. Results: 46 groups of patients were selected into highly-sensitized group and non-sensitized group. In both groups, there was no statistical difference in the renal function, urine protein and WBC (all P>0.05). Highly sensitized recipients at day 7 and day 14 following the surgery, had a significantly lower percentage of lymphocyte counts and lymphocyte proportion compared to other groups, with statistical differences(all P<0.05). Both groups had a similar incidence of DGF(2.2%) and no occurrence of PNF. 19.5% of highly sensitized recipients experienced acute rejection and 13% in control group. More specifically, no statistical difference was noted in the rate of infection required hospitalization(30.4% vs 22.2%), graft loss(2.2% vs 0) and the mortality rate of patients with good allograft function(4.3% vs 2.2%)(all P>0.05). The graft survival rate was 97.8% in the highly-sensitized group, while 100% in the control group. And the rate of patient survival in these two groups was 95.7% and 97.8%, with no statistical differences(all P>0.05). Conclusions: Immune-induction therapy that combines Rituximab with ATG can significantly inhibit lymphocyte proliferation. It is effective and safe in treating hypersensitive patients. The survival rate of human/kidney of hypersensitive patients in the short and medium term is comparable to those with low immune risk.

Objective To preliminarily explore the clinical efficacy of ipsilateral simultaneous pancreas and kidney transplantation (SPK) .Methods Ipsilateral SPK was performed in 40 patients from September 2016 to August 2018 .During a follow-up period of 6 to 29 months ,we summarized the efficacy and complications of the technique .Results Up to now ,38 patients achieved an exceelent clinical efficacy with no major surgical complications .However ,two patients died of severe pneumonia .The postoperative serum levels of creatinine at 3 ,6 ,12 ,24 months were 107 ,102 ,107 ,110 umol/L ;creatinine clearance rate 64 ,67 ,64 ,63 ml/min;fasting glucose 4 .6 ,5 .1 ,4 .6 ,5 .2 mmol/L ;glycated hemoglobin 4 .8％ , 5 .4％ ,4 .9％ ,5 .2％ respectively .And 1/2-year pancrea and kidney graft survival rates both were 92％ . Complications included kidney graft rejection (n= 11) ,pancreas graft rejection (n= 12) ,simultaneous renal & pancreas graft rejection (n=6) ,renal graft DGF (n=1) ,pulmonary infection (n=14) ,urinary tract infections (n=18) ,gastrointestinal bleeding (n=10) diarrhea (n=6) ,splenic venous thrombosis (n=2) ,incomplete ureteric obstruction of renal allograft (n=3) ,urine leakage (n=1) and pancreas allograft dysfunction (n= 2) .There were no severe surgical complications .After aggressive interventions ,all postoperative complications were cured and none required excision of kidney or pancreas .Conclusions Ipsilateral SPK has definite therapeutic efficacy and it is worth wider popularization .

目的 通过长期病理随访探讨青年受体接受高龄亲属活体供肾肾移植的安全性.方法 根据供体年龄不同,将28例青年受体分为观察组(14例,高龄供体)和对照组(14例,中青年供体).分别比较两组移植肾术后7年的存活情况及术后各时间点的血清肌酐(Scr)水平;比较两组在零时、术后6个月、术后7年移植肾活组织检查(活检)的慢性病理损伤评分;比较两组受体术后6个月、术后7年移植肾间质纤维化相关指标结缔组织生长因子(CTGF)、转化生长因子(TGF)-β、层黏连蛋白(LN)、纤维连接蛋白(FN)及细胞衰老相关指标细胞间连接蛋白(Cx)43及哺乳动物雷帕霉素靶蛋白(mTOR)的表达量.结果 观察组和对照组移植肾术后7年存活率分别为78.5％和92.8％,差异无统计学意义(P>0.05).观察组、对照组术后7 d Scr水平分别为190、160μmol/L,术后1个月Scr水平分别为170、125μmol/L,观察组术后各时间点的Scr水平均高于对照组,差异均有统计学意义(均为P<0.05).观察组移植肾组织零时活检的慢性病理损伤总评分明显高于对照组(P<0.05),但两组术后7年的慢性病理损伤总评分无明显差异(P>0.05).观察组和对照组组内各时间点比较,术后7年活检的慢性病理损伤总评分均高于零时活检及术后6个月活检的慢性病理损伤总评分(均为P<0.05).两组术后7年移植肾组织中CTGF、TGF-β、LN、FN、mTOR、Cx43表达量的比较差异均无统计学意义(均为P>0.05).结论 长期随访结果显示青年受体接受高龄供肾与接受中青年供肾的病理学改变相似,从病理学角度考虑青年受体接受高龄供肾是安全可行的.

