Đánh giá kết quả lấy, rửa, và ghép thận từ người cho chết não tại bệnh viện Việt Đức

Header Page of 161 B GIO DC V O TO TRNG I HC Y H NI Lấ NGUYấN V B Y T Cụng trỡnh c hon thnh ti: TRNG I HC Y H NI Ngi hng dn khoa hc: PGS.TS NGUYN TIN QUYT PGS.TS HONG LONG Phn bin 1: GS TS TRN QUN ANH Phn bin 2: PGS TS V NGUYN KHI CA Phn bin 3: PGS TS TRN VN HINH Chuyờn ngnh: NGOI THN V TIT NIU Mó s: 62720126 Lun ỏn c bo v trc Hi ng chm lun ỏn cp Trng t chc ti Trng i hc Y H Ni Vo hi gi phỳt, ngy thỏng nm 2014 TểM TT LUN N TIN S Y HC Cú th tỡm hiu lunỏn ti : - Th vin Quc gia - Th vin Thụng tin Y hc Trung ng - Th vin Trng i hc Y H Ni H NI - 2014 Footer Page of 161 Header Page of 161 DANH MC công trình nghiên cứu liên quan đến đề tài luận án công bố Lờ Nguyờn V, Hong Long, Nguyn Tin Quyt (2013) ỏnh giỏ qui trỡnh v kt qu ghộp thn t ngi cho cht nóo ti bnh vin Vit c, Tp nghiờn cu y hc, 83 (3), 80 87, Trng Thnh, Lờ Nguyờn V, Ngc Sn (2013) ỏnh giỏ kt qu iu tr hp niu qun sau ghộp thn: nhõn trng hp Y hc Vit Nam, 409, 296- 302 Lờ Nguyờn V, Nguyn Tin Quyt, Ngc Sn v cng s (2012) Kt qu 12 trng hp ghộp thn t ngi cho cht nóo ti bnh vin Vit c Tp y dc hc quõn s , 37, (5), 138-144 Footer Page of 161 Header Page of 161 T VN Vit Nam ghộp thn c trin khai t nm 1992 Tuy nhiờn, s lng bnh nhõn ghộp cũn hn ch ngun thn ghộp ly t ngi cho sng Ly tng t ngi cho sng khỏc vi ly tng t ngi cho cht nóo Mun xõy dng c mụ hỡnh ly tng v ghộp tng t ngi cho cht nóo hu hiu, chỳng ta phi tham kho mụ hỡnh cỏc nc tiờn tin, v thc hin trờn hon cnh Vit Nam xõy dng c mụ hỡnh phự hp nht Thc t ti Vit Nam cho ti thi im hin cha cú mụ hỡnh t chc ghộp tng ly t ngi cho cht nóo chớnh thc Vỡ vy tụi thc hin ti nghiờn cu ỏnh giỏ kt qu ly, v ghộp thn t ngi cho cht nóo ti bnh vin Vit c nhm mc tiờu: Nghiờn cu ng dng qui trỡnh ly thn, v ghộp thn t ngi cho cht nóo ỏnh giỏ kt qu ghộp thn t ngi cho cht nóo Tớnh cp thit ca lun ỏn cỏc quc gia phỏt trin, ngun tng ch yu ly t ngi cho cht nóo hay ngng tim ú Vit Nam ngun tng ch yu ly t ngi cho sng iu ny lm thu hp phm vi iu tr, ngun tng hn ch Bờn cnh nhiu khớa cnh xó hi hn ch vic hin tng sau cht thỡ ngi bnh cng t e ngi nhn tng t ngi cho khụng cũn sng Vỡ vy iu kin Vit Nam cú th ly tng t ngi cho cht nóo, ghộp cho ngi bnh phự hp cn cú mt mụ hỡnh t chc tt, thc hin ỳng qui trỡnh , trỏnh mt thi gian ch i vỡ iu ny nh hng ỏng k n chc nng tng thu c Nhng úng gúp mi ca lun ỏn - L cụng trỡnh nghiờn cu u tiờn ng dng qui trỡnh ly a ph tng ú cú ly ra, bo qun thn ghộp t ngun ngi cho cht nóo ng dng hon cnh v iu kin ti Vit Nam - T nhng thnh cụng ban u ca ghộp thn t ngi cho cht nóo, cụng trỡnh nghiờn cu m mt hng mi cho vic cung cp Footer Page of 161 ngun tng ghộp, v c bit cú thờm s la chn cho nhng BN suy thn mn cú ch nh ghộp B cc ca lun ỏn Lun ỏn cú 129 trang, bao gm cỏc phn: t (2 trang), tng quan (36 trang), i tng v phng phỏp nghiờn cu (20 trang), kt qu (34 trang), bn lun (35 trang), kt lun (2 trang) Lun ỏn cú 56 bng, 50 hỡnh, biu , s 124 ti liu tham kho ú cú ti liu ting Vit, ti liu ting Anh., ting Phỏp Chng TNG QUAN 1.1 LCH S GHẫP THN LY T NGI CHO CHT NO Nm 1966 khỏi nim cht nóo c chp nhn ti Phỏp Nm 1984 quy trỡnh ly a tng t ngi cho cht nóo ó c Stazl v cng s mụ t ln u tiờn v cho n quy trỡnh ny ó c ph bin rng rói trờn ton th gii Ngy ly tng t ngi cht nóo ó thun li rt nhiu nh cú dch v bo qun thn Hc vin Quõn Y l ni xng ghộp thn, ghộp gan, ghộp tim Tuy nhiờn, bnh vin Vit c li l n v tiờn phong ghộp tng t ngi cho cht nóo vi c tng thn, gan v tim Cựng thi gian ú bnh vin Ch Ry, Hc vin quõn Y v bnh vin Trung ng Hu cng bt u tin hnh ghộp thn t ngi cho cht nóo 1.2 LY A TNG, BO QUN THN T NGI CHO CHT NO 1.2.1 Tiờu chun bnh nhõn cht nóo hin tng: - Chc nng thn gii hn bỡnh thng - Khụng mc bnh tiu ng, cao huyt ỏp hoc cỏc bnh ỏc tớnh tin trin khỏc tr mt s ung th nguyờn phỏt ca h thn kinh cha cú di cn (ung th da v ung th t cung ) - Khụng mc cỏc bnh nhim khun hoc iu tr bnh trc Header Page of 161 cht khụng b nhim khun (viờm gan C mn tớnh, bnh giang mai, bnh lao tin trin, bnh nóo bỏn cp) hay HIV (+) - Nhng bnh nhõn trc cht nóo chn thng huyt ỏp ti a di 80mmHg 24 gi hoc thiu niu, vụ niu cng khụng cú ch nh hin tng 1.2.2 K thut ly tng t ngi cho cht nóo 1.2.2.1 Kớp phu thut: Trong trng hp ly a tng thng cú nhúm phu thut viờn tham gia ly tng l nhúm tim mch - nhúm gan v nhúm tit niu Cuc m s c tin hnh theo trỡnh t: Nhúm phu thut chung, sau ú n nhúm chuyờn khoa (gan v tim mch) 1.2.2.2 Qui trỡnh ly a tng qui trỡnh ly a tng * Bc 1: thm dũ, ỏnh giỏ tim cũn p: ỏnh giỏ cht lng tng v i th, phỏt hin cỏc bin i gii phu: * Bc 2: Bc l nhng mch mỏu ln sau phỳc mc: Lun lc MCB v TMCD on di thn Chun b v trớ t canul cỏch 3cm phớa trờn ni chc ba ch chu Lun lc tnh mch mc treo trng di (TM MTTD) t ng truyn th hai qua h thng TM ca mt s trng hp ly gan kt hp Lun lc MCB on di c honh: - Thỡ ngc: M ngc, bc l M ch ngc on trờn c honh 1.2.3.1 Bo qun nhit thp Hai k thut bo qun h nhit hay c s dng l bo qun lnh n thun v truyn dch lnh liờn tc Tng ghộp c t tỳi vụ trựng ngõm dch bo qun v liờn tc 1.2.3.2 Bo qun bng mỏy truyn i vi thn thỡ mỏy truyn ny cho kt qu tt hn rt nhiu so vi bo qun lnh n thun 1.3 GHẫP THN 1.3.1 V trớ t thn: cú khuynh hng Ly thn no thỡ ghộp vo h chu cựng bờn ú Ly thn bờn no cng chn ghộp vo h chu phi Ghộp thn vo h chu i bờn 1.3.2 Ghộp thn cú bin i gii phu h thng mch mỏu v ng bi tit 1.3.2.1.Cú bin i gii phu v M Ni M thn - M chu ngoi kiu tn bờn nh ming tai M ( carrel patch) Ni M cc - M thng v di kiu tn tn: Ni M