佐々木 ひと美

© 2015 Elsevier Inc. Introduction Three-dimensional (3-D) printing systems allow for the creation of surgical models mimicking real tissue. We developed a kidney graft and pelvic cavity replica as a patient-specific 3-D model using a 3-D printing system with simultaneous jetting of different materials and subsequently evaluated the usefulness of surgical simulation and navigation of living kidney transplantation. Methods After generating a stereolithographic file of the organ surface based on multidetector computed tomographic data, we created a 3-D organ model using an inkjet 3-D printer and manufactured a pelvic cavity replica using patient-specific data. Results The patients' individual 3-D printed models were used to plan and guide the surgical procedures for laparoscopic donor nephrectomy and recipient transplantation surgery. The 3-D organ replicas obtained using transparent materials allowed for the creation of models that showed the visceral organs, blood vessels, and other details, thereby overcoming the limitations of conventional image-guided navigation. Our pelvic replicas can be made according to each patient's specific anatomical data, thus representing personalized surgical procedures. This level of detail of the anatomy enables the surgeons and trainees to virtually treat various pelvic conditions before they perform the surgical procedure. The use of these replicas may also reduce the length of the operation and provide better anatomical reference tools for tailor-made simulation and navigation of kidney transplantation surgery, consequently helping to improve training for the operating room staff, students, and trainees. Conclusions We believe that our sophisticated personalized donor graft and pelvic replications obtained using a 3-D printing system are advantageous for kidney transplantation surgery.

© 2015 Elsevier Inc. All rights reserved. Background Nutritional status affects clinical outcomes in patients with chronic renal failure. Glucose intolerance, dyslipidemia, obesity, hypertension, and a calcium-phosphorus-vitamin D imbalance are the major nutritional and metabolic problems that occur in posttransplant patients. In this study, we assessed the daily intake in long-term renal transplant recipients to determine whether they have sufficient nutrients based on the Japanese nutrition recommendations (recommended dietary allowances [RDA] in Japan 2010). Subjects and Methods Thirty-one renal allograft recipients followed for >10 years (median, 16.3) were recruited. The median serum creatinine level was 1.2 g/dL (95% CI, 0.6-3.4). We estimated the intake of nutrients, including protein and salt, using a simple food frequency questionnaire. Results The median body mass index was 20.1 kg/m2. The median total energy intake was 1566 kcal/d (95% CI, 892-2556). The daily intake of protein and salt was 65.1 and 9.1 g/d, respectively. The calcium, iron, vitamin D, and vitamin K intakes were 423 mg, 7.0 mg/d, 9.7 μg/d, and 197 μg/d, respectively. Patients with dyslipidemia displayed greater amounts of lipid and calcium than those with normal lipid levels. Discussion Our findings suggest that long-term renal transplant recipients in Japan seem to restrict caloric intake, while maintaining appropriate intake of protein, lipids, carbohydrates, and vitamins A, D, and K. However, daily calcium and iron intake were insufficient; salt intake was greater than the recommended dietary allowances in all subjects. In patients with dyslipidemia, calcium intake was lower than those in patients without dyslipidemia, although their intake of lipids was also lower than those without dyslipidemia. Conclusion Nutritional guidance beginning during the early posttransplant phase helps to foster a healthy body mass index and nutritional balances for long-term renal transplant recipients. However, greater salt restriction was needed, and additional nutritional guidance aiming to prevent osteoporosis seems to be considered.

