【作者】 王琳；

【导师】 刘章锁；

【作者基本信息】 郑州大学 ， 内科学（肾脏病学）， 2017， 博士

【摘要】 第一部分基于三种不同供肾来源的肾移植术后患者临床疗效分析背景和目的早在1954年,美国医师Merrill进行了世界上首例活体亲属肾脏移植手术,器官移植手术迅速开展并在内科治疗学的带动下不断走向成熟。其中,肾移植手术因其理想的疗效和预后得到医学专家的青睐和广大患者的认可。在过去的30多年里,国内器官移植供体主要为亲属活体和尸体器官两大来源,以死囚器官捐献为主的尸体器官曾经是我国器官移植手术最主要的供体。2015年1月,我国政府全面禁止使用尸体器官,公民自愿器官捐献继而取代死囚尸体器官捐献;同时,亲属活体器官供体也成为器官供应的有效来源,极大地缓解了器官移植供体紧张的局面。在此之前的2011年5月,卫生部在多家定点医院启动了心脏死亡捐献器官移植的试点工作,极大地缓解了目前器官移植的供需矛盾。心脏死亡器官捐献分控制型和非控制型两种,其肾移植短期和长期效果接近与其它类型的移植手术。但每年一定数量的肾移植术后患者因种种原因出现排斥反应、继发感染等多种并发症,致使术后人/肾存活率降低,进一步影响病人肾脏功能和身心健康。研究提示:群体反应抗体(PRA)>50%、排斥反应、非创伤性供者、重复移植手术等,诸多因素均可提高心死亡肾移植受者出现移植物功能延迟恢复和移植肾功能衰竭的机率。目前,慢性移植物功能减退的机制仍未完全明了,但异体免疫反应是公认的最主要的原因,分为免疫性和非免疫性两类。前者系供体抗原依赖的相关因素,如人类白细胞抗原(HLA)错配、急性排斥反应的发生、较高的PRA水平或非特异性炎症反应;后者系脑死亡时间、缺血/再灌注损伤、供肾质量以及供者存在长期糖尿病、高血压病史等。我国心脏死亡器官捐献供肾移植尚处于起步阶段,开展时间较短、数量较少,同时缺乏大规模全面的针对不同供肾来源的肾移植术后患者临床疗效及术后不良事件相关影响因素的分析。本研究收集郑州市第七人民医院自2009年以来开展的包括上述三种不同供肾来源肾移植手术308例的临床资料,调查患者术后出现移植肾排斥反应、移植肾功能衰竭等并发症的情况,并整理病人对应的临床资料包括血液生化、影像学、肾脏穿刺活检之病理表现等辅助检查资料,进行详细地临床疗效分析,同时比较三组患者术后肾功能恢复情况及不良事件发生率,分析不同时间节点影响不良事件的危险因素;探讨不同供体来源的肾移植术后并发症发生的原因,并对影响并发症的相关因素进行分析,为肾移植术后健康指导、病情监测及治疗改进提供理论依据。方法采用回顾性研究方法,收集308例上述三种不同供肾来源的肾移植患者的一般资料及术后临床监测指标,包括:肾移植术后不同时间节点病人肾功能恢复情况、肾移植术后并发感染、死亡的比率;采用SPSS17.0统计学软件分析,计量统计量值均以?x±s表示(人/肾存活率除外),采取描述性统计分析、方差检验、非条件Logistic多元回归分析、Cox多因素回归分析、Pearson相关分析等统计方法,了解三组不同供肾来源的肾移植术后患者人/肾存活率,评价患者影像学检查与不同时间肾功能恢复之间的相关关系,探析影响患者和移植肾存活率的危险因素。结果1.研究人群基线资料2009.6.1——2014.12.31郑州市第七人民医院共开展共开展肾移植手术308例,供肾来源如下:尸体供肾、亲属供肾例和心死亡供者(CIII类),平均年龄(37.93±19.47)岁,其中男性211人(68.51%),女性97人(31.49%),男女比例为1:0.46,失访20例,失访率6.49%,有效资料288例,尸体供肾、亲属供肾和心死亡供肾各组分别为182例、71例和35例,亲属供受关系分别为亲子(67.61%)、同胞(21.13%)和夫妻关系(11.26%),心死亡供者20例,年龄30.13±5.24岁,病因分别为颅脑外伤(55%)、脑卒中(40%)、和急性食物中毒(5%),心死亡供体来源肾手术比例逐年增加,由最初的8.45%升至53.66%。2.肾移植术后1个月内治疗效果在182例尸肾移植患者(A组)中,在术后1个月内180例(98.90%)患者存活,2例(1.10%)患者死亡,存活患者中29例(15.93%)未能完全恢复正常,7例(3.85%)需行血液透析治疗,术后28天151例肾功能完全恢复正常(82.97%);在71例尸肾移植患者(B组)中,在术后1个月内患者无死亡,2例曾发生移植肾延迟恢复,后全部脱离血液透析治疗,64例(90.14%)肾功能完全恢复正常;在35例心死亡肾移植患者(C组)中,在术后1个月内34例(97.14%)患者存活,1例(2.86%)患者死亡,存活患者中29例(82.86%)完全恢复正常,2例(5.71%)需行血液透析治疗。三组治疗效果进行比较,无统计学差异(P>0.05);对1个月内术后并发症两组进行比较:分别将A、B两组和B、C两组进行组间比较,差异具有统计学意义(P<0.05),提示亲属活体供肾移植术后1个月,患者肾功能恢复优于其它两组患者。3.肾移植术后1年内治疗效果在A组中,在术后1年内175例(96.15%)患者存活,7例患者死亡(3.85%),134例(73.63%)患者肾功能正常,41例(22.53%)患者出现移植肾功能不全,其中8例(4.40%)行血液透析治疗;在B组中,在术后1年内患者4例死亡,57例(80.28%)肾功能完全恢复正常,11例(15.49%)患者肾功能不全,其中2例(2.82%)行血液透析治疗;在C组中,在术后1年内34例(97.14%)患者存活,1例(2.86%)患者死亡,25例(71.43%)完全恢复正常,未出现血液透析病例,三组进行比较,无统计学差异(χ2=0.697P=0.404),分别将A、B两组和B、C两组进行组间比较时,差异亦无统计学意义(P>0.05),表明:就远期并发症发病率而言,亲属活体供肾移植术后患者与其它两组接近。4.三组不同供肾来源的肾移植患者各检测指标相关性比较三组患者术后1个月及1年CNI谷值及彩超血流指数、肾活检CADI评分,各组差异无统计学意义(P>0.05)。应用线性回归对数据进行分析,肾动脉的RI、PI与术后6个月、1年的e GFR呈负相关(P<0.05);环孢素谷浓度与Cs A-NT及其CADI无相关关系(P>0.05),提示Co A-NT的发生发展与环孢素谷浓度无相关性。5.三组不同供肾来源的肾移植患者术后并发症分析A、B、C三组肾移植患者术后1月内常见并发症依次为:肺部感染(23.50%)、代谢综合征(21.91%)、急性排斥反应(16.73%),三组肾移植患者术后1年内常见并发症依次为:肺部感染(35.83%)、急性排斥反应(28.35%)、慢性性排斥反应(13.39%),三组比较差异无统计学意义(P>0.05)。既往存在糖尿病、急性排斥反应是患者继发肺部感染的独立危险因素,与对照组比,既往有糖尿病病史的患者,发生继发感染的风险增加了1.842倍;既往存在急性排斥反应病史的患者,感染的风险增加2.367倍;而预防性应用更昔洛韦为肺部感染的保护因素,即与没有使用上述患者相比,发生肺部感染的风险减少了43.5%(OR=0.435)。6.三组肾移植患者术后死亡相关分析将三组肾移植术后患者1个月内及术后3个月、6个月和12个月的人/肾存活率进行比较分析,发现各组差异无统计学意义(P>0.05)。慢性排斥和感染是移植肾功能丧失的主要原因,而肾移植患者死亡的主要原因是难以控制的感染和心脑血管疾病;进行Cox多因素回归分析,提示:降低患者移植肾存活率的独立危险因素分别是既往存在移植史、糖尿病、急性排斥反应、高血压、细菌感染和DGF(P<0.05);降低患者存活率的独立危险因素分别是既往存在DGF、糖尿病、高血压、急性排斥反应和真菌感染(P<0.05)。结论心死亡供肾移植与传统尸体供肾移植和亲属活体供肾移植在人/肾存活、术后并发症等方面无统计学差异,急性排斥反应、高血压、糖尿病、DGF、真菌感染是影响患者存活的独立危险因素。第二部分基于三种不同供肾来源的肾移植术后患者生存质量评估背景和目的生存质量(quality of life,QOL),又称生活质量或生命质量,研究始于20世纪30年代的美国,发展到70年代末逐渐备受医学界关注。它是机体健康、社会关系、独立水平、个人信仰、心理状态等概念的反映,具有多维性、主观性和文化特异性。医学领域将生命质量的理论和医学实际相结合,研究疾病对生命质量造成的生理、心理及社会等诸多方面的影响。在其中,广为应用的有WHO生活质量评定量表(WHOQOL-100)及简表(WHOQOL-BRIEF)、简明健康测量量表(MOS SF-36)、诺丁汉健康量表(NHP)和中华生存质量量表。其中,SF-36应用最为广泛,它是上世纪90年代美国波士顿健康研究所研制的简明健康调查问卷,从生理功能(physiological function,PF)、生理职能(role-physiea,RP)等8个维度全面概括了被调查者的生命质量。有研究认为免疫抑制药物的长期应用,昂贵的经济负担,对慢性排斥反应的担忧,对移植肾失功能的恐惧,长期反复的随诊复查,多种药物引起的各种不良反应以及家庭角色、社会适应的再调整等从躯体健康与功能、社会经济地位、心理、精神及家庭等各方面影响患者的生活满意度。HRQOL体系的建立和研究,作为评估疗效的指标之一,提示病人对结果的主观评价,体现了现代医学对人的价值更为全面的尊重和理解。肾移植患者作为一类特殊群体,在手术前大多经历了长期的血液透析或腹膜透析,常并发高血压、贫血、电解质代谢紊乱等病症,长期经历多种并发症的困扰和折磨。移植手术挽救了众多慢性肾功能衰竭患者的生命,患者肾移植手术的成功率及肾存活率较高,人/肾1年存活率分别为95.6%/93.0%,5年存活率为87.5%/82%,挽救了病人的生命,但随着术后时长的推移,肾移植患者会呈现出不同的特征性的心理变化。在移植早期阶段患者感到欣慰、满足、乐观、重获新生的快乐感。