cc - M thn chớnh kiu tn bờn: To hỡnh M thn thnh thõn chớnh kiu nũng sỳng ni vi M chu ngoi kiu tn bờn * Bc 3: t Canul - t Clamp MCB - Ra tng lm lnh ti ch: t canul vo MCB Canul MCB c ni vi h thng ra, sau ú cm tỳi dch tng lnh vo t canul TMCD gim ỏp c cp v t nh trờn M ng qua canul MCB v TM MTTD Ph ỏ ton b bng v mng ngoi tim Kt thỳc truyn ht dch ra qua canul TMCD cú mu l c 1.3.3.2 Ghộp ni TM: * Bc 4: Ly tng: n ly tng theo trỡnh t ngc li: nhúm tim mch - nhúm gan - nhúm tit niu.Thn c ly c bao gm c on M ch v TM ch sau ú c phõn thnh thn 1.3.3.6 Bt thng niu qun 1.2.3 Bo qun tng Footer Page of 161 i vi thn ghộp ly t ngi cho cht nóo: v c bn ming ni cng tng t nh ngi cho sng Nu TM thn ngn s phi to hỡnh kộo di ming ni TM bng cỏch s dng on TM ch bng Kt qu TM thn cú th t chiu di ti thiu l 25 - 35mm sau ú mi tin hnh ghộp ni Niu qun ngn: khõu ni NQ thn ghộp NQ ngi nhn tn tn, c bit hiu qu trng hp m phn NQ thn ly cho ghộp cũn li quỏ ngn (do b chớt hp hoc b ct t phu thut) Header Page of 161 Niu qun ụi: Cú th to hỡnh niu qun thnh ming ni nht ni vi bng quang hoc cm bng ming ni riờng bit tỏi phỏt, bnh thn virus, ỏi thỏo ng, ng c thuc Chn oỏn bng sinh thit thn ghộp 1.4 DIN BIN V BIN CHNG SAU GHẫP THN 1.6 CC YU T NH HNG N CHC NNG THN GHẫP 1.4.1 Giai on sm 1.6.1 nh hng hũa hp HLA lp v lp lờn thn ghộp: - Chy mỏu sau m: nguyờn nhõn ngoi khoa cn m li - Huyt cp: khong 2% gp M hoc TM , cú nguy c mt thn ghộp - Rũ bch huyt: gp khong % sau ghộp - Bin chng niu khoa: gp khong 10% xỡ rũ nc tiu v trớ cm niu qun, khõu hp ming ni, hp v trớ cm niu qun 1.4.2 Giai on mun - Huyt TM: chim 6%, huyt TM sau 8.3% sau ghộp khụng iu tr d phũng chng ụng mỏu - Huyt M: xut hin bt k giai on no cn cn thip cp cu sm mi hy vng cu thn ghộp - X hp M thn ghộp: t 1-23% sau ghộp Siờu õm Doppler l mt xột nghim dựng theo dừi v phỏt hin bin chng ny 1.5 CC BIN CHNG NI KHOA 1.5.1 Giai on sm 1.5.1.1 Thi ghộp: thi ghộp ti cp din sau m, Thi ghộp cp tng tc sau 24 gi n ngy ỏp ng th dch nh li Hỡnh thỏi ny hay gp nhng BN cú tin mn cm cao > 50% hoc ghộp li ln Thi ghộp cp: Din t ngy n ngy th sau ghộp 1.5.1.2 Thn chm chc nng: Thn chm chc nng TCCN: c nh ngha l cn h tr CTNT tun u sau ghộp Tiờu chun vng chn oỏn TCCN l sinh thit thn T l TCCN thng gp nhúm BN nhn thn t NCCN nhiu hn so vi ngi cho sng, v nhúm BN phi ghộp thn li ln 1.5.2 Giai on mun: thi ghộp xy vũng thỏng u v t 5-50% thỏng u tiờn sau ghộp Thi ghộp mn , bnh thn c Footer Page of 161 Nm 1998 Reisaeter v cng s nghiờn cu 655 BN ghộp thn nhn thy hũa hp HLA nh hng ln n chc nng thn ghộp Khi hũa hp cỏc locus HLA- DR t l thn ghộp cũn chc nng sau nm l 90%, ú nu cú hoc khỏng nguyờn HLA- DR khụng hũa hp t l ny ch l 82% v 73% S khỏng nguyờn HLA- DR khụng hũa hp cng nhiu, s t thi ghộp cp cng tng Theo Peter N Bredan hũa hp HLA ớt cú vai trũ ghộp thn t ngi cho cht nóo v ngi cho khụng cựng huyt thng 1.6.2 nh hng ca cỏc yu t khỏc lờn thi gian sng ngi nhn thn v thn ghộp Kt qu lõu di ca thn ghộp tựy thuc vo nhiu yu t nh chc nng ca thn ghộp, phu thut ghộp, iu tr v theo dừi sau ghộp, s t thi ghộp cp Nhng bin chng ngoi khoa cn quan tõm l: bin chng mch mỏu, tc niu qun, rũ nc tiu, v nhim trựng, hoc nhim c calcineurin dn n thi ghộp Yu t tiờn lng liờn quan n : tui ngi cho v ngi nhn , thi gian thiu mỏu lnh, ngi nhn thn bộo phỡ, ngi cho din tiờu chun m rng mc hũa hp khỏng nguyờn HLA v nhúm mỏu 1.6.3 Thi gian sng ca thn ghộp v ngi nhn thn: Hin nay, t l thnh cụng sau nm ca ghộp thn t ngi cho cht nóo l 91% sau nm v sau nm l khong 69% so vi ngi cho sng sau nm t t l 98% Ti chõu theo cụng b ca UNOS t l sng sau nm cao hn vo khong 78% Thi gian tn ti mt na ca tng ghộp t ngi cho sng l 20 nm, t ngi cho cht nóo l 12 nm Chng I TNG V PHNG PHP NGHIấN CU Header Page of 161 2.1 I TNG 38 BN suy thn mn c ghộp thn ly t 20 ngi cho cht nóo theo qui trỡnh ly a ph tng ti bnh vin Vit c tớnh t thi im 5/2010 n 12/2013 2.1.1 Tiờu chun la chn BN cht nóo hin tng: + BN tui t 18 - 60 tui ó c chn oỏn cht nóo + Khụng bao gm cỏc BN chn thng s nóo kốm a chn thng, chn thng bng, chn thng ngc + Chc nng thn gii hn bỡnh thng + Khụng mc cỏc bnh nhim khun hoc iu tr bnh trc cht nóo khụng b cỏc bnh nhim khun bao gm viờm gan B, viờm gan C, HIV, bnh giang mai, bnh lao tin trin 2.1.2 Tiờu chun chn BN nhn thn: Tiờu chun ngi nhn thn ging nh nhng ngi nhn thn ly t ngi sng Cross-match õm tớnh trc ghộp BN c xột nghim tin mm cm xỏc nh khụng cú khỏng th khỏng HLA ngi cho 2.1.3 Tiờu chun loi tr BN nhn thn: BN suy thn nhng khụng iu kin ghộp thn mc cỏc bnh lý sau: Ung th thn, bnh lý ni khoa nng (suy tim, lon nhp tht, vũng thỏng gn õy b tai bin mch mỏu nóo hoc b nhi mỏu c tim), bnh nhõn b tõm thn, HIV +, ỏi thỏo ng ó cú suy chc nng nhiu c quan, nghin ma tỳy, x gan 2.2 PHNG PHP NGHIấN CU 2.2.1 Phng phỏp nghiờn cu: mụ t tin cu 2.2.2 C mu: Chn mu thun tin vi õy l bnh him, ớt gp 2.2.3 Thit k nghiờn cu 2.2.3.1 c im BN cht nóo hin tng Chn oỏn BN cht nóo theo tiờu chun b y t ỏnh giỏ trờn lõm sng bng cht nóo c thc hin ca nhúm chuyờn khoa c lp gõy mờ hi sc v phu thut thn kinh lm ln cỏch ting ln Glasgow im Xỏc nh cht nóo bng cn lõm sng : bao gm in nóo , siờu õm Doppler xuyờn s v chp M nóo Tiờu chun vng l Footer Page of 161 chp M nóo 2.2.3.2 c im BN suy thn mn nhn thn - Nguyờn nhõn suy thn, thi gian chy thn nhõn to - Tỡnh trng nhim Virus HbsAg (- ) HIV(-) EBV (-) - Ho hp nhúm mỏu , mc ho hp HLA - Bilan ỏnh giỏ khỏc ging nh tiờu chun BN ghộp ca b y t 2.2.3.3 K thut ly tng ghộp mụ hỡnh ly a tng Bc 1: M bng thm dũ ỏnh giỏ tim