| Part? 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(?2=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 ? 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. |
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