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血管外科技术在器官移植中的应用
血管外科技术是普通外科技术的延续和发展,重要的特点是操作要求极为精细、准确和无损伤.血管外科技术涉及血管的暴露、游离、阻断、切开、缝合及吻合或移植等一系列操作.近年来,以动脉造影、血管栓塞、球囊扩张和支架置放为主要内容的血管介入技术成为血管外科技术中有活力和发展快的部分.
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中国器官移植术后结核病临床诊疗指南(2016版)
结核病是实体器官移植(solid organ transplantation,SOT)术后一种较为少见但后果严重的感染性疾病,SOT受者结核病患病率明显高于正常人群.由于免疫抑制剂的长期使用,抗结核药物肝肾毒性及其与免疫抑制剂相互的代谢干扰,使得SOT受者临床抗结核治疗复杂性明显增加,致死率明显高于非移植结核病患者.
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免疫抑制剂在器官移植中的应用
免疫抑制剂在器官移植排斥反应的预防和治疗中有极其重要的作用.
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器官移植基础与临床研究进展
早在公元前5世纪,据传中国的神医扁鹊就成功地进行过换心术.
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与器官移植相关的精神状况评估及常见精神障碍
器官移植已成为治疗器官功能衰竭的有效手段,是20世纪医学进展令人瞩目的学科之一.随着新型免疫抑制剂的使用以及移植后的长期随访管理制度的建立等,全世界的器官移植数量在过去10年里增长很快.然而,器官来源的短缺在很大程度上限制了器官移植的发展.供体和受体之间数的不平衡性导致了等待器官时间的延长,增加了等待序列中受体的死亡率.随着以往的生物医学模式向现今的生物-心理-社会医学模式的转变,国内外学者对器官移植患者出现的情绪障碍、心理排斥反应、心理同化现象以及患者的心理社会功能康复、心理社会因素等给予了广泛关注,患者的精神和心理问题正如传统的医学问题一样,也会影响器官移植终的成功与否[1].本文综述与器官移植相关的精神状况评估及常见的精神障碍概况.
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器官移植及其引发的心理、伦理和法律问题
器官移植是20世纪医学领域重要的进展之一,但伴随着器官移植也引发了一些心理、伦理和法律问题,对这些问题关注将有利于器官移植的健康发展.本文主要介绍由器官移植引发的心理、伦理和法律问题.
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实体器官移植术后抗巨细胞病毒的治疗进展
随着器官移植技术及其相关领域和学科技术的进步,在国内外各大器官移植中心,只要手术适应证选择得当,接受器官移植受者术后的近期效果已经被充分肯定.为了能够更好体现器官移植技术在生命科学中的优越价值,医学界开始将关注点向器官移植手术前后更远的时间范围延伸.涉及器官移植术后远期生存效果的因素众多,焦点之一是克服由免疫抑制剂诱发的感染、肿瘤及代谢紊乱.致力于新型免疫抑制剂研发自然是具前景和诱惑力的,但在目前情况下,仍然有大量理论和临床依据指导我们改进实际的临床工作,进而提高器官移植受者的长期生存率.对移植术后巨细胞病毒(CMV)感染的防治就是可预见的、能够改善移植受者预后的现实和典型的例子.
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实体器官移植受者巨细胞病毒感染的危险因素及实验室诊断方法
人巨细胞病毒(CMV)是一种重妻的条件致病病原体,属疱疹病毒β亚科的双螺旋DNA病毒,是人类疱疹病毒中大的一组.因被它感染后的细胞肿胀很大,并有巨大包涵体而得名.巨细胞病毒在正常宿主感染后常呈现为潜伏感染或无症状的慢性感染.在器官移植受者中由于机体免疫力低下容易被巨细胞病毒感染,不同器官移植cMv病的发病率分别为:肾脏8%、心脏25%、肝胰29%、心肺39%[1].
