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II. ХИРУРГИЯ
CLINICO-MORPHOLOGICAL DATA OF ACTIONS AT STAGES OF CONDITIONING AND PRESERVATION AT DONOR ORGANS RECEPTION
UDC 616-092.19
Zainalov A.K., Yenin E.A., Pismareva A.V., Balabekov A.G., Ten N.S., Tazhdinov D.B.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty Abstract
Results of researches of the held events referred on protection against ischemic damages of organs to an organism of the donor and a preservation choice are reflected in this publication. Paying attention to a regimen of cardiotonic support at conditioning, the choice of sequences of use of solution with various viscosity at a stage of preservation of an organ is used. Research is conducted after conditioning and protection of donor organs at 74 potential organ donors of kidneys. Importance of the morphological research confirming the significance in using sequence of solutions at preservation of donor kidneys after their extraction from a donor's organism, at which various doses of preparations of cardiotonic support at conditioning stages were used, is defined.
ABOUT THE AUTHORS
Zainalov Akimzhan Kurmetovich - head of the department of renal transplantation and urogynecology; can. med, a high level certificate physician, surgeon; Yenin EvgenyAlbertovich - head of the pathology laboratory, a high level certificate physician.
Key words
donor, kidney, reception, transplantation, organ.
Клинико-морфологиялык тап осы шаралардьщ ауа тазарту кезецдершде жэне консервациялаудьщ донорлык органдардьщ алуы жанында
Зайналов Э.К., Енин Е.А., Писмарева A.B., Балабеков А.Г., Тен Н.С., Таждинов Д.Б.
А.Н. Cbi3f3H0B атындаш Улттык, шлыми хирургиялык, орталыш, Алматы
Ацдатпа
Органдык донордын организмында органдардын ишимиялык закым келу'шi к;ор€анышк;а багытталган шаралардын MafbiHa жэне консервациялау тандауы маныздылык кайтарушы мына жариялауда зерттеулер^н нэтижелерi шамлыскан. Ауа тазарту жанында орган консервациялауы кезеннде жабыскактыкпен эр^Yрлiмен ерiтiндi колдануы жуйелЫктернН тандау колданЕан CYЙеу кардиотоникалык тэртпке назар аударылды. Зерттеу ауа тазартудан кешн етюзлген жэне донорлык органдардын корfaныштaры 74 бYршiктердiн потенциалды орган донорларынын. Орган донор организмынан олардын алып тастауынан кешн донорлык бYршiктердiн консервациялауы жанында ертндшердн жYЙелiлiк колдануынын маныздылык растайтын морфологиялык зерттеулер маныздылык айкын кайсынын ауа тазарту кезендернде CYЙеу кардиотоникалык дэрлердн эртYрлi мeлшерлерi колданылды.
Туйш сездер
донор, бYPШiK, эд/с, трансплантация, орган.
Клинико-морфологические данные мероприятий на этапах кондиционирования и консервации при получении донорских органов
Зайналов А.К., Енин Е.А., Писмарева A.B., Балабеков А.Г., Тен Н.С., Таждинов Д.Б.
Национальный научный центр хирургии им. Сызганова, Алматы
Аннотация
В данной публикации отражены результаты исследований проведенных мероприятий, направленных на защиту от ишемических повреждений органов в организме донора и выбор консервации. Обращая внимание на режим кардиотонической поддержки при кондиционировании, использован выбор последовательностей применения раствора с различной вязкостью на этапе консервации органа. Исследование проведено после кондиционирования и защиты донорских органов у 74 потенциальных органных доноров почек. Определена важность морфологического исследования, подтверждающего значимость использования последовательности растворов при консервации донорских почек после их изъятия из организма органного донора, у которого использовались различные дозы препаратов кардиотонической поддержки на этапах кондиционирования.
ОБ АВТОРАХ
Зайналов Акимжан Курметович - заведующий отделением трансплантации почек и урогинекологии; к.м.н., врач высшей категории, хирург, e-mail: zainalov62@mail.ru; Енин Евгений Альбертович -заведующий патологоанатомической лабораторией, врач высшей категории, e-mail: enin66@mail.ru
Ключевые слова
донор, почка, прием, трансплантация, орган.
