In order to further standardize the diagnosis and treatment of long-term systemic complications in kidney transplant recipients,Branch of Organ Transplantation of Chinese Medical Association initiated the formulation of"Clinical Diagnosis and Treatment Guidelines for Long-term Systemic Complications in Kidney Transplant Recipients in China".Experts on organ transplantation were organized to summarize and integrate the latest progress in this field based on existing clinical guidelines,systematic evaluations,case studies,expert consensus.The guideline was formed after multiple rounds of discussion and reaching a consensus which included complications of hematological system,central nervous system,cardiovascular system,ocular,cutaneous and osteoporosis disorders.The full text focuses on 27 clinical problems and forms 40 recommendations,mainly involving the risk factors,classification,diagnosis,treatment and prevention of various complications.This guideline graded the quality of evidence and the strength of recommendation for each clinical issue using 2009 Oxford Centre for Evidence-Based Medicine(OCEBM)Grading and Strength of Recommendation criteria,so as to provide reference for the diagnosis and treatment of late complications,comprehensively improve the management capacity of clinicians to benefit kidney transplant recipients.

Objective:To evaluate the effect of applying high-fidelity simulation model in the teaching of lower urinary tract injury.Methods:A total of 50 junior medical students majoring in clinical medicine were enrolled. They were randomly assigned to the control group or the experimental group. The students in the control group were taught using the traditional method involving PPT presentation and videos on lower urinary tract anatomy, surgical basis of lower urinary tract injury, and operative methods for lower urinary tract injury. The students in the experimental group were taught using the simulation model for observation and related operation. After four class hours (40 minutes/class hour) of teaching, the students in the two groups were subjected to theoretical assessment and questionnaire survey. The differences between the two groups were compared and analyzed using the t and χ 2 tests in SPSS 26.0. Results:The total scores of theoretical assessment were (36.80±4.00) and (33.12±3.62) in the experimental group and the control group, respectively, and the difference was significant ( P<0.05). The results of the questionnaire showed that the self-evaluation of the experimental group was better than that of the control group in the mastery of theoretical knowledge, clinical operation, early treatment, operation process, and key steps, and the differences were statistically significant ( P<0.05). Conclusions:Compared with the traditional teaching method, the high-fidelity simulation model improves the efficiency of learning anatomy knowledge and operation process, and promotes the mastery of important and difficult knowledge in lower urinary tract injury. This method merits popularization.

Objective:To explore the clinical characteristics, diagnosis and treatment of secondary adrenocortical insufficiency(SACI)after kidney transplantation.Methods:Retrospective analysis was conducted for clinical data of 12 recipients with SACI after transplantation from March 2018 to November 2019(observation group). Meanwhile, 10 healthy subjects(control group)were randomly selected for in-hospital physical reexaminations during the same period. General data and morning cortisol levels of adrenocorticotropic hormone(ACTH)and aldosterone were compared between two groups.Results:In observation group, there were 8 male and 4 female with an average age of (43.67±8.81) years. Six cases(50.0%)of SACI occurred during recovery period within 30 days and 3 cases(25.0%)within 30 to 90 days post-transplantation. Deceased citizen donation(DCD)was performed in 9 cases(75.0%)and re-transplanted in 3 cases(25.0%). Oral immunosuppressive regiments were administered in a low-dose prednisone-based triple/quadruple regimen. The mean eGFR of observation group was(54.08±20.03)ml/min. The first patient had adrenal crisis, the fourth had sole symptom of fatigue and the remainder stayed asymptomatic. All of them had persistent hyperkalemia and hyponatremia. The average level of plasma cortisol was(62.24±24.16)mmol/L and it was much lower than normal in all patients at 8 am. The determination of plasma ACTH at 8 am showed that 7 patients(58.33%)were lower than normal and the remaining 5 slightly surpassed the low limit of normal. The average level of plasma cortisol at 8 am was significantly lower in observation group than that in control group(141.34±26.28)nmol/L( t=-7.349, P<0.001). The average ACTH level of observation group at 8 am was(1.08±0.515)pmol/l and it was significantly lower than that of control group(2.53±1.06)pmol/L( t=-4.178, P<0.001). The level of aldosterone was normal in both groups and showed no significant difference. All patients in observation group received an intravenous injection of hydrocortisone with satisfactory outcomes. Conclusions:Transplant surgeons should be on a high alert for an occurrence of SACI in renal transplant recipients. Serum potassium and sodium levels may be the predictors of SACI.

