[Some aspects of clinical kidney transplantation from marginal cadaver donors].

The results of kidney transplantation from marginal donors were compared in two groups of patients who had received high-dose dopamine (10-35 mcg/kg/min). Group 1 consisted of 652 patients with grafts from stable donors given dopamine in doses from 0 to 10 mcg/kg/min, group 2--of 112 patients with grafts from donors given high-dose dopamine (10-35 mcg/kg/min). Mean follow-up was 52 +/- 19 months. The following parameters were compared: percent of delayed graft function, primary nonfunction transplants, acute graft rejection, graft survival, biopsy-proven ischemic-reperfusion graft injury. The rate of delayed graft function, primary non function transplants was higher in group 2 (59 and 51%, 7 and 4%, respectively). Five-year survival of the transplants and recipients was less in group 2 (68 vs. 73% and 78 vs. 71%, respectively, p < 0.05). At the end of the follow-up the level of serum creatinine was 151 +/- 50 in group 1 and 165 +/- 80 mcmol/l in group 2 (p > 0.05). Thus, despite worse results in group 2, kidney transplantation from such marginal donors can be used.

[Comparative evaluation of two methods for the uretero-cystic anastomosis]. / Sravnitelnaia otsenka dvukh metodov mochetochnikovo-puzyrnogo anastomoza.

Comparative analysis of two types of ureterocystic anastomosis in kidney transplantation showed the advantages and shortcomings of the method developed at the Moscow Regional Scientific Research Clinical Institute. The new anastomosis fundamentally differs from the traditional Mebel-Shumakov method in the absence of sutures between the ureter and the bladder mucosa. This feature makes it possible to avoid injury to the bladder mucosa which is often changed in prolonged anuria and reduce the edema and ischemia of the terminal part of the ureteral graft. This facilitates adaptation of the anastomosis to polyuria which often occurs in the early postoperative period. The relatively simple techniques shortens the time needed for the operation. These advantages of the new method of ureterocystotomy are manifested by decrease of the total number of urological complications and the relative incidence of serious early urological complications like fistula of the ureterocystic anastomosis and necrosis of the ureter which most often lead to loss of the transplant and sometimes to death of the patient. The use of the anastomosis developed at the Clinical Institute, however, is attended by a relatively high incidence of ureteral stricture in the late-term postoperative period, evidently due to prolonged contact of urine with the bladder muscular coat and the ureteral adventitia. Thus, the more favorable results of ureterocystic anastomosis formed by the method developed at the Clinical Institute allow it to be recommended for further use in kidney transplantation.

[The treatment of ureteral stricture in patients following kidney transplantation]. / Lechenie striktury mochetochnika u bol'nykh posle transplantatsii pochki.

Ureteral strictures in kidney recipients are serious urological complications often responsible for the transplant rejection and sometimes for the recipient's death. The stricture-related slight and nonspecific symptoms often underlie its late diagnosis and inadequate treatment. Obligatory follow-up ultrasonic investigations promote early detection of ureteral stenosis. Eight kidney recipients with ureteral stricture initially underwent transcutaneous puncture nephrostomy preserving the transplant function and preventing aggravation of the condition. In view of threatening infection and weak reparative capacity of immunosuppressed patients, less traumatic transcutaneous interventions seem preferable in further treatment: bouginage, balloon dilatation or the stricture dissection followed by insertion of the inner stent. In uneffective transcutaneous surgery due to extended ureteral strictures or complete obstruction of the ureter it is valid to conduct pyeloureterostomy with the recipient's own ureter.

[Clinical x-ray criteria for a differential approach to the surgical treatment of uremic osteodystrophy]. / Kliniko-rentgenologicheskie kriterii differentsirovannogo podkhoda k operativnomu lecheniiu uremicheskoi osteodistrofii.

To define the criteria for a differential approach to operative treatment of uremic osteodystrophy arising in hemodialysis 51 patients were examined clinically, biochemically and roentgenologically before and after parathyroidectomy. Basing on the X-ray picture, the patients were divided into 3 groups: patients with fibrous osteodystrophy seen at X-ray examination (group 1); patients with fibrous osteodystrophy, osteomalacia in predominance of secondary hyperthyroidism (group 2); patients with osteodystrophy and osteomalacia in predominance of osteomalacia syndrome (group 3); patients with uremic osteodystrophy diagnosed only biochemically. Parathyroidectomy proved most effective in group 1 patients. For group 2 patients it is indicated in a subtotal or partial form in a failure of the conservative treatment. In group 3 patients parathyroidectomy is not recommended to avoid a drastic progress of osteomalacia.

[Infectious-inflammatory complications in patients after transplantation of the kidney]. / Infektsionno-vospalitel'nye oslozhneniia u bol'nykh posle peresadki pochki.

The work deals with the results of retrospective analysis of infectious complications (IC) in 323 patients with terminal renal failure (TRF) who underwent 371 operations for allotransplantation of cadaver kidney (ATCK). IC frequency was 41%, their mortality, 42.6%. The structure of the IC was as follows: pulmonary 29.6%, wound 22.4%, urinary 20.4%, sepsis 19.1%, others 8.5%. Gram-negative microorganisms predominated in the etiology of the IC; gram-positive cocci, microbial associations, yeastlike fungi, and cytomegalovirus were encountered less frequently. The development of IC did not depend on the patients' sex, primary disease of the kidneys which led to TRF, or the duration of previous treatment by hemodialysis, but was directly related to the age of the recipients. It was found that the character of the basic and anticrisis immunosuppressive therapy influenced the frequency of IC occurrence. The authors recommend some preventive and therapeutic measures for reducing the risk of the development of IC in patients after ATCK.

