[Influence of physical rehabilitation on quality of life after renal transplantation].

BACKGROUND: Aim of this study was to evaluate the role of physical rehabilitation to improve the quality of life (QOL) of people after kidney transplantation. PATIENTS AND METHODS: Analyzes the results of treatment of 57 recipients (mean age 35 +/- 9.65 years) donor kidney at different times of the postoperative period. Depending on the physical rehabilitation program allocated 3 groups of patients: group II--physical rehabilitation was carried out only in the first week after surgery to prevent early postoperative complications, in group I--during the year; in group III combined 30 relatively healthy people do not need an organ transplant and with a mean age 33.7 +/- 8.7 years, leading a normal life, not engaged in regular recreational physical culture. Quality of life was assessed using a questionnaire SF36 at 1, 3, 6 and a 12 months after surgery. RESULTS: One year after surgery in both groups compared with preoperative indicators marked improvement according to all scales of the questionnaire. However, in group I indicators of quality of life were higher than in group II from 11.4 to 19.7%, and even some items questionnaire SF-36 is higher than in group III which is associated with the physical rehabilitation. CONCLUSION: It has been shown that exercises is an important component of treatment and rehabilitation after kidney transplantation and help improve both the psychological and the physical component of quality of life.

[The analysis of relationship between numbers of hemopoietic hematoblasts and laboratory indicators of state of hepatobiliary system in children with congenital and hereditary diseases of liver].

The content of CD34/CD45dim-positive cells in peripheral blood of children with congenital and hereditary diseases of hepatobiliary system is studied. The analysis of relationship between numbers of studied cells and level of C-reactive protein, sCD40L, sCD30 and laboratory parameters specific to liver functions is applied The number of CD34-positive hemopoietic hematoblasts in children with hepatocirrhosis correlated with the level of C-reactive protein, albumin, hemoglobin concentration and quantity of blood erythrocytes. No relationship was established with the levels of sDC40L and sDC30. The number ofstudied cells in children with liver diseases was higher than in healthy adult donors.

[Prognosis for patients with chronic diseases of the liver in formulating indications to orthotopic liver transplantation].

AIM: To analyse a clinical course of hepatic cirrhosis of various etiology in potential recipients of donor liver; to formulate symptom complex which determines life span prognosis in patients with chronic diffuse diseases of the liver (CDDL). MATERIAL AND METHODS: We studied 74 recipients of the liver (73 adults aged 15-58 years and 1 boy aged 13 years, mean age at liver transplantation 27.04 +/- 1.5 years, 41% males, 59% females). Orthotopic transplantation of the liver (OTL) was made from a live relative donor. All the patients have undergone clinical, biochemical, immunological, virological, ultrasonic, x-ray and other examinations. Severity of the patients' condition was assessed according to the Child-Pugh classification. Indications to transplantation of the liver were formulated basing on the syndromal approach. RESULTS: Asthenic syndrome was diagnosed in 34, pruritus--in 25, articular syndrome--in 11, jaundice--in 43, hepatomegaly--in 40, splenomegaly--in 65, ascitis--in 26, peripheral edema-- in 8, esophageal varicose veins--in 66, encephalopathy--in 5 patients. Main syndrome manifestations of CDDL involved in formulating indications for liver transplantation consisted in the syndrome of liver cell insufficiency (diagnosed in 77% cases), syndrome of portal hypertension (detected in 100% cases), edemo-ascitic syndrome (41% cases), cholestasis syndrome (95% cases), autoimmune cytopenia syndrome (77% cases), hepatorenal syndrome (5.4%). Most of potential recipients who had liver transplantation were classified as having class B and C by Child-Pugh (66.3%), but often indications for OTL were considered in terms of a combination of various syndromes significant for life prognosis in each patient and in terms of urgency of OTL performance. CONCLUSION: In determination of indications for OTL syndromal approach seems most adequate. Main syndromes influencing primarily on OTL decision making are portal hypertension with consideration of esophageal varicose veins, syndrome of hepatic cell deficiency, edemoascytic syndrome, hepatorenal syndrome, syndrome of autoimmune cytopenia and cholestasis.

[Indications and optimal terms of liver transplantation in chronic diffuse hepatic disease].

Patients with chronic diffuse hepatic disease (CDHD) take a great part in structure of morbidity of adult population. Problem of treatment of patients with hepatic cirrhosis (HC) is still very important. Main contingent of these patients who need hepar transplantation consists from HC patients with various ethiology, cholestatic diseases, inborn metabolism disturbances and hepatic tumors. At present in the world there is a tendency to early performing of operation while decompensation of other organs and systems still do not exist. When there is diagnosis of inborn metabolism disturbance indication to ortotopic transplantation of hepar (OTH) are put at the same time with verification of diagnosis. In case of HC urgency of OTH depends on stage of disease (system assessment of severity of hepatic insufficiency by 'hild-Pugh, MELD), response of patients on therapy and frequency of hospitalizing. Performance of OTH makes possible to prolongate of patients' life and significantly improve its quality.