而在肾移植手术初期恢复后,其对手术期望值过高,心理压力较重,易发生心理冲突和应激反应,同时面临终生服药、定期复查及病情复发等让诸多问题,又会变得沮丧、失望、烦躁、悲观等一系列不同程度的焦虑抑郁症状。随着术后时间的延长以及治疗和随访状态的适应,患者焦虑、抑郁症状逐渐减轻,后精神心理趋于稳定,与肾移植状态达成心理相容、整合过程[8]。据调查,焦虑和抑郁是肾移植患者术后较为常见的心理反应,焦虑发生率在17%-28%之间,抑郁的发生率在22%-41.4%之间。二者可造成患者心境烦躁,或坐立不宁、紧张担心、焦虑不安,或情绪消沉、自卑抑郁、闷闷不乐,甚至悲观厌世,严重者可有自残、自杀的企图或行为,部分转为慢性长期迁延不愈。这不仅影响正常的生存生活状态,也影响着患者的功能愈后。器官移植专业的医师对疾病治疗方法的选择和治疗效果的评价转向能反映病人生命质量及心理状态,协助肾移植状态患者摆脱焦虑、抑郁症状状态,保持积极向上、乐观开朗的生活状态,从而顺利回归社会。我国传统器官移植来源为尸体、亲属捐献,尸体来源器官移植已于2015年在全国全面废止,而心脏死亡器官捐献是扩大器官来源的有效途径,而如今肾移植术后患者为尸体、亲属捐献,尸体来源器官移植三种状态并存,学术界缺乏尸体供肾、亲属捐献、心脏死亡器官捐献三种不同器官来源肾移植术后患者生活质量和心理状况比较分析,作为临床医师,不仅要关注这三类肾移植患者排斥反应的控制、并发症的处理、移植肾功能的维持,更应重视他们的生存质量和心理健康,如肾移植患者家庭关系、生产生活、包括焦虑和抑郁等心理状态的变化。目前肾移植领域的研究集中在存活率、移植失败、急慢性排斥等的治疗方面,而针对肾移植术后患者生存质量与精神心理评估方面的研究较少。本研究应用SF-36简明健康测量量表、焦虑自评量表和抑郁自评量表,调查尸体供肾、亲属捐献及心死亡捐献供肾三种不同供肾来源的肾移植术后患者的生存质量及精神心理状况,探寻影响患者生存质量的生理、心理、社会因素及公共卫生等相关因素,以便为肾移植患者实施切实有效的社会、人文及心理干预,为制定合理的治疗方案、个性化的健康教育提供理论依据。方法对2015年1月-2015年12月在郑州市第七人民医院门诊复诊的肾移植患者,以非随机便利抽样的方法对其进行调查,对照组选择中国人健康人群常模及透析人群常模。在医院伦理委员会批准并取得患者知情同意情况下,实施问卷调查。调查问卷当场发放当场回收问卷由4部分组成:(1)一般资料问卷(自制):收集包括患者年龄、职业、家庭人均月收入、年治疗费用、医疗保险、商业保险及民政救助等;(2)肾移植专科情况问卷(自制):收集肾移植术后患者供肾来源、术前等待时长、术后时长、复诊情况、所经历的感染和排斥次数、免疫抑制方案、目前存在并发症、肾功能状态及移植相关住院次数等情况;(3)简明健康测量量表即健康状况调查问卷SF-36,用于调查某种特定慢性疾病患者的生存质量,该量表含有36个条目,从8个维度测定被调查者的生存质量。在8个维度评分分基础上,可分别计算生理健康总分和心理健康总分;(4)焦虑自评量表(SAS)和抑郁自评量表(SDS):依照评分分无、轻度、中度、重度4个等级;结果1.研究人群基线资料2015.1.1——2015.12.31郑州市第七人民医院肾移植门诊向前来复查的肾移植术后患者发放一般资料问卷、健康状况调查问卷SF-36、肾移植专科情况问卷、焦虑自评表、抑郁自评表等调查问卷,共入选247份,年龄21-62岁,年龄(37.71±17.47)岁,其中男性156人(63.16%),女性91人(36.84%),男女比例为1:0.58。入选的患者中,尸体供肾、亲属供肾及心死亡捐献供肾来源的分别为92例(37.25%)、61例(24.70%)和94例(38.06%)。在三种不同供肾来源的肾移植术后患者中,除术后时间、免疫抑制方案存在统计学差异外(P<0.01),其它分类指标分布无统计学差异(P>0.05)。2.研究工具的信度分析重测人群中SF-36的躯体健康总评和精神健康总评的重测信度系数分别为0.81和0.77,而SAS及SDS的重测信度系数分别为0.79和0.76,均在0.75以上,提示各测量工具重测信度良好;用克隆巴赫(Chronbach’s alpha)系数进行调查量表的内部一致性信度检验,SF-36的躯体健康总评和精神健康总评两个维度的Chronbach’s alpha系数分别为0.79和0.82,焦虑自评量表及抑郁自评量表的cronbach’s alpha系数分别为0.76和0.73,提示各测量工具的内部各条目的一致性较好。3肾移植患者生存质量评估分析3.1生存质量评定量表测评结果247例肾移植患者SF-36量表PF、RP、BP、GH、VT、SF、RE和MH等8个维度的评分分别为:81.9±14.2、54.7±15.9、82.7±9.5、50.5±10.4、53.7±11.3、59.8±12.2、68.2±13.5和67.9±10.7,其总评分为526.5±32.8,将其与健康人群常模、透析人群常模进行统计分析,三组总评分存在统计学差异(P<0.05)。将其与健康人群常模相比,肾移植患者总评分(526.5±32.8)低于健康人群常模(630.7±32.6),t=1.45,P<0.05,高于透析患者(322.1±39.9),t=3.91,P<0.05;同时,将肾移植患者SF-36生存质量量表八个维度评分分别与健康人群常模、透析患者进行组间两两比较,肾移植患者各维度评分低于健康人群常模(P<0.05或P<0.01),肾移植患者各维度评分高于透析患者(P<0.05或P<0.01)。将尸体供肾、亲属供肾和心死亡供肾三组患者SF-36量表评分分别为513.8±19.6、538.2±24.1和520.4±21.7,其差异无统计学意义(P>0.05);同时,将三组SF-36生命质量调查八个维度的调查结果进行比较,组成生存质量的各个维度评分亦无统计学差异(P>0.05)3.2肾移植患者生存质量影响因素分析经单因素分析及多元线性逐步回归性分析,所经历的排斥次数、是否规律复诊及肾功能状态三类因素对肾移植生理健康总分影响较大,其标准偏回归系数分别为-0.82、0.66和-0.54(P<0.05),肾功能状态、存在的并发症和年均治疗费用三类因素对肾移植心理健康总分影响较大,其标准偏回归系数分别为-0.62、-0.57和-0.54(P<0.05)。4.肾移植术后患者焦虑、抑郁评估分析4.1肾移植术后患者焦虑、抑郁评分结果肾移植患者SAS和SDS两个量表的评分分别为:43.35±10.01和45.55±9.72,肾移植患者SAS和SDS评分高于健康人群常模(P<0.05);焦虑总检出率18.62%(46/247),焦虑总检出率16.19%(40/247)。尸体供肾、亲属供肾和心死亡供肾各组患者焦虑检出率分别为20.65%、17.39%和18.09%,抑郁检出率分别为14.13%、11.48%和13.83%,三组焦虑及抑郁检出率差异无统计学意义(P>0.05);进一步行焦虑及抑郁患者严重程度的比较,其病情分布状况无统计学差异(P>0.05)。4.2肾移植术后患者焦虑、抑郁状态影响因素分析经单因素分析及多元线性逐步回归性分析,所经历的排斥次数、存在的并发症及肾功能状态三类因素对肾移植患者焦虑评分影响较大,其标准偏回归系数分别为0.73、0.61和0.59(P<0.05);存在的并发症、肾功能状态和所经历的排斥次数三类因素对肾移植患者抑郁评分影响较大,其标准偏回归系数分别为0.73、0.70和0.56(P<0.05)。5肾移植患者生存质量与焦虑、抑郁状态的关系SAS得分与生存质量维度中活力(VT)、社会功能(SF)、情感职能(RE)、精神健康(MH)得分呈负相关(P<0.01),其r值分别为-0.32、-0.41、-0.37和-0.44,提示抑郁情绪与生存质量中的心理健康关系密切;SDS得分与生存质量维度中活力(VT)、情感职能(RE)、精神健康(MH)得分呈负相关(P<0.01),其r值分别为-0.39、-0.41、-0.27和-0.46,提示抑郁情绪与生存质量中的心理健康存在一定相关关系。焦虑具有较大的负向预测作用,解释了9.3%的生存质量变异,抑郁对生存质量也有显著著的负向预测作用,解释了7.7%的生存质量变异。结论将尸体供肾、亲属供肾和心死亡供肾三组患者进行生存质量分析比较,三组患者无明显差异;所经历的排斥次数、是否规律复诊及肾功能状态三类因素对肾移植生理健康总分影响较大。更多还原

【Abstract】 PartⅠ The study on the curative effect for the kidney transplantation from three types of donorsBackground and Objective In 1954,an American doctor named Merrill had an operation of the living-relative renal transplantation on the twin brothersfirstly.From then on,the technology of the renal transplantation has developed faster and faster.The renal transplantation ranks in the first place on the operation cases and the success rate of organ transplantation.The renal transplantation has been accepted widely by medical professionals and patients,for the satisfied effect and prognosis.In the past twenty years,there are two sources