A 27-year-old man was diagnosed with IgA nephropathy and Crohn's disease. He had been diagnosed with proteinuria and hematuria since he was 20 years old. Diarrhea had been a continuing problem during the past 5 months. Neither corticosteroid therapy nor tonsillectomy was performed. Hemodialysis was required at age of 30, while the symptoms of Crohn's disease were ameliorated by an elemental diet. He received a renal transplant from his mother 4 months after starting dialysis therapy. The initial immunosuppression therapy consisted of methylprednisolone, mycofenolate mofetil, cyclosporine, and basiliximab. Eight months after transplantation, proteinuria and hematuria appeared and serum creatinine was 1.4 mg/dL. Relapse of IgA nephropathy was confirmed by the one-year protocol biopsy. He had suffered from tonsillitis at 32 months after the transplantation. Urinary protein increased to 3 g/day and serum creatinine was elevated to 2.04 mg/dL. Renal biopsy was performed 2 weeks after the urinary findings were aggravated. The cellular crescents constituted 36 % of the glomeruli. The findings of rejection were not confirmed in both biopsies. Tonsillectomy was performed thereafter. No additional immunosuppressive therapy was added. Proteinuria and hematuria disappeared at 4 and 20 months, respectively, after tonsillectomy, even when the symptoms of Crohn's disease worsened 69 months and 89 months after transplantation. A renal biopsy was performed 101 months after transplantation. Although IgA in the mesangium area was confirmed by immunohistochemical staining, no active lesion was seen. Tonsillectomy along with immunosuppressants for the graft might be an effective treatment for some patients with active recurrent IgA nephropathy.

症例は64歳男(O型)で、13年前に血液透析導入となり、妻(A型)をドナーとする血液型不適合生体腎移植を希望した。入院時の抗A抗体価はIgMが64倍、IgGが4096倍以上と著明高値で、移植予定日14日前にリツキシマブ200mg/dayを投与し、同日よりミコフェノール酸モフェチル1000mgを開始した。さらに10日前よりcyclosporinを開始し、6、4、2日前に二重濾過血漿分離交換を、1日前に血漿交換を行って減感作療法としたが、抗体価のリバウンド現象を認めたためいったん延期した。同減感作プロトコールを1クール追加し、移植当日にリツキシマブ200mgをさらに投与し、移植を施行した。移植当日のIgG抗A抗体価は256倍であった。術後経過は良好で血清クレアチニン値は速やかに低下し、IgG抗A抗体価も徐々に低下して32〜64倍で維持され、その後も上昇はない。

Pancreatic graft thrombosis is the primary cause of nonimmunologic graft loss, with an incidence ranging from 5% to 15%. Therefore, developing a screening test to detect graft thrombosis after pancreatic transplantation is important. We created a screening test to assess graft thrombosis after pancreatic transplantation using contrast-enhanced ultrasonography (CEUS) with Sonazoid in addition to Doppler ultrasonography. A total of seven patients were examined using CEUS after undergoing pancreatic transplantation. All patients were observed to have a clear blood flow from the horizontal region to the peripheral region of the splenic vein in the pancreatic graft, and only one of the seven patients exhibited a blood flow in the horizontal portion of the splenic vein on Doppler ultrasonography performed immediately after pancreatic transplantation. Results from CEUS with Sonazoid showed the blood flow in the splenic vein and parenchyma of the pancreatic graft in detail, despite the slow and lateral blood flow in the splenic vein of the pancreatic graft immediately after transplantation.

Background. Currently, there are no published data on pharmacokinetics (PK) of everolimus in combination with cyclosporine in Japanese renal transplant patients. We evaluated the PK of everolimus in Japanese de novo renal transplant patients who received everolimus in combination with cyclosporine. Methods. In this phase 3, multicenter, randomized, open-label study, patients were randomized (1:1) to 1 of the 2 groups: everolimus 1.5 mg (targeted C-0 of 3-8 ng/mL) plus reduced-dose cyclosporine or mycophenolate mofetil 2 g/d plus standard-dose cyclosporine. PK assessments for everolimus were performed on day 28 (month 1) in the PK subpopulation. Results. A total of 11 patients (7 men), mean age 47.5 +/- 11.21 years, were enrolled for PK analysis of everolimus. Starting at 1.5 mg (0.75 mg twice a day), the mean dose over a period of 28 days was 0.705 +/- 0.1011 mg. Everolimus mean trough concentration was 4.307 +/- 1.2459 ng/mL and mean peak concentration was 13.539 +/- 3.5330 ng/mL, which peaked at 1 to 2 hours postdose. The average concentration was 7.558 +/- 1.4723 ng/mL, area under the concentration-time curve was 90.70 +/- 17.667 ng h/mL, and peak-trough fluctuation was 122.6%. The PK parameters of everolimus were comparable to those in the earlier phase 3 studies (A2306 and A2307). The mean everolimus trough levels were within the target ranges at all time points ranging from 3.4 to 5.5 ng/mL (everolimus 0.75 mg twice a day, safety population). The majority of patients (>85% from day 7 onward) were maintained within the targeted everolimus trough blood levels (safety population). These data were similar to a non-Japanese study (A2309). Conclusions. The pharmacokinetic characteristics of everolimus in Japanese de novo renal transplant patients did not differ from those previously observed in non-Japanese patients, hence the same dosage of everolimus may be acceptable in Japanese patients.

