Modern trends in surgical correction of arterial stenosis of transplanted kidney.

In 17 patients at different time after transplantation of the allogenic kidney, artery stenosis of the transplant accompanied by gross hypertension and deterioration of renal function was registered. To diagnose the pathology isotope renography with I131 hippuran, rheography of the transplant, thermometry, thermography and selective angiography were used. Five patients were operated on. They successfully underwent different reconstructive procedures on the affected renal artery of the transplant. As a result arterial pressure returned to normal in all the patients and the transplant's function improved. Four patients underwent balloon dilatation of the stenosed renal artery. The effect was temporary.

[Pyogenic infectious complications in recipients with allogenic kidneys: clinical and bacteriological aspects]. / Infektsionno-gnoinye oslozhneniia u retsipientov allogennykh pochek (klinicheskie i bakteriologicheskie aspekty).

The bacteriological study of wound discharge indicated no changes in the structure of the microflora in the allogenic kidneys of recipients throughout the follow-up. Among microbes isolated there were prevalent gram-positive microbes whose proportion has slightly increased in the past year, with Staphylococcus, mainly epidermal Staphylococcus, which contributes to the etiology. At the same time, studies of wound discharge in the past years showed that the incidence of mixed infections had increased from 4.3 in 1989-1991 to 15.6% in 1994-1997. Bacteriological urinalysis found no great differences in the etiological structures of the microflora. Gram-negative microbes are prevalent in all patients in three periods of follow-up. Noteworthy, there was an increase in the amount of yeast fungi (from 5.7 to 21.1%). Urinalysis showed that the rates in the isolation of bacterial and bacterial and fungal associations were steady-state and higher in all patients (20, 4-23, 5%). Examining the etiological structure of the pathogens of sepsis ascertained that patients of the early observation were found to isolate gram-negative microorganisms more frequently, while those of other observation periods have gram-positive ones. The overall proportion of microbial and microbe-fungal associations was 10.3% in the past 9 years. Since the patient's body is occupied by other pathogens due to immunosuppression, sepsis or wound infection was accompanied by high bacteriuria, cytomegalovirus infection, pneumocystic pneumonia, fungal infection, etc. For this reason, the patients had actually much higher quantities of mixed infections in sepsis, wound infection, or urinary infection than those taken into account while studying the only type of an infectious complication. The above leads to the conclusion that the incidence of mixed infection of recipients of allogenic kidneys is rather high. This infection substantially makes the choice of drugs and therapy difficult, the course of a wound process aggravated. For successful control of mixed infections, it is necessary to introduce new drugs having a high activity against bacteria, fungi, viruses, and protozoa and to use the latest differentially diagnostic culture media, to make diagnosis and treatment of pyoseptic diseases better.

[Status of the kallikrein-kinin system, proteinase inhibitors and nonspecific resistance factors in patients with chronic kidney failure on hemodialysis as well as in kidney transplant recipients]. / Sostoianie kallikrein-kininovoi sistemy, ingibitorov proteinaz i faktorov nespetsificheskoi rezistentnosti u bol'nykh s khronicheskoi pochechnoi nedostatochnostiu, nakhodiashchikhsiia na gemodialize, i uretsipientov pochechnogo transplantata.

A state of the kallikrein-kinin system, activity of proteolysis inhibitors were studied simultaneously with the functional activity of neutrophils and content of lysozyme in blood serum of 21 patients with chronic kidney insufficiency. Two types of alterations in the kallikrein-kinin system were found in 13 patients maintained on hemodialysis: in four patients content of kallikrein was increased 8-fold as compared with normal level with a decrease in content of prekallikrein, while in nine patients activity of kallikrein was similar to control values but content of prekallikrein was still further decreased. Content of alpha 1-proteinase inhibitor (PI) was distinctly decreased (2-2.5-fold) in these patients, however, the decrease of the inhibitor was not observed in four patients; activity of alpha 2-macroglobulin tended to decrease. The ratio of active neutrophils and content of lysozyme were increased in blood serum of the majority of the patients. Hemodialysis, activation of the kallikrein-kinin system and stimulation of neutrophils appear to be responsible for a decrease in PI activity. The decrease in the PI activity and stimulation of the kallikrein-kinin system suggest that impairments in regulation of proteolysis could be corrected by means of exogenous proteinase inhibitors. In crisis of allogenic kidney rejection activities of PI and prekallikrein were decreased. Drastic, uneven alterations of the patterns studied were detected in pyo-inflammatory complications not related to the rejection crisis.