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人工肝支持系统并同种异体肝移植治疗重症肝炎5例
背景:由于肝移植的特殊性,目前面临的大的问题是能否及时获得供体进行肝移植治疗,另外寻找合适的肝移植前过渡支持方法,以提高手术成功率,改善患者预后也是目前该领域的重点之一.目的:观察在人工肝支持系统支持下行同种异体肝移植治疗重症肝炎的效果.设计:回顾性病例分析.单位:安徽医科大学第三附属医院普外科器官移植中心.对象:选择2004-06/2005-05安徽医科大学第三附属医院器官移植中心在人工肝支持系统支持下行同种异体肝移植治疗重症肝炎5例,均为男性,年龄25~48岁.纳入患者均符合2000-09西安全国传染病与寄生虫学术会议关于重症肝炎的诊断和分期标准;符合常规肝移植指征;患者和家属均对治疗知情同意.治疗方案经医院伦理委员会批准.方法:全部患者在肝移植前采用非生物型人工肝行血浆置换和持续静脉血液滤过的方式行人工肝支持治疗.取来自于20~38岁男性成人的供肝,肝移植前均取得本人及其直系亲属的许可,并签署器官捐献同意书.5例肝移植受者均行经典非转流原位肝移植.主要观察指标:肝移植后随访31~38个月,每个月回院复查肝肾功能.结果:5例肝移植均获得成功,其中1例患者在肝移植后出现肾功能衰竭及肺部感染,于肝移植后2周死亡;另外4例在随访期间未出现排异反应,乙型肝炎复发等不良并发症,4例患者生活工作正常.结论:同种异体肝移植是治疗重症肝炎有效方法,人工肝支持系统可作为肝移植前过渡支持治疗的有效手段.
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Endovascular management in liver transplantation
Liver transplantation was developed for the treatment of hepatic failure, and the first human liver transplantation was done in 1963. From the 1990 s,liver transplantation was generally accepted as a treatment modality for both end-stage liver disease and selected liver malignancies. Initially, liver transplantation was started with deceased donor whole-size liver transplantation (whole-size LT) as in other organ transplantation, but there is now a shortage of deceased liver donors has occurred. As a solution, deceased donor split liver transplantation (split LT) began in 1989 and living donor liver transplantation (LDLT) in the early 1990 s. Current liver transplantation techniques include whole-size LT, reduced-size liver transplantation (reduced-size LT), split LT and single or dual LDLT. Two donors give a part of their livers to one adult recipient simultaneously in dual LDLT.
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新型免疫抑制剂在器官移植上的应用分析
近代器官移植由于还未能彻底解决人体排异反应的难题,所以常影响移植器官存活的时间.为此世界各国的医药工作者进行了不懈的努力,开展了同种移植器官排斥免疫学的研究,如采用正确合理的组织配型、供移植用器官的保存方法、手术前预处理方式的改进等,还应用免疫抑制剂这一重要手段来减少排斥反应.
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器官移植患者的霉酚酸酯治疗药物监测
麦考酚酸酯(霉酚酸酯,mycophenlate mofetil,MMF)是麦考酚酸(霉酚酸,mycophenolic acid,MPA)的一种酯类衍生物.MMF无生物活性,口服后迅速水解为具活性的MPA.MMF是近年来发现的一种新型免疫抑制剂,临床上主要用于预防和治疗器官移植排斥反应.2004年的一项调查发现,79%的肾移植、48%的肝移植和75%的心脏移植患者均服用MMF[1].