cũn p Bc 2: Bc l mch mỏu ln sau phỳc mc (thỡ bng) Lun lacet ( dõy treo) MCB, TMCD on di thn v TM MTTD chun b v trớ t canuyl (ng ra) cỏch - 3cm phớa trờn ni chia chc ba ch chu Thm dũ thn Thỡ ngc Ca xng c, bc l M ch ngc on trờn c honh Bc 3: t canuyl v t Clamp MCB, tng lm lnh ti ch * Mụ hỡnh 1: ly gan thn tim m ng qua canuyl MCB v TM MTTD Tin hnh cho dch thn chy, ỏp lc t nhiờn (cao 1m so vi bng bnh nhõn) Thng bng - lớt dung dch Custodiol Ph ỏ ton b bng v mng ngoi tim, mng phi phi * Mụ hỡnh 2: ly gan thn khụng ly tim Nhúm tim khụng ct xng c, ly tng tim cũn p Bc l tng nh mụ hỡnh Quỏ trỡnh truyn tng bt u bng clamp MCB di c honh Tht M chu hai bờn, Ct ụi TMCD di c honh Tin hnh tng bng dch Custodiol, ỏ vo bng * K thut ly thn mụ hỡnh ly a tng: Kiu 1: thn c ly thnh gm c ng mch v tnh mch ch sau ú s phõn chia cung mch sau Kiu : Ly thn v phõn chia bng TMCD v MCB c ct dc mt gi cho mch mỏu cung thn cú din ct ng mch v tnh mch rng Kim tra v chnh sa M, TM thn v niu qun trờn khay phu thut 2.2.3.4 Quy trỡnh thn bờn ngoi v bo qun thn : - Thn t khay ỏ, lun kim 18-20G cho dch chy liờn tc Theo dừi dich chy theo TM ly mu dch ờm hng cu bch cu Kim tra M - TM thn Sa lai mm M - TM phc hi cỏc thng tn Sinh thit thn Header Page of 161 -Bo qun thn: t thn vo tỳi polyethylen cú cha dung dch Custodiol lnh C Buc cht tỳi , t tỳi cú thn vo tỳi th buc cht tỳi, t vo tỳi th buc cht tỳi, t tỳi thn vo hp ỏ Lu gi thn t lnh C * ỏnh giỏ kt qu thn sau ly bo qun thn + Kt qu tt: Thn sau trng ng, cng chc, o kớch thc M thn TM, NQ di, hoc khụng cú vt thng mch mỏu, kt qu thn khụng cú hng cu, nu cú sinh thit thn khụng cú hoi t t bo + Kt qu trung bỡnh: Cú vt thng vo nhu mụ thn, M, TM thn, thn kớch thc nh nu cú sinh thit thn cú xõm nhp viờm + Kt qu xu: thn tớm, cng nhc khụng th ghộp c 2.2.3.5 Qui trỡnh ghộp thn: nh ghộp thn thng qui - T th BN nm nga , rch da theo ng Gibson bờn phi - t thn vo v trớ ghộp: thn trỏi o ngc trc sau ca thn , thn phi theo t th bỡnh thng Cỏc k thut khõu M: M thn vi M chu ngoi Trng hp M ni 2M M Chu ngoi bng ming ni riờng r hoc khõu ni M thn M chu gc Khõu ni TM : Ni TM thn TM chu ngoi, ni TM thn TM chu gc Cm NQ vo Bng quang theo phng phỏp Lich- Gregoire cú t ng thụng JJ niu qun bng quang * ỏnh giỏ hot ng ca thn sau ghộp mch mỏu, tỡnh trng cp mỏu cho thn, tit nc tiu sau ghộp: Cú nc tiu sau ghộp 2- phỳt * Theo dừi sau ghộp + Theo dừi s thay i cỏc ch s ure, creatinin mỏu sau ghộp Theo dừi sỏt din bin lõm sng sau m Siờu õm Doppler ỏnh giỏ tỡnh trng thn ghộp v nhu mụ, ng mch, tnh mch + iu tr c ch dch theo phỏc thuc + Xỏc nh cỏc yu t nh hng n hi phc thn quỏ trỡnh hu phu Theo dừi cỏc bin chng: Hoi t ng thn cp , thn chm chc nng, thi ghộp cp T vong sau m: l t vong xy vũng 30 ngy u sau m 2.2.3.10 Xp loi chung Kt qu tt: thn ghộp hot ng tt, cỏc ch s gii hn bỡnh thng, cỏc bnh lý c c kim soỏt v iu tr tt Siờu õm thn ghộp tt Kt qu trung bỡnh : cú biu hin nhim trựng ng tit niu, cú cỏc biu hin hp niu qun hoc cn phi nm iu tr vin vỡ cú t thi ghộp Kt qu xu: t vong hoc mt thn ghộp vỡ bt c nguyờn nhõn gỡ Cú nc tiu sau ghộp nhng chm, s lng ớt dn Khụng cú nc tiu * ỏnh giỏ kt qu sm thn ghộp - Thn tt (thnh cụng): M, TM thn ghộp sau th kp tt, cng phng, mỏu v tt, khụng chy mỏu ming ni Cú nc tiu sau ghộp hoc chm sau vi phỳt, thn hng li nhanh u, thn cng - Thn cha tt: Ming ni cha cng phng, M hp nh hoc cú xon vn, phi lm li ming ni ming ni, phi khõu tng cng ming ni Nhu mụ vựng thn b tớm nh ng dp hoc thiu mỏu, t mỏu di bao Nc tiu sau ghộp cú chm, ớt dn hoc khụng cú nc tiu Chng Footer Page of 161 2.3 X Lí S LIU: x lý theo phn mm SPSS16 2.4 VN O C TRONG NGHIấN CU Y HC Vi nghiờn cu ny, quỏ trỡnh thc hin ti, tụi trit tuõn th lut hin tng ghộp tng ca Quc hi, Chớnh ph, B Y t, tụn trng s ng thun v hin tng ca thõn nhõn BN vỡ mc ớch nhõn o cu ngi KT QU NGHIấN CU 3.1 C IM CHUNG NGI HIN TNG CHT NO Tui: Trung bỡnh: 29.9 10.21 Gii: Nam: 17(85%); N: (3)15% T l nam/n: 5.67 Nguyờn nhõn cht nóo: CTSN n thun (17 BN tai nn giao thụng ) 3.2 CHN ON CHT NO VI CC TEST LM SNG, CN LM SNG - Thi gian t tai nn n c chn oỏn cht nóo: Trung Header Page of 161 bỡnh l 48h (29h - 63h) c im - Khi BN GCS im, trỡ huyt ng thc hin test lõm sng ( phn x ng t, giỏc mc, u mt, tin ỡnh, phn x ho, test ngng th): ln mi ln cỏch ting - Chn oỏn hỡnh nh: siờu õm Doppler xuyờn s mt tớn hiu M mng nóo gia bờn in nóo khụng cũn tớn hiu Chp M nóo khụng hin hỡnh M t ngoi s ( 15 TH) - Khụng cú suy gim chc nng thn c 20 BN Mc lc cu thn: 74.80 13.70 ml/phỳt 3.3 NG DNG QUI TRèNH LY A TNG - Mụ hỡnh thc hin ph bin nht: 70% - ng cú th qua TMMTTT (16 trng hp), hoc qua TMMTTD (3 TH), hoc qua TM lỏch ( trng hp) - Thi gian trung bỡnh ca ca vic chun b tng l : 3.1 0.76 ( gi) ngn nht l gi 30 phỳt, di nht gi 50 phỳt - Thi gian tng trung bỡnh l 25 phỳt S lng dch trung bỡnh l 8.2 lớt Bng 3.1 Cỏc thụng s quỏ trỡnh ly tng Thi gian (T) T ( gi ) bc l tng MH1 3.110.76 MH2 2.770.51 4.941.16 136.5049.80 4.070.60 125.526.36 T (phỳt) tng 25.005.00 21.206.53 S lng dch (lớt) 8.202.05 8.601.34 T (gi) phu thut T(phỳt)thiu mỏu lnh* - Cỏc kiu ly thn: ly thn c TN (20%), ly thn riờng l 80% Khụng cú bt thng v bnh lý i vi tt c cỏc thn ly 3.3.1 o c thn sau ly thn Bng 3.2 : Chiu di ca M v TM thn ly ( n v: cm) Footer Page of 161 Chiu di M kớnh M Chiu di TM kớnhTM Chiu di NQ kớnh NQ Thn phi TB SD Thn trỏi TB SD 3.4 0.7 2.9 1.2 15.2 0.5 3.4 0.7 3.0 1.2 14.9 0.5 0.8 0.81 1.03 0.31 1.61 0.11 0.81 0.92 0.89 0.30 2.00 0.12 Bng 3.3 : Kớch thc thn ( n v cm) c im Chiu di thn