for kidney transplantation in the domestic: living-relative organ and cadaveric organ.Cadaveric organ was once the main source of domestic organ transplant donors,while it was banned from 2015 in our country.Then the citizens of voluntary organ donation replaced it forever.The living related kidney transplantation,as an important source,has lessed the renal pressure.The office of the Ministry of Health initiated the donation of cardiac death since 2011 in variousprovinces and cities all over the courtry.The pilot work of the organ transplantation eased the strain of the organ source to a large extent.It is an effective complement to the organ donation besides the relatives of organ transplant in the current.With continuous improvements of surgical techniques and immunosuppressive drugs,the survival rate of the human or kidney of the renal transplantation have improved significantly.According to statistics,it is approximate for the renal transplant recipients of the curative effect between short-term and long-term of the renal transplantation from the cardiac death donation,besides the control and non control and othe sources of the organ donation.The graft survival rate within the first year is more than 90% and the rate within the six year is more than 70%.Howerer,there are all sorts of reasons lead to the emergence of acute rejection and chronic rejection reaction and other complications every year in some patients,which leads to the decrease of the long-term survival rate of the renal transplantation,affecting the outcome and quality of life.Since many complications after renal transplantation has aroused people’s attention,it is found by multi-factor analysis that different aspects such as panel reactive antibody levels by over 50%,glucocorticoid resistance rejection,repeated transplantation of organs and non traumatic causes,death and donor age more than 35 yearsmay increase the chance for delayed graft function and dialysis for transplantation recipients,about two times.The more further research works has to need to carry on on how to avoid or reduce the occurrence of adverse events after renal transplantation,while the risk factors of causing kidney failure is still in progress.At present,the study on the mechanism of the chronic graft dysfunction is still uncertain.In traditional view,the allogeneic immune response is the main and first reason,while there may exist other causes at the same time.The factors leading to allograft dysfunction based on domestic and international researches are divided into two categories: immune’s and non immune’s.Immune factors mainly include the donor antigen dependent factors,such as the occurrence of acute rejection,appropriate immune suppression scheme,high panel reactive antibody levels,human leukocyte antigen mismatch,non specificity inflammation reaction and immune response.Non-immune factors include quality of donor kidney,brain death time,recipient of hypertension,diabetes,ischemic or reperfusion injury,infection of cytomegalovirus,the quality of donor kidney and so on.Some studies have been pointed out that acute rejection is the primary reason of dysfunction,while more studies indicate that other sustained-effect factors such as high blood fat,hypertension and proteinuria factors may cause renal damage.In our country,the organ donation of the heart death for kidney transplantation is still in the initial stage,short-time development,fewer-number cases,and the lack of large-scale studies for the corpse for kidney,living related donor kidney and cardiac death donor kidney transplantation.There is little related-analysis on curative effects and influencing factors of complications coming from three different source of donor kidney,besides patients’ or renal survival rate.In this study,308 cases were enrolled and the clinical data were collected since 2006 in the Seventh People’s Hospital of Zhengzhou City,including three different sources of renal transplantation donor.We studied various complications such as renal function insufficiency,pulmonary infection occurred in patients including blood biochemical,imaging and pathology examination of the renal biopsy,and compared three groups