CLINICAL ASPECTS OF RENAL TRANSPLANTATION

В статье приведен литературный обзор, посвященный современным проблемам в трансплантологии почек. Нерешенными проблемами остаются оценка донора, низкая приверженность пациентов иммуносупрессивной терапии и развитие дисфункции трансплантата. Развивающиеся осложнения после трансплантации и иммуносупрессивной терапии требуют междисциплинарного подхода в лечении и наблюдении реципиентов донорской почки. Также необходимо широкое развитие трупного донорства для снижения числа потенциальных пациентов с хронической болезнью почек. The article presents a literature review of contemporary problems in kidney transplantation. Donor evaluation, low adherence of patients to immunosuppressive therapy and the development of graft dysfunction remain as unresolved problems. Developing complications after transplantation and immunosuppressive therapy require an interdisciplinary approach in the treatment and monitoring of recipients of donor kidney. It is also indispensable to the development of cadaveric donation to reduce the number of potential patients with chronic kidney disease.

Removal of Electrophysiological Devices in the Context of Heart Transplantation: Comparison of Combined and Staged Extraction Procedures

Background During heart transplantation (HTx), tip of the leads of cardiac implantable electrophysiological devices (CIEPD) has to be cut when resecting the heart. Timing of the removal of the remaining device and leads is still discussed controversially. Methods Between 2010 and 2021, n = 201 patients underwent HTx, of those n = 124 (61.7%) carried a present CIEPD. These patients were divided on the basis of the time of complete device removal (combined procedure with HTx, n = 40 or staged procedure, n = 84). Results CIEPD was removed 11.4 ± 6.7 days after the initial HTx in staged patients. Dwelling time, number of leads as well as incidence of retained components (combined: 8.1%, staged: 7.7%, p = 1.00) were comparable between both groups. While postoperative incidence of infections (p = 0.52), neurological events (p = 0.47), and acute kidney injury (p = 0.44) did not differ, staged patients suffered more often from primary graft dysfunction with temporary mechanical assistance (combined: 20.0%, staged: 40.5%, p = 0.03). Consecutively, stay on intensive care unit (p = 0.02) was prolonged and transfusions of red blood cells (p = 0.15) and plasma (p = 0.06) as well as re-thoracotomy for thoracic bleeding complications (p = 0.10) were numerically increased in this group. However, we did not observe any differences in postoperative survival. Conclusion Presence of CIEPD is common in HTx patients. However, the extraction strategy of CIEPD most likely did not affect postoperative morbidity and mortality except primary graft dysfunction. Especially, retained components, blood transfusions, and infective complications are not correlated to the timing of CIEPD removal.

Multimodal Temporary Mechanically Circulatory Assistance for Primary Graft Dysfunction after Heart Transplantation—A Case Report

Background Primary graft dysfunction (PGD) remains a serious complication after heart transplantation (HTx). Although there is no therapy available, veno-arterial extracorporeal life support (va-ECMO), may be a bailout strategy in selected cases. Especially in patients with severe biventricular failure, chances of survival remain poor. Case Summary Here we report a case of a 56-year old patient suffering from severe PGD after HTx with biventricular failure (ejection fraction < 20%) who was successfully bridged to recovery of the donor graft by temporary multimodal mechanically circulatory assistance by combining both, va-ECMO and a microaxial pump (Impella®, Abiomed, Inc., Danvers, MA, USA), a concept also referred as ECMELLA. During ECMELLA support, the patient experienced multiple severe thoracic bleeding complications with need for four re-thoracotomies and temporary open chest situation. Nevertheless, ventricular function recovered and the patient could be weaned from mechanical circulatory support after twelve days. During follow-up, the patient recovered and was successfully discharged. After the following rehabilitation, the patient now shows no persistent signs of heart failure with normal biventricular function of the cardiac graft. Discussion ECMELLA may offer a therapeutic option for patients with severe PGD after HTx. Special awareness and further studies addressing targeted anticoagulation strategies for patients on dual-mechanical support are needed to diminish the incidence of bleeding complications.