Chiu rng thn Chiu dy thn Thn phi TB 11.3 6.1 4.6 SD 1.13 1.25 0.74 Thn trỏi TB 11.5 6.2 4.5 SD 1.19 1.29 0.71 - Khụng cú s khỏc bit v chiu di M- TM thn sau ly vi p>0.05 Nhu mụ thn trng ng: 37TH (97.37%) thn cú mt vt thng cc di (2.63%) * c im M- TM thn - T l thn ghộp cú M: 57.89%, M: 42.11%, - T l thn ghộp cú TM :89.47% , TM 10.53% 3.3.2 Cỏc k thut can thip mch sau thn (N =38) Bng 3.4 : Cỏc k thut can thip mch sau thn Cỏc k thut Chnh sa M TH cú M Sa li mnh tai M TH cú M sa li mnh tai M ct thnh ming ni riờng r TH cú M Sa li mnh tai M Khõu vt thng bờn M ni M cc M chớnh N % 22 22 11 2 57.59 57.59 28.95 18.42 10.53 13.16 5.26 5.26 2.63 - 4TH thn cú M cú mnh tai M ch ó ct thnh ming ni trỏnh din ghộp quỏ rng Header Page of 161 Creat* (àmol/l) albumin (g/l) Gluc (mmol/l) Kali ( mmol/l) SGOT (UI/l) SGPT (UI/l) 3.3.3 Bo qun thn - 35 TH thn c a vo ghộp : 92.1% - TH bo qun 23 chim t l 21.05% (8TH) BN viờm gan C xỏc nh HCV-RNA trc m t ngng cho phộp < 100copies/ml nờn c ghộp thn Kt qu vi loi virus EBV, CMV: 100% ngi cho v nhn u cú IgG dng tớnh v IgM õm tớnh - S BN CTNT < nm chim t l 21.05% Cú BN cha CTNT c ghộp Bng 3.6: Chc nng gan thn BN ghộp Ure (mmol/l) TB 22.2 Footer Page of 161 SD 8.52 95%CI 19.38 Bng 3.7: Phõn b phự hp HLA Phự hp HLA 0/6 1/6 2/6 3/6 4/6 Tng S lng 13 38 T l (%) 18.42 23.68 34.21 21.05 2.63 100 - Mc hũa hp HLA thp 0/6 gp 18.42% - T l BN cho cựng nhúm mỏu l 89.47% ( 34BN) Nhúm mỏu OO: 21 TH (55.26%) Nhúm mỏu , O-A: TH Nhúm mỏu A-A:8 TH, nhúm mỏu B-B:4 TH, nhúm mỏu AB- AB TH - Xột nghim Crossmatch: m tớnh 100% 3.4.3 Ghộp thn t NCCN Bng 3.8 : Khõu ni TM thn Ni TM thn TH cú TM TMT- TMCN TMT TMCG TH cú TM Ni TM thn _ TMCN Tng N T l % 32 84.22 5.26 38 10.52 100 Bng 3.9 : Khõu ni M thn Ni M thn TH cú M N 22 T l % Header Page 10 of 161 MT- MCN MT MCG Tng TH cú M Khõu ming ni riờng r Khõu c tai M Tng TH cú 3M To hỡnh M MCN, M ni M chu gc Ni M_ MCN qua tai M, M M chu gc Tng 21 22 11 11 95.45 4.55 100 40 100 36.36 63.64 100 60 Bng 3.10 Thụng s m ghộp thn ( phỳt) - - T.gian TB SD Min-Max 95%CI Ni M Ni TM CmNQ-BQ T gian m 16.7 19.2 23.2 102.8 6.80 8.0 6.39 17.0 - 33 - 45 11 - 35 74 - 150 14.4- 19.0 16.5-21.8 21.1 25.3 97.2- 108.4 V trớ thn ghộp: 38 trng hp u ghộp vo h chu phi Khi cú M - TM thn v trớ ni u tiờn ca M TM chu ngoi Khụng cú trng hp no ni vi M chu Thi gian thiu mỏu m th ( thi gian ni mch) TH cú M1TM l: 33.9 8.08 phỳt Thi gian thiu mỏu m th thn cú nhiu mch mỏu l 40.8 17.29 phỳt Thn cú nhiu mch thỡ thi gian khõu ni cú tng lờn nhng khụng cú ý ngha thng kờ vi p > 0.05 Phng phỏp cm niu qun - bng quang: 100% trng hp u thc hin theo phng phỏp Lich - Grộgoir cú ng thụng JJ 3TH phi truyn mỏu nhng s lng ớt ch 1- UI mỏu 3.5 NH GI THN NGAY SAU KHI GHẫP MCH MU * ỏnh giỏ thn sau ghộp mch mỏu Footer Page 10 of 161 Bng 3.11 : ỏnh giỏ thn sau m kp mch mỏu Chc nng thn ghộp Cú nc tiu ti bn < phỳt Cú nc tiu sau ghộp nhng chm ớt dn Khụng cú nc tiu Tng N 36 38 % 94.74 5.26 100 - TH cú nc tiu sau ghộp nhng chm ớt dn ú cú TH xon M phỏt hin trc th kp ó x trớ li - Khụng cú trng hp no thn khụng hot ng Thi gian cú nc tiu : 52.21 69.08 giõy, nhanh nht l giõy nhiu nht l 300 giõy (5 phỳt) * Tai bin v bin chng m : 7.89% - 2BN cú chy mỏu nh ming ni: c khõu tng cng - BN xon xon cung thn mt vũng Tai bin c phỏt hin m v lm li ming ni M Thi gian lm li ming ni M l 10 phỳt Sau th kp mch mỏu thn cng hng tr li, cú nc tiu trờn bn m nhng chm Truyn mỏu m 2UI mỏu * ỏnh giỏ kt qu sm thn ghộp : tt 94.74% cha tt: 5.26% 3.6 TèNH TRNG CHC NNG THN TRONG NHNG NGY U Bng 3.12 : Lng nc tiu 24h u gia cỏc nhúm Lng nc tiu 24h u < 3000ml 3000-5000ml 5000-7000ml 7000-9000ml > 9000ml Tng Nhúm 1M_1TM 10 22 T l % 13.64 4.55 45.45 22.73 13.64 100 Nhúm >1M_1TM 16 T l % 12.50 0.00 31.25 12.5 43.75 100 - S BN a niu gia nhúm cú s khỏc bit nhng khụng cú ý ngha thng kờ vi p = 0.299 >0.05 Bng 3.13 Tỡnh trng chc nng thn ngy sau ghộp Header Page 15 of 161 HANOI MEDICAL UNIVERSITY The Work has been successfully completed at: HANOI MEDICAL UNIVERSITY LE NGUYEN VU Science Instructors: Ass.Prof PhD NGUYEN TIEN QUYET Ass.Prof PhD HOANG LONG Opponent 1: Prof PhD NGUYEN TIEN QUYET Opponent 2: Ass.Prof PhD Vu Nguyen Khai Ca Specialism: UROLOGY Opponent 3: Ass.Prof PhD Tran Van Hinh Code: 62720126 MEDICAL DOCTORAL THESIS The thesis has been defended at University-level Thesis Evaluation Council held in Hanoi Medical University At, (hour), ./ /2014 (date) This thesis may be found at: HANOI - 2014 - National Library - Central Medicine Information Library - Library of Hanoi Medical University Footer Page 15 of 161 Header Page 16 of 161 list of announced research projects related to thesis topic Le Nguyen Vu, Hoang Long, Nguyen Tien Quyet (2013) Evaluate process and results of kidney transplantation from brain dead donor in Vietnam - German Hospital, Medical Research Journal, 83 (3), 80 87, Do Truong Thanh, Le Nguyen Vu, Do Ngoc Son (2013) Evaluate treatment results for Ureteric stricture after kidney transplant: multiple patients Vietnam Medicine, 409, 296- 302 Le Nguyen Vu, Nguyen Tien Quyet, Do Ngoc Son et al (2012) Results from 12 patients with kidney transplant from deceased donor in Vietnam - German Hospital Military Medicine and Pharma Magazine, 37, (5), 138-144 Footer Page 16 of 161 Header Page 17 of 161 BACKGROUND The kidney transplant has taken place in Vietnam since 1992; however, number of transplanted patients is small because of kidney sources from living donors Harvesting