佐々木 ひと美

OBJECTIVES: Kidneys procured from the deceased hold great potential for expanding the donor pool. The aims of the present study were to investigate the post-transplant outcomes of renal allografts recovered from donors after cardiac death, to identify risk factors affecting the renal prognosis and to compare the long-term survival from donors after cardiac death according to the number of risk factors shown by expanded criteria donors. METHODS: A total of 443 grafts recovered using an in situ regional cooling technique from 1983 to 2011 were assessed. To assess the combined predictive value of the significant expanded criteria donor risk criteria, the patients were divided into three groups: those with no expanded criteria donor risk factors (no risk), one expanded criteria donor risk factor (single-risk) and two or more expanded criteria donor risk factors (multiple-risk). RESULTS: Among the donor factors, age ≥50 years, hypertension, maximum serum creatinine level ≥1.5 mg/dL and a warm ischemia time ≥30 min were identified as independent predictors of long-term graft failure on multivariate analysis. Regarding the expanded criteria donors criteria for marginal donors, cerebrovascular disease, hypertension and maximum serum creatinine level ≥1.5 mg/dL were identified as significant predictors on univariate analysis. The single- and multiple-risk groups showed 2.01- and 2.40-fold higher risks of graft loss, respectively. CONCLUSIONS: Renal grafts recovered from donors after cardiac death donors have a good renal function with an excellent long-term graft survival. However, an increased number of expanded criteria donors risk factors increase the risk of graft loss.

A 70-year-old woman was referred to our department after being diagnosed with right hydronephrosis on the basis of computed tomography (CT). CT and magnetic resonance imaging results indicated circumferential wall thickening in the right middle ureter. A retrograde pyelogram revealed an approximately 20 mm stricture in the right middle ureter, and urine cytology results were pseudo-positive. Ureteroscopy was performed due to suspicion of a malignant tumor of the urinary tract, but no malignant lesions were found. Biopsy results showed only the pathology of nonspecific ureteritis, and a diagnosis could not be made even with immunostaining. The patient's blood IgG4 levels were high (317 mg/dl). Based on the diagnostic criteria, the patient was given a possible diagnosis of an IgG4-related disease and treated by the placement ofa ureteral stent and administration of steroid therapy. After starting treatment, blood IgG4 levels decreased and the imaging findings showed improvement. The ureteral stent was removed in the 12th week, and steroid administration was discontinued in the 14th week. No recurrence has since been noted.

63歳、男性。両下肢浮腫を主訴に受診。造影CTで直径5cm大の左腎腫瘍と肝静脈流入部直下まで達する下大静脈腫瘍塞栓を認め、腫瘍塞栓により下大静脈は完全閉塞していた。IVCフィルター留置後、左腎癌(eT3bN0M0)の診断で左腎摘除術および腫瘍塞栓摘出術を予定した。術中、右腎茎部周囲および下大静脈近傍の側副血行路からの出血が持続し血圧維持が困難となったため、やむを得ず右腎を摘出した。また、腫瘍塞栓が血管壁と強固に癒着していたため、下大静脈を離断し左腎とともに合併切除した。一旦閉創後、右腎を右腸骨窩に自家腎移植した。病理診断はClear cell carcinom、G2、pT3bN0であった。術後に腎不全を認めたが持続血液透析を行い、術後86日目に透析を離脱し社会復帰している。(著者抄録)

© 2016 The Authors. Background The waiting time for deceased-donor kidney-only transplantations in Japan is long. Herein, we assessed the effect of length of dialysis on the outcomes of these patients. Methods We divided patients into 2 groups based on length of dialysis (Group A, <15 years, and Group B, ≥15 years), and compared the background and outcomes after kidney transplantation. Results Group A included 210 patients and Group B included 35 patients. In Group B, 20% of transplants were from living donors. Patient age (P =.017) and the hepatitis C infection rate (P =.018) were significantly higher in Group B, whereas hypertension (P =.011), diabetes (P =.041), and ABO-incompatibility rates (P =.015) were significantly higher in Group A. The 5- and 10-year survival rates were 97.0% and 95.4%, respectively, in Group A and 97.1% and 97.1%, respectively, in Group B. The 5- and 10-year graft survival rates were 95.4% and 84.8%, respectively, in Group A and 97.1% and 73.1%, respectively, in Group B. There were no significant differences between the groups in patient survival (P =.74) and graft survival (P =.72). The 5- and 10-year cardiovascular event-free survival rates were 95.9% and 92.4%, respectively, in Group A and 88.6% and 76.8%, respectively, in Group B. Cardiovascular event-free survival was significantly higher in Group A (P =.038). Cox stepwise multivariate analysis indicated that length of dialysis was a significant predictor of cardiovascular events (hazard risk, 1.007; range, 1.001-1.012; P =.012). Conclusion The prognosis after kidney transplantation is promising even after a long length of dialysis, although evaluation of the cardiovascular risk is needed in these cases.

