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Klinika Chirurgii Ogólnej i Transplantacyjnej TRANSPLANTATION Maciej Romanowski Maciej Romanowski.

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Presentation on theme: "Klinika Chirurgii Ogólnej i Transplantacyjnej TRANSPLANTATION Maciej Romanowski Maciej Romanowski."— Presentation transcript:

1 Klinika Chirurgii Ogólnej i Transplantacyjnej TRANSPLANTATION Maciej Romanowski Maciej Romanowski

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7 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 7 Historia 1902 - Opracowanie techniki zespoleń naczyniowych i eksperymentalnego przeszczepiania nerek u zwierząt 1912 - Nagroda Nobla Alexis Carrel

8 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 8 Historia 1933 – Pierwszy allogeniczny przeszczep nerki z zespoleniem do naczyń udowych Jurij Voronoy

9 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 9 Historia Joseph Murray 1953 - Pierwsze udane przeszczepienie nerki między dwoma jednojajowymi bliźniętami Peter Bend Brigham Hospital, Boston 1991 - Nagroda Nobla (wraz z J. Merrill)

10 1954 Chirurdzy : J.E. Murray & J.H.Harrison we współpracy z nefrologiem J.P. Merill przeprowadzili pierwszy udany przeszczep nerki The Peter Bent Brigham Hospital in Boston, USA

11 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 11 Historia Thomas Starzl 1963 – Zastosowanie steroidów i azatiopryny w leczeniu immunosupresyjnym

12 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 12 Historia Prof. Jan NielubowiczProf. Tadeusz Orłowski

13 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 13 Transplantation Currently, the most frequently performed transplants are: kidney kidney liver liver heart heart lung. lung.

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16 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 16 Transplantation Various terms and definitions are used in transplant technology. Allotransplantation means transplantation from a non-identical donor to a recipient of the same species (i.e. an allograft). Almost all human transplants are in this category. Xenotransplantation, transplanting between members of different species, is rare. Grafts which are implanted into a recipient are termed orthotopic if they occupy their normal anatomical site (e.g. liver transplants) or heterotopic if they occupy an ectopic site (e.g. renal transplants). Grafts which are implanted into a recipient are termed orthotopic if they occupy their normal anatomical site (e.g. liver transplants) or heterotopic if they occupy an ectopic site (e.g. renal transplants).

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18 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 18 Transplantation Rejection and immunosuppression Early transplants inevitably failed because of a complex rejection process, which involved cellular immunity (T and B cell lymophocytes) and humoral immunity (circulating antibody) mechanisms.

19 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 19 Transplantation The host response to the donor graft depends upon the tissue matching. The two most important compatibility systems are: ABO blood group ABO blood group HLA (human leucocyte antigen) Class I and Class II systems. HLA (human leucocyte antigen) Class I and Class II systems.

20 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 20 Transplantation The therapeutic goal of immunosuppression is to overide any response of the immune system to tissue histoincompatibility while at the same time to preserve the remaining functions of the recipient's immune system to protect against infection.

21 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 21 Transplantation Three patterns of rejection are recognised: hyperacute hyperacute acute acute chronic chronic

22 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 22 Transplantation Hyperacute rejection. This occurs within minutes to hours after transplantation. The transplanted organ becomes swollen and tender and there is severe vascular damage, with thrombosis and endothelial damage. There is an abrupt cessation of graft function. This injury is medi- ated by circulating recipient antibodies and is usually caused by a major ABO or HLA system incompatibility.

23 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 23 Transplantation Acute rejection. This develops within a few weeks/months of transplantation and is of rapid onset. The graft becomes tender and swollen and there is a deterioration in function. The rejection process is mediated by a combination of cellular and humoral (antibody) mechanisms. Biopsy of the graft will reveal a mixed cellular infiltrate (lymphocytes, monocytes and plasma cells) together with evidence of antibody-mediated vascular endothelial damage.

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25 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 25 Transplantation Chronic rejection. This begins months/years after transplantation. It is characterised by a progressive deterioration of the transplanted organ, with a mononuclear cellular infiltration on graft biopsy.

