2017年 · 第97卷第02期

In 1954, American surgeon Murry successfully completed the first kidney transplant in the world, ushering in a new era of organ transplantation. In 1960, Chinese Academician Wu Jieping took the lead in implementing the first human kidney transplantation in China. In the course of more than 60 years of development, many breakthroughs have been made in kidney transplantation at home and abroad, but there are still many fields to be explored in depth by kidney transplantation colleagues. This article summarizes the recent research hotspots of renal transplantation.

A 35-year-old male was admitted to the Department of Endocrinology of Peking Union Medical College Hospital on April 19, 2016 due to roundness of his face, weight gain for 9 years, and aggravation with fatigue for 1 year. Beginning in 2007, the patient's face became rounded and red, his weight increased from 60 kg to 70 kg within 1 year, and his abdominal circumference increased, which was not paid attention to. In 2008, I developed left abdominal colic, and the B-ultrasound in an outside hospital showed "ureteral calculi". After the stone was discharged in the urine, the abdominal pain was relieved and there was no recurrence. In 2009, abdominal skin lesions occurred, and the local hospital considered "tinea corporis". Oral terbinafine 0.25 g/time, once/d, for a total of 14 days, tinea corporis subsided, but it still appears repeatedly. So far, it has been treated with terbinafol for a total of 4 times (the same as above). In 2010, I accidentally discovered purple lines on the skin on the inner side of both thighs. Loss of libido occurred in 2012. In March 2015, I developed easy drowsiness, obvious fatigue, and no soft paralysis. My weight increased from 70 kg to 80 kg within half a year. I went to a local hospital and my blood pressure was checked at 180/140 mmHg (1 mmHg =0.133 kPa). I was diagnosed with "hypertension". I was given nifedipine controlled-release tablets 30 mg/time, once/d. After 2 months of treatment, my blood pressure was re-checked at 150/110 mmHg. In January 2016, the liver and kidney function and electrolyte were examined in the local hospital, and the circadian rhythm of blood cortisol and adrenocorticotropic hormone (ACTH) disappeared (Table 1)。 Overnight low-dose dexamethasone inhibition test (LDDST): not inhibited (blood cortisol 1 523 nmol/L after administration); Classical high-dose dexemide inhibition test (HDDST): can be inhibited (blood cortisol 25 nmol/L after administration). CT scan of the adrenal gland showed that the bilateral medial and lateral adrenal branches were thickened, and the left medial branch was prominent, with a transverse diameter of about 6 mm. Dynamic enhanced MRI of the pituitary gland showed delayed enhancement of the right pituitary gland. Considering "Cushing's disease, secondary hypertension", lacidipine 4 mg/dose, once/d, metoprolol 50 mg/dose, once/d, and blood pressure was controlled at 135/85 mmHg. He visited our hospital in March 2016. The outpatient blood cortisol (8:00 am) was 1116 nmol/L (normal reference value: 110-615 nmol/L), ACTH (8:00 am) was 17.6 pmol/L (normal reference value: 0-10.1 pmol/L), and 24 h urine free cortisol (24 h UFC) was 3 176 nmol (normal reference value: 34-285.7 nmol). Due to the recurrence of tinea corporis in the abdomen, terbinafine was taken orally from March 25 to April 10, 2016 at the same dose as before, and tinea corporis improved after the medication. Deny history of taking antidepressants, long-term glucocorticoids, cottonseed oil, licorice and other drugs. Personal History: Pet doctor, prolonged X-ray exposure for 10 years, no alcohol consumption. Past history, marriage and childbirth history, and family history are not special.

A 60-year-old male was admitted with "sudden right upper abdominal pain for 1 d". With a history of hypertension for more than 10 years, oral nifedipine can control blood pressure. Previous history of cerebral infarction without sequelae. Abdominal ultrasonography after admission revealed a solid tumor between the right liver and kidney, approx. 14.6 cm ×12.0 cm ×9.3 cm. Emergency blood test showed hemoglobin (Hb) 53 g/L and hematocrit 16%. Emergency red blood cell transfusion showed that Hb rose to 103 g/L. Partial thromboplastin time was 44.2 s, fibrinogen was 5.36 g/L, and plasma D-dimer was 2.33 μ g/ml. Emergency abdominal CT showed: retroperitoneal adrenal mass rupture and bleeding. Because of the unstable circulation, the patient underwent right subclavian vein puncture and catheterization in the intensive care unit. The puncture was successful, the depth of catheterization was 16 cm, the catheter was sealed with heparin water, and the chest X-ray film was performed. Chest orthographic radiograph showed ectopic central venous catheter (Figure 1), but the infusion was unobstructed, so the central venous catheter was not removed. The patient's vital signs were stable after blood transfusion and fluid rehydration treatment, and temporary conservative treatment was recommended after multi-department consultation. After 2 days of conservative treatment, circulation and Hb were still unstable, and B-ultrasound showed signs of enlargement of retroperitoneal hematoma, and then ultrasound-guided abdominal puncture did not coagulate, so exploratory laparotomy was planned. The patient's blood pressure after entrance was 200/103 mmHg (1 mmHg =0.133 kPa), pulse oxygen saturation (SpO₂) was 88%. The catheter was removed because there was no blood in the right subclavian vein catheter. The patient was given intravenous injections of midazolam 2 mg, etomidate 6 mg, fentanyl 0.15 mg and rocuronium 50 mg for induction of anesthesia and mechanical ventilation after intubation. After induction, right internal jugular vein puncture was performed, the puncture was smooth, and the blood returned smoothly. Subsequently, the guide wire was inserted, but the guide wire was blocked during placement. After the guide wire was removed, the blood drawn was smooth, but the guide wire placement was still not smooth. Subsequently, 7.5 MHz linear ultrasound examination was used, and it was found that the internal jugular vein (about 10 cm long) had uneven echoes, and the lumen of the probe compression could not be completely closed (Figure 2)。 The right internal jugular vein puncture was abandoned, and another upper extremity vein was opened. Intraoperative continuous infusion of propofol, remifentanil and cis-atracurium maintained anesthesia. The operation went smoothly, with about 500 ml of intraoperative bleeding, 400 ml of plasma, 4 U of red blood cells and 100 ml of autologous blood transfusion, and returned to the general surgical intensive care unit (ICU) with tracheal intubation after operation. Postoperative jugular ultrasound diagnosis: right internal jugular vein thrombosis (partial type). Results of the postoperative pathological diagnosis of the patient: malignant neoplasm of the adrenal gland.

