The experience of pancreas transplantation with isolated splenic artery supply

Aim. To demonstrate the possibility of successful transplantation of pancreaticoduodenal complex with isolated splenic artery supply and to assess the quality of its perfusion. Methods. 6 patients who underwent pancreas transplantation with isolated splenic artery blood supply were examined. The recipients were 3 men and 3 women, the median age was 36.5 [31; 42] years. To evaluate the state, quality of transplant perfusion and their function, the laboratory data, doppler ultrasound, measurement of blood flow volume (CT-perfusion) and treatment outcomes were assessed. Results. Based on the results of investigations, adequate pancreatic graft blood supply through the splenic artery alone was detected. Pancreatic transplant function in all patients was satisfactory, blood glucose levels remained within normal values. Hospital mortality was 0%. Conclusion. Successful transplantation of pancreaticoduodenal complex with isolated splenic artery supply is technically possible due to the presence of intraorganic arterial collaterals

EVALUATION OF PATIENT’S LIFE QUALITY AFTER SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANTATION

Introduction: the use of standardized questionnaires for  assessment of patients’ life  quality after organ transplantation has not been widely used in our country.Purpose: The assessment of patients’ quality of life after the simultaneous pancreas & kidney transplantation using the SF-36 questionnaire.Material and methods: 35 patients with type I diabetes mellitus (DM1) complicated by end-stage chronic renal failure were investigated. There were 16 women (45.7%) and 19 men  (54.3%). The median age was 36 [33; 45] years. The patients were divided into 2 groups depending on the transplantation type:  group I included the patients who underwent isolated kidney transplantation, group  II  included those  after combined kidney and  pancreas transplantation. Patients’ life quality was estimated using the SF-36 questionnaire.Results: Patients in group II had significantly better physical functions, general health  status, and vital activity.Conclusion: Simultaneous pancreas & kidney transplantation considerably improves the life quality of patients with DM1

Клеточное отторжение панкреатодуоденального трансплантата

Aim. The evaluation of donor’s duodenum histological examination in diagnosis of pancreaticoduodenal graft rejection.Materials and methods. The 35-yo patient with terminal diabetic nephropathy undergone simultaneous retroperitoneal kidney and pancreas transplantation  with enteric exocrine drainage of the graft via inter-duodenal anastomosis. When performing the esophagogastroduodenoscopy 2 years posttransplant we  implemented histologic examination of the duodenum of the graft.Results. We diagnosed and verified severe cellular rejection of pancreaticoduodenal graft. Successful etiopathogenetic treatment of acute  rejection of the graft (pulse therapy with glucocorticoids) was performed.Discussion. The diagnostic value of donor’s duodenum morphological examination in the diagnosis of pancreaticoduodenal graft  rejection, the efficacy of anti-rejection treatment were performed in this case.Цель исследования. Оценка значимости морфологического исследования слизистой оболочки донорской двенадцатиперстной кишки в диагностике отторжения панкреатодуоденального трансплантата.Материалы и методы. Пациенту 35 лет с терминальной стадией диабетической нефропатии была произведена сочетанная забрюшинная пересадка почки и поджелудочной железы с  кишечным вариантом отведения панкреатического сока через междуоденальный анастомоз.  Спустя 2 года при проведении эзофагогастро-дуоденоскопии мы выполнили гистологическое  исследование слизистого слоя двенадцатиперстной кишки трансплантата.Результаты. Была диагностирована и морфологически верифицирована тяжелая степень клеточного отторжения панкреатодуоденального трансплантата. Обосновано и  успешно проведено патогенетическое противокризовое лечение – пульс-терапия  преднизолоном, с положительным клиническим эффектом.Заключение. На клиническом примере показана эффективность гистологического исследования слизистой оболочки двенадцатиперстной кишки панкреатодуоденального  трансплантата в диагностике отторжения, возможность обосновать и успешно провести противокризовую терапию

