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Kidney transplantation in National scientific center of surgery
Zainalov A.K., Ten N.S., Nursan E.N., Arinov S.N., Tazhdinov D.B., Balabekov A.G.
JSC "Syzganov's National Scientific Center of Surgery", Almaty, The Republic of Kazakhstan
Abstract: This publication describes the prevalence of the disease and data on patients with terminal chronic renal failure in the Republic of Kazakhstan in need of treatment of kidney transplantation. We describe the principles, lessons learned and results of 600 organ transplants since 1978 and currently guiding the office of National scientific center of surgery named of A.N. Syzganov.
In the present period of modern surgery is generally accepted that successful kidney transplantation the best way to restore - stvo quality of life for patients with end-stage renal disease, providing them with full medikal and social rehabilitation. At the same time, all patients in need can not be achieved by transplantation of limited number of - tained, one of the major limiting factor is the shortage of donor organs.
Department of Transplantation and Artificial Organs in the Republic of Kazakhstan was launched in May 1978, before the opening of Alma-Ata session of the World Health Organization. After installing the dialysis equipment, long-term preparation and organization of groups on the fence and conservation bodies, Immunology, Biochemistry, education specialist in October 1978 had been taken ill with terminal chronic renal failure (ESRD).
The first successful transplantation of donor kidneys from donor asistolicheskogo in Kazakhstan was on April 17, 1979. Total for the period grew to more than 600 donor kidney transplants, 80 of them carried out kidney transplants from related donors, 7 autotransplantation of the kidneys and more than 30 kidney transplants for children aged 6 to 18 years. The survival rate of kidney transplant during the first year currently stands at 89%, while the number of acute rejection crises nekupiruemyh tends to decline and up to 7,8%. In clinical kidney transplantation, Transplantation Service is engaged in development of liver and heart transplants in the experiment.
At the present time in Kazakhstan mastered and improved clinical kidney transplantation, and this trend transplantation has always been and remains relevant as the number of patients with terminal chronic renal insufficiency in the country has been steadily increasing, so for 1 year on renal replacement therapy on statistics is more 1700 patients - 65 per 1 million population. Mortality on the waiting list for kidney transplantation in our country - 35,4%.
Za Soviet period there was closer cooperation on the system «Evrotransplant» in this period of Transplantation Service of the republic guided a single legislative framework that enabled the exchange of donor organs with the other republics. Republic of Kazakhstan for the period from 1978 to 1990 for the transplant centers of different countries were given more than 30 donor agencies.
With the collapse of the USSR and Kazakhstan gained sovereignty arose legislative vacuum including on the issue of organ and tissue transplantation. Therefore, any issues relating to organ transplants, needed especially in the legislative basis. That is why, along with the decision of a medical prob-
lem, there is an acute need for a speedy solution of problems of legislation, taking into account the legal, national, economic, cultural and other peculiarities of Kazakhstan.
In-depth analysis of existing precedents in the world based on the situation of organ transplantation of the World Health Organization, developed a draft law and regulations governing organ and tissue transplants in the country. In the Republic of Kazakhstan adopted the Law «On protection of citizens' health» new article «Organ and tissue transplantation», which includes the following items: 1. The donor of organ and tissue transplantation may be someone dead man, as well as animals. 2. Forced removal of organs and tissues and their transplantation are not allowed. 3. The procedure of transplantation of organs and tissues from person to person, from the corpse of a man and from animals to humans is established by the Ministry of Health of the Republic of Kazakhstan. Order of the Ministry of Health of the Republic of Kazakhstan approved by the general provisions on the transplantation of organs, tissues and instructions on the procedure for removal of organs and tissue from a donor corpses and instructions for confirming death by irreversible cessation of brain function, together with the relevant acts.
Currently in the Republic of Kazakhstan transplantation can be performed and patients from group of so-called high-risk (patients older than 60 years, diabetes mellitus, gipersensibilizirovannye patients, small children), but despite this probable contingent recipients It should there - lowing absolute contraindications to TP: tumor disease, chronic heart failure of stage II B, III; chronic respiratory failure, active hepatitis, cirrhosis of the liver, extensive atherosclerosis with lesions of the vessels of the heart, brain, blood vessels of the lower extremities, chronic infection that is not treatable, mental disorders.