A 55-year-old female was admitted to the hospital in August 2015 due to "intermittent chest and back pain for 1 month 6 years after aortic dissection". In 2009, the ascending aorta and right hemiarch were replaced in the emergency department due to DeBakey type Ⅰ aortic dissection, and the coronary artery and aortic valve were not involved. The postoperative recovery was good without obvious symptoms, and intermittent chest and back pain began 1 month ago. With a history of hypertension for more than 10 years, blood pressure control can be achieved; Renal insufficiency for 3 years, creatinine up to 190 μ mol/L. Systolic blowing-like murmur can be heard in auscultation of the neck and chest, and pulsatile mass can be palpable in abdominal examination without tenderness. Preoperative CT angiography showed that after aortic dissection, ascending aorta and right hemiarch replacement, two intimal ruptures were seen at the distal anastomosis of the artificial blood vessel in the arch, and the contrast agent entered the false lumen through the ruptures. The maximum diameter of thoracic aortic dissection aneurysm was about 65 mm. The celiac trunk artery, superior mesenteric artery and both renal arteries were all supplied with blood from the true lumen. There were multiple ruptures in the abdominal aorta segment, and the dissection involved bilateral common iliac arteries (Figure 1)。 The patient has a history of surgery in the past, so the anatomy of the arch is complicated, and it is difficult to simply observe the axial position of CT and imagine the spatial relationship of three-dimensional reconstruction images. In order to further understand the anatomy of the lesion, the CT data was processed by software before operation, and the interference information was removed, so that the size and location of the rupture could be clearly seen (Figure 2)。 The patient had no other rupture in the thoracic aorta segment. The symptoms of thoracic and back pain this time were considered to be mainly related to the rupture of the arch, and the dissecting aneurysm was at risk of rupture. After careful measurement and preoperative discussion, it was decided to use ventricular septal occluder combined with coil embolization to repair the rupture, and the abdominal aorta segment was not treated temporarily. Because the rupture location is close to the unnamed artery and the left common carotid artery, in order to determine whether the occluder will affect the blood flow of the branches after placement, a transparent lesion model was made by 3D printing technology before operation, and simulated operation was performed in vitro, which showed that the occluder did not affect the blood flow of the branches (Figure 3)。

Arterial stenting has been widely used in the treatment of atherosclerotic diseases. With the accumulation of therapeutic experience, the current mainstream stents expose advanced thrombus and cause restenosis problems also attract people's attention, so fully bioabsorbable stents (BRS) have entered the sight of therapists again. Compared with the conventional non-absorbable stent, it has good biocompatibility and bioabsorptivity. After the BRS is implanted in the stenosis site, it can provide effective support in the early stage to ensure the patency of blood vessels. After the stent is absorbed in the later stage, its decomposition products can be absorbed, utilized or discharged by the body, and there is no residual foreign body in the target blood vessel, which can restore the vasomotor function to the greatest extent and leave room for secondary intervention^[1,2,3,4]。

The homeostasis of iron in the body is mainly achieved by the coordination of systemic iron homeostasis and intracellular iron homeostasis^[1,2]However, systematic iron homeostasis is closely related to the regulatory axis of hepcidin membrane iron transporter. Iron is an essential mineral in the body, which is involved in a wide range of cellular biological processes such as hemoglobin synthesis, DNA replication and enzyme function regulation^[3]Once the regulation of this axis is impaired, it will inevitably lead to iron metabolism disorders, thus affecting the occurrence and development of many diseases^[4]。 Of course, it can also cause bone mass loss and even cause osteoporosis^[5]。 It can be seen that the occurrence of osteoporosis is inextricably related to the regulation of the function of this axis.