<p>【Objective】Kidney transplant recipients are at increased risk of developing cancer in comparison with the general population. To effectively manage post-transplant malignancies, it is essential to proactively monitor patients. A long-term intensive screening program was associated with a reduced incidence of cancer after transplantation. This study evaluated the usefulness of the gene expression profiling of peripheral blood samples obtained kidney transplant patients and adopted a screening test for detecting cancer of the digestive system (gastric, colon, pancreas and biliary tract cancer).<br/>【Methods】Nineteen patients were included in this study, and a total of fifty-three gene expression screening tests were performed. The gene expression profiles of blood-delivered total RNA and whole genome human gene expression profiles were obtained. We investigated the expression levels of 2,665 genes associated with digestive cancers and counted the number of genes in which expression was altered. A hierarchical clustering analysis was also performed. The final prediction of the cancer possibility was determined according to an algorithm.<br/>【Results】The number of genes in which expression was altered was significantly increased in the kidney transplant recipients in comparison to the general population (1,091±63 vs. 823±94, p=0.0024). The number of genes with altered expression decreased after the induction of mTOR inhibitor (1,484±227 vs. 883±154, p=0.0439). No cases of possible digestive cancer were detected in this study period.<br/>【Conclusion】The gene expression profiling of peripheral blood samples may be a useful and non-invasive diagnostic tool that allows for the early detection of cancer of the digestive system.</p>

A 53-year-old woman who had undergone deceased donor kidney transplantation twice, at 35 and 43 years of age, presented with renal impairment. She was infected with hepatitis C virus (HCV). The histology of the graft kidney revealed post-transplant membranous nephropathy (MN) with podocytic infolding and antibody-mediated rejection (AMR). IgG subclass staining showed fine granular deposits of IgG1 and IgG3, but not IgG4, in the glomerular capillary walls. Panel reactive antibody scores for human leukocyte antigen class I and class II were 92.67% and 66.68%, respectively. Thus, this case of post-transplanted MN was considered to be associated with AMR and HCV infection.

仙骨腟断端固定術は経腟的骨盤底形成術と比較してメッシュによる合併症が少なく本邦でも2014年から腹腔鏡下手術が保険適応となったことから各施設における手術件数が増加している。当院では2013年からロボット支援下での仙骨腟断端固定術を開始した。術後1年以上を経過したロボット支援仙骨腟断端固定術4例を報告する。症例:4症例の年齢は59歳から70歳(平均年齢:64.5歳)、既往歴として2例で子宮摘出術を施行されていた。いずれもPOPIIIの骨盤臓器脱を認めた。子宮摘出後の2例では腟断端仙骨固定術のみを行い、1例は腟上部切断にて子宮を摘出、他1例は腟上部切除および両側付属器切除を施行、その後腟断端仙骨固定術を施行した。結果:コンソール時間はそれぞれ180分、162分、200分、240分で出血量は平均28mlであった。4例とも術後経過は良好であり5PODに膀胱造影を施行、平均在院期間は術後8日間であった。術前後に施行したQOL調査では5点から1点に改善、尿失禁を認めた1例は術後1年目にTVTを施行した。結語:daVinci Siサージカルシステムを用いた腹腔鏡下腟断端仙骨固定術は良性疾患に対するロボット手術適応拡大が期待できる術式と思われる。(著者抄録)

現在,骨盤臓器脱の治療として経腟的,経腹的手術が施行されている。経腹的仙骨腟断端固定術は経腟的手術に比べメッシュによる合併症が少ないことが報告されており,また2014年から腹腔鏡手術での保険適用が可能となったことから手術件数が増加している。しかしながら奥深い骨盤底での縫合など術者の熟練度を要求される手術でもある。本稿ではロボット支援仙骨腟固定術の手術手技および腹腔鏡手術または開腹手術との手術成績を比較しロボット支援仙骨腟固定術の有用性について述べる。(著者抄録)

42歳女性。肉眼的血尿および左側腹部痛を主訴に救急外来受診となった。腹部CTにて左水腎症を指摘され、腎泌尿器外科へ紹介となったが、初診時、血液検査では異常所見は認められなかった。しかし、腹部単純CTでは左水腎症と中部尿管に全周性の尿管壁肥厚が認められた。一方、経静脈尿路造影(IVU)では左腎盂は描出されなかったが、逆行性腎盂造影(RP)では左中部尿管に約2cmの陰影欠損像が認められ、尿管悪性腫瘍が疑われた。そこで、確定診断のため尿管鏡検査を施行、内視鏡所見からは全周性の腫瘍性病変が疑われたほか、表層2ヵ所の生検では炎症性変化のみで不十分と考え、左尿管鏡下再生検を施行した。その結果、病変部の深層を含め計7ヵ所の生検によりアミロイドーシスと診断されたが、上部・下部内視鏡生検ではアミロイド沈着は認められなかった。だが、Bence-Jones蛋白陰性、血清蛋白分画正常であることから限局性尿管アミロイドーシスと診断され、左尿管部分切除術が施行された。手術は術直前にRPを施行し、病変部直下に目印の尿管ステントを留置して傍腹直筋切開にてアプローチした。尿管は硬く肥厚し周囲と癒着していたが、尿管ステント直上より2cm尿管を切除して残存尿管内腔に病変がないことを確認後、D-Jステントを挿入し、残存尿管は計8ヵ所で端々吻合した。尚、摘出標本の内腔は閉塞し、病理所見では帯状のアミロイド沈着が認められた。D-Jステントについては術後3ヵ月で抜去され、IVUでは水腎症は消失していた。

A 42-year-old female visited our hospital with the chief complaint of macrohematuria and left lateroabdominal pain. Computed tomography and retrograde pyelogram showed left hydronephroureter and obstructive uropathy which was 20 mm in diameter in the middle ureter. Urine cytology was negative. Ureter biopsy revealed amyloidosis. Our diagnosis was localized amyloidosis of the ureter, because amyloid was not found in other places in her whole body inspection. Partial ureterectomy was performed. Left renal function was preserved. The patient has been free of recurrence for 18 months after surgery.