[Reparative regeneration of the human liver grafted from a cadaver and a relative donor]. / Reparativnaia regeneratsiia pecheni cheloveka, transplantirovannoi ot trupa i rodstvennogo donora.

The morphological features and dynamics of regeneration of the grafted human liver were studied by using data on 609 needle biopsies obtained for morphological monitoring in 38 recipients during transplantation of the liver from cadavers and relative donors. The biopsy specimens of donor organs taken prior to grafting served as a control. Irrespective of the type of grafting, regenerative processes in the grafted liver were shown to have common regularities and to run by using the mechanisms of both intracellular regeneration and proliferation. Their maximum rate was seen within a month after grafting of a cadaverous organ and within 3 months after grafting a part of the liver from a relative donor. In cadaverous transplantation, regenerative processes depended mainly on the degree of ischemic lesions; in relative donor organ transplantation, that depended on the fitness of graft mass (the index K being close to 0.5), proliferative processes and the time of higher hepatocytic ploidity increased. An adequate evaluation of the status of a cadaverous organ, estimation of the optimum mass of a grafted hepatic part from a relative donor, and effective immunosuppressive therapy ensure required reparation rates and a complete recovery of the structure of a graft.

[Transplantation of the right hepatic lobe from an alive relative donor]. / Transplantatsiia pravoi doli pecheni ot zhivogo rodstvennogo donora.

The use of relative donors in the transplantation of the liver has shown a good performance as an alternative line in its orthotopical grafting. Shortage of donor organs actively stimulates the development of relative transplantation. The main problem of relative hepatic transplantation is the limited capacity of obtaining a required mass of a hepatic graft for obese recipients. To settle this problem, the Russian Surgery Research Center, Russian Academy of Medical Sciences, has developed an original safe procedure for obtaining the right lobe of the liver from an alive relative donor and for implanting it in a recipient. In November 1997 to October 2001, transplantation of the right hepatic lobe from an alive relative donor was made in 23 recipients (10 males and 13 females aged 9 to 55 (mean 22.3 +/- 3.1) years. Their body weight was 24 to 80 (mean 51.4 +/- 3.0) kg. Indications for surgery were as follows: hepatic cirrhosis (HC) at the end stage of the Wilson-Konovalov disease (n = 10), primary sclerotic cholangitis (n = 4), HC of viral etiology (n = 3), Bailer's disease (n = 2), primary biliary HC (n = 2), HC in the presence of alpha 1-antitrypsin deficiency (n = 1), and secondary biliary HC (n = 1). The donors of the right lobe of the liver were recipients' mothers in 9 cases, their fathers in 6 cases, sisters in 2 cases, sons in 1 cases, their daughter, brother, aunt, cousin in 1 case each. The donors' age ranged from 19 to 49 (mean 37.9 +/- 1.4) years. The donors underwent right hemihepatectomy, complications were absent in them. There were early mortality among the recipients. Two patients died in the late postoperative period. The remaining 21 recipients were survivors and followed up for 1 to 48 (mean 14.9 +/- 2.9) months. Their life quality was good. The use of the right lobe of the liver from an alive relative donor is the optimum alternative to transplantation of the cadaverous liver and partially compensates the shortage of donor organs for children, adolescents, and adults.

[Anesthesia during liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

Different methods and components of anesthesia during operations in donors and recipients were studied by using the experience in maintaining anesthesia during 39 relative and 7 cadaveric hepatic transplantations. The experience in using epidural anesthesia and total intravenous anesthesia at the donor stage of hepatic lobar transplantation was comparatively analyzed. Combined epidural anesthesia (CEA) may be used during long-term and traumatic operations dealing with hepatic lobectomy in a relative donor since it is noted for low hepatotoxicity and no drastic hemodynamic exposures. CEA can substantially reduce pharmacological loading with opioids or myorelaxants, which is particularly important in taking the lobe of the liver. This reduces the recovery period of adequate own respiration, activates a patient more rapidly, substantially reduces the risk for postoperative iatrogenic complications. Balanced general anesthesia whose major component is inhalational anesthesia with isoflurane is the method of choice in performing an operation in the recipient. The use of isoflurane in the minimal-flow mode is cost-effective and safe. When anesthesia is performed in the recipient, it is necessary to take in account drastic hemodynamic pattern changes at the liverless stage during vein-venous bypass surgery, including the liver into systemic circulation, and the likelihood of development of significant reperfusion and concomitant metabolic and coagulative disorders.

[liver portion transplantation from living donor: pilot clinical experience]. / Transplantatsiia chasti pecheni ot zhivogo rodstvennogo donora: pervyi klinicheskii opyt.