[Problem of kidney transplantation (on the 25th anniversary of the first successful transplantation of the kidney in the USSR)]. / Problemy transplantatsii pochki (k 25-letiiu pervoi uspeshnoi peresadki pochki v SSSR).

The first successful transplantation of a kidney from an alive relative donor in the USSR was performed by B. V. Petrovsky at the All-Union Research Institute of Clinical and Experimental Surgery (now the All-Union Surgery Research Center, AMS, USSR) on April 15, 1965. In November, 1965 he transplanted a cadaver kidney for the first time with a good outcome. The Center possesses an experience with 987 kidney transplantations to date, among which 101 were related transplantations. The authors discuss the progress made in this field of surgery in a period of 25 years. The longest survival period among recipients with a functioning related kidney is 22 years and among those with a cadaver kidney, 19 years. With the use of Cy A 86% of transplanted related kidneys and 76% of cadaver kidneys function for 12 months or longer. The authors discuss the advantages of a new original method for transorganic oxygen preservation of a kidney suggested by G. A. Asoyan, instrumental-functional methods developed at the Center for appraising the hemodynamics of the transplanted kidney and diagnosis of the rejection crisis, cyclosporine nephrotoxicity, and progress in the techniques of kidney transplantation and immunosuppressive therapy. The authors believe that further improvement in the results of allogeneic kidney transplantation is well-grounded.

[Aspects of the transplantation of kidneys from relatives]. / Aspekty peresadki rodstvennykh pochek.

104 transplantations of the kidney from living relative donors (LRD) in patients with an end-stage of chronic renal insufficiency (CRI) were carried out in Research Center of Surgery from April 15, 1965 to November, 1993. Donors of the kidneys were: mother (55), father (21), sister (18), brother (10). Analysis of the accumulated data showed, that the results of LRD transplantations (one year survival of recipients 84 +/- 6%) are much better than those from cadaver donors (one year survival of recipients 33 +/- 6%). The examination of the relative donors in long-term periods after the operation has demonstrated, that nephrectomy in them entails small risk, because it does not negatively influence their psycho-emotional sphere and social status. The reserved (retained) kidney is able to support homeostasis of donor organism during all his life. Therefore the operation of kidney transplantation from living relative donors is the most effective method of treatment of patients with an end-stage of chronic renal insufficiency.

[Characteristics of the early postoperative period following kidney allotransplantation and immunosuppression using Sandimmune (cyclosporin A)]. / Osobennosti rannego posleoperatsionnogo perioda posle allotransplantatsii pochki pri provedenii immunosuppressii sandimmunom (tsiklosporinom A).

The authors analysed the early postoperative period in 100 patients who received sandimmune (cyclosporine A) as the main immunosuppressant after kidney allotransplantation and compared it to that in a control group of 60 patients treated by the usual measures of immunosuppression: azathioprine and steroids. The number of rejection crises was 1.9 times less in the group of patients given sandimmune than in the control group and were more benign in character, while the number of irreversible crises reduced from 26% to 6%. In treatment with sandimmune the dose of oral prednisolone was reduced by 1.9 times and the dose of intravenous methypred by 1.4 times. Nephrotoxicity was the main side effect of sandimmune, it was encountered in 26% of patients. All sandimmune side effects are reversible in decreasing the dose. Sandimmune improves the results of kidney transplantation significantly.

[Etiology and classification of arterial stenosis of transplanted kidney]. / Etiologiia i klassifikatsiia stenoza arterii peresazhennoi pochki.

Stenosis of the artery of a transplanted kidney, which developed in late-term periods after allogeneic kidney transplantation, was revealed in 30 patients, which accounts for 6% of the total number of patients who underwent transplantation. The authors discuss the etiology of this complication in detail and suggest their own classification.

[Storage of cadaver kidney by trans-organ oxygen insufflation]. / Konservirovanie trupnoi pochki transorgannoi kislorodnoi insuffliatsiei.

Transorganic oxygen preservation was used in storage of 87 cadaver kidneys. The kidneys were stored for 14 to 56 h (34 +/- 1.95 on the average). After storage, all organs were transplanted to 87 patients with chronic renal insufficiency in the terminal stage. The patients age ranged from 18 to 55 years. All recipients were divided into 3 groups according to the results of the operation. Group 1 (55 patients)-the function of the organ was restored immediately, blood creatinine normalized on the 5th-10th postoperative day; subsidiary hemodialysis was not needed. Group 2 (22 patients)-the function of the transplant was restored 14-21 days after the operation; 2 to 8 sessions of hemodialysis had to be conducted. Group 3 (10 patients)-the transplant did not function due to acute irreversible canalicular necrosis or irreversible rejection. No correlative dependence between restoration of the transplant function and the duration of storage was noted (r = 0.15). Our experience allows us to assert that transorganic oxygen perfusion can ensure long-term safe storage of cadaver kidneys.

