【作者】 代将；

【导师】 钱传云； 许汪斌；

【作者基本信息】 昆明医学院 ， 麻醉学， 2008， 硕士

【摘要】 引言:慢性肾功能衰竭是一种进展性疾病,有潜在无法治疗的可能。肾脏异体移植手术已成为可以接受的治疗慢性肾衰的方法。成功的肾移植可以改善患者的生存质量和延长其寿命。但肾移植患者的长期预后,依赖于移植受者对移植物的耐受性。供体的排斥反应是肾移植最为常见的并发症。鉴别早期移植排斥反应的失败将导致不可挽回的损失,并且移植物的损害实际上先于临床和生物化学检查异常发生。目前,没有单项的临床、生化、影像诊断能判断肾移植排斥反应或者从其它肾脏疾病进程中鉴别排斥反应。最近对细胞膜磷脂的分解的现象进行广泛的研究,发现尤其在脑的实验模型中如脑缺血、缺氧、低血糖、癫痫和中枢性损伤等,细胞膜分解更为常见。在肾移植中,移植物的排斥反应也会导致细胞损伤,这种情况下,监测移植物细胞间液的甘油变化尤其有意义。血乳酸水平的测定作为评估组织缺氧的一种方法。血乳酸水平是非特异性氧化损害。在排斥反应期间,可能反映早期移植物的灌注改变。方法:此次临床实验中有9例病人被选入研究。在手术结束时,于移植肾上极,皮质层内直视下置一根微透析管,透析管外部连接一个装满生理等渗透析液的微泵。手术最后,放置同样的微透析导管与患者的腹部皮下(作为自身对照),关腹。手术后,每隔一个小时,对采集的透析样本中的葡萄糖、乳酸、丙酮酸、甘油进行实时定量的测定。同时对病人进行常规的监测肾功能变化及临床观察。此次临床实验研究中,不干涉其临床用药。以乳酸浓度2mmol/L以下为正常乳酸浓度,大于2mmol/L为乳酸异常。结果:1、血尿素氮从术前的16.73±5.77mmol/l,在术后的两天内快速降到8.68±3.39 mmol/l,与既往比较其P值均小于0.05。并在以后的监测时间里尿素氮维持在6-8 mmol/l的正常水平。2、血肌酐从术前的984.2±244.79ummol/l,在术后两天内快速降到283.06±102.99 ummol/l,与既往比较其P值均小于0.05。并在以后的监测时间里维持在120-200 ummol/l的水平。3、移植肾的甘油水平明显低与对照组皮下的甘油(P=0.000)。术后早期,皮下甘油有明显升高,140.73±52.35 umol/L到672.57±194.62umol/L。可持续19个小时左右。在术后的57个小时再次出现一个升高,持续约25个小时后下降。与此同时,肾脏的甘油高峰与皮下甘油第二次吻合,但升高幅度低于皮下。4、移植肾的甘油在研究中并没有明显成倍的升高,从69.54±19.36 umol/L到318.93±105.94 umol/L。每隔一个小时的移植肾甘油均值比较P值均大于0.05。5、在研究中,甘油和乳酸有较好的相关性(R=0.487,P=0.000)。随着甘油水平的升高,乳酸也有相应的升高。在所有病人总体正常组乳酸与异常组的比较,正常组甘油平均为86.21±31.65 umol/L,异常组为204.37±77.76 umol/L,P=0.000。差异有统计学意义。结论:1.微透析技术是一种可以应用于临床实时监测移植肾早期代谢变化的先进方法。2.甘油保持在一个较为稳定的正常水平,预示病人预后良好。3.乳酸浓度的升高对细胞有一定的损害。更多还原

【Abstract】 Backgrounds:Chronic renal function failure（CRF）is a progressive and fatal disease.Renal all transplantation has become an accepted means of treating humans with chronic renal failure.When successful,a renal allograft may offer the recipient an improved quality of life and extended lifespan.But the long-term prognosis of a kidney transplantation patient is highly dependent on recipient acceptance of the allograft.Rejection of the donor kidney is a common complication.Failure to identify early graft rejection may result in the irretrievable loss of the organ and damage to the graft may be substantial prior to the onset of clinical and biochemical abnormalities.There is currently no single clinical, biochemical,or diagnostic imaging test to diagnose renal allograft rejection or to differentiate rejection from other disease processes of the allograft.Recently,increased lipolytic activity has mainly been studied by measuring phospholipids extracted from tissue homogenate samples in animal models of ischemia,hypoxia,hypoglycemia and epilepsy. Interstitial glycerol harvested by microdialysis seems to be a marker for monitoring of membrane lipolysis.Graft rejection leads to cell injury after renal transplantation.Under this circumstance,it is important to monitor the changes of glycerin in intercellular fluid of graft.The.level of blood lactate may be useful for evaluating anoxic tissue and reflect non-specificity oxidative lesion.During the reject reaction,lactate may reflect early changes of graft.Methods:There are nine patients in this clinical experiment.Before the operation is over,we put amicrodialysis catheter upper pole and in lamina cortex of the graft.External part of microdialysis catheter link to a minipump with fulling load of iso-osmia dialysate.At the same time,we put the same microdialysis catheter in abdominal subcutance,consecutive serial samples are collected at 1-hintervals after the operation,glucose, lactate,pyruvate and glycerol concentrations are measured.At the same time,patients do some routine examination and are observed continually. In this clinical empirical study,clinical medications are let alone. Lactate concentration below 2mmol/L is normal and exceeding 2mmol/L is abnormal.Results:Urea nitrogen post-operative quickly decrease from 16.73±5.77 mmol/l to 8.68±3.39mmol/l（p＜0.05）.Urea nitrogen maintain 6-8mmol/l of normal level.Carnine post-operative quickly decrease from 984.2±244.?9ummol/l to 283.06±102.99ummol/l（P＜0.05）.Carnine maintain 120-200ummol/l of normal level.The glycerin in graft obviously is lower than in subcutance（P=0.000）. Nonage of post-operative,the glycerin in subcutance obviously increase from 140.73±52.35umol/L to 672.57±194.62umol/L and maintain 19 hours. At 57^thhours,the glycerin in subcutance emergence thesecond time heightening.At thesame time,the glycerin in graft heighten.The glycerin in graft do not duplicatly heightened after operation. The range is from 69.54±19.36umol/L to 318.93±105.94umol/L ummol/l. The glycerin of every other one hour comparation is not statistical significance（P＞0.05）In our study,lactate and glycerin of the graft have better correlation （R=0.289,P=0.000）.All patients including normal group（86.21±31.65） umol/L and abnormal group（204.37±77.76）umol/L,glycerin of the graft in abnormal obviously exceed normal group（P=0.000）.Conclusion:Microdialysis method allows continuous bedside monitoring the changes of metabolism in the graft.After renal transplantation of relatives in vivo,the glycerin in graft maintains stable level and has no dupilicatily increasing.With the increasing of lactate,the glycerin in graft also increases. It is damage for the increasing concentration of lactate.更多还原