The unique in Russia experience of 35 liver transplantations since 1990 has revealed benefits of the method and quite encouraging results with 81% survival of the recipients. But the extreme shortage of cadaveric donor organs followed by more than 60 per cent mortality in waiting list and absence of any real facilities to improve the situation dictate the living related donation to become a considerable alternative. Totally 12 living related liver transplant procedures were performed with no morbidity in donors. In 7 donors the routine surgical technique of harvesting were used to get left lateral segment in five and whole left lobe in two cases. The unique twin-to-twin liver left lobe donation with no consequent immunosuppression was observed in this series. New special technique of living donor surgery was successfully developed for liver right lobe harvesting. The living related liver right lobe replacement was used in 5 cases and appeared to become a real compensation of donor organs shortage for elder children with body weight more than 20 kg and adults.

[Clinical experience with low- and minimal-flow isoflurane in extensive resections of the liver and liver transplantation]. / Klinicheskii opyt ispol'zovaniia izofliurana v rezhimakh low- i minimal-flow pri obshirnykh rezektsiiakh i transplantatsii pecheni.

A comparative study was performed of general balanced anesthesia on the basis of neuroleptic analgesia (NLA) and inhalation low- and minimal-flow anesthesia with isoflurane in anesthesiological management of extensive operations on the liver. A total of 75 anesthesias were conducted. Because of low hepatotoxicity, absence of its metabolites' pharmacological activity, fast elimination from the body unchanged, isoflurane is effective in long and traumatic operations on the liver. Low-flow isoflurane significantly lowers pharmacological load with opiates, myorelaxants which is essential in patients with hepatic diseases. This leads to more rapid recovery of adequate spontaneous respiration and activation of the patient in low risk of postoperative iatrogenic complications.

[The anesthesiological support of liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

The choice of anesthesia for a high risk operation, orthotopic transplantation of the liver (OTL), is discussed. The authors propose a protocol of anesthesia for OTL. For induction anesthesia, intravenous drugs should be preferred; the liver-free stage of the operation is carried out under anesthesia with a closed isoflurane contour, and the initial metabolic disorders of patients are corrected. When the bloodflow is let in the transplanted organ, intravenous drugs (ketamine, phentanyl, and benzodiazepines) should be administered in order to reduce the vasodilating effect of isoflurane and vasopressors for preventing relative hypovolemia. At the final stage of anesthesia, isoflurane is used. Before transporting the patient into intensive care ward, phentanyl in a dose of 1.5-3 micrograms/kg was injected, because of rapid elimination of isoflurane and awakening of the patient. This protocol maintained the hemodynamics and the major metabolic parameters at the optimal level.

[Orthotopic liver transplantation]. / Ortotopicheskaia transplantatsiia pecheni.

Orthotopic liver transplantation is the only method of choice for many severe liver diseases with poor prognosis. The development of liver transplantation programmes is based on medical science achievements and high technology in surgery, anesthesiology and perfusiology. The experience of the Surgery Research Center, Russian Academy of Medical Sciences, made it possible to obtain positive results of liver transplantation and posttransplantation management. This in turn provided longer survival for 80% of recipients. At the same time the mortality of potential recipients was 60.4%, which is due to the greater shortage of donor organs and which is the main problem in the development of organ grafting in Russia. The fact that there is a high proportion of children who are recipients for the donor's liver requires that liver transplantation from living related donors should be developed.

[Orthotopic liver transplantation: surgery research center's experience]. / Opyt ortotopicheskoí transplantatsii pecheni v Nauchnom Tsentre Khirurgii RAMN.

From 1990 to 1996, 178 patients with severe diffuse and advanced focal liver diseases with grave prognosis were observed for indications to orthotopic liver transplantation (OLT). According to the revealed indications and contraindications, 95 patients were enrolled for the procedure. Eighteen patients underwent 19 OLTs, including 1 urgent retransplantation and 3 living related graftings. Surgical techniques were conventional; with these, intraoperative mortality and biliary complications could be avoided. Long-term survival (6 to 68 months) was achieved in 8 recipients, including in those after liver retransplantation. Double or triple suppressive regimens were used. These included corticosteroids, cyclosporin A, azathioprine, antithymocytic globulin. The life quality of recipients promoted restoration of their working capacities. Two recipients gave birth to healthy babies.

[Radical resections in advanced hepatic tumors]. / Radikal'nye rezektsii pri obshirnykh ochagovykh porazheniiakh pecheni.

Experience with 32 curative major and extended liver resections performed in 30 patients with different disseminated focal diseases. The scope of resections was 50 to 85% of the liver parenchyma. Owing to the developed criteria for resectability and surgical techniques of operations, there was no hepatic failure due to the small mass of the liver stump. There were no intraoperative deaths. Postoperative complications were observed in 15.6% of cases. Early postoperative mortality was 6.25%, the deaths were caused by fulminant pleuropneumonia and acute cerebrovascular circulatory disorder. Late mortality (at months 2.5 to 28 (mean 17.6 +/- 4.0 months) was 18.75% and it was due to the generalization of cancer diseases. After extensive hepatic resections, survival was observed in 73.3% of cases with the maximum time of 63 months. The authors' own guidelines for extensive and maximum large resections of the liver are presented in the paper.