佐々木 ひと美

Robot-assisted radical prostatectomy (RARP) is one of the most widely used procedures for localized prostate cancer (PCa). In the present study, the clinical and oncological outcomes of RARP with bilateral or unilateral nerve sparing (NS) for D'Amico high-risk PCa cases were assessed. Among the 767 cases who received RARP at Fujita Health University Hospital between August 2009 and December 2016, 230 high-risk PCa cases who were observed for >6 months comprised the retrospective study cohort. Bilateral NS was performed with the bilateral neurovascular bundle in eight, unilateral in 125 and none in 97 cases. Perioperative parameters [surgery time, console time, estimated blood loss, pathological stage, positive lymph node metastases [pN (+)], and surgical margin positivity] did not exhibit significant differences between the NS and non-NS cohorts. During a median follow-up time of 25 months, the 1- and 3-year biochemical recurrence (BCR)-free survival rates in the NS/non-NS cohorts were 84.4/86.0 and 72.7/75.0%, respectively. There were no significant differences identified between the two groups at each time period. According to multivariate analysis, the resection margin was an important factor for time to BCR, regardless of the NS technique used. The numbers of pads used daily at 3 and 6 months after RARP between the NS/non-NS cohorts were 1.1/1.5 and 0.6/1.0, respectively (P=0.045 and P=0.009), suggesting that the NS technique resulted in significantly improved outcomes regarding urinary continence recovery. In selected high-risk PCa cases, the NS technique resulted in equivalent oncological outcomes and improved urinary continence compared with the non-NS RARP group.

本邦ではロボット支援腹腔鏡下腎部分切除術(RAPN)は腎癌に対し保険収載され、今後も飛躍的な症例の増加が見込まれる。手術適応については当初T1aに限定し、比較的容易な症例から経験を重ねる施設が多いと推測されるが、徐々に適応を拡大しT1b以上あるいは手術困難が予想される完全内包型や腎門部腫瘍にも適応拡大が期待される。一方、単腎症例や既に腎機能低下に至っている症例、いわゆるimperative caseに対するRAPN実施については、手術適応と術前評価、術式、周術期管理に至る配慮を要する。本稿では当院での経験をもとに、imperative caseに対する工夫について概説する。(著者抄録)

OBJECTIVES: To evaluate the prognostic value of the warm ischemic time and the validity of the Kidney Donor Profile Index/Kidney Donor Risk Index for predicting the survival of donors after cardiac death grafts. METHODS: We retrospectively assessed 315 kidneys retrieved from donors after cardiac death at Fujita Health University Hospital, Toyoake, Aichi, Japan. The Kidney Donor Profile Index/Kidney Donor Risk Index was calculated and the grafts were enrolled. RESULTS: The median follow-up period was 11.9 years. The Kidney Donor Profile Index had a markedly asymmetric distribution (median 94%), and the Kidney Donor Risk Index had high index rates (0.79-2.94, median 1.70). The overall 5-, 10- and 15-year graft survival rates were 67.5%, 52.1% and 38.9%, respectively. The Kidney Donor Profile Index correlated with graft survival. The 5-, 10- and 15-year graft survival rates for the Kidney Donor Profile Index <1.2 were 87.7%, 73.5% and 59.2%; those for the Kidney Donor Risk Index >2.0 were 55.0%, 34.7% and 22.1%, respectively. A Cox multivariate analysis identified the Kidney Donor Risk Index (hazard ratio 2.06, 95% confidence interval 1.48-2.86, P < 0.0001) and warm ischemic time (hazard ratio 1.21, 95% confidence interval 1.09-1.34, P = 0.0010) as independent risk factors for graft loss. The addition of warm ischemic time >30 min had a significant effect, as measured by the C-index (0.708-0.731, P = 0.032), improving the net reclassification improvement score (0.256, P = 0.0039) and integrated discrimination improvement score (0.042, P = 0.0022). CONCLUSIONS: The Kidney Donor Profile Index/Kidney Donor Risk Index is a good prognostic tool for determining the outcomes of donors after cardiac death grafts. However, the warm ischemic time should also be included in the allocation system for donors after cardiac death grafts.

ラット腎瘢痕モデルを作製して腎瘢痕形成に関わる網羅的遺伝子解析を行い、発現の持続亢進が認められたNGAL(Neutrophil gelatinase-associated lipocalin)に着目し、VUR児における腎瘢痕バイオマーカーとしての有用性について検討した。検討方法は、VUR児群(34例)と正常児群(28例)とで尿中NGAL値を比較した。また、VUR児群のみを対象とし、腎瘢痕の有無と尿中NGAL値との関連性について他のマーカー(血清クレアチニン、尿中BMG、尿中NAG)と比較した。結果、正常児群に比べてVUR児群は尿中NAGLが有意に高値であった。腎瘢痕の有無との関連では、尿中NGALは他のマーカーに比べて特異度が高かった。

昨今,わが国でのドナーは高齢で高血圧や糖尿病など合併症を伴う場合も多く,献腎移植施設でドナー適応について判断に難渋することもある.この総説では,日本臨床腎移植学会の委員会で移植後に無機能であった腎臓移植との関連を解析した既知のドナーリスク因子のデータ,及び日本臓器移植ネットワーク臓器提供・移植データブック2017で解析された腎臓移植生着率のドナーリスク因子のデータを紹介する.また,諸外国で使用されているドナー腎機能の適応評価のドナーリスククライテリアや基準を紹介する.最後に,日本独自の献腎移植ドナーのリスク基準を提唱すべく,研究プロジェクトが立ち上がったことを報告する.(著者抄録)

We investigated the effect of the mammalian target of rapamycin (mTOR) inhibitor everolimus on tuberous sclerosis complex- (TSC-) associated autistic symptoms and focal seizures with impaired awareness in a female child with TSC. We further evaluated the relationship between improved autistic symptoms and seizures and increased the serum levels of the antioxidant proteins, ceruloplasmin (Cp) and transferrin (Tf), and oxidant-antioxidant status indicated by the oxidant marker oxidized low-density lipoprotein (ox-LDL) and the antioxidant marker total antioxidant power (TAP). Everolimus treatment improved impaired social cognition and autistic behaviors; however, seizure and epileptic activity persisted. Serum Cp and Tf levels gradually increased in response to improved autistic symptoms. Serum TAP levels gradually decreased from baseline to the lowest value at 16 weeks and then increased at 24 weeks, showing a trend toward decreased total score of the Aberrant Behavior Checklist. This study revealed that everolimus treatment improved impaired social cognition with increased serum levels of the copper mediator (Cp) and iron mediator (Tf) via homeostatic control of mTOR activity accompanied by overlap of the oxidant-antioxidant system. Everolimus had no effect on TSC-related epileptiform discharges, and thus, the autistic symptoms and epileptic activity may be two independent end results of a common central nervous system disorder including mTOR hyperactivity. This trial is registered with JMAS-IIA00258.