The source of donor kidneys for heterotopic allotransplantation in our country may be living or cadaveric donor, while the law of the republic in the case of a living donor is permitted trans - plantation of organs only from related donor, and only in government health facilities. The main criteria for sister body donation is to guarantee the safety of donors in the postoperative period and a high standard of renal transplantation - Tata.
V during past decade in Kazakhstan is a shortage of donor organs and interest asistolicheskim corpses donors with irreversible cardiac arrest is always growing, so in the case of cadaveric transplantation expectations - tion compatible organ can last months and years.
The allocation of the donor, depending on the reasons causing the deaths of Transplantation Service of the Republic of Kazakhstan is guided by general principles of selection: an acute brain injury, intracranial hemorrhage, benign brain tumor, polytrauma without kidney damage. There are also universally accepted criteria for determining the indications for explantation of donor organs: the age of 60 years, absence of opportunistic infections (HIV, hepatitis, syphilis, sepsis), the absence of associated systemic diseases (cancers, diabe-
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Вестник хирургии Казахстана №3, 2014
tes, autoimmune vasculitis, malignant arterial hypertension), absence of lesions and purulent-inflammatory processes in the retroperitoneal space, the plasma creatinine level no higher than 0.12 mmol / l, plasma urea level no higher than 10 mmol / l in the absence of urinalysis proteinuria, Piura, gross hematuria, bacteria and fungal spores.
Upon receipt of authority from the donor asistolicheskogo there is not one link of health workers with the primary goal is to keep donor organs from the effects of several factors influencing them at the stages of explantation, preservation, and directly to transplantation. Getting preserved donor organ depends largely on the characteristics of the donor, which in turn depends on the experience of the doctor, the number of anesthesiology and intensive care hospital - the donor base. Despite the factors that depend on the joint work anesthesiology and intensive care and transplant center solution to many organizational issues remain the competence of the administrations of clinics and forensic services.
The standard technique of transplantation of donor kidney recipient, previously non-transference of such an operation is to form anastomoses between the arterial and venous vessels of the kidneys of the same name and the internal iliac vessels of the recipient, as well as in the formation of anastomosis between the donor ureter and bladder of the recipient.
Horoshim and satisfactory result of a donor kidney transplantation is considered normal levels of urea, creatinine, and adequate diuresis in the recipient within 7 - 14 days after transplantation, in the event of diuresis and the subsequent normalization of slag composition and blood electrolytes during the period from 14 to 20 days after transplantation function of the transplant is considered to be delayed, the complete absence of graft function for more than 20 days is an indication for transplantatektomii.
Immunosuppression in patients after transplantation of donor kidney is achieved through the use of calcineurin inhibitors (cyclosporine, tacrolimus), suppression of lymphocyte proliferation (mayfortik, sellsept) inhibitors and monoclonal antibody inhibitors of the proliferative signal (everolimus or sertikan), specific effects on macrophages and T cells and nonspecific and anti-inflammatory effects (kortikosteroydy). Despite significant advances in immunosuppressive therapy, the main problem in the Republic of Kazakhstan is still a crisis of graft rejection in the early and late postoperative period. To monitor the transplanted kidney in patients receiving treatment for a donor kidney transplants are carried out clinical diagnostic tests and immunological monitoring in this case the importance of these surveys has morphological study biopsionnogo material from the transplant.
With the development of acute or chronic rejection crisis produced events to depression of immune response in transplant recipients and activities aimed at preventing the progression of renal graft rejection crisis for which vypolnetsya correction of immunosuppressive therapy, activities aimed at improving tissue blood flow in the transplanted organ. A set of measures aimed at preventing or stopping of renal graft rejection crisis could include a session or sessions hemosorp-tion and therapeutic plasmapheresis, which also reduces the immune response of recipient, to improve tissue blood flow in the transplanted organ and the prevention of intravascular coagulation. Indeed the main objective in the treatment of patients after transplantation of donor kidney and developed
nephropathy and a crisis of rejection of transplanted kidneys is to maintain its function, but in each case considering the feasibility and attempts to preserve the graft, as this may nephropathy appear to irreversible loss of function, so a possible option transplantatektomii considered in each case to prevent the patient's life-threatening complications.