Optimal method of treatment of patients with a chronic renal failure is heterotopic allotransplantation of a donor kidney and the result from such treatment directly depends on quality of receiving and the quality of the received donor kidney [1,2,7,8,14,15,16]. Living and cadaveric donors can be a source of donor kidneys for transplantation to recipients. In case of an organ donorship from the living donor quality of the received donor kidneys and respectively result of transplantation are more optimum in comparison with transplantation when receiving a donor kidney from the marginal donor, such difference of results is explained by various duration and intensity of influence of the damaging factors which are followed throughout time as at their receiving, preservation, and at their transplantation [3,8,9,12,14,16]. Intensity of ischemic damage of a parenchyma of donor kidneys can have various expression, and its expression depends on aggression of a vasoconstriction of the dosage of cardiotonic support depending on level which is directly dictated by an initial condition of a hemodynamics of an donor's organism [3,5,6,8,12].
At using the donor with asystolic heart, even when keeping the general conditions of its conditioning of the providing action referred on conservation of viability of his/her kidneys, the probability of high-quality receiving donor kidneys can be not always equated to the demands approached to the satisfactory. Important point at stages of receiving donor kidneys there is an ensuring their protection and maintenance in them of viability and preserving of this condition directly depends on safety in a lumen of their vascular bed of a blood flow, however this blood flow can always decrease or be lost in dependence of influence of the factors which are followed at aggravation of instability of a hemodynamics in an donor's organism. Depression or loss of a blood flow in donor kidneys leads to presence at a microcirculatory bed of cortical substance of a stasis and a plethora, or to formation of fibrinous thrombi, and these consequences lead to development of dystrophic changes mainly in an epithelium of the convoluted tubules or necrotic processes of renal structures [1,2,5,11,13,16].
The purpose of this research is confirmation of value of using sequence of solutions at conservation of donor kidneys depending on regimens of cardiotonic support when conditioning an organism of the donor.
Materials and methods
Assessment of antiischemic protection and quality of perfusion of 148 donor kidneys of 74 organ donors, received when conditioning is carried out with asystolic heart of various treatment-and-
prophylactic establishments, which are in intensive care units from 2000 to the present, was provided. From 148 donor kidneys there were transplanted to recipients 86 kidneys, other kidneys weren't transplanted in connection with various factors, which were contraindication to transplantation - an anatomic structure, existence of the infections, which are transferred in the hemotransfusion way, immunologic incompatibility, impossibility of an washing of a kidney. The age of the donor ranged from 17 till 57 years. Antiischemic actions provided pharmacological protection of an organ which would be extracted according to the general demands of the maintaining the potential donor. At conditioning the hemodynamics at the potential organ donor was corrected by the "Dofaminum" cardiotonic medicine and monitoring the BP level demanded various dosage of cardiotonic. It is known that Dofaminum in a dose of 10 mkg/kg/min. stimulates postsynaptic beta1-adrenoreceptors that causes positive inotro-pic effect and augmentation of minute volume of a blood, and also provides intensifying of a circulation in kidneys, the glomerular filtration and is stimulates removing of ions of sodium and a diuresis. In high doses - more than 10 mkg/kg/min. or more prevail stimulation of alfa1-adrenoreceptors, there is an increase of the CCR and narrowing of renal vessels that in turn reduces earlier enlarged renal blood flow and a diuresis. For definition of a target dosage of Dofaminum counted intensity of its introduction to an organism of the donor, thus calculation was made on substance of the corresponding 1 kg of body weight of the donor and on rate of his/ her introduction.
Extraction of donor kidneys at potential donors was made according to the standard scheme of J. R. Ackermann. However the sequence of composition of solutions for primary perfusion of a kidney after their extraction was various. Options of sequences of solutions were such: either Custodiol solution, or a normal saline solution the incorporating Heparin divorced in the ratio 1:100 that is 1,0 ml of Solution of the Heparin on 100,0 ml of NaCl of 0,9%, temperature of solution 14 - 16°C and after that further washing of kidneys with Custodiol.
Hypothermal pharmacocooling conservation of a donor kidney after its extraction from the potential organ donor, provides its initial washing from a blood the preserving solutions of relatives on ionic structure to intracellular liquid - Collins's solutions, Saks, SIUT and AO-2, Ross and Marshall, Bred-shnayder. Despite the above-mentioned actions, measures referred on conservation of a donor organ have the specific features as the task of an organ washing from a blood lays down on the conservat-ing solutions having excess viscosity [1, 2, 4, 10]. As solution with the smallest viscosity in the studied
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1-2015
work to conservation of a donor kidney and washing of a lumen of vessels of the finest order from a blood and bloody clots was applied the sequence of solutions - the Heparin divorced in a normal saline solution in the ratio of 1:100 that is 1,0 ml of Solution of the Heparin on 100,0 ml of NaCl of 0,9% in the temperature range 14 - 16°C and after that further washing of kidneys Custodiol solution.