[Immunologic criteria of severity of suppurative infections in patients on programmed hemodialysis]. / Immunologicheskie kriterii tiazhesti gnoinoi infektsii u bol'nykh programmnom gemodialize.

Certain parameters of the immune system were studied in patients under programmed hemodialysis with and without pyo-inflammatory complications. It was found that patients without pyo-inflammatory diseases are characterized by the state of immune deficiency while in patients with purulent infection the degree of inhibition of immune response of the organism correlates with spread of the suppurative process.

[The outpatient management of patients with a transplanted kidney]. / Ambulatornoe vedenie patsientov s transplantirovannoi pochkoi.

Organization of the management of outpatients with a transplanted kidney is described. The basis of such organization is formed by documentation of the patients' status during the entire observation period in a special card containing the data on the donor; distant monitoring of cyclosporin A for patients living far from the clinic; training of patients. The main complications that occur in patients with a transplanted kidney in the long-term postoperative period are related. They are pyelonephritis of the transplant, essential hypertension and symptomatic hypererythrocytosis. The 2-year survival of the patients is 70.8%, that of the transplant 73.1%.

[Use of an autovenous transplant, polytetrafluoroethylene prosthesis and human umbilical vein bioprosthesis for creating an arteriovenous fistula for programmed hemodialysis]. / Primenenie autovenoznykh transplantatov, protezov iz politetraftorétilena i bioprotezov iz veny pupoviny cheloveka pri sozdanii arterio-venoznykh fistul dlia programmnogo gemodializa.

The work presents an experience with 84 operations of making nonstandard arteriovenous fistulas in 75 patients using autovenous transplants, polytetrafluorethylene prosthesis and home bioprostheses from human umbilical veins made at plant "Sever". Results of the operations were followed-up during 3 years. It was shown that arteriovenous fistulas made of plastic materials generally have a higher level of complications and shorter terms of functioning as compared with ordinary fistulas. Nevertheless, using nonstandard fistulas is justified in a certain category of patients.

[A method for determining the cyclosporin A concentration in capillary blood]. / Metod opredeleniia kontsentratsii tsiklosporina A v kapilliarnoi krovi.

A new method is described, which enables one to follow the blood concentration of CyA in patients living in remote regions, being far away from the transplantation hospitals. The method is based on the use of chromatographic paper FN-17 intended for application of the patients' blood spots. The pieces of paper with dried blood spots are sent by post to the laboratory where CyA is extracted from the spots, followed by the CyA concentration measurement with the aid of RIA. A procedure has been elaborated, permitting the measurement of the CyA concentration in patients with a poor access to the veins.

[The significance of early dysfunction of the transplanted kidney]. / Znachenie rannikh disfunktsii transplantirovannoi pochki.

The paper is concerned with the results of 39 transplantations of the kidney. All the patients received two basic immunosuppressants, namely prednisolone in a dose of 30 mg/day and Cy in a dose of 10-12 mg/kg a day. Within 6 to 11 months, the recipients' survival amounted to 82.5%, that of the organs to 84.5%. In 63.1% of the patients, immediate function of the transplant could be observed. It has been demonstrated that delayed function of the transplant was conjugated with reduction of the survival of the organs and recipients as well as with decrease of the quality of transplant functioning. Delayed function of the transplant might be determined not only by ischemic but also by immunologic injuries to the organ.

[Use of Soviet-made bioprostheses from the human umbilical vein in hemodialysis]. / Ispol'zovanie otechestvennykh bioprotezov iz veny pupoviny cheloveka pri gemodialize.

The work presents data on using a Soviet bioprosthesis made of a human umbilical cord at the firm "Sever" which was used as arteriovenous fistulas for hemodialysis. Operations were performed on 45 patients, 55 fistulas being formed. The maximum period of the follow-up was 3 years. An analysis of complications is given as well as of rational methods of their prevention and treatment. The bioprostheses are recommended for the formation of non-standard fistulas.

[Ways of intensification of hemodialysis therapy]. / Puti intensifikatsii gemodializnogo lecheniia.

Three methods of intensive hemodialysis were compared: routine hemodialysis (HD) (12 h/m2/week), HD on a highly permeable membrane with ultrafiltration (ordinary in volume and increased up to 10.5 l), and hemodiafiltration with the replacement of 16.4 l. Clearance, pre- and postdialysis concentration in the plasma of urea, creatinine, phosphate and average molecular mass substances were analyzed during investigation; dynamometry was used at the beginning and end of investigation to assess right forearm muscle strength. Better results were obtained with hemodiafiltration. The successive use of three methods of hemodialysis resulted in the patients' improved somatic state and a significant increase in muscle strength. In the authors' opinion, the use of hemodiafiltration would facilitate rehabilitation and reduce a period of preparation of uremic patients for kidney transplantation.