Objective To investigate the distribution and drug resistance of pathogens in infected organ donors from donation after the citizen death (DCD).Methods Clinical data of 217 DCD donors from January 2013 to June 2017 were retrospectively analyzed.The phlegm,urine,blood and drainage fluid from all of the donors were routinely cultured.The infection rate of the donors,the composition ratio of pathogens and the distribution of specimen sources were observed and the drug resistance was analyzed.Results Of all the 217 donors,128 were infected and the infection rate was 59％.A total of 218 pathogens were isolated from these infected donors,including 55.5％ (121/218) of gram-negative pathogens,33.5％ (73/218) of gram-positive pathogens followed by 11.0％ (24/218) of fungi.The pathogenic specimens were mainly derived from sputum samples (72.5％),followed by urine (15.6％).The mainly two gram-negative pathogens were Klebsiella pneumonia and Acinetobacter baumannii.Klebsiella pneumonia exhibited varying degree of resistance to commonly used antibiotics,whereas susceptible to imipenem and meropenem.Acinetobacterbaumannii was highly resistant to most of the antibiotics,and the drug resistance rate of imipenem and meropenem was over 60％,displaying a tendency of multi-drug resistance.Staphylococcus aureus,as the mainly gram-positive pathogen,was generally resistant to penicillin and clindamycin,but still sensitive to tovancomycin,teicoplanin and linezolid.Conclusions DCD donors have a high infection rate,and respiratory infection is most common.Gram-negative pathogens are the primary pathogens causing infection in DCD donors.Klebsiella pneumonia maintain susceptible to imipenem and meropenem,while Acinetobacter baumannii reveals a tendency of multi-drug resistance.Gram-positive pathogens are still sensitive to vancomycin,teicoplanin and linezolid.

目的 探索移植前快速冰冻病理活检评估在发现肾小球内微血栓方面的应用价值.方法 供肾获取后在进行移植手术前,进行快速冰冻病理活检,根据肾脏病理组织学评分标准和临床指标进行初步评估,决定供肾是否可以用于进行移植手术.结果 1年中共产生捐献案例88例,有32例进行移植前快速冰冻病理评估,在其中5例的供肾组织学评分中,有4个A级和1个B级,但却因肾小球内多发微血栓形成而导致肾脏弃用.5例供肾捐献者的血肌酐水平基本在正常范围内,且获取前血肌酐水平未见明显升高,凝血功能指标异常明显.对其中供肾进行体外低温机械灌注,并在灌注液中加入50万U尿激酶,并在灌注后再次进行快速冰冻病理活检,供肾肾小球内微血栓未见明显改善,最终弃用该肾脏.结论 因器官捐献者在进行获取手术前经历的病理生理改变,可能会导致临床不能发现的脏器功能损害,在移植前供肾快速冰冻病理可以发现肾脏潜在的病理改变;同时,针对供肾肾小球内微血栓形成后是否可以应用于临床仍需大样本的动物实验和临床研究.

目的:评价肾动脉支架置入术联合药物治疗肾移植术后粥样硬化性肾动脉狭窄(ARAS)患者的疗效.方法:选择肾移植合并ARAS患者93例,随机分为对照组与观察组.对照组行单纯药物治疗,观察组在单纯药物的基础上加用肾动脉支架置入术治疗,比较两组治疗前后血压、心功能指标变化及肾功能改善情况.结果:观察组治疗后收缩压(120.65±12.93)mmHg与舒张压(62.34±3.17)mmHg分别较对照组低 (P>0.05);观察组治疗后LVEDD、心功能分级分别比对照组低,且LVEF(65.65±5.34)%比对照组高 (P<0.05).观察组肾功能获益率95.92%,明显高于对照组肾功能获益率72.73% (P<0.05).结论:肾移植合并ARAS患者行肾动脉支架置入术与药物联合治疗,可有效调节患者血压,并改善其心功能及肾功能.