an organ from an living donors differs from that from the brain dead donor To develop an effective and efficient model of organ harvesting and transplanting from brain dead donor, we should refer to the models in developed countries and apply to our background of Vietnam so as to build the most suitable model In fact of Vietnam, up to now, there is no official model of organ transplanting and harvesting from brain dead donor Therefore, I managed to pursue this thesis titled Evaluate outcomes from harvesting, preparation and transplanting kidney from brain dead donor in Vietnam - German Hospital for purposes of: Applying research on processes of harvesting, preparation, transplanting kidney from the brain dead donor Evaluating outcomes from kidney transplantation Urgent nature of the project In the developed countries, the organ sources come from the brain or cardiac deceased donors; whereas, in Vietnam the sources origins from living donors which narrows scope of treatment due to limited organ sources Except from social aspects limiting to the organ donation after death, the patients hesitate to receive an organ from deceased donors So, with conditions in Vietnam, extracting an organ from a brain dead donor and transplanting into a suitable patient should be laid into a good management model, strict process to avoid any wait time that may have much adverse effect on functions of the harvested organ New contributions from the thesis: - It is the first research project to apply the multiple-organ extraction process, including kidney harvesting and transplanting, from the brain dead donos with present background and conditions in Vietnam Footer Page 17 of 161 Thesis outline: This thesis covers 129 pages, including: preamle (2 pages), the overview (36 pages), materials and method (19 pages), outcomes (34 pages), discussion (35 pages), conclusion (2 pages), recommendation (1 page) It consists of 50 tables, charts There are 124 references, in Vietnamese, English and French Chapter OVERVIEW 1.1 HISTORY OF HARVESTING AND TRANSPLANTING KIDNEY FROM THE BRAIN DEAD DONORS In 1996, concept of brain death was accepted in France Vietnam Military Medical Academy initiated transplantation of kidney, liver, heart but Vietnam - German Hospital is the pioneer in transplanting three organs from brain dead donors which are kidney, liver and heart At the same time, Cho Ray hospital, Vietnam Military Medical Academy and Hue Central Hospital began to perform kidney transplant from the brain dead donor 1.2 HARVESTING MUTIPLE-ORGAN, STORING KIDNEY FROM THE BRAIN DEAD DONORS 1.2.1 Criteria of a brain dead donor: - Renal functions are in normal limitation - The donor is not a sufferer of diabetes, high blood pressure or any malignant diseases except for primary cancers in the nervous system without metastasis (skin cancer and uterus cancer) - The donor is not a sufferer of infections or before death, the donor was not infected (chronic hepatitis C, syphilis, actively spreading tuberculosis, subacute encephalopathy) or HIV (+) - The donor, who has blood pressure no higher than 80mmHg through 24 hours or suffers from pliguria, anuria before brain death is caused by wound or injury, should not be accepted to donate any organ Header Page 18 of 161 1.2.2 Technique of harvesting kidney from a brain dead donor 1.2.2.1 Surgical team: A multiple-organ harvesting normally involves three teams of surgeons in charge of cardiovascular - liver and urinal respectively 1.2.2.2 Multiple-organ harvesting process * Step 1: sounding, evaluation when the heart is beating: evaluating the organ quality in general, detecting any surgical change: * Step 2: revealing the large bloor vessel behind peritonaeum Preparing position to place cannula 2-3cm far from and above iliacaortic trifurcation - Chest: Open the chest; reveal the thoracic aorta above the diaphragm * Step 3: Implant Cannula - Implant Clamp for the abdominal aorta - Cleansing and cooling the organ on site: * Step 4: Organ harvesting: 1.2.3 Organ storage 1.2.3.1 Storage at low temperature Two storing techniques at low temperaturea that is applied popularly are cool storage in common or continuous dip feeding with cooled immersion fluid 1.2.3.2 Preservation in the cleansing and transferring machine For the kidney, this cleansing and transfering machine is much better than static cool storage to the carrel patch Graft end-end anastomoses to polar artery and inferior epigastric artery: Graft end-side anastomosis to polar artery and renal artery: grafts side-side anastomosis with renal arteries to end-side anastomosis with external iliac artery 1.3.3.2 Graft vein: For kidney transplanted from a deceased donor: substantially the connecting moupatients is similar to the living donor 1.3.3.6 Ureteric complications Short Ureter: suture and graft end-end ureteral anastomosis Double Ureter: two separate connecting mouths 1.4 DEVELOPMENT AND COMPLICATIONS AFTER KIDNEY TRANSPLANT 1.4.1 Early stage - Postoperative bleeding: - Thrombosis: nearly 2% in aorta - Lymphocele: % patients after transplantation - Ureteral complications: about 10% patients 1.4.2 Late stage - Venous thrombosis : vascular thrombosis occur in nearly 6% - Aortic thrombosis: - Renal artery stenosis following transplantation: from 1-23% 1.3 KIDNEY TRANSPLANT 1.5 INTERNAL COMPLICATIONS 1.3.1 Where to transplant a kidney: there are three