of patients with postoperative renal function recovery and the incidence of adverse events,risk factors for adverse events in different time points;the complication of different donor renal transplantation,and influencing factors the complications were analyzed,providing a theoretical basis for the improvement of health guidance,monitoring and treatment of disease after renal transplantation.Methods The clinical indexes,coming from 308 patients after kidney transplantation three sources of donor kidneys,were collected in the retrospective method,including the general information,the postoperative renal function recovery,the incidence of adverse events and etc.All statistics were demonstrated as?x±s except for the rate of human or kidney survival with SPSS17.0 statistical software.Descriptive statistical analysis,variance analysis,Pearson correlation analysis and other statistical methods were adopted besides the application of Kaplan-Mmeier method for survival rate curve.There is an statistics differencein case of P<0.05 and significant difference in case of P<0.01 among groups.Results 1.Demographic data at baseline The data of population at baseline were collected from June 1,2009 to Noverber 31,2014 in the hospital.There were 308 cases of renal-transplantation operations carried out,including three different sources of donor kidney: cadaveric donation,relative donation and donation of cardiac death(CIII),consisting of 97(31.49%)women and 211 men with 37.93±19.47(68.51%)years old,in which the ratio of the male to the female was 1: 0.46.20 cases were lost to follow-up,meaning the dropout rate was 6.49% while 288 cases were followed up.The amounts of cadaveric donor,relative donor and cardiac death donor were 182 cases,71 cases and 35 cases respectively.The relations of relatives between donors and recipients were parent-child(48 cases),sibling(15 cases)and couple(8 cases).20 cases of cardiac death donors,were 30.13±5.24 years old,in which the causes were trauma(55%),stroke(40%),and acute food poisoning(5%).It is obvious that the proportion of donors after cardiac death increased year by year,from 8.45% to 53.66%.2.The comparison of curative effect in one month after the operation There were 2 cases(1.10%)died,29 cases(15.93%)failed to complete recovery,and 7 cases(3.85%)undergoing hemodialysis treatment.151 cases after 28 days of renal function recoveried to normal(82.97%)in 182 cases of cadaveric renal transplant patients(group A),within one month after operation in 180 cases(98.90%)patients;There no death occurred within one month after operation in 71 cases of cadaveric renal transplant patients(group B),while 2 cases of delayed recovery took placeand 64 cases(90.14%)recovered completely;There was one death(2.86%)occurred within one month after operation in 35 cases of cadaveric renal transplant patients(group C),while 29 cases(82.86%)recovered completely,with 2 cases(5.71%)undergoing hemodialysis treatment.There is no statistical difference in comprison of three groups(P>0.05).But there is statistical difference on complications in comprison of two groups: group A and group B,group B and group C within postoperative one month(P<0.05).It is suggested that the recovery of patients from living-relatives donor for renal transplantation is better than two others.3.The comparison of curative effect within one year after the operation There are 175 cases(96.15%)surived,7 cases died(3.85%),134 cases(73.63%)normal renal function,41 cases(22.53%)renal insufficiency,and 8 cases(4.40%)hemodialysis treatment in group A in one year after the surgery;There are 4 cases died,57 cases(80.28%)renal function returned to normal,11 cases(15.49%)renal insufficiency,2 cases(2.82%)hemodialysis treatment in group B;There are 34 cases(97.14%)surived,,1 case(2.86%)died,25 cases(71.43%)returned to normal in group C,in which no hemodialysis existed.No significant difference exists among the three groups(P>0.05).The same thing happened in two groups: A and B,C and B.No significant difference was found between group A and the other groups in the incidence of long-term complications(P>0.05).4.Relationship of different detecting parameters among three groups