Objective To explore whether therapeutic dosing timing of proteasome inhibitor bortezomib(BZ) would impact its clinical efficacy .Methods From 2012 to 2018 ,35 biopsy-confirmed cases of acute antibody-mediated kidney transplant rejection (AMR) were collected .They received intravenous immunoglobulin (IVIG) plus sirolimus (Sir) plus bortezomib (BZ) .Three groups were assigned according to dosing timing of BZ .After a diagnosis of AMR ,ET (early treatment ) group began BZ dosing within 7 days (n=16) while DT (delayed treatment) group within 8-14 days (n=11) and LT (late treatment) group > 14 days (n= 8).Their clinical parameters and incidence of complications were analyzed .Results DSA reversal rate of ET ,DT and LT groups was 87 .5％ , 45 .5％ and 25 .0％ (P=0 .006) while DSA declining rate 93 .8％ ,90 .9％ and 50％ respectively (P=0 .019);recurrent rate of AMR was lower in ET/DT group than LT group (6 .6％ vs 10％ vs 75％ , P=0 .042) .No significant differences existed in blood perfusion score of allograft at 1 month post-dosing among three groups .In three groups ,creatinine (Cr) of ET group was lower than DT group at month 1/3/12 while DT group was lower than LT group .No significant difference existed in the incidence of adverse reactions among 3 groups .Conclusions More likely to enter the window period , early dosing of BZ is more effective for treating acute AMR .An earlier intervention yields a better efficacy .

Objective After the islet transplantation,observed blood glucose and survival time in the islet transplantation mice model to explore the effect of intestinal epithelial γδT cell in islet transplantation rejection.Methods Established the mice model of islet transplantation,divided into wild type mice group,γδ gene knockout mice group and γδ gene knockout γδT cell reinfusion mice group,observed blood glucose in 1,3,5,7,9,11,13,15,17,19,21,23,25,27,29 days after surgery and pathological conditions aft er two weeks of transplantation.Results After transplantation,the rising blood glucose of wild type mice group and γδ gene knockout γδT cell reinfusion mice group were significantly slower than that of γδ gene knockout mice group (P＜0.05),but there was no significant difference in between two groups (P＞0.05).The survival time of wild-type mice group was (27±2) days,and γδ gene knockout γδT cell reinfusion mice group was (24±1) days,they were significantly longer than (17±3) days of γδ gene knockout mice group (P＜ 0.05).Conclusion As a special kind of T cells,γδT intestinal epithelial cell plays an important role in the islet transplantation rejection.

Objective To investigate the effect of mycophenolate mofetil (MMF) on the changes of intestinal gamma delta (γδ) T cells and the secretion of plasma IL-6 and TNF-α.Methods Adult male C57BL/6 (C57) mice were randomly divided into two groups by SAS 9.1.3 software:normal saline (NS) group and MMF group.The changes of γδ T cells in each intestinal segment of mice were detected by flow cytometry.ELISA was used to determine the levels of serum IL-6 and TNF-α.Results As compared with the NS group,the ratio of γδ T cells in the epithelial cell to lymphocyte (IEL) of the intestinal tract decreased,and the concentrations of plasma IL-6 and TNF-α increased in MFF group (P＜0.05 for all).Conclusion In mycophenolic acid-related enteritis,the proportion of γδ T cells in intestinal IEL decreased,and the secretion of IL-6 and TNF-α increased.

Objective To investigate the etiology, clinical characteristics, diagnosis and treatment of intestinal complications after renal transplantation. Methods Clinical data of 47 patients presenting with intestinal complications following renal transplantation were retrospectively analyzed. The etiology, clinical characteristics and treatment experience of intestinal complications were summarized. Results Forty-seven patients with intestinal complications after renal transplantation were followed up for 3-36 months with the median time of 18 months. Intestinal complications included the upper gastrointestinal bleeding in 4 cases, the lower gastrointestinal bleeding in 1 case, acute enteritis in 25 cases, chronic enteritis in 12 cases, intestinal tuberculosis in 1 case, colon cancer in 1 case, and intestinal obstruction in 3 cases, respectively. Among patients with gastrointestinal bleeding, the symptoms occurred after the use of high-dose adrenal cortex hormone in 4 cases and 2 patients developed hemorrhagic shock. In patients with acute enteritis, 7 cases received immunosuppressants for the first time during the perioperative period of renal transplantation, the remaining18 patients had dirty diet or catched cold and 4 were positive for pathogens. Among patients with chronic enteritis,plasma concentrations of mycophenolic acid or tacrolimus were elevated in 12 patients, water, electrolyte, and acidbase imbalance was detected, 2 were positive for pathogens, and 8 were accompanied with severe anemia. One case of intestinal obstruction occurred during the perioperative period of renal transplantation, and 2 cases experienced toxic shock. According to the type and severity of disease, symptomatic and etiological treatments were actively implemented.In the 47 patients, 45 were cured and 2 died from the lower gastrointestinal bleeding and respiratory failure caused by lung metastasis of colon cancer. Three patients suffered from transplanted renal insufficiency. Conclusions The intestinal complications after renal transplantation are diverse, which are correlated with the imbalance of intestinal homeostasis.Both the acute and chronic diseases can cause various degrees of damage to the function of transplanted kidneys. Clinical prognosis is poor at the presence of severe complications. Active prevention and management should be implemented to reduce the risk of postoperative complications and enhance the cure rate.