目的 总结西罗莫司(SRL)在肾移植术后新发恶性肿瘤患者中的临床应用经验.方法 对完成的2 000余例肾移植患者进行随访和统计,共发现在术后新发的恶性肿瘤15例,其中泌尿系统肿瘤6例(40%),呼吸系统肿瘤3例(20%),消化系统肿瘤3例(20%),卡波西肉瘤、子宫内膜癌和黑色素瘤各1例.在明确恶性肿瘤的诊断后,立即进行以SRL为主的免疫抑制方案的调整,并结合肿瘤的生物学特点再辅以手术和放化疗等治疗手段.结果 在所有15例新发恶性肿瘤患者的随访中,有10例一直维持较好的生存状态,并且定期复查肾功能情况稳定.而另外5例患者在发现后2~42个月内死亡,但移植肾功能未见明显变化,且死亡患者中以肺癌、肝癌和前列腺癌较多见.结论 在肾移植术后新发恶性肿瘤患者中,使用以SRL为主的免疫抑制方案可以取得稳定的肾功能的基础上,同时可控制或缓解恶性肿瘤的进展,但新发肿瘤的生物学特点仍是决定患者生存的主要因素.

Objective To investigate the quality of life and psychological status of donors and recipients of living-related donor kidney transplantation. Methods Selected the treatment of living donors in the hospital (n = 80)and recipients(n = 80)from January 2014 to January 2017 as the research objects,and 80 cases of hemodialysis patients at the same period as the control group. Using the SF-36,Zung Self-rating Anxiety Scale (SAS),and the Self-rating Depression Scale(SDS)to evaluate the psychological status of the two groups and com-pared.Results Scores of donors′physiological function,and general health compared with the norms were not sig-nificant(P>0.05),while the somatic pain scores were significantly lower than the norms(P<0.05).There was no difference between the donors group and the norms in scores of vitality,social function and emotional function (P>0.05).The scores of physical health and mental health of recipients were significantly higher than those of the control group(P < 0.05). The donors′ SAS and SDS anxiety and depression scores were significantly higher than the norms(P<0.05).Besides,SAS and SDS anxiety and depression scores of the recipients were also significantly higher than the norms(P < 0.05),but significantly lower than the control group(P < 0.05). Conclusion The living-related donor kidney transplantation does not affect the quality of life and psychological state of the donor, but can improve the quality of life and reduce the anxiety and depression of the recipient.

Objective:To evaluate the effect of preoperative panel reactive antibody(PRA)levels on long-term survival after kidney transplantation. Methods:Data on 1 162 patients underwent first kidney transplantation performed between January 2001 and June 2014 were included in our center. According to the preoperative PRA levels,the patients were divided into negative group( PRA≤10%) and positive group( PRA>10%) ,which were retrospectively analyzed. Results: The 1-,5-,10-year patient survival rates of the negative group calculated by Kaplan-Meier were 96. 8%,89. 4%,78. 6%,respectively,while the positive group were 93. 5%,81. 6%, 65. 4%. The 1-,5-,10 -year death-censored graft survival rates of the negative group were 95. 9%,84. 8%,63. 1%,respectively,while the positive group were 92. 3%,74. 1%,51. 9%. The log-rank test revealed that there was significant difference between the patient and graft survival curves (χ2 =9. 623/11. 019, P=0. 002/0. 001 ) . Cox multivariate analysis found that preoperative PRA levels were independent risk factors for reducing the patient or graft survival rates(P<0. 001). Logistic multivariate regression analysis confirmed the significant association between preoperative PRA levels and the risk of acute rejection ( OR=8. 25,95% CI=2. 86-5. 72, P<0. 001). The 5-,10-year creatinine values were significantly lower in the negative group compared to the positive group(all P<0. 05), while there was no difference in the 1-year. In addition, Logistic multivariate regression analysis confirmed the significant association between preoperative PRA levels and the production of donor specific antibody(DSA)(OR=6. 89,95% CI=4. 52-9. 17,P<0. 05). Conclusion: The detection of preoperative PRA is an important indictor predicting the sensitivity status of the recipients. The preoperative PRA positive recipients need careful monitoring and diagnosis of acute rejection and DSA after kidney transplantation.