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11
II. ХИРУРГИЯ
CURRENT STATUS OF CADAVERIC KIDNEY TRANSPLANTATION IN KAZAKHSTAN
Baimakhanov B.B., Chormanov A.T., Ibragimov R.P., Madadov I.K., Syrymov Zh.M.
JSC «National Scientific Center of Surgery named after A.N. Syzganov», Almaty, Kazakhstan
Abstract
Transplantation of organs saves thousands of lives annually all over the world. Of all kinds of transplantation of organs the most well-developed, as in whole world so as in Kazakhstan, is kidney transplantation. Increasing number of patients, seeking for kidney transplantation lead to shortage of donors. In whole world there is a common problem of shortage of donors in different grades. According to local social, ethic, religious and other considerations deceased donor transplantations and living donor kidney transplantations are developed diversely.
Казакстанда кадаврдан бYЙректi ауыстырудьщ Ka3ipri жагдайы
Баймаханов Б.Б., Чорманов А.Т., Ибрагимов Р.П., Мададов И.К., Сырымов Ж.М.
А.Н. Сызганов атывда™ Улттык, Рылыми Хирургия орталь™, Алматы, Казахстан
киддтпа
Орган трансплантациясыжыл сайындуниежузнде мындаган ем1р куткарыпжатыр. Орган трансплантациясыныц дуниедепжэнеде К^аза^стандагы ендамыган тур\ буйрек трапснплантациясы болып саналады. Буйрек трансплантациясы кут1п журген наукас саныц кебею\ донор жет1спеуш1л1г1н тугызды. Дуниежуз\ бойынша донор жет1спеуш1л1г1 проблемасы бар Социальд\, этникалык, дин\ жэне де баска да кезкарастар мен байланысты турл\ мемлекеттерде мэутт\к донордан немесе т\р\ донордан буйрек трансплантациясы гурл\ дэрежеде дамы&ан.
MPHTM 76.29.46
ABOUT THE АUTHORS
Baimakhanov B.B. - professor, transplant-surgeon, chairman of Board of JSC «National Scientific Center of Surgery named after A.N. Syzganov» (info@baimakhanov.kz, 87017223381).
ChormanovA.T. - can of med sci., transplant-surgeon, cheaf physician of JSC National Scientific Center of Surgery named after A.N. Syzganov (almat7676@mail.ru, 87019899900).
Ibragimov R.P. - urologist, transplant-surgeon, head of kidney transplantation, urology and nephrology department, scientific manager. (rava747@mail.ru 87017472070)
Madadov I.K.- urologist, kidney transplantation, urology and nephrology department (dominic89@mail.ru 87478397110)
Zh.M. Syrymov - urologist, kidney transplantation, urology and nephrology department. (syrymov89@mail.ru 87072727002)
Keywords
kidney, transplantation, deceased-donor, Kazakhstan.
АВТОРЛАР ТУРАЛЫ Б.Б. Баймаханов - профессор, трансплантолог дэр\гер\, «УлттыкГылыми Хирургия орталыры» А^-нын баскарма теарарасы (info@baimakhanov. kz,, 87017223381). А. Т. Чорманов - медицина рылымдарыныц кандидаты, трансплантолог дэр\гер\, «Улттык£ылыми Хирургия орталыры» А%-ныц бас дэр\гер\ (almat7676@mail.ru, 87019899900). Р. П. Ибрагимов - уролог-транспланто-логдэр\гер\, буйрек трансплантациясы, урология жэне нефрология бел\мшес\н\ц жетекш\с\, рылыми жетекш\(rava747@mail. ru 87017472070)
И.К. Мададов - уролог дэр\гер\, буйрек трансплантациясы, урология жэне нефрология бел\мшес\, к\ш\ рылыми кызметкер (dominic89@mail.ru 87478397110) Ж.М. Сырымов - уролог дэр\гер\, буйрек трансплантациясы, урология жэне нефрология бел\мшес\ (syrymov89@mail. ru 87072727002)
ТуЙ1И сездер
трансплантация, буйрек, мэутт\к донор, ÎÇазакстан.
Современное состояние трансплантации трупной почки в Казахстане
ОБ АВТОРАХ
Б.Б. Баймаханов - профессор, трансплантолог, председатель правления АО «Национального научного центра хирургии им. А.Н. Сызганова» (info@baimakhanov. kz, 87017223381).
А.Т.Чорманов - к.м.н., главный врач, АО Национального научного центра хирургии им. А.Н. Сызганова (almat7676@mail.ru,
Баймаханов Б.Б., Чорманов А.Т., Ибрагимов Р.П., Мададов И.К., Сырымов Ж.М.