Objective To describe the experiences when different methods were used to treat early-onset antibody-mediated rejection (AMR) after kidney transplantation.Methods The clinical data of 42 recipients who experienced early-onset acute AMR after kidney transplantation in our department from Jan.2010 to Apr.2016 were retrospectively analyzed.The recipients were divided into 3 groups based on different strategies against AMR:group A (plasma exchange with intravenous immunoglobin);group B (bortezomib solo),and group C (combination of bortezomib and sirolimus).Results All the AMR episodes were diagnosed by kidney biopsy 9-27 days after transplantation.The AMR reversal rate in groups B and C was significantly higher than that in group A (100％ versus 60.00％,P=0.034;100％ versus 60.00％,P=0.007).The AMR recurrence rate in groups B and C was significantly lower than that in group A (0 versus 41.67％,P =0.035;0 versus 41.67％,P =0.007).The recipient survival rate was 100％ in all the three groups.There were 11 graft losses in group A,and none in group B or C.The graft survival rate in group B at 6 months,1 year and 3 years was significantly higher than in group A (100％ versus 60.00％,P =0.034;100％ versus 55.00％,P =0.021;100％ versus 50.00％,P =0.013).The graft survival rate in group C at 6 months and 1 year was significantly higher than in group A (100％ versus 60.00％,P =0.007;100％ versus 55.00％,P =0.003).There was no significant difference in AMR reversal rate,AMR recurrence rate and graft survival rate between groups B and C.There was no significant difference in incidences of infection,hyperlipidemia and bone marrow suppression among the three groups.The incidence of diarrhea in groups B and C was significantly higher than in group A (50.00％ versus 0,P =0.001;42.86％ versus 0,P =0.001).The incidence of peripheral neuritis in group B was significantly higher than in group A (25.00％ versus 0,P =0.02),but similar to group C.There was no significant difference in average serum creatinine level among three groups within 1 year after treatment (P＞ 0.05).Antibodies against human leukocyte antigen (HLA) and donor specific antibodies were detected in all the 42 recipients before treatment.The negative conversion ratio of panel reactive antibody (PRA) in group A was significantly lower than in groups B and C (10.00％ versus 87.50％,P＜ 0.001;10.00％ versus 92.86％,P ＜ 0.001).The PRA recurrence rate in group A was significantly higher than in groups B and C (85.00％ versus 37.50％,P＜0.001;85.00％ versus 0,P＜0.001),while that in group B was significantly higher than in group C (37.50％ versus 0,P =0.014).The ratio of Treg in peripheral blood at 3-12 month after treatment in group C was significantly higher than in groups A and B (P＜0.05).Conclusion Treatment for early-onset AMR after kidney transplantation based on bortezomib might be an effective and safe strategy.Graft longterm survival might benefit from the combination of bortezomib and sirolimus.

Objective To investigate the effect of preoperative hyperbaric oxygen therapy upon the incidence of hypoxemia in patients after renal transplantation. Methods In the experimental group, 55 patients received hyperbaric oxygen therapy prior to renal transplantation, and 66 counterparts in the control group underwent conventional renal transplantation. Postoperatively, the incidence of hypoxemia, pulmonary infection, time of in-bed oxygen inhalation and length of hospital stay were statistically compared between two groups. Results In the experimental group, 12 among 55 patients (22%) presented with hypoxemia after renal transplantation, and 20 of 66 (30%) in the control group. In the experimental group, 4 cases suffered from pulmonary infection with an incidence of b7%, and 14 (21%) in the control group. In the experimental group, the incidences of hypoxemia and pulmonary infection were lower than those in the control group (both P<0.05). Inthe experimental group, the time of in-bed oxygen inhalation and length of hospital stay were (5.9±2.0) d and (17.7±3.7) d, significantly shorter compared with (6.8±2.6) d and (20.5±4.2) d in the control group (both P<0.05). Conclusions Prior to renal transplantation, hyperbaric oxygen therapy can significantly reduce the risk of hypoxemia and pulmonary infection after renal transplantation, which can be served as a conventional preventive measure against the incidence of hypoxemia following renal transplantation.

Objective To investigate the hemostatic function of biological glue in renal trauma.Methods Establishment of rab-bit kidney scratch,partial nephrectomy and renal injury penetrating wound models were available with a biological glue and hemo-static powder processing,observed and recorded the amount of bleeding and bleeding time.Tissue sample were transected from the wound of kidneys in each group after a month,and the renal wound healing condition was observed by pathological examination.Re-sults The hemostatic function of biological glue was better than styptic powder,the amount of bleeding in biological glue group and hemostatic powder group of kidney scratched model were(1.39±0.09)mL,(1.77±0.44)mL,the difference was not statistically significant(P =0.115);the bleeding time were(5.02 ±0.23)s,(66.40± 7.35)s,the difference was statistically significant(P <0.01);the amount of bleeding in two models of partial nephrectomy and renal penetrating wound were(2.07±0.25)mL,(11.42± 1.33)mL;(2.01 ± 0.36)mL,(3.95 ± 0.39)mL and bleeding time were(6.16 ± 0.69)s,(139.38 ± 8.97)s;(7.68 ± 0.80)s, (144.26±9.27)s,the differences were statistically significant(P <0.01).Pathology results showed that the wounds healed well. Conclusion The hemostatic function of biological glue in renal trauma were remarkable and stable,and was worth to be further promoted.