The main clinical criteria of quality of the car-ried-out actions at stages of extraction the donor kidneys referred on their "protection" namely at a stage of conditioning and a stage of their conservation were the beginning of excretory function after immediate transplantation and further conservation of these parameters with long-term adequate functioning. The condition of a nephrosites, convoluted tubules, vascular glomulus, degree of a dystrophia and a condition of a canaliculus of a kidney, existence of contents and fullness of a vascular glomu-lus of a kidney were the main morphological data of quality of extraction of donor kidneys, these data were regarded at 400 and 1000 multiple augmentation when coloring by a hematoxylin and eosine and the basal fuchsine of an azur 2 methylene blue terms of opportunity to trace such data were at the time of conservation of a donor kidney, for the 5th and 21st days after transplantation of this kidney.
Results of research
As it was specified earlier conditioning of 74 potential organ donors was followed by expense of different dosages of the Dofaminum cardiotonic medicine, and depending on the spent dosage 28 organ donors had cases of receiving to 5mkg/kg/ min, and respectively receiving cases 10mkg/kg/ min Dofaminum was at 46 donors. In a type of selection of the received donor kidneys suitable for transplantation became 86 kidneys, the washing of a vascular bed among these 86 kidneys is only applied by Custodiol solution at conservation of 62 kidneys and an washing of a vascular bed with conservation and application of the normal saline solution having in structure the Heparin divorced in the ratio 1:100 and after that by Custodiol solution it is used in 24 cases.
From 62 donor kidneys, which washing of a vascular bed was with application, only Custodiol solution of 36 kidneys were received from organ donors with conditioning cardiotonic support with Dofaminum dosage - no more 5mkg/kg/min - group I was used.
The prepared donor kidneys washing of a vascular bed at a stage of conservation was made only by Custodiol solution and at a stage of conditioning of the organ donor Dofaminum dosage to 10mkg/ kg/min was 26 - group II.
The prepared donor kidneys in number of 24 washing of a vascular bed was with application of the normal saline solution having in structure the Heparin divorced in the ratio 1:100 and after that were received by Custodiol solution from organ donors at which conditioning cardiotonic support with the raised Dofaminum dosage more 10mkg/kg/min
- group III was used.
Results of research at the time of immediate transplantation according to clinical data at recipients received the donor kidneys from the organ donors with the spent Dofaminum dosage when conditioning to 10mkg/kg/min and in cases of replacement and a washing of a vascular bed in a donor kidney by Custodiol solution - (group II) were the following: the beginning of excretory function after transplantation of a donor kidney was as in the next period immediately after transplantation and in terms of the first days to terms of 5 days, however adequacy of an uropoiesis was delayed and in 40% of cases there was a need for replacement renal therapy by a hemodialysis, further conservation of adequacy of a hydroballans and uropoiesis in terms from 6 months and till 5 years is noted at 60% of the recipients who received a donor kidney of this group.
Recipients of donor kidneys of this group at a stage of preservation of kidneys had such results of morphological research: the tissue of a kidney is presented by a glomulus of a usual look, the capsule of a glomulus is a little thickened at the expense of an edema. In some focuses of vision in vessels of a glomulus erythrocytes meet, the nephrothelium of convoluted tubules is high, is edemtous, nucleus of spherical forms with indistinct contours and condensation of a chromatin. In some vessels the stuck together erythrocytes, an interstitial tissue edema-tous become perceptible, the distracted, and in some vessels of capillary type a basal membrane is goffered, endothelial cells are dystrophically changed, enlarged in a size and evaginate in a lumen of vessels.
In 5 days at the same recipients who received donor kidneys from organ donors of the same group
- group II: intensifying of an edema in an interstitial tissue, emergence single the lymphoid cells and plasmocytes round blood vessels is noticed. The nephothelium of convoluted tubules is high with the expressed dystrophic changes with small quantity of PAS positive includings. The vacuolar degeneration of many epithelial cells of a Canaliculi and the endothelium exfoliating in a lumen of capillaries becomes perceptible which basal membrane is sharply edematous, homogenized by places.
