Background. Simultaneous pancreas and kidney transplantation is a gold standard in the treatment of diabetes mellitus complicated by stage 5 chronic kidney disease as a result of diabetic nephropathy. One of the main problems of clinical pancreas transplantation is the pancreas graft exocrine drainage. In order to preserve the advantages of the retroperitoneal graft location and avoid the main disadvantage of duodenal drainage, namely, fatal complications potentially arising in case of necessary graft removal, we have proposed a modified method of retroperitoneal pancreatic transplantation with exocrine drainage via a modified Roux-en-Y duodenojejunostomy. It reduces the number of severe surgical complications and increases the recipient survival rate. When this method was used in previous years, it was not possible to assess the condition of donor duodenum mucosa and interintestinal anastomoses. Objective. To demonstrate the possibility of endoscopic assessment of interintestinal anastomoses when performing retroperitoneal pancreas transplantation with small intestine drainage of exocrine secretions. Results. The article presents the initial experience of endoscopic assessment of the interintestinal anastomoses and the mucous membrane of the donor duodenum after retroperitoneal pancreas transplantation with exocrine drainage via a Roux-en-Y duodenojejunostomy. Conclusion. The presented case demonstrates the feasibility of diagnostic endoscopic interventions when performing retroperitoneal pancreas transplantation with small intestine drainage of pancreatic secretions.

Background. The possibility of inducing immunological tolerance in allogeneic organ transplant recipients is a research goal of the transplantology community, as it will ensure the likelihood of complete engraftment of a foreign organ. However, such a task presently remains difficult to accomplish. Objective: to demonstrate longterm kidney graft survival without signs of acute rejection and without immunosuppressive therapy in a patient who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) from a haploidentical donor for post-transplant lymphoproliferative disorder (PTLD). Methods and materials. Recipient’s graft function was assessed using clinical, laboratory, instrumental and pathomorphological examination methods. Results. With no immunosuppressive therapy for more than four years, the kidney recipient showed stable, satisfactory graft function. Conclusion. The described clinical case demonstrates the development of immunological tolerance to a kidney graft in a recipient of allogeneic hematopoietic stem cells (HSCs).

The origin of the recipient is one of the recipient-related factors that statistically significantly affects the outcomes of kidney transplantation, but this factor is not so relevant in our country. The article presents the first experience of kidney transplantation in a patient of African descent at the N.I. N.V. Sklifosovsky. Material and methods . Allogeneic renal graft transplantation from a post-mortem donor was performed in a 60-year-old African male patient with stage 5 chronic kidney disease as a result of hypertensive nephroangiosclerosis. Results . The early postoperative period was complicated by the development of acute cellular graft rejection grade 1a-b according to Banff. Anti-crisis therapy was performed with some positive effect, however, in the late postoperative period, a loss of renal graft function was noted, and the patient was returned to renal replacement therapy with program hemodialysis. Conclusion . Patients of African ancestry are at increased risk of adverse outcomes due to immunological causes and require more careful immunological selection of a donor organ, an enhanced immunosuppressive regimen, and close monitoring after transplantation.

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.

Pancreas transplantation followed by stumpless duodenal exocrine drainage was performed in 2 patients. Primary kidney and pancreas graft function was noted in both cases. Two procedures of pancreas transplantation followed by stumpless duodenal exocrine drainage were carried out for the first time. Perhaps, absent donor duodenal stump has several advantages for the further course of postoperative period that may be confirmed in prospective trials.

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.

AIMRetrospective analysis of safety and efficacy of preventive anterior abdominal wall repair in recipients of renal allograft.MATERIAL AND METHODSKidney transplantation was performed in 396 patients with terminal renal failure within January 2015 - May 2017. Preventive endoprosthetics (PE) was applied in 28 (7.1%) patients. There were 7 women (26.9%) and 19 men (73.1%) aged 25-69 years (mean 44.5 (35, 56) years). Median of body mass index (BMI) was 27.5 (23.9, 29.9) kg/m2.RESULTSPostoperative morbidity was 42.3%. Complications were mild (type I and II) and did not require invasive treatment. Postoperative morbidity was similar regardless protocol of immunosuppressive therapy (IST).CONCLUSIONPreventive abdominal wall repair after kidney transplantation is effective and safe to prevent postoperative hernia.

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.

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.

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.