[Transplantation of the kidney with numerous arteries from a living relative-donor]. / Peresadka pochki s mnozhestvennymi arteriiami ot zhivogo rodstvennogo donora.

Among 99 operations for transplantation of a kidney from a living kindred donor 6 were carried out with the use of kidneys which had many arteries. Five patients received a kidney with 2 arteries, and one patient, a kidney with 3 arteries. The donors were: a mother (1), a father (2), a sister (2), a brother (1). The left kidney was transplanted in all cases. In 5 patients kidney implantation was preceded by extracorporeal reconstruction on the arteries of the kidney (accessory arteries were anastomosed end-to-side with the main trunk of the renal artery) carried out under conditions of cold storage. In one female patient first the kidney was implanted by the standard method whereas the artery of the lower pole was anastomosed end-to-end with the inferior epigastric artery by means of microsurgical techniques. The transplants functioned well from the first day after the operation in all patients. In one patient the transplant was rejected 2 years and 7 months after the operation. The others function satisfactorily. The longest follow-up period is 5 years and 8 months, the shortest, 9 months. It is concluded that transplantation of a kidney with numerous arteries from a living kindred donor is an effective method for the treatment of patients suffering from the terminal stage of chronic renal insufficiency.

[Intraoperative hemodynamics in relative living donors]. / Intraoperatsionnaia gemodinamika u zhivykh rodstvennykh donorov.

The intraoperative hemodynamics was evaluated in 42 relative kidney donors. Electromagnetic flowmetry was used for the evaluation. The rate of blood flow was calculated with the formula of Hunt. The comparison of the existing rate of blood flow with a proper one has demonstrated the existence of intrakidney angiospasm. The donors over 50 years of age and the female donors are more predisposed to angiospasm. It was noted that in harvesting the right kidney the intraorganic angiospasm is expressed much more strongly than in harvesting the left kidney. The phenomena of intrakidney angiospasm in harvesting kidneys in live donors is of practical importance. Special measures should be undertaken to prevent this complication.

[Transplantation of allogeneic veins and xenogeneic arteries in the reconstructive surgery of occlusive diseases of arteries of the lower extremities]. / Transplantatsiia allogennykh ven i ksenogennykh arterii v rekonstruktivnoi khirurgii okkliuzionnykh porazhenii arterii nizhnikh konechnostei.

The article discusses the results of 91 reconstructive operations with the use of allogeneic veins and xenogeneic arteries in the management of occlusive lesions of the arteries of the lower limbs. The method of obtaining and storing the grafts and the operative techniques are described. Patency of the allogeneic and xenogeneic shunts in occlusions of the lower limb arteries was 47% in the long-term follow-up periods.

[Radiologically-guided dilatation in arterial stenosis of transplanted kidney]. / Rentgenovaskuliarnaia dilatatsiia pri stenoze arterii transplantirovannoi pochki.

Stenosis of the artery of a transplanted kidney is a grave complication of the posttransplanation period. Two method are applied for correction of the disease: reconstructive operation and radiologically-guided endovascular dilatation (RED). The primary method of choice is RED of the stenosis. We applied it in 20 patients. The result of the operation in the early postdilatation period was good in 15 (75%) patients, satisfactory in 2 (10%) patients. In 3 cases the method of RED of the stenosis failed because of technical complications. Restenosis occurred in 8 (47%) patients in the late-term periods after correction. Attempts to repeat RED were successful in 5 patients.

[Early postoperative rejection crises after transplantation of the kidney from the living related donors]. / Rannie posleoperatsionnye krizy ottorzheniia pri peresadke pochki ot zhivogo rodstvennogo donora.

The frequency of the development of rejection crises in the early postoperative period in 32 recipients of allogeneic kidneys from alive related donors was analysed depending on the histocompatibility according to the antigens of the HLA-AB system and the nature of the immunosuppressant therapy. The results of the analysis showed that the frequency of rejection crises was 100% when the donor and recipient were compatible in 1-2 antigens, and 40% in compatibility according to 3-4 antigens. The incidence of rejection crises was 71.4% among patients who received the standard immunosuppressant therapy (corticosteroids + azathioprine) and 36% among those given also sandimmune. Analysis of the frequency of rejection crises according to the ABO blood group system to which the donor-recipient pair occurred, showed that rejection crises occurred most frequently among patients with A (II) blood group.