issues: left kidney donor (LKD) should transplant into left iliac fossa or vice versa; any kidney donor should transplant into the right iliac fossa; left kidney donor (LKD) should transplant into right iliac fossa and vice versa 1.3.2 Kidney transplant in case of surgical change in blood vessel system and excretory gland 1.3.2.1.Surgerical change in aorta Graft end-side anastomosis with external iliac artery owing 1.5.1 Early stage 1.5.1.1 Rejection: 1.5.1.2 Kidney dysfunction: 1.5.2 Late stage: Footer Page 18 of 161 1.6 FACTORS AFFECTING GRAFT SURVIVAL 1.6.1 Influence of HLA matching layers and on the transplanted kidney: Header Page 19 of 161 With matching at HLA- DR locus, survival rate after transplantation was 90% at year, 82% and 73% with one or two HLA-DR antigen nonmatching The more the HLA-DR antigen nonmatching was, the higher acute rejections occurred Peter N Bredan stated that HLA matching had inconsiderable role in the kidney transplant from brain dead donor and consanguineous compatible donors 1.6.2 Others affecting the survival of the kidney transplant recipients and transplanted kidney Long-term results of transplanted kidney depend on many factors such as functions of the transplanted kidney, implantation operation, treatment and monitoring after transplantation, quantity of acute rejections Anticipated factors are related to: age of donors and recipients, duration of cold blood shortage, obese recipients, donors under extension standards of HLA antigen matching and blood type 1.6.3 Graft survival in the renal transplant recipients: In Asia, the UNOS report said that survival rate at years is higher with 78% Survival of a half of organs transplanted from the living donors is at 20 years, from the deceased donors it is at 12 years trauma, chest trauma + Renal functions within normal threshold + No infectious diseases or no infectious diseases including hepatitis B, hepatitis C, HIV, syphilis, actively spreading tuberculosis during pathologic treatment before brain death 2.1.2 Inclusion criteria of kidney transplant recipients: Criteria of kidney transplant recipients are similar to those of kidney transplant recipients from living donor The patients are diagnosed with end-stage chronic renal failure: Creatinine clearance < 15ml/minutes, survival rate at years 2.1.3 Exclusion criteria of transplant candidates: The kidney failure patient is ineligible for kidney transplant because of catching the pathologic diseases: renal cancer, severe internal diseases (heart failure, ventricular arrhythmias, for the last of months having cerebrovascular accident or coronary), psychopath, HIV +, diabetes with multiple-organ failure, drug addiction, cirrhosis 2.2 STUDY METHOD 2.2.1 Study method: description study 2.2.2 Specimen size: satisfactory 2.2.3 Research design 2.2.3.1 Characteristics of the deceased donors Chapter MATERIALS AND METHOD 2.1 MATERIALS 38 chronic renal failure patients receiving kidney from 20 brain dead donors by the multiple-organ harvesting process in Vietnam German Hospital from May 2010 to 12/2013 2.1.1 Selection criteria of deceased donors: + Patients aged from 18 - was diagnosed with brain death + Except for cranial trauma patients with polytrauma, adnominal Footer Page 19 of 161 Diagnosing the brain dead patients follow criteria as announced by Ministry of Health Clinical evaluation by means of brain death tests was conducted by two independent teams of anesthetics and nerve surgery three times per hours once near to Glasgow points Identifying the brain death paraclinically includes electroencephalography, Doppler ultrasonography across the brain and imaging the cerebral artery Golden standard is to image the cerebral artery 2.2.3.2 Characteristics of transplant candidates of chronic renal failure - Kidney failure patient, duration of hemodialysis Header Page 20 of 161 - Virus HbsAg (- ) HIV(-) EBV (-) - Compatibility of blood type , grade of HLA matching - Bilan had different and same evaluation as the criteria of transplant candidate published by Ministry of health 2.2.3.3 Organ harvesting technique in the multiple-organ harvesting model Step 1: Open the stomach to reveal and evaluate while the heart remains beating Step 2: reveal the large bloor vessel behind peritonaeum (abdominal episode) Implant a lacet (suspension wire) under the abdominal aorta, inferior vena cava below the kidney and inferior mesenteric vein to prepare location to implant the canuyl (cleansing tube) 2-3 cm far from and above the iliac-aortic trifurcation Probe two kidneys Chest episode Saw the sternum to reveal the thoracic aorta above the diaphragm Step 3: Implant the canuyl and the clamp into the abdominal aorta; clean the organ on the spot * Model 1: Remove liver, heart, kidney to open a cleansing path via canuyl of the abdominal aorta and inferior mesenteric vein Let the kidney cleansing liquid flow into so as to reach and maintain natural pressure (1m height above the patient stomach) It is often using - liters of Custodiol to cleanse Cover the entire abdomen and the pericardium, the right pleura with ice * Model 2: Remove kidney, liver but heart The heart team shall not cut sternum and remove the organ while the heart remains beating The organ is revealed as in model Organ cleansing process starts by clamping the abdominal aorta below the diaphragm The pelvic arteries are tightened in both sides