Национальный Научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан
Аннотация
Трансплантация органов ежегодно спасает тысячи жизней по всему миру. Из всех видов трансплантаций органов наиболее развитым как во всем мире, так и в Казахстане является трансплантация почки. Стремительное увеличение количества пациентов, нуждающихся в пересадке почки привело к нехватке доноров. По всему миру существует проблема донорства в разной степени. В зависимости от социальных, этнических, религиозных и других соображений в разных странах в различной степени развиты трупное донорство и трансплантация от живого родственного донора.
Р. П. Ибрагимов - уролог-трансплантолог, заведующий отделением трансплантации почек, урологии и нефрологии, руководитель исследования (rava747@ mail.ru 87017472070) Ж.М. Сырымов - уролог, отделение трансплантации почек, урологии и нефрологии (syrymov89@mail.ru 87072727002) И.К. Мададов - уролог, отделение трансплантации почек, урологии и нефрологии, младший научный сотрудник (dominic89@ mail.ru 87478397110)
Ключевые слова
трансплантация, почка, трупный донор, Казахстан.
Table 1
Comparative Evaluation of Organ Donation and Transplantation System.
Introduction
Cadaveric donation allows effectively solve the problem of shortage of donor organs. Kidney transplantation is financially effective in contrast to hemodialysis. In USA annual expenditure for one patient on hemodialysis is 87000 dollars whereas for one patient with kidney transplantation - 29000 dollars (1, 2, 3).
1-year kidney graft and patient survival from deceased-donor is 73,5% and 88,2%, respectively. Whereas 5-year kidney graft and patient survival from deceased-donor is 58,8% and 61,7 %, respectively (4).
Life-span of patients after kidney transplantation is longer in contrast to patients on hemodialy-sis. Kidney transplant patients at the age of 55 live 10 years longer more than patients on hemodialysis (5, 6).
In an attempt to improve cadaveric donation, criteria for donor selection were expanded. Such criteria as age and concurrent disease were now reconsidered.
Thus, according to clinical trials there were no significant differences in rates of 1-, 3- and 5-year graft survival from deceased - donors below and over 50 years old, 95% vs 90%, 65% vs 60% u 40% vs 35%, respectively (15).
Results of 21 kidney transplantations from extended criteria deceased-donors with concurrent diseases were investigated (hypertension, diabetes mellitus). According to the follow up for 11 months, mean cre-atinine level was 1.59 +/- 0.63 mg/dl. In 10 patients was delayed graft function. In 11 patients was biopsy proven acute tubular necrosis. In 7 patients there was an acute graft rejection reaction, of them 6 cases were managed by anti-rejection treatment (16).
According to the data from Republic Center for coordination of transplantation and high-technology medical services currently there are 2575 people on waiting list for kidney transplantation in Kazakhstan. Of them, 2528 are adult patients, 47 - pediatric patients. From 2012 to 2017 years there were performed 1019 kidney transplantations in Kazakhstan. Of them, 885 from living related donor
and 134 from deceased-donor (19).
In other countries the situation is the same. In 2015 there were performed 84.347 kidney transplantations in 89 countries in the world (7), whereas according to the data from Organ Procurement and Transplantation Network, at the beginning of 2018 there were 95,354 people on waiting list. Mean duration of waiting time for kidney transplantation of patients in hemodialysis is 5-10 years. Unfortunately among this period there is a gradual increase of risk of mortality and concurrent diseases.
Thus, despite the annual increase in rates of kidney transplantations, number of patients necessitating kidney transplantation just increasing. Being an Asian country where traditionally there are 5 and more people in family, there is a good opportunity to improve living organ donation. But in reality even on preoperative evaluation contraindications for organ donation are not uncommon now even in young patients. Another problem is ethical and religious considerations and decreased willingness to be a donor. This is all sourcing from poor awareness of people. Thus it is of paramount interest to improve deceased-donor kidney transplantation in Kazakhstan.
Material and methods
Literature review of cadaveric kidney transplantation in different countries, legal aspects of cadaveric donation and the ways to improve it.
Results
In Saudi Arabia rates of cadaveric kidney transplantation comprises 35 % of total number of kidney transplantations (8). For instance, in USA cadaveric kidney transplantation comprises 63,1%, in Europe - 69,5%, in Middle East - 30,2 %, South Asia - 19,4 %, in Kazakhstan - 13.1 %, in Africa -6,2%, respectively (9).