The paper describes the first experience with endovascular embolization of artery of kidney graft irreversibly lost its function in fifteen years after transplantation, during preoperative preparation of patient to nefrotransplantatectomy. The purpose of the study – to show the effectiveness of the artery rentgenendovascular embolization of the artery of kidney transplant before the nefrotransplantatektomy as a method of preventing massive intraoperative bleeding and related complications. An angiography and the rentgenendovascular embolization of the artery of kidney transplant executed on the day of surgery allowed us to remove nefrotransplantat without any technical difficulties. The total intraoperative blood loss did not exceed 50 ml.

Background. The verification and identification of the transplanted pancreas rejection type requires a morphological examination of the graft tissue. The pancreas graft transcutaneous biopsy procedure is associated with a high risk of surgical and infectious complications, and with the risk of the graft loss. Relatively safe is the biopsy of the donor duodenum mucosa.Objective: to evaluate the efficacy of morphological examination of the donor duodenum mucosa in early diagnosis of an acute rejection crisis of pancreas graft.Material and methods. The study presents a retrospective analysis of 35 donor duodenum mucosa biopsies performed in 19 recipients. In order to assess the correlation between clinical and morphological signs of rejection, the patients were divided into two groups. The first group included 6 patients with clinical signs of graft dysfunction; the second group included 7 patients without signs of rejection. Statistical processing of the study results was made using the descriptive statistics methods.Results . The signs of immunological complications were identified in 18 donor duodenum mucosa biopsies (51.4%) in 12 recipients (63.2%). In most cases (n = 13; 72.2%), the histological signs of mild rejection were found, the signs of moderate and severe rejection were less frequent (n = 3; 16.6% and n = 2; 11.1%, respectively). Morphological signs of acute rejection were found in all the patients of the 1st group (n = 6), including the signs of mild rejection in 4 cases (66.6%), of medium and severe rejection in 1 case each (16.7%). In the 2nd group, morphological signs of mild rejection were found in 3 patients (42.9%). Differences between the groups in the incidence of immunological complications were statistically significant (p < 0.05).Conclusions: the biopsy of donor duodenum mucosa is an important criterion in the diagnosis of an acute rejection crisis of the pancreatoduodenal complex, and also remains a safe method, even in the earliest postoperative period.

Objective: to evaluate the effects of pre-existing HLA antibodies on the posttransplantation period and to study changes in the generation of donor-specific antibodies in recipients after allogeneic cadaveric kidney transplantation.Materials and methods. One hundred and ten serum samples from patients on the kidney transplantation waiting list (WL) were tested for pre-existing HLA antibodies. To evaluate the effect of preantibodies, the investigators examined 55 patients (32 males and 23 females, whose age was 28 to 63 years) who had undergone kidney transplantation at the N.V. Sklifosovsky Research Institute of Emergency Care in October 2009 to September 2010. In the second part of the investigation, HLA antibody levels were monitored in the posttransplantation period. A total of 27 patients (15 males and 12 females aged 26 to 61 years) were examined after kidney transplantations made at the N.V. Sklifosovsky Research Institute of Emergency Care in March to September 2010.Results and discussion. Since November 2009, the serum level of pre-existing HLA antibodies had been measured in all the patients registered on the kidney transplantation WL at the N.V. Sklifosovsky Research Institute of Emergency Care. One hundred and ten patients have been examined today; of them 69 males and 41 females are waiting for kidney transplantation.Conclusion. The level of pre-existing HLA antibodies must be estimated in the recipients to be prepared for kidney transplantation since this makes it possible to identify in practice a group of patients requiring a more thorough selection of donor organs and preoperative preparation that involves the methods of extracorporeal blood correction and medical therapy.

The paper presents a 5-year experience of the Sklifosovsky Research Institute for Emergency Medicine in the treatment of patients after liver transplantation. The authors have reviewed the data on acute rejection in liver transplant recipients, analyzed the incidence of early liver transplant loss resulted from a non-controllable rejection, proposed prevention and treatment modalities for the cases of acute rejection.

The paper presents a 5-year experience of the Sklifosovsky Research Institute for Emergency Medicine in the treatment of patients after liver transplantation. The authors have reviewed the data on acute rejection in liver transplant recipients, analyzed the incidence of early liver transplant loss resulted from a non-controllable rejection, proposed prevention and treatment modalities for the cases of acute rejection.

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.

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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.