The inferior vena cava is cut off into two under the diaphragm Then the organ is cleansed with Custodiol while ice is placed into the abdomen * Kidney harvesting techniques in the multiple-organ harvesting model: Type 1: two kidneys are removed in one block including aorta Footer Page 20 of 161 and vena cava; after that, their pedicles shall be separated Type : Remove the kidney and separate it in the stomach The inferior vena cava and the abdominal aorta are cut lengthwise in both faces to keep arterial and venal width of two-renal pedicle vessels Check and rectify the renal artery, vein and ureter ton the surgical tray 2.2.3.4 Procedures of kidney external cleansing and preservation : - The kidney is placed in a ice tray with a needle18-20G threaded to discharge the fluid ceaselessly Observe the discharge fluid in the vein and take three specimens of cleanse fluid to count number of red blood cells and white blood cells Check the renal artery - vein Rectify the top of artery - vein and recover any injury Execute the renal biosy - Kidney preservation: The kidney is placed into a polyethylen bag containing cold Custodiol at C * Evaluate the kidney after harvesting and storage + Good result: The after-cleaning kidney becomes ivory white, full, firm It is measured The renal artery and vein, ureter is long enough, without trauma on vessels; the cleansed kidney shows no red blood cell; in case of renal biosy, no cell necrosis is detected + Average result: Having parenchymal renal trauma, artery, renal vein; the kidney's size is small in case of renal biosy, inflammation is possible + Bad result: the kidney becomes too blue, inflexible to be transplanted 2.2.3.5 Kidney transplant process: similar to normal rules of kidney transplant - Let the patient lay on his back and rip a right Gibson lien on the skin - Implant the kidney in the graft location: the left kidney is reversed front and behind of the kidney which must be on normal position Artery suturing techniques: suture the renal artery to anterior iliac artery In case of grafting two arteries to two arteries, RY external iliac artery by separate connecting mouths hoc suturing the renal artery common iliac artery Suture a vein : Graft the renal vein Header Page 21 of 161 innominate vein, Graft the renal vein common iliac vein Insert URETER into Bladder by Lich- Gregoire method with catheter for JJ ureter bladder * Evaluate renal functions after vessel graft, blood feeding to the kidney, urinary excretion after the transplant: Have urine 2- minutes after transplantation Have urine immediately following transplantation but slowly and gradually-decreased volume Have no urine * Evaluate the early outcomes of kidney transplant - The kidney works well (successful): The renal artery, vein grafts after clamps are removed are good, full with good blood circulation and no bleeding from connecting mouth The patient has urine right after the operation or several minutes later The kidney looks ruddy and full evenly, - The kidney is not satisfactory: Connecting mouths is not full; the artery is lightly narrowed and twisted Those requires to re-make the connecting mouths, to suture the connecting mouths intensively Parenchyma in the kidney area gets slightly blue caused by crash or blood shortage, subcapsular congestion There is urine after the transplant but discharging slowly in small volume or evenly no urine *After-transplant monitoring + Monitor any variance in urea, creatinine in the blood after the transplantation Monitor any clinical development after the operation Take the Doppler ultrasonography to assess status of the transplanted kidney in respec to parenchyma, artery, vein + Immunosuppressive treatment according to the three-medicine therapy + Determine any factor that may influence the renal recovery in the postoperative process Monitor any complication: Acute tubular necrosis , kidney dysfunction, chronic rejection Postoperative fatality: the death may occur for the first 30 days after the operation Footer Page 21 of 161 10 2.2.3.10 General classification Good result: transplanted kidney works well; indexes are in normal threshold; previous pathologies are under good control and treatment Ultrasonography on transplanted kidney shows the good results Average result: manifest infectious urinary tract, narrowed ureter that reuired hospitalization in case of rejection Bad result: fatality or loss of transplanted kidney irregardless of causes or reasons 2.3 DATA PROCESSING: data are processed on SPSS16 software 2.4 ETHICS IN MEDICAL RESEARCH In this study, I totally obeyed the law on organ donation as enacted by the National Assembly, the Government, Ministry of health as well as respected consent and organ donation of the patient relatives for humanity purpose that is to save human life Chapter STUDY RESULTS 3.1 Common characteristics of brain dead donor Age: Average: 29.9 10.21 Gender: Male: 17(85%); Female: (3)15% Male/female ratio: 5.67 Causes of brain death: cranial trauma (17 patients of traffic accidents) 3.2 Diagnosis of brain death with tests, paraclinical clinical - Duration from accident till diagnosis of brain death: It is 48h (29h - 63h) on average - When a patient undergoes GCS (deep coma), dynamic blood is maintained to carry out clinical tests (pupil reaction, cornea, eye, vestibule, cough reflex, test on suspension of breathing): three times