СОСУДИСТЫЕ ОСЛОЖНЕНИЯ ПОСЛЕ ТРАНСПЛАНТАЦИИ ПОЧКИ

Aim: evaluation of the incidence and the pattern of vessel complications, efficacy of the prophylactic anticoagulation therapy after kidney transplantation. Materials and methods. From March 2007 till January 2013 421 patients: 230 men (54,6%) and 191 women (45,4%); mean age 43,07 ± 11,62 undergone 429 kidney transplantations in the department of pancreas and kidney transplantation of the Scientific-Research Institute of Emergency Care named after N.V. Sklifosovsky. In order to evaluate the condition and the function of the kidney transplant ultrasound investigation (daily) andacquisition(weekly) wereused. In cases of kidney dysfunction and assumption of vessel complications we used computerized tomography. Besides, we used daily analysis of biochemical and clinical parameters of blood and urine. Results. The most common vessel complication was the thrombosis of the microvasculature of the kidney transplant due to acute humoral and combined rejection resistant to antirejection therapy (n = 9; 2,1%); in 4 cases there was a breakage of the transplant due to the acute rejection and the urgent transplantatectomy in an effort to save the patient; thrombosis of the transplantat artery occurred in 1 case (0,23%); we observed 2 cases (0,46%) of the artery stenosis and 2 cases (0,46%) of venous thrombosis. Conclusion. Summary frequency of vessel complications in our clinic, including thrombosis due to rejection, was 3,49%. It fully corresponds with data obtained from the global medical community. The incidence of great vessel thrombosis was less than 1% which indicates the adequate prophylactic anticoagulation therapy. For the benefit of early diacrisis of complications Doppler sonography is needed. In case of assumption of vessel complications urgent acquisition, computerized tomography and/ or angiography are to be held. Цель: определение частоты и причин сосудистых осложнений после трансплантации почки; оценка эф- фективности их профилактики. Материалы и методы. С марта 2007 г. по январь 2013 г. в НИИ СП им. Н.В. Склифосовского было выполнено 429 трансплантаций почки 421 пациенту: 230 мужчинам (54,6%) и 191 женщине (45,4%); средний возраст пациентов составил 43,07 ± 11,62 года. Для оценки состояния и функции почечного трансплантата применялись клинико-лабораторные методы: ультразву- ковое и доплероскопическое исследование ПАТ – ежедневно, динамическая нефросцинтиграфия – еже- недельно. КТ с в/в усилением проводилась при дисфункции трансплантата и подозрении на сосудистые осложнения. Ежедневно проводился анализ биохимических и клинических показателей крови, мочи. Результаты. Из сосудистых осложнений в нашей клинической практике наиболее часто встречались тромбозы микроциркуляторного русла ПАТ в результате развития острого гуморального или смешанного отторжения, резистентного к проводимой терапии (2,1% случаев; n = 9); в 4 случаях острое отторжение привело к разрыву трансплантата и экстренной трансплантатэктомии; тромбоз магистральной артерии ПАТ наблюдался в одном случае (0,23%); выявлено два случая (0,46%) развития стеноза почечной арте- рии; в двух случаях (0,46%) наблюдался венозный тромбоз ПАТ. Заключение. Суммарная частота всех сосудистых осложнений, включая тромбозы, возникшие в результате отторжения, в нашем стационаре составила 3,49%, что сопоставимо с данными мировой литературы. Частота тромбозов магистральных сосудов ПАТ составляет менее 1%, что свидетельствует об адекватной профилактической антикоагулянт- ной терапии. Для ранней диагностики осложнений реципиенту показано ежедневное выполнение УЗДГ ПАТ, а при подозрении на развитие сосудистых осложнений – скорейшее проведение динамической не- фросцинтиграфии, компьютерной томографии ПАТ с в/в контрастным усилением и/или ангиографии не- фротрансплантата.

ПЕРВЫЙ ОТЕЧЕСТВЕННЫЙ ОПЫТ ЗАБРЮШИННОЙ ТРАНСПЛАНТАЦИИ ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ C ФОРМИРОВАНИЕМ ДУОДЕНО-ДУОДЕНОАНАСТОМОЗА

Simultaneous pancreas-kidney transplantation is a valid therapeutic option for patients with type 1 diabetes mel- litus (DM) and secondary diabetic nephropathy, which enables to achieve an insulin-independent euglycemic state with normalization of glycosylated hemoglobin levels, prevent the secondary complications of diabetes and consequently improve patients, quality of life. There are various transplantation procedures exist. Although pancreas is transplanted because of its endocrine function, one of the main issues, which prevent the successful development of pancreas transplantation, is an exocrine drainage. The aim of this paper was to summarize our first experience of retroperitoneal pancreas transplantation with the formation of duodeno-duodenal anastomosis for enteric drainage. Сочетанная трансплантация почки и поджелудочной железы (ТП и ПЖ) – метод выбора в лече- нии пациентов, страдающих сахарным диабетом 1-го типа, осложненным терминальной диабе- тической нефропатией, которая позволяет достигнуть инсулинонезависимости, остановить или существенно замедлить развитие вторичных осложнений сахарного диабета. Одним из важней- ших условий успешной трансплантации является адекватное дренирование экзокринного секре- та поджелудочной железы. В статье описан первый отечественный опыт забрюшинной сочетан- ной ТП и ПЖ с ретроперитонеальным формированием дуодено-дуоденоанастомоза.