Some indicators were compared among the three groups of patients after one month and one year such as CNI valley value,color Doppler ultrasound blood flow index and renal biopsy CADI score.There is no significant difference on the above-mentioned indexes among the three groups(χ2=0.697 P=0.404).There is significantly negative correlation between RI or PI of renal artery’s and e GFR(P> 0.05),and the correlation grew gradual stronger with the extension of time;No significant difference exists among the three groups(P>0.05)between cyclosporine concentration and Cs A-NT or CADI had no correlation(P>0.05),suggesting there was no correlation between Co A-NT and cyclosporine concentration;Same thing happened among indexes of BUN,SCR,SUA and e GFR(P>0.05).5.Analysis for postoperative complications among three groups Common complications after renal transplantation within the first month were pulmonary infection(23.50%),metabolic syndrome(21.91%),acute rejection reaction(16.73%).Common complications after renal transplantation within the first year were pulmonary infection(35.83%),acute rejection(28.35%),chronic rejected reaction(13.39%).There was no statistical difference in comprison of three groups(P>0.05).Diabetes and acute rejection were risk factors independently for pulmonary infection.The risk of secondary infection increased 1.842 times for patients with previous diabetes and the risk increased 2.367 times for patients with the experience of acute rejection response.However,the risk of pulmonary infection reduced to 43.5% when the ganciclovir was be given in preventative oral dose(OR=0.435).6.Kaplan-Meier correlation analysis among three groups There is no statistical difference in comprison of the survival rate of three groups within 1 month,3 months,6 months and 12 months after operation(P>0.05).There were two main reasons leading to graft loss: chronic rejection and infection,two reasons leading to death: unmanageable infection and cardiovascular disease;It was showed that gender,age,transplantation duration,times of transplantation,dialysis time and other factors are not independent risk factors to lower the survival rate of the kidney by the Cox multi-factor regression analysis(P>0.05)while transplantation,hypertension,diabetes mellitus,acute rejection,DGF,bacterial infection are to lower the survival rate of the kidney while experience of acute rejection,hypertension,diabetes Disease,DGF,and fungal infections are independent risk factors for the survival of patients(P<0.05).Conclusion There is no statistical difference in comprison of the postoperative complications and the survival rate among three groups,while the experiences of acute rejection,hypertension,diabetes Disease,DGF,and fungal infections are independent risk factors for the survival of patients.Part Ⅱ The study on the life quality for kidney ransplantation from three types of donorsBackground and Objective The study on the quality of life(QOL)began in the United States at 1930 s.It was concerned with the development of improvement at the end of 70 s.The World Health Organization defines the quality of life as individuals in different cultures and values in the life state of their goals,expectations,standards,and things which they care about.Different country has a different environment on the living and working,resulting in different understanding on the quality of life.It is the reflection on the body health,mental state,level of independence,social relationship and personal belief,which have multidimensional,subjectivity and culture specific nature.The theory,consisting ofthe quality of life and the practice of the medicine,is to study on the impact of some diseases to the quality of life caused besides physiological,psychological and social aspects,which constructs the health system and completes the quality of life evaluation system.There are several assessment tables used widely such as quality of life assessment table,medieal outcomes study 36-iterm short form health survey,Nottingham health measurement scale table and the Chinese quality of life scale.Among them,SF-36 is the most widely application,which was established at the Boston Health Research