26 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 26 Transplantation lmmunosuppressive drugs used in transplantation Action Side effects Cyclosporin A Inhibits immunoactive leucocytes Nephrotoxic, hepatotoxic Azathioprine Inhibits RNA and DNA synthesis Bone marrow depression Steroids Inhibits inflammation Growth retardation, hypertension, increased infection risk Antiiymphocyte globulin Reduces lymphocyte numbers Antithymocyte globulin Reduces thymocyte numbers

27 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 27 Transplantation Legal criteria for diagnosis of brain death (UK) Legal criteria for diagnosis of brain death (UK) 1. There must be a positive diagnosis of severe structural brain damage 2. The condition causing brain damage must be irreversible 3. There must be complete loss of brain stem functionevidenced by fixed pupils, no spontaneous eye movements or response to caloric testing, absent corneal, eyelash and blink reflexes, absent laryngeal and cough reflexes, and no response to deep painful stimuli (note: some spinal reflexes may be retained despite brain death) 4. On removal of ventilatory support, there must be no spontaneous respiratory activity in the presence of a physiologically adequate increase in PCO 2 5. Any possible effects of hypothermia and drugs (e.g. muscle relaxants, respiratory depressants, alcohol) must be excluded

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30 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 30 Transplantation Renal transplantation The main indication for transplantation is irreversible renal failure. The three most frequent causes are: chronic glomerulonephritischronic glomerulonephritis chronic pyelonephritischronic pyelonephritis diabetic nephropathy.diabetic nephropathy.

31 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 31 Transplantation Renal transplantation Most patients who are on a transplant waiting list will require peritoneal or haemodialysis until a suitable kidney becomes available.

32 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 32 Transplantation Renal transplantation Donor sources Kidneys for transplantation come from two sources: brain-dead donors (cadaveric transplants) brain-dead donors (cadaveric transplants) living donors living donors

33 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 33 Transplantation Renal transplantation Most donor kidneys come from patients who have recently died in hospital, following either a stroke or a major head injury. Donors are accepted provided there is no evidence of active infection, extracerebral malignancy, hepatitis A, B or C infection or HIV infection.

34 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 34 Transplantation Renal transplantation Live donation is usually reserved for related donors who wish to help a family member with renal disease. Transplantation between unrelated individuals is less common and is fraught with ethical problems.

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36 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 36 Transplantation Renal transplantation Once brainstem death is confirmed and consent obtained, the kidneys are harvested as part of a multiple organ donation involving liver, kidneys, heart and lungs. Immediately the circulation is arrested, the intraabdominal organs are perfused with a cold preservation fluid in order to minimise the period of warm ischaemic time and thus prevent organ degeneration.

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41 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 41 Transplantation Two basic methods are used for preserving organs between donation and transplantation: Simple cold storage. The organ is flushed with ice-cold preservation solution and stored at 0-4°C on ice. Using specially formulated preservation solutions with agents designed to counter hypothermic cell swelling, it is now possible to store kidneys in this way for 24-36 hours, livers for 12-18 hours and hearts for 4- 6 hours Simple cold storage. The organ is flushed with ice-cold preservation solution and stored at 0-4°C on ice. Using specially formulated preservation solutions with agents designed to counter hypothermic cell swelling, it is now possible to store kidneys in this way for 24-36 hours, livers for 12-18 hours and hearts for 4- 6 hours Continuous oxygenated hypothermic pulsatile perfusion using special colloid-based (starch, plasma or albumin) solutions. This technique is more complex and expensive but enables kidneys to be stored for 2-3 days; the equipment is portable and can be used during transportation but the technique has not been extended to clinical preservation of other organs Continuous oxygenated hypothermic pulsatile perfusion using special colloid-based (starch, plasma or albumin) solutions. This technique is more complex and expensive but enables kidneys to be stored for 2-3 days; the equipment is portable and can be used during transportation but the technique has not been extended to clinical preservation of other organs

42 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 42 Transplantation Hypothermia reduces the metabolic demands of the organ and is the mainstay of effective organ preservation. The period of warm ischaemia between circulatory arrest and cooling by perfusion with ice-cold preservation fluid must be kept to a minimum if irreversible damage to the organ is to be avoided.

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44 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 44 Transplantation Transplant surgery The kidney is transplanted into a heterotopic site in either the left or right iliac fossa. An extraperitoneal pouch is prepared to receive the kidney and the renal vessels are anastomosed to the adjacent external iliac artery and vein. The ureter is usually implanted into the recipient's bladder using an intramural tunnel to prevent reflux.

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67 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 67 Step by step

68 2014-01-05 Klinika Chirurgii Ogólnej i Transplantacyjnej 68 Transplantation Liver transplantation The main indications for transplantation in adults are: cirrhosis secondary to viral hepatitis cirrhosis secondary to viral hepatitis fulminant liver failure. fulminant liver failure. Transplantation is performed less often for: hepatocellular cancer hepatocellular cancer alcoholic cirrhosis. alcoholic cirrhosis.

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