佐々木 ひと美

Because of a worldwide shortage of renal grafts, kidneys procured from donors after cardiac death (DCD) have recently become an important source of renal transplants. However, DCD kidneys often have complications with delayed graft function (DGF) and recipients require hemodialysis (HD) in the early period after kidney transplantation (KTx). This study evaluated serum NGAL as a potential specific parameter to predict early functional recovery of transplanted DCD kidneys. The average serum neutrophil gelatinase-associated lipocalin (NGAL) level in normal samples was 53 +/- 30 ng/ml, while that in patients with chronic renal failure requiring HD was markedly raised at 963 +/- 33 ng/ml. In patients undergoing a living-related KTx from a living donor (n=11), serum NGAL level decreased rapidly after KTx, and only in two cases, with serum NGAL levels over 400 ng/ml on postoperative day 1 (POD1), was HD required due to DGF. In contrast, all patients undergoing a KTx from a DCD (n=5) required HD due to DGF. Even in these cases, serum NGAL levels decreased rapidly several days after a KTx prior to the recovery of urine output and preceding the decrease in serum creatinine level. The pattern of decline in serum NGAL was biphasic, the decrease after the second peak indicating a functional recovery within the next several days. These data suggest that monitoring of serum NGAL levels may allow us to predict graft recovery and the need for HD after a KTx from a DCD.

Stress urinary incontinence (SUI) is a major urologic health problem and the number of patients with SUI will rise dramatically as the population of elderly people continues to increase in Japan. This condition causes unnecessary and detrimental psychological distress, social isolation, and public expense for care. Surgery remains the cornerstone of treatment for female SUI and also in those who have failed to improve with conservative measures. Many surgical procedures, however, have been described with varying degree of success. The ideal surgical treatment for this disease should be effective in QOL improvement, minimal invasive and durable for the long-term. Based on a new understanding of the pathophysiology of SUI as well as the development of surgical techniques and devices, mid urethral sling operations such as TVT (tension-free vaginal tape) have become widely used and they provide significant short-term and long-term cure rates. However, perioperative complications, including serious problems like bowel, vascular and bladder injuries have been reported. Most complications are related to blind trocar passage in the retropubic space. The alternative procedure transobturator procedure was developed to minimize these complications, in which tape is introduced through the obturator foramen. This technique provides high short-term cure rates, similar to those achieved with TVT, but with fewer complications. A number of injectables have been used for the treatment of SUI, including collagen, coated-beeds and Teflon. Although injectable treatment is convenient and minimally invasive, efficacy and durability are lower than other surgical procedures. Modification by tissue-engineering techniques using autologous stem cells or precursors of mature cells showed regeneration and reconstitution of urinary sphincteric function. In the future this strategy may be an attractive therapy for SUI. The choice of operation should be tailored to suit each individual case based on the clinical and urodynamic findings, as well as the age and the expectations of treatment outcome.

子宮全摘除術後の腟円蓋部脱、膀胱脱は外陰部異和感(下垂感)や残尿感等の下部尿路症状を呈する。本病態は女性骨盤臓器脱(POP)の一所見であり、手術療法として腟前壁形成術のみではいずれ再発、または他の脆弱部位である後壁よりの直腸脱等が現出してくる。また、開腹手術は侵襲性で難点があり、この点腹腔鏡下仙骨腟円蓋固定術(Laparoscopic Sacrocolpopexy;LSCP)は低侵襲性と長期有効性が期待できる術式とされ、近年欧米で頻用されている。当科にて現在までに7例に対しLSCPを施行した。平均手術時間は3時間50分で、術後の在院日数は6日間(中央値)であった。特記すべき合併症は認めず、全症例で患者満足度は良好で、レ線や内診等の他覚所見も改善を認めている。子宮全摘後の膀胱脱に対するLSCPは低侵襲にて有効な手術法と考えられた。今後長期的なDurability等についても検討していきたい。(著者抄録)