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Immunosuppressive strategies and management
Advances in immunosuppressive therapy have significantly improved short-term allograft and patient survival.However,chronic allograft failure,antibody mediated rejection,recurrent diseases and immunosuppressive drug associated adverse effects remain serious barriers to long-term survival and quality of life.New immunosuppressive agents and protocols are being evaluated to combat these problems.Importantly,clinicians must work to manage post-transplant complications and avoid complex medication regimens,which will potentiate drug interactions and non.compliance.Different organs have different immunogenicities and each recipient has a unique clinical and immunologic profile.The clinician must recognize these variations and customize the immunosuppressive regimens and treatment protocols based on the individual condition.The general principles of an individualized immunosuppressive protocol should take the following factors into account:organ type,donor and recipient characteristics,quality of the donor organ,recipienVs medical history,recipient's undedying disease,immunologic risk for acute rejection,potential co-morbidity related to immunosuppression,significant druginteractions,medication costs and patient compliance.In addition,the combination of immunosuppressive drugs must have a pharmacologic rationale to achieve the desired goal of suppressing the individual's immune system to render the patient tolerant to the allograft while minimizing co-morbidities.For the past few years,many clinical strategies have been applied in an attempt to improve graft survival or to reduce immunsuppressants induced side-effects.Specific protocols include steroid or CNI avoidance,minimization or withdraw,desensitization,and treatment for antibody mediated rejection,disease specific,and pediatric specific.The short-term outcomes from these different strategies are promising but the long-term results remain to be determined.Unfortunately,current immunosuppressive agents or strategies have failed to adequately control chronic rejection in most of solid organ transplantation except liver transplantation.Eady post-transplant complications aye generally related to the operation,the severity of pre-operative illness,immunologic status,and the quality of the donor organ.Careful recipient and donor selection is paramount to minimize severity of disease and medical comorbidities.These early complications include allograft dysfunction,cardiovascular and hemodynamic instability,and immunosuppressive drug-induced adverse effects.Acute infection remains a common and serious early complication despite new and effective drug therapies,placing the responsibility on the clinician for early recognition and treatment.Emerging resistant bacteria and fungi require early and aggressive intervention.Unlike infection,early aUograft rejection is usually limited and manageable with the newer immunosuppressive agents.However,it must be distinguished from other causes of allograft dysfunction(ie.recurrent hepatitis C,ealcineurin induced nephrotoxicity,or infection).Recently approved Cylex@immune cell function assay allows clinicians to tailor and individualize immunosuppression to prevent organ rejection while minimizing infection and complications.Improved patient and allograft survival has enabled transplant recipients to reach milestones and return to productive lives provided they are compliant. It was also challenged the clinician to manage the long-term complications of immunosuppression therapy, adverse drug interaction, recurrent diseases and chronic allograft failure. Long-term immunosuppressive therapy places transplant recipients at risk for renal insufficiency, cardiovascular and metabolic diseases, de novo malignancies, and psychosocial challenges. The management of viral hepatitis C re-infection, chronic allograft nephropathy, vasculopathy, and obliterative bronchiolitis is currently the greatest challenges facing the transplant specialist. The management of immunosuppressants induced adverse effects/drug interactions, chronic allograft failure and recurrent disease is dependent on regular clinical follow-up, an accurate diagnosis and appropriate treatment.Our challenge for the future will be to develop strategies to determine the best, cost-effective regimens for an individual patient to prevent long-term graft loss. I believe the management of immunosuppression and posttransplant complications is best met with a multidisciplinary team approach. This presentation will discuss the current immunosuppressive strategies and the common post-transplant complications. It is designed to help the clinician recognize individual risk factors and provide appropriate management.
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器官移植中心器官联合移植的历史、现状及展望
20世纪50年代,在美国波士顿施行了全球首例成功的肾移植,此后,临床肝、胰腺、肺、心脏、小肠等实体器官移植相继取得实质性突破.随着移植技术的发展及新型免疫抑制剂的不断问世,器官移植已经成为挽救众多器官功能衰竭患者生命的有效手段.迄今为止,全球已施行各种器官移植超过100万例次,长期存活者不断增多.但是,单个器官移植的成功并不能挽救同时出现2个或2个以上器官功能衰竭患者的生命,器官联合移植与多器官移植技术应运而生,经过20余年的发展,取得了长足进步,丰富了器官移植学科的内涵.
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器官移植后的个体化免疫抑制治疗
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.
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关注活体器官移植供者安全
在器官移植技术日益成熟的今天,全世界器官移植医师都面临着同一个挑战--无法获得足够的尸体器官来救治更多的生命,迫于这种形势,近年来活体器官移植得到迅速发展.活体器官捐赠,要同时考虑供者和受者的利益和价值问题,如果不能保证供者的安全和健康利益,就是用一个人的生命去换另一个的生命,这在伦理学和一般社会道德上是难以接受的.
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再论器官移植的实验研究
我在去年本刊的述评中说过:"实验研究是临床医学的先导、基础、依据和保证",肯定了实验研究在器官移植学科中的重要作用.从本刊选稿中也有同样体会,1997年全年刊出论著76篇,实验研究占一半有余,为39篇.回顾上次述评内容,意犹未尽,适值重逢本期实验研究重点号,再谈几点,以作补充: