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ных условий для методики ЛДФ, датчик устанавливался на нижней трети предплечья. Статистическую обработку полученного материала проводили с использованием программы «BIOSTAT». Применялись непараметрические методы. Описательная статистика изучаемых параметров представлена медианой и межквартильным интервалом (25-го и 75-го перцен-тилей).
Результаты и обсуждение.
При изучении микроциркуляции установлено, что у пациентов с ХВГ, ПМ был снижен по сравнению с контролем на 38% (5,3 [4,2;6,2] и 7,3[6,7;7,6], соответственно) (р<0,05). При оценке среднеквадра-тического отклонения, характеризующего среднюю модуляцию кровотока (с) достоверных отличий между группами выявлено не было (1,07[0,6;1,1] в группе больных ХВГ;1,1[0,8;1,2] в группе здоровых). Коэффициент вариации, отражающий соотношение между перфузией ткани и величиной ее изменчивости (Kv), у пациентов с ХВГ наоборот был выше аналогичного показателя в контроле (22,3[12,8;22,9] и 16,1[11,9;19,1], соответственно) (р<0,05).
Таким образом, у пациентов с ХВГ выявлено снижение капиллярного кровотока.
POSSIBLE CAUSES OF PURULENT-SEPTIC UROLOGIC COMPLICATIONS AFTER KIDNEY
TRANSPLANTATION
M. Krstic, V.V. Bazaev, E.I. Prokopenko, A.V. Vatazin, A.B. Zulkarnaev
M.F. Vladimirsky Moscow regional clinical research institute Moscow, Russia
E-mail: [email protected]
A Purulent-septic urologic complication after kidney transplantation is quite complex and multi-disciplinary problem. This is largely due not only to the need for adequate immunosuppressive therapy, but also the difficulties arising from the differential diagnosis of postoperative infectious complications of other etiology (viral, fungal) and bacterial infections at other sites. Transplantation of kidneys, like any other surgery, carries risks of septic complications, including - urosepsis. Analysis of published data suggests the most important factors that are predictors of septic urologic complications:
1. Kidney transplantation may be complicated by septic processes (including urosepsis), which are particularly difficult to occur in recipients of renal transplant (RT).
2. Donor agencies (including kidney) may be infected with the organism has the potential donor, as well as on the stage of explantation.
3. At the time of surgery and post-transplant period, carried out in the central vascular catheterization, bladder
drainage of the wound, which creates additional conditions for the development of localized, and then a generalized infection.
4. Potential recipients of RT in a state of uremia, suffer from anemia, protein-energy deficiency may have metabolic disorders, which are themselves significantly alter the immune status.
5. Conduct a post-transplant period immunosuppres-sive therapy creates the conditions for secondary immunodeficiency, i.e. inhibition of proliferation of T - lymphocytes and B - lymphocytes, antibody production, and reduction of deep ant infectious immunity.
Thus, the incidence of these complications according to foreign and domestic research remains high for decades. The development of such complications depends on various factors. Purulent-septic urologic complications (including urosepsis) affect not only the outcome of kidney transplantation and duration of operation of the RT, but can often be the cause of unfortunate loss of functioning grafts, and sometimes death, transplant patients due to the generalization of the infectious process. What testify foreign publications including reports, United States Renal Data System according to which, in recipients of RT has an increased risk of hospitalization (41.53 times) over the septicemia as compared with the general population. The development of septicemia in hospitalized recipients often been associated with urinary tract infections - 30.6% of cases. In RT recipients with septicemia median survival was 9.03 years compared with 15.73 years for patients with kidney transplantation without this complication.
Thus, knowledge of the causes of septic complications after a kidney transplant clinicians to allow us to create an algorithm, as well as the principles of prevention and treatment of these complications and will improve the survival rate of recipients of the RT and improve their quality of life, reduce the period of examination and treatment hospital.
THE MODERN VIEW OF PURULENT-SEPTIC COMPLICATIONS IN PATIENTS WITH CHRONIC RENAL FAILURE WITH UROLOGICAL DISEASES BEFORE AND AFTER KIDNEY TRANSPLANTATION
M. Krstic, V.V. Bazaev, A.B. Zulkarnaev, A.V. Vatazin
M.F. Vladimirsky Moscow regional clinical research institute Moscow, Russia
E-mail: [email protected]
In the overall structure of the etiological causes of chronic renal failure (CRF), urological diseases ranging from 29% to 44,5% (Shilov E.M., 2008). The most common cause leading to chronic renal failure in urological patients, is a pyelonephritis. In second place is urolithiasis. Not rare causes of ESRD are congenital changes in
2012 Тюменский медицинский журнал
the kidneys, urinary tract, bladder outlet obstruction (Shi-lov E.M., et al., 2010). Any of these diseases can cause the development of infectious and inflammatory complications in particular, and urosepsis, where mortality ranges from 20 to 60% (Om PK. et al., 2009). It is noted as an increase in the number of patients and treatment costs (VS Saveliev et al., 2011). A huge role in preparing patients for kidney transplantation is the elimination of all possible foci of infection, as in post-transplant period used large doses of immunosuppressive drugs, which reduce the reactivity of the body and increase the risk of septic complications, even in the presence of small latent foci of infection (Bernabeu-Wittel M. et al., 2002). The most specific and threatening complication of immuno-suppressive therapy after renal transplantation is sepsis, in which mortality reaches 70-76% (Volynchik E.P., 2007). Sepsis has a direct effect on renal graft function (Becker S. et al., 2011). In the appointment of any immu-nosuppressive therapy, purulent focus in the recipient's body, especially the patient's own kidneys infected with pyelonephritis, are a potential source of bacteremia and hematogenous pyelonephritis of the transplanted kidney (Kabulbaev K.A., 2010) The structure of the causes of urosepsis in this category of patients are of particular importance increased virulence of opportunistic pathogens, activation of the endogenous microflora, and mixed viral infections (Prokopenko E.I. et al., 2010). Attempts to expand the range of used antibiotics do not give the expected results. This is due to the one formed by patients with chronic renal urologic etiology of the disease for many years, tolerance to many classes of antibacterial drugs, the other high frequency stability of community-acquired strains of microorganisms that cause infectious-inflammatory diseases of the urinary tract, to the widely used drugs such as aminoglycosides, aminopenicillins, cephalosporins (including Generation III and IV), (Koz-lov R.S., 2010). Resistance of gram-negative bacteria is a significant problem worldwide, especially enterobacteria producing beta-lactamase extended spectrum of action. At the present time in Russia, the prevalence of resistance factor beta-lactamase extended spectrum ranges from 52% to 71%, which is several times greater than in Europe (Grabe M. et al., 2010). Hope to "... the appearance in the near future, new antibiotics that satisfies all the requirements, it is seldom ...» (Paterson D., 2009). Especially in patients with chronic renal failure before and after kidney transplantation. In recent years there have been reports of successful use in the selective adsorption of endotoxin urosepsis Gram-negative bacteria. Published in the literature allows to state the high efficiency and absence of side adverse effects when using selective adsorption in sepsis. (Vatazin A.V. et al. 2011). Analysis of the current domestic and foreign literature, which suggests that the use of complex treatment of selective adsorption of endotoxin can not only compete successfully with emerging septic complications, but also significantly improve the performance of early and late survival in patients with surgical sepsis (Ronco C. et al., 2005; Casella et al., 2006, Yaroustovsky M.B. et al., 2008).
However, the application of the selective adsorption of endotoxin of gram-negative bacteria in patients with chronic renal failure urologic etiology, pre-and postkidney transplant unit devoted to the study, which was the basis for this study.
FEATURES OF PATIENTS WITH UROLOGICAL DISEASES WITH SEPTIC COMPLICATIONS, RECEIVING RENAL REPLACEMENT THERAPY
M. Krstic, V.V. Bazaev, O.N. Vetchinnikova, A.B. Zulkarnaev
M.F. Vladimirsky Moscow regional clinical research institute Moscow, Russia
E-mail: [email protected]
Improvement and implementation of the health system methods of renal replacement therapy provided treatment and prolong life in patients with end-stage chronic renal failure (CRF), but led to other problems. To date, it is obvious that the quality of medical and social rehabilitation, and life expectancy of these patients is mainly determined by the underlying disease and not the choice of method of renal replacement therapy, the addition of many related diseases, such as the special place occupied by an infectious-suppurative processes of various locations. Interestingly, in patients with end-stage renal failure is characterized by certain peculiarities, both in terms of risk factors and the clinical manifestations and therapeutic approaches. Thus, in the Russian Federation according to the Register of renal replacement therapy at the end of 2009 in the treatment of dialysis (hemodialysis and peritoneal dialysis) were almost 19 000 patients (133,6 people per million population), five years earlier, only 11 (77,8 persons per million population) (Bikbov B.T. et al., 2011). Formation of secondary immunodeficiency in patients with chronic renal failure receiving replacement therapy with hemodialysis, explains their easy susceptibility to bacterial infection and the possibility of depression as a result of humoral factors of nonspecific protection activate pathogenic microorganisms. Reducing the number of granulocytes in the inflammation, as well as the suppression of the phagocytic function may contribute to the development of systemic infection. In turn, the generalization of the process of bacterial infection, causes more inhibition of the function of all parts of the immune system (Kalantar-Zadeh K. et al., 2003). With the inevitability of empirical antibiotic use is not indicated the use of drugs, rapidly leading to the development of microbial resistance. But even without complying with this principle, the choice of drugs is complex. Thus, isolated from the urine of seven nosocomial Klebsiella strains were susceptible only to imipenem (71,4%), polymyxin (100%) and colistin (100%), sensitivity to piperacillin / tazobactam, tsefaperazon / sulbac-
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