膵臓移植におけるもっとも重要な手術合併症は静脈血栓症であり、その発症頻度は膵臓移植の5-13%とされている。膵臓移植の約80%は膵腎同時移植であるため、周術期に造影CTは行いづらい。したがって、静脈内血栓のスクリーニングはドップラー超音波検査を行なわれることが多いが、移植膵脾静脈内の血流は乏しく、超音波進入方向に対し直交するため、ドップラー超音波では静脈血流を描出できないことがしばしばある。そこで当科では膵臓移植後の静脈血栓のスクリーニングのためソナゾイドによる造影超音波検査を行っている。造影超音波検査により、ドップラー超音波で描出できかった移植膵脾静脈内の静脈血流も描出可能となっただけでなく、移植膵実質内の微小な静脈血流も描出が可能となった。(著者抄録)

Kidneys procured by donation after cardiac death (DCD) may increase the donor pool but are associated with high incidence of delayed graft function (DGF). Urinary liver-type fatty acid-binding protein (L-FABP) level is an early biomarker of renal injury after kidney transplantation (KTx); however, its utility is limited in DGF cases owing to urine sample unavailability. We examined whether serum L-FABP level predicts functional recovery of transplanted DCD kidneys. Consecutive patients undergoing KTx from living related donors (LD), brain-dead donors (BD), or DCD were retrospectively enrolled. Serum L-FABP levels were measured from samples collected before and after KTx. Serum L-FABP decreased rapidly in patients with immediate function, slowly in DGF patients, and somewhat increased in DGF patients requiring hemodialysis (HD) for >1 wk. Receiver-operating characteristic curve analysis demonstrated that DGF was predicted with 84% sensitivity (SE) and 86% specificity (SP) at cutoff of 9.0 ng/mL on post-operative day (POD) 1 and 68% SE and 90% SP at 6.0 on POD 2. DGF >7 d was predicted with 83% SE and 78% SP at 11.0 on POD 1 and 67% SE and 78% SP at 6.5 on POD 2. Serum L-FABP levels may predict graft recovery and need for HD after DCD KTx.

Background. Under a revision to the law in 2010, the number of pancreas transplantations from brain-dead donors has been increasing in Japan. We started a new Pancreatic Transplant Program at Fujita Health University Hospital in September 2012. Methods. A total of 11 cases of pancreas transplantation from brain-dead donors performed at Fujita Health University Hospital were analyzed in terms of the background characteristics of the donors and recipients and the outcomes. Results. The mean age of the recipients was 45.2 years, and all recipients had a long-term history of diabetes (mean: 32.5 years). In the simultaneous pancreas and kidney transplantation (SPK) cases, the patients also had a long history of hemodialysis (mean: 8.0 years). Although the average donor age was 42.5 years, 90% of the donors were marginal donors, defined according to the following factors: (1) > 45 years old, (2) death from cardiovascular disease, (3) episodes of cardiac arrest, (4) use of high doses of catecholamines. The pancreatic graft survival rate was 100%, although 1 patient required a small amount of insulin to maintain euglycemia. In addition, the kidney graft survival rate was also 100% in the SPK cases. Conclusions. The new Pancreatic Transplant Program at Fujita Health University has provided excellent outcomes for type 1 diabetic patients.