Use of tacrolimus to prevent acute kidney graft rejection in sensitized patients

The emergence of new immunosuppressants, such as the macrolide drug tacrolimus (prograf), has recently become one of the most important advances in transplantology. Tacrolimus belongs to calcineurin inhibitors and differs from cyclosporine in a rapider and uniform bile acid-independent absorption, causing a reduction in the individual variability of the blood concentration of the active ingredient. On renal transplantation in sensitized patients and/or repeated allografting, the use of tacrolimus makes it possible to reduce the percentage of hormone-resistant crises by more than twice and to prevent intractable acute rejection crisis

The choice of immunosuppressive therapy depending on the level of anti-HLA antibodies in kidney transplantation

Seeking to develop immunosuppression regimens that would take into account the patient's level of sensitization to the antigens of the main histocompatibility complex, we studied 123 patients after kidney transplantation. Depending on the choice of immunosuppressive therapy, two groups were formed. The study group included 55 patients who received the immunosuppression regimen adapted to their HLA sensitization level. In the comparison group, 68 patients received baseline immunosuppression, including calcineurin inhibitors, mycophenolic acid preparations, and corticosteroids. AntiHLA antibody detection was performed by assessing the mean fluorescence intensity (MFI) on the Luminex platform when patient's placing on the transplant waiting list. It was found that highly HLA-sensitized recipients should receive antithymocyte polyclonal antibodies with or without plasmapheresis immediately after surgery in order to prevent the rejection reaction. The moderately HLA-sensitized patients should receive the baseline immunosuppression in combination with administration of monoclonal antibodies (simulect); the polyclonal antibodies should be administered only if necessary (in decreased diuresis rate, increased creatinine, etc.). In unsensitized patients, the baseline immunosuppression is enough to induce tolerance. Thus, the administration of immunosuppressive therapy adapted to the pre-existing HLA-sensitization level can significantly improve the treatment oucomes in kidney transplant recipients in the post-transplant period

Use of hyperbaric oxygenation in the combination therapy of posttransplant kidney patients in the early postoperative period

Background. Posttransplantation acute tubular necrosis (CTN) is mainly an ischemic injury caused predominantly by reperfusion syndrome, impaired microcirculation, and worsening hypoxia of a transplanted organ. Hyperbaric oxygenation (HBO) making possible the delivery of oxygen to organs and tissues, by dissolving it in the body’s fluids, is one of the methods for combating systemic and regional hypoxia underlying the development of ischemic graft injury.Objective: to evaluate the efficiency of HBO in the combination therapy of patients with severe ischemic kidney graft injury in the early postoperative period.Subjects and methods. The early postoperative period after kidney transplantation was comparatively analyzed in 2 patient groups: study (29 patients were given HBO sessions in the combination therapy) and control (24 patients receiving traditional therapy) ones. HBO sessions were carried out in single-person medical altitude chambers at 1.2-1.6 ATA for 40 min. A correlation analysis was made between cold graft ischemia time and indicators, such as recovered water excretory function, normalized azotemia level, the level of creatinine and urea, and the number of hemodialysis sessions in the above comparison groups.Results. The performed analysis has shown that there is a direct correlation between the parameters under study. In the study group, renal graft function recovered in the earlier periods than that in the control group.Conclusion. The early incorporation of HBO into combination treatment after kidney transplantation contributes to prompter recovery of graft function. The conducted study permits one to consider that HBO should be incorporated as soon as possible into the combination treatment performed in the early period after kidney transplantation

Comparison of combined general anesthesia with complex inhalation and epidural anesthesia for kidney and pancreas transplantation

Objective: To determine the efficacy of epidural anesthesia as part of combination inhalation anesthesia in patients undergoing kidney and pancreas transplantationMaterial: The study enrolled 21 patients after combined kidney and pancreas transplantation in in the Sklifosovsky Research Institute for Emergency Medicine.Results: Use of combined inhalation and epidural anesthesia allows for early mobilization of patients after kidney and pancreas transplantation

Cellular rejection of pancreaticoduodenal graft

Aim. The evaluation of donor’s duodenum histological examination in diagnosis of pancreaticoduodenal graft rejection.Materials and methods. The 35-yo patient with terminal diabetic nephropathy undergone simultaneous retroperitoneal kidney and pancreas transplantation  with enteric exocrine drainage of the graft via inter-duodenal anastomosis. When performing the esophagogastroduodenoscopy 2 years posttransplant we  implemented histologic examination of the duodenum of the graft.Results. We diagnosed and verified severe cellular rejection of pancreaticoduodenal graft. Successful etiopathogenetic treatment of acute  rejection of the graft (pulse therapy with glucocorticoids) was performed.Discussion. The diagnostic value of donor’s duodenum morphological examination in the diagnosis of pancreaticoduodenal graft  rejection, the efficacy of anti-rejection treatment were performed in this case