Institute in the 1990 s.It is a comprehensive summary of the survey of the quality of life from eight dimensions such as physiological function,physiological function and others by the concise health survey questionnaire.Many researches show that long-term application of immunosuppressive drugs,expensive economic burden,fears for chronic rejection,worry about the transplanted kidney dysfunction,long-term repeated following-up,which take an effect on the the patient’s life satisfaction from somatic health and function,social economic status,psychological,spiritual and family affect.The research of quality of life assessment system,as one of the indicators and the evaluation to evaluate the efficacy,shows more comprehensive respect and understanding to the people for modern medicine.It is benefit for clinicians to evaluate the impact of the treatment and make a clear choice of treatment methods.Patients with renal transplantation,as one kind of special groups,have experienced hemodialysis or peritoneal dialysis before the operationfor a period of time.Most of them have some complications such as hypertension,anemia,electrolyte metabolism disorder and etc.Transplant operations save the lives of many chronic renal failure patients in the successful rate.It is observed that the survival rate of patient or kidney withinone year is 95.6%/93.0% respectively,and the survival rate in 5 year is 87.5%/82% respectively.Howerer,renal transplant patients would show different characteristics of psychological changes over long time.Patients may feel comfort,satisfaction,optimism,to regain the joy of new sense,at the early stage of transplantation.Then,they pay plenty expectations on operations with heavy psychological pressure resulting in psychological conflict and stress responses.Some of them become depressed,disappointed,irritability,pessimistic in anxiety and depression symptoms when facing lifelong medication,regular reexamination,disease recrudescence and so on. With the extension of postoperative time and the following-up,symptoms about anxiety and depression reduce gradually,after the mental and psychological stabilization,and the status of renal transplantation to achieve psychological compatibility,integration process.According to the survey,anxiety and depression is common psychological reactions after kidney transplant patients,with the incidence of anxiety in between 17% and 28%,the incidence of depression in between 22% and 41.4%.Both of them result in irritable mood,or sitting restless,nervous,low self-esteem depression,depressed,and even pessimism,whichlead to self mutilation,suicide attempt or behavior,part of which does not heal,affecting not only the normal living state but also the patients immune function,nutritional status,treatment compliance,even the function of the kidney transplantation.Depression is one of risk factors for poor treatment compliance in patients,resulting in adverse outcomes in transplant recipients.Mental factors also play an important role in the quality of life of patients.Depression can lead to a significant decline in physical function and medication compliance,resulting in the increase of the prevalence rate,the recurrence rate and the mortality rate.Self-rating-scale(SDS)has ever been used in the heart transplant recipients.The results showed that scores for transplantation on depression were higher than those in normal persons and depression had a negative effect on the quality of life of transplantation patients.There are several assessment tables for the anxiety widely used such as self-rating anxiety scale(SAS),Hamilton Anxiety Scale,Hamilton anxiety scale(HAMA),state-trait anxiety inventory(STAI).There are several tables assessment tables for the depression such as self-rating depression scale(SDS),Hamilton depression Scale,Beck depression self rating scale and so on.The transformation for the therapy and the therapeutic evaluation of physicians reflects the quality of life and mental state of the patients with organ transplantation,assisting patients to get rid of the symptoms of anxiety and depression and maintain a positive,optimistic,cheerful life state,then returning to society smoothly.There