Discussion
Legal aspect of regulation of cadaveric donation is consent of patient.
System Advantages Drawbacks
• Slow increase of donation rate
Informed consent • No moral and ethical problems • False negative (the kidney donation cannot be proceed if no informed consent made though the individual want to donate)
Presumed consent • Significant increase of kidney donation • Moral and ethical questions • False positive (the transplant authority may take organ against donor's will)
• Reduce financial burden of the
Financial donor and the family • Moral and ethical questions
incentives • A potential to increase kidney donation • Against some religious views
m «A « *
Z 1*2 Il IS* |i* StS*
Table 2
Kidney Donation Rate from Deceased Donor in 2016. Source: The International Registry of Organ Donation and Transplanta-tion28. *2015,
** per million population.
In such countries as Japan, USA and Great Britain people give informed agreement for donation in case of death. This is called informed consent ("opt-in" system). In contrast, in European countries and in Kazakhstan, if a person during his life does not give official refusal for organ donation, in case of death he is considered as cadaveric donor. This is called presumed consent ("opt-out" system). Nowadays despite the illegality of organ purchasing in some countries such as Iran, Singapore, Saudi Arabia financial incentives for the relatives of donor are now being considered (10) Table 1 . For instance, in Pakistan 50 % of cases of donations are paid donations. In Saudi Arabia government pays a compensation for about 50000 riyals (13000 dollars) to the family of deceased-donor, in order to support psychologically and reimburse funeral expenditure (17). In Singapore government subsides 50 % of expenditure on medical care to the family of deceased-donor during 5 years (18). Table 2.
Discussion
In Asia, presumed consent was first introduced in Singapore in 1987 (11), in Republic of Kazakhstan in 2009r. In practice, there are 2 types of presumed consent: hard or soft, which relates to how far the family's consideration is placed (15).
Transplant team in countries with hard presumed consent, such as Austria and Singapore, is likely to remove organs from a deceased donor without asking the family's view. Spain and Kazakhstan have been practicing a soft presumed consent in which the medical staff is urged to consult with the donor's family prior the organ removal (12).
Table 3 shows statistical data of organ donation rate and public attitudes in some European countries.
It obviously showed that countries with high level of donation rate (such as Netherlands and Spain) tend to have higher level of willingness to donor and willingness to give consent to other family member to donate (>50%), regardless the system practiced in those countries. On the contrary, countries with low level of such public attitudes toward organ donation (such as Romania and Bulgaria) have low donation rates. Those suggest that there is a linier relation between public attitudes and organ donation rate.
According to the Eurobarometer survey in 2010, the low level of public attitudes is influenced by several reasons which are dominated by the lack of public trust in the organ donor and transplant system and the fear of manipulation of human body. Public distrust of the system leads to an increase
Country Legal System Otgan Donation Number* per year (PMP)37) Willingness to donor %)38) Family's willingness to consent organ donation38)
Netherlands Informed Convent 56,1 64 62
Romania 13,3 31 34
Spain Presumed Consent 49,74 61 59
BnJsana 5,31 42 44
Table 3
Statistical data of organ donation rate and public attitudes
number of the unwilling organ donor and a protest against presumed consent system in Russia (13, 14). To promote and improve the public awareness on organ donation and transplantation, educational campaign is a vital approach. Studies showed that the more the public is informed about the various aspects of organ donation and transplant, the higher the public awareness (20, 21). The public distrust is also the same in Kazakhstan. People have a fear of manipulation with their body, suspecting commercial intents of transplant team. The willingness of relatives to consent organ donation is also very low, because of ethical and religious consider-
References
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3. United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2016).
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ations. People have very poor imagination of how donor organs can be helpful for the patients that are at high risk of mortality.
Conclusion
Thus, in order to increase the rates of cadaveric kidney transplantation it is necessary to inform the public to increase their awareness, elucidate the problems of the shortage of donor organs, the rates of mortality of patients on waiting list, to clarify the work of transplant team, introduce the clarity about social, ethical and religious aspects of organ donation.
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13. Burkov, A. Russia's unknown, unwilling organ donors. The Moscows Times (2014).
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19. https://transplant.kz/ru/statistika.html
20. Terbonssen, T., Settmacher, U., Wurst, C., Dirsch, O. & Dahmen, U. Effectiveness of Organ Donation Information Campaigns in Germany: A Facebook Based Online Survey. Interact. J. Med. Res. 4, e16 (2015).
21. Scheuher, C. What is being done to increase organ donation? Crit. Care Nurs. Q. 39, 304-307 (2016).