The objective is to investigate the outcome of transplantation using kidney grafts from donors after cardiac death (DCDs) with a total ischemia time (TIT) longer than 24 h. All 373 kidneys were procured from DCDs. They were procured using the in-situ regional cooling technique. Grafts were classified into two groups according to TIT. Fifty-three grafts had a TIT longer than 24 h (group 1), and the other 320 grafts (group 2) were less than 24 h. The numbers of never functioning grafts (PGF) were 3 in group 1 (5.7%) and 17 in group 2 (5.3%), a nonsignificant difference. Graft survival rates at 3, 5 and 10 years posttransplant were 84.9%, 73.0% and 64.1% in group 1, and 76.3%, 69.9% and 57.1% in group 2, which demonstrate no significant difference. The significant risk factors for graft failure were donor age, serum creatinine level on hospitalization and WIT. However, TIT longer than 24 h was not employed. Multivariate logistic regression indicated that only WIT was associated with an increase in the risk of PGF. Our results demonstrate that kidneys from DCDs, even if their TIT is more than 24 h, should be considered a worthwhile source of renal grafts. © 2007 The Authors.

Purpose: The objective of this study was to investigate the outcome of transplantation using kidney grafts donated after cardiac death (DCD) with a total ischemic time (TIT) longer than 24 hours. Patients and methods: We followed 373 kidneys recovered from DCD donors and transplanted at 41 centers. All kidneys were procured from uncontrolled DCD donors. Grafts were classified into two groups according to TIT. We recorded renal function and duration of the survival period for each graft. Results: Fifty-three grafts had a TIT longer than 24 hours (group 1). The other 320 grafts had a TIT less than 24 hours (group 2). The number of never functioning grafts were three in group 1 (5.7%) and 17 in group 2 (5.3%). Delayed graft function (DGF) occurred in 44 group 1 (83.0%) and 254 group 2 kidneys (79.4%) for intervals of 13.5 ± 12.6 versus 10.9 ± 12.6 days, respectively. Graft survival rates at 3, 5, and 10 years posttransplant were 84.9%, 73.0%, 64.1% for group 1, and 76.3%, 69.9%, 57.1% for group 2. In a Cox proportional hazards model, TIT longer than 24 hours was not a significant independent risk factor. Conclusion: Our results showed that even kidneys with TITs of over 24 hours yielded comparable results despite a higher incidence of DGF. © 2006 Elsevier Inc. All rights reserved.

Background: There has been a considerable literature describing the use of pulsatile perfusion (PP) to evaluate the efficacy of organs from deceased donors. Since 1979, we recovered 469 kidneys from deceased donors after cardiac death (DCDs), using an in situ regional cooling technique and preservation by simple cold storage. In this study, the posttransplantation outcomes as well as long-term survivals of renal grafts from DCDs were compared with PP data in the recent literature. Materials and Methods: We compared our recent data with 176 kidneys recovered between 1993-2002 using an in situ regional cooling technique. Patient and graft survivals were compared with those from the Scientific Registry of Transplant Recipients (SRTR) database. Results: Following transplantation, 4.5% of the grafts never recovered; 10.3% of the grafts showed immediate renal function; 85.2% of the grafts had delayed graft function (DGF) with an average acute tubular necrosis (ATN) period of 13.1 days compared with 54.3% DGF from DCD using PP. Graft survival rates at 1, 3, 5, and 10 years were 90.8%, 86.5%, 77.8%, and 69.0%, respectively, compared with 89% at 1 year and 80% at 3 years reported for DCD by the SRTR in which almost 30% of the grafts underwent PP. Conclusions: Although PP seemed to have some advantage to decrease the DGF ratio, an in situ regional cooling technique with simple cold storage may provide excellent graft function and long-term graft survival as well as having benefits in cost and transportation. © 2006 Elsevier Inc. All rights reserved.

小児泌尿器科周術期の抗菌薬使用に関してアンケートを行い,ガイドライン作成について検討を行った.25名の回答を集計した結果,対象疾患に対する術式や留置カテーテルの種類などが施設間で大きく異なっており,術式が多岐にわたる疾患ではガイドライン作成は困難であると考えられた.コンセンサスが得られた疾患・術式は,後部尿道弁などに対する内視鏡手術,尿道下裂形成術,包茎,停留精巣,精索捻転,陰嚢水瘤,精索静脈瘤に対する手術であった