Morphological data of biopsy material on 21st day at the same recipients who received donor kid-
neys from organ donors of the same group - group II taped a plethora of a vascular glomulus and vessels of an interstitial tissue of a kidney, an endothelium in some vessels the small outgrowths which bulked up, giving to a lumen narrowing a lumen. In a cytoplasma the fine vacuoles located round a nuclear membrane become perceptible. The basal membrane on some sites is thickened, destruct-ed, edematous with loss the tinctorial properties. Round some glomulus and vessels moderately expressed roundcellular infiltration presented by plas-mocytes and lymphocytes of the average size in the ratio Q becomes perceptible. The lumen of the convoluted tubules is reduced at the expense of augmentation in volume a nephrothelium in which shift of a nucleuses to an apical surface, with formation small and sometimes the vacuoles merging among themselves in a cytoplasma becomes perceptible. In single fields of vision single nephrocytes in a necrobiosis stage are observed. Infiltration scanty, is located a chain between a canaliculus of a kidney and generally limphoplasmocytic.
Results of research of the organ donors who received the donor kidneys from group received at the time of immediate transplantation according to clinical data at recipients (group III) with the spent Dofaminum dosage when conditioning to 10mkg/ kg/min and in cases of replacement and washing of a vascular bed in a donor kidney a normal saline solution having in structure the Heparin divorced in the ratio 1:100 and after that Custodiol solution were such: the beginning of excretory function after transplantation of a donor kidney was immediate, hydroballance and an uropoiesis corrected from first days after transplantation in 80% of observations in other observations of this group - 20% correction of a hydroballans and uropoiesis became perceptible in terms up to 5 days, need for replacement renal therapy a hemodialysis at this group of recipients wasn't. Further conservation of adequacy of a hydroballans and uropoiesis in terms from 6 months and till 5 years is noted at 90% of recipients.
Results of research of the organ donors of group III who received the donor kidneys from group received at the time of immediate transplantation according to morphological data at recipients were such: in the majority of the studied glass-slides of the tissue of a kidney consists of a small amount of a glomulus which are presented by the thin Boumen's capsule covered by podocytes which the little bulked up. Loops of vascular glomulus are thin, lumens are empty. Mesangial cells are in usual structure. Lumens of the convoluted tubules are covered by cylindrical nephrothelium which is swelled by places, nucleuses of cells are displaced to the periphery. A cytoplasma is of bright pink
color with sites of an enlightenment and formation of fine vacuoles. In some cores ill-defined condensation of a chromatin becomes perceptible. Cells lie on an accurate basal membrane which is a little destructed at the expense of an edema. Vessels of arterial type are mainly capillary structure, have an accurate basal membrane on which the flattened endothelium is located. Lumens of vessels are empty.
After 5 days at the same recipients who received donor kidneys from organ donors of the same group - group III: in the studied tissue of a kidney the small destruction of basal membranes in a nephrothelium of some convoluted tubules becomes perceptible, the augmentation of a destruction of basal membranes is noticed. The lumen of separate canaliculi is reduced because of the expressed dystrophic changes in a nephrothelium. Vessels are full-blooded, an endothelium "juicy", nucleus are hyperchromic, condensation of a chromatin in nucleus is more expressed. The interstitial tissue is full-blooded, edematous. In perivascular space single lymphocytes are met.
Morphological data of biopsy material on 21 st day at the same recipients who received donor kidneys from organ donors of the same group - group III: lumen of the convoluted tubules of a spherical form, are covered by high nephrothelium and which nucleuses are displaced to a basal membrane. In separate nucleus the small central condensation of a chromatin, a basal membrane accurate becomes perceptible vessels of capillary type are full-blooded, covered by the flattened endothelium, on some sites the thickening of basal membranes becomes perceptible. Vascular glomeruli are presented by loops of the vessels of capillary type filled with a blood. In some fields of vision microfocuses of proliferative activity of podocytes and ill-defined dystrophic changes of mesangiocytes become perceptible.
Results of research of the organ donors who received the donor kidneys from group received at the time of immediate transplantation according to morphological data at recipients (group I) with the spent Dofaminum dosage when conditioning no more than 5 mkg/kg/min and in cases of replacement and washing of a vascular bed in a donor kidney only by Custodiol solution were similar to data as at recipients of the organ donors of group III who received donor kidneys from group that is which when conditioning had a spent Dofaminum dosage to 10mkg/ kg/min and however replacement and washing of a vascular bed in a donor kidney at which was provided by a normal saline solution having in structure the Heparin divorced in the ratio 1:100 and after that Custodiol solution in the beginning.