are two sources for the organ transplantation traditionally in our country: living-relatives organ donation and corpse organ donation.The latter has been abolished all over the country since 2015 and organ donation after cardiac death is an effective way to expand the source of organs.There coexists three types of renal transplantation patients at present.Clinicians should pay attention not only to cope with these complications of patients but also the status of psychological,such as family relationship,anxiety and depression and other psychological state.It is of great significance to assess the quality of life and eliminate the psychological barriers,besides promoting postoperative rehabilitation.At present,there are few researches on the quality of life and psychological assessment of patients after kidney transplantation the research on the field of kidney transplantation while excess focus on the treatment of survival rate,allogeneic failure,rejection reaction and etc.The study investigates the life quality and psychological status of renal transplantation patients’,from three types of donors in SF-36 health survey scale,SAS and SDS.It explores the influence factors of affecting the patients’ quality of physiology,psychology,social and public health for renal transplant patients to implement effective social,providing theoretical basis for the formulation of reasonable treatment,individual service.Methods Outpatients with renal transplantation were carried on the investigation with convenience sampling method in the Seventh People’s hospita,with the control group of Chinese healthy people and dialysis population.Under the approval of the hospital ethics committee and consent of patients,we implemented the questionnaire survey.The questionnaires were consists of four parts:(1)The general information questionnaire(homemade),including age,sex and occupation,education,marriage,residence area,living situation,employment status,family income,treatment costs,medical insurance,commercial insurance and civil relief of patients’.(2)Renal transplant specialist questionnaire(homemade): source of renal dornor,preoperative waiting time,postoperative time,times of infection and rejection,times of immunosuppression,complications,renal function,related hospitalization and etc.(3)SF-36 health status questionnaire,containing 36 items of physical health score and mental health,from eight dimensions of determination to assess the quality of life of patients’.(4)Anxiety self rating scale(SAS): containing a total of 20 items,according to the symptom frequency that none,mild,moderate and severe in 4 grades to evaluate severity and the treatment table.(5)Depression self rating scale(SDS): a total of 20 items reflecting the depression patients with subjective feelings,to assess the severity of the individual depression.Results 1.Baseline data of the study population We send special questionnaire to patients including SF-36,SAS and SDS for gathering information of population from January 1,2015 to Noverber 31,2015 in the Seventh People’s Hospital.There were 247 cases enrolled,consisting of 156(63.16%)women and 91(36.84%)man with 37.71±17.47 years old,in which the ratio of the male to the female was 1: 0.58.The amounts of cadaveric donor,relative donor and cardiac death donor were 92 cases(37.25%),61 cases(24.70%)and 94 cases(38.06%)respectively.In three different donor kidney transplantation patients after kidney transplantation,there was no statistically significant difference except for the postoperative time and immune suppression(P<0.01),so other indicators were(P>0.05).2.Reliability analysis of the research instruments The reliability coefficients for retesting were 0.81 and 0.77 in physical and mental assessment of SF-36,0.79 and 0.76 in SAS and SDS respectively,all of which were above 0.75,indicating good reliability;The chronbach’s alpha coefficients were 0.79 and 0.82 in physical and mental assessment of SF-36,0.76 and 0.73 in SAS and SDS by Cronbach’s alpha coefficient of internal consistency reliability,indicating that the measuring tool of internal consistency was well.3.Evaluation of quality of life in 3 patients with renal