Experience in most developed countries shows that we are on the right path - if there is a full-fledged legal framework in Kazakhstan progress is possible through the provision of proper organization of (part of the main doctors) to provide specialized care, namely, the recovery in the post-mortem organ donation.
Nesmotrya on the existing experience of service of transplantation of the republic are still many important organizational issues standing in the way of organ donation. One important task of the service is addressing issues of organ donation, which obviously is joint awareness in understanding and unity of the medical staff at various stages of removal of organ donation and transplantation and the need to address the social tensions of the population. The next task is to improve the service of transplantation of donor services by strengthening the legal framework for organ donation and transplantation in the Republic. Expansion of nephrological service and inclusion in its duties management of patients after kidney transplantation. Development and implementation of the concept of building a unified state system of organ and tissue transplantation integrated with transplantation of other states, whose main goal is the transition from individual cases to the wide use in the practice of organ transplants and tissue.
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Тужырым
Негзгi свздер: Бауыр ауруынын терминалды саты-сы, бауыр трансплантациясы.
К/'р/'спе: Казакстан Республикасында бауыр ауруларынын терминалды сатысындагы наукастарды емдеу вте взектi маселелерд/'н бр1 болып табылады. Ел ¡м/'зде бауыр транслантациясы багдарламасы 2011 жылы бастаган, содан бер 2014 жылдын кыр^йег1не дейн алты медициналык орталыктарда 40-тан астам бауыр трансплантациясы жасалды.
Казакстанда бауыр трансплантациясынын твмен даму себебтер/'нщ брi, ол мэиттк донорлар тапшылыгы жэнэ жерг/'л/'ктi халыктын трансплантацияга деген квзкарасынын взгешл/'гi. Осыган байланысты, ел/'м/'зде медицина кауымдастыгынын Yлкен тэж1рибеа болмай тура, бауыр трансплантациясынын ен бр ку^рдел1 тYрi - бауырдын туыстык трансплантациясынан бастауга тура келдi. Осыган орай, осындай курдел1 оталарды енг1зу1 ел Шздщ медицинасынын дамуынын жалпы денгейi вте жогары екенн кврсетт/'.
Тэслдер: «А.Н. Сызганов атындагы ¥лттык гылыми хирургия орталыгы» АК-да 2011 жылдын желтоксан айы-нан бастап бауыр ауруынын терминалды сатысындагы
15 рецепиентке бауыр трансплантациясы жасалынды; онын 12-де бауырдын бр бвл/'гi т ¡р туыстык донорлар-дан алынса, 3-де мэй/'тт/'к донорлардан бYтiн бауыр алынган.
Нэтижелер: Жалпы «А.Н. Сызганов атындагы ¥лттык гылыми хирургия орталыгы» АК-да бауыр трансплантациясы багдарламасынын басталуынан берi ота кезндегi кврсетюштер1 мен отадан кей1нг1 емделу кезен/нде жаксы нэтижелер байкалады. БYгiнгi танда бауыр трансплантациясынан кейн наукастарды бакылау мерз/'мi 32 аптадан асады. Ота жасалган 15 реципиенттщ 10-ны (67,7%) жумыска жарамды калыпты вм1р сYPуде, вздерне тистi иммуносупрессивт1 ем/'н кабылдауда. Вирусты гепатит салдарынан бауыр циррозына шалдыккан рецепиенттерде отадан кей н вирустын кайталануы аныкталган жок..
Корытынды: Алдын ала кврсетлген нэтижелерге байланысты Казакстанда бауыр трансплантациясы багдарламасын дамыту орасан зор екен/'н кврсетед. Туыстык донорларда отадан кей/'н аскынулар саны жогары болу кау:п1не байланыста, мэи/'тт/'к донорлар трансплантациясынын дамуы ти/'мдi болып есептел нед .