For the fifth days after transplantation of a donor kidney at recipients of the organ donors who received donor kidneys from group (group I) with the spent Dofaminum dosage when conditioning no more than 5 mkg/kg/min. and in cases of replacement and washing of a vascular bed in a donor kidney only by Custodiol solution such data were noticed: the small thickening of a Boumen's capsule at the expense of a destruction of connective tissue structures becomes perceptible, a glomeruli is presented by plethoric loops, intervascular spaces are expanded, vessels of capillary type of a spherical form. A basal membrane accurate, on it a little reinforced endothelial cells settle down. Focuses of the spherical endothelial cells which are given in a lumen meet. The nephrothelium of convoluted tubules of a kidney edematous, high, the cytoplasma in the majority is homogenized with fine vacuoles. Nuclear membrane and contours of a nucleus accurate. The central condensation of a chromatin becomes perceptible. The interstitial tissue a little edematous, is full-blooded. Round vessels of capillary type single lymphocytes and plasmocytes meet.
The results of morphological research received by means of a biopsy of the transplanted kidney after 21st day at recipients of the organ donors who received donor kidneys from group (group I) were similar to data as at recipients of the organ donors of group III who received donor kidneys from group, namely data of morphological research of biopsy materials from donor kidneys of the donors of I and III groups received when conditioning and in the subsequent replaced to recipients showed existence of mild dystrophic changes in a parenchyma or in structures of the transplanted kidney bound to an ischemia which were gradually reduced on 21st day after transplantation.
The results of research received after transplantation of a donor kidney from group of organ donors (group I) were similar to data as well as at recipients of the organ donors of group III who received donor kidneys from group that is which when conditioning had a spent Dofaminum in dosage 10mkg/kg/min and however replacement and washing of a vascular bed of donor kidneys at which it was executed by a normal saline solution having in structure the Heparin divorced in the ratio 1:100 and after that Custodiol solution.
Concluding results of morphological data in 3 groups of the prepared donor kidneys and respectively in 3 groups of the recipients who received these kidneys from organ donors with the spent Do-faminum dosage when conditioning no more than 5 or more than 10 mkg/kg/min and in cases of replacement and washing of a vascular bed in a donor
kidney at conservation only by Custodiol solution or in cases of the replacement and washing of a donor kidney by a normal saline solution having in structure the Heparin divorced in the ratio 1:100 and after that Custodiol solution taped various results.
The received donor kidneys from group of organ donors with the spent Dofaminum dosage when conditioning no more than 5 mkg/kg/min and in cases of replacement and washing of a vascular bed in a donor kidney only by Custodiol solution and the received kidneys from organ donors with the spent Dofaminum dosage more than 10 mkg/ kg/min and however with application of replacement and washing of a vascular bed of a donor kidney a normal saline solution having in structure the Heparin divorced in the ratio 1:100 and after that Custodiol solution are similar that is lumens of vessels in a vascular glomeruli have in the beginning more smaller fullness with formulated elements of a blood and expression of a vacuolar dystrophia of nephrothelium of the convoluted tubules is insignificant or ill-defined. At complex morphological research cases of receiving donor kidneys from group of organ donors with the spent Dofaminum dosage when conditioning to 10mkg/kg/min and in cases of replacement and washing of a vascular bed in a donor kidney only by Custodiol solution showed that dystrophic changes of nephrothelium of the convoluted tubules are considerably expressed, the edema and a destruction of basal membranes of the majority of blood vessels with sites of "goffering" of an intima the stucked together erythrocytes in lumens of vessels and in loops of a vascular glom-erulus is noted.
Thus despite the standard concepts on maintenance of hemodynamic parameters by means of cardiotonic support by the medicine Dofaminum when conditioning organ donors and applications of various sequence of solutions, different in structure, at conservation of donor organs functional full value of the received organs aren't always identical that is bound to a series of factors. When carrying out actions of the damaging factors referred on protection against action the greatest reduction of level of a dosage of cardiotonic medicines is really necessary, different degree of a vasoconstriction of renal vessels attracts the changes developing in system of their microcirculation. In case of various degree of expression of a vasoconstriction undergone by donor kidneys for the purpose of their protection at a stage of conditioning it is necessary to make selection of structure and sequence of solutions at conservation stages for the purpose of compensation of washing and replacement of contents from a lumen of a vascular bed.
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