[Study of parameters of central hemodynamics in patients during hemodialysis]. / Issledovanie parametrov tsentra'lnoi gemodinamiki u bo'lnykh vo vremia gemodializa.

The article discusses the results of study of the cardiac output (CO) and circulation blood volume (CBV) in patients at the beginning and end of hemodialysis. The dynamics of changes of these parameters during hemodialysis was studied in 31 patients (42 sessions). The CO and CBV reduced significantly. In a group of 10 patients who felt worse, the CO reduced by more than 30 per cent in 7, the CBV diminished by 25 and 30 per cent in 2, and CBV and CO reduced by more than 30 per cent in 1 patient in relation to the initial level. The CO and CBV were measured by means of the method of dilution of electroimpedance indicators.

[Differential diagnosis of the rejection crisis and toxic and immune-induced nephropathy]. / Differentsia'lnaia diagnostika kriza ottorzheniia i toksicheskoi sandimmunovoi nefropatii.

The work is based on the analysis of materials concerning 26 patients with transplanted allogeneic kidneys. All the patients received immunodepressive therapy with a combination of prednisolone and sandimmune. The posttransplantation period was complicated by sandimmune nephropathy in 11 and by a rejection crisis in 15 patients. The following tests were used in the differential diagnosis of these two complications: clinical (firmness of the allogeneic kidney determined by palpation, arterial hypertension, hyperthermia), laboratory (level of creatinine in blood and its clearance, potassium and sodium in urine), and instrumental-functional (ultrasonic examination, electrothermometry, rheography). With the use of these tests, nephrotoxicity of sandimmune origin and rejection crisis were differentiated successfully in all cases.

[Local hemostasis in surgical practice]. / Mestnyi gemostaz v khirurgicheskoi praktike.

Results of experimental and clinical investigations of a new local highly effective hemostatic drug " Gelplastan " are presented. Gelplastan was found to increase blood coagulation, to have strong adhesive and prolonged antibacterial properties. It is well resolved in the tissues, is biologically intact, has no side effects.

[Hypertension syndrome in kidney transplantation]. / Sindrom gipertenzii pri transplantatsii pochki.

Removal of the recipient's own kidney is indicated in cases with non-controlled arterial hypertension before and after transplantation of the kidney with the exclusion of chronic rejection and stenosis of the transplant artery. Embolization of the renal arteries is indicated to patients of high surgical risk. Roentgen-endovascular catheter dilatation of the stenosed artery of the transplanted kidney allows the operative treatment of recipients with chronic rejection of the transplant to be avoided. Surgical correction of stenosis is indicated to patients with a short-term hypotensive effect after dilatation.

[Instrumental and functional diagnosis of pyelonephritis in the transplanted kidney]. / Instrumental'no-funktsional'naia diagnostika pielonefrita peresazhennoi pochki.

The authors analyse complex employment of the method of ultrasonic echography, rheography and thermography in detecting early symptoms of acute pyelonephritis of the transplanted kidney in 246 patients. Characteristic features of acute pyelonephritis of the transplanted kidney are determined and the method of differential diagnosis between acute pyelonephritis of the transplant and the rejection crisis is proposed. The methods of examination are described allowing the dynamic observation of the transplanted kidney state.

[Reconstructive surgery of arterial stenosis in a transplanted kidney]. / Rekonstruktivnye operatsii pri stenoze arterii transplantirovannoi pochki.

Two patients were successfully operated upon for stenosis of the artery of transplanted kidney causing stable malignant hypertension. After the operation the arterial pressure was found to decrease from 240-260/140-170 mm Hg to 120-140/70-80 mm Hg. A considerable improvement of the transplant functioning was also noted.

[Evaluation of the condition of an allotransplanted kidney during the treatment with Sandimmune]. / Otsenka sostoianiia allotransplantirovannoi pochki pri lechenii sandimmunom.

Instrumental-functional examinations (echography, rheography, electrothermometry) were performed in 22 patients with the allotransplanted kidney treated by Sandimmune and in 20 patients treated by standard immunodepression (Azathioprine and corticosteroids). An analysis of the examinations performed has shown reliable differences between the complications which involved the transplant size, cortical layer, skin-temperature gradient, the degree of the venous wave.