transplantation 3.1 quality of life assessment scale assessment results 247 cases of patients have taken part in the questionnaire with SF-36 consisting of PF,RP,BP,GH,VT,SF,RE and MH mentions.Eight dimensions scores were 81.9±14.2、54.7±15.9、82.7±9.5、50.5±10.4、53.7±11.3、59.8±12.2、68.2±13.5 and 67.9±10.7,the total score is 526.5±32.8.There was a significant difference in comparion of three groups: heath norm,dialysis norm and patients after renal transplantation,and the total score of the three groups(P < 0.05).The total score of renal transplant patients was lower than healthy people norm(P<0.05 or P<0.01),higher than dialysis patients(322.1±39.9).(T=3.91,P<0.05).The score of eight dimensions was lower than healthy people norm and higher than dialysis patients(P<0.05 or P<0.01).The scores of three groups in SF-36 were 513.8±19.6,538.2±24.1 and 520.4±21.7 respectively.There was no significant difference in comparion of three groups(P> 0.05),the same thing happens in each dimension score(P > 0.05).3.2 Analysis of influencing factors for the life quality of patients with renal transplantation There were some factors such as times of rejection reaction,whether or not regular referral,renal function with great impact on scores of physiological health in the standard partial regression coefficient-0.82,0.66 and 0.54 respectively(P<0.05),by single factor analysis and multivariant linear stepwise regression analysis.There were some factors such as renal function,complications and averageannualcostoftreatmentwith great impact on the score of physiological health in standard partial regression coefficients(-0.62,-0.57 and-0.54)(P < 0.05).4.Assessment of anxiety and depression for patients with renal transplantation 4.1 Scores of anxiety and depression in three groups of patients The SAS and SDS scores of the patients’ were 43.35±10.01 and 45.55±9.72 respectively and scores of patients on SAS and SDS were higher than the healthy people of the norm(P < 0.05).The detection rates of anxiety were 18.62%(46/247)and the rate of anxiety were 16.19%(40/247)in patients.The detection rates of anxiety for three groups of renal patients(cadaveric donor,living-relative and cardiac death)were 20.65%,17.39% and 18.09% respectively,while the detection rates of depression were 14.13%,11.48% and 13.83%.There was no significant difference in three groups of anxiety and depression(P > 0.05),and so werethe severity of anxiety and depression(P > 0.05).4.2 Analysis on the influence factors of anxiety and depression in patients after kidney transplantation There were some factors such as times of rejection reaction,whether or not regular referral,complications and renal function with great impact on the score of anxiety in the standard partial regression coefficient0.73,0.61 and 0.59 respectively(P<0.05),by single factor analysis and multivariant linear stepwise regression analysis.There were some factors such as complications,renal function and times of rejection reaction with great impact on the score of depression in the standard partial regression coefficient(0.73,0.70 and 0.56)(P < 0.05).5.Relationship among the life quality,anxiety and depression in patients with renal transplantation There was negative correlation between the SAS score and dimensions such as vitality,social function,role emotional and mental health with R values-0.32,-0.41,0.37 and-0.44,which meant close relationship between anxiety and the mental health.There was negative correlation between the SDS score and dimensions such as vitality(VT),role emotional(RE),mental health(MH)with R values-0.39,-0.41,-0.27 and-0.46,which meant close relationship between depression and the mental health.Anxiety had a large negative predictive effect,explaining 9.3% of the variance in the quality of life,while depression on the quality of life also had a significant negative predictive effect,explaining 7.7% of the quality of life variation.Conclusions There is no statistical difference in comprison of the postoperative the quality of lifeamong three groups,while some factors such as times of rejection reaction,whether or not regular referral,renal function with great impact on scores of physiological health.更多还原