per hours - Diagnosis with image: Transcranial Doppler ultrasonography Header Page 22 of 161 11 12 loses the signal of neuromeningeal artery between two sides Electroencephalography has no more signal Image of the cerebral artery does not display arteries from external cranium ( 15 patients) - There is no deficiency of renal functions in all of 20 patients Grade of Glomerular filtration rate: 74.80 13.70 ml/minutes Vena length Vena diameter Ureteric length Ureteric diameter 0.89 0.30 2.00 0.12 3.0 1.2 14.9 0.5 1.03 0.31 1.61 0.11 Table 3.3 : Size of a kidney (unit: cm) 3.3 APPLICATION OF MULTIPLE-ORGAN HARVESTING PROCESS - Model is the most popular: 70% - Cleansing path may go through the vena mesenterica superior (16 cases), or the vena mesenterica inferior (3 cases), or the splenic vein ( case) - Average time for organ preparation: 3.1 0.76 (hours), the shortest is hours 30 minutes, the longest is hours 50 minutes - Average time for organ cleansing is 25 minutes Average volume of cleanse fluid is 8.2 liters 2.9 1.2 15.2 0.5 Characteristics Renal length Renal width Renal thickness Characteristics Right kidney TB SD TB SD 11.3 6.1 4.6 1.13 1.25 0.74 11.5 6.2 4.5 1.19 1.29 0.71 MH1 MH2 T ( hours ) revealing the organ 3.110.76 2.770.51 T (hours) operating 4.941.16 4.070.60 T(minutes) cold blood shortage* T (minutes) organ cleansing 136.5049.80 25.005.00 125.526.36 21.206.53 - There is no difference between arterial - venal length of two kidneys after removal at p>0.05 Renal parenchyma is ivory white: 37 patients (97.37%) One kidney gets a lower polar trauma (2.63%) * Characteristics of the renal artery - vein - Transplant rate with one kidney: 57.89%, arteries at 42.11% - Transplant rate with one vein : 89.47%, veins at 10.53% 3.3.2 Vascular intervention techniques after renal cleansing (N =38) Volume of cleanse fluid (liters) 8.202.05 8.601.34 Table 3.4 : Vascular intervention techniques after renal cleansing Table 3.1 Specifications of a organ harvesting process Time (T) - Types of kidney removal: Remove the kidney in full for patients (20%) and remove the single kidney (80%) No pathologic abnormality is found on all of the removed kidneys 3.3.1 Measure the kidney after organ harvesting Table 3.2 : Length of a renal artery and vein after extraction (unit: cm) Characteristics Arterial length Arterial diameter Right kidney Left kidney TB SD TB SD 3.4 0.7 0.81 0.92 3.4 0.7 0.8 0.81 Footer Page 22 of 161 techniques N % Rectify the artery Patients have artery Rectify the aortal piece patients have artery Rectify the arterial piece cut into separate connecting mouths patients have artery Rectify the aortal piece 22 22 11 5 57.59 57.59 28.95 18.42 13.16 13.16 5.26 Header Page 23 of 161 13 14 Suture the arterial trauma Graft the polar artery aorta 5.26 2.63 - patients receiving kidney have arteries with aortal piece which was cut into connecting mouths to avoid too broad graft area 3.3.3 Kidney preservation - 35 patients receiving the kidney was operated and transplanted with kidney without due delay : 92.1% - patients are waiting for months years after hospital discharge Monitoring results N % Renal functions were good Connecting mouths of ureter-bladder Tuberculous loss of transplanted kidney Recurring of internal pathology 34 92.11 5.26 2.63 37 100 Total - patient got acute rejection in need of recurring hemodialysis because he got tuberculosis from his daily life - patients, one months after pulling out JJ, manifested symdromes of oedematose face, limbs and increased blood creatinine at 189 àmol/l, minor oedema on face, limbs were resulted from the narrowed connecting mouths on ureter-bladder of which JJ was reimplanted by method of urethra endoscopy Blood creatinine after reimplanting the sonde JJ is 125,8 àmol/l on average, ranging from 75 153 àmol/l For other patients, renal functions were recovered well Header Page 26 of 161 19 20 3.6.4 Classify the general results end moment, was 82.3821.18 àmol/l that lies under normal threshold Table 3.15 : Evaluate the graps results Results of transplantation Good Average Bad Total kidney N % 34 2 38 89.48 5.26 5.26 100 - Kidney with good functions at three years was: 89.48% Chapter DISCUSSION 4.1 SELECTION OF DONORS AND PREOPERATIVE PREPARATION For successful functions of transplanted kidney, a standard criteria donor (SCD) has to meet: age < 40, die of trauma, brain death, stable dynamic blood till the organ harvesting and no infectious pathology The organ donors in this study satisfy such criteria although in case of emergency, all the tests were conducted to diagnosis of brain death as well as to evaluate functions of the removed organ for the transplantation Electroencephalography and transcranial Doppler ultrasonography began after the brain death was diagnosed and confirmed with the second clinical tests Imaging the cerebral artery was performed with 15/20 patients after standard time and diagnosis of brain death by clinical tests, electroencephalography and transcranial Doppler ultrasonography This is a golden standard to evaluate the brain death 18/20 persons donated their organ(s) prior to 48 hours of accident We not have any group of too young patients or aged at 55 and over or associated with internal pathologies Glomerular filtration rate as estimated with Cockcroft formula for our patients was 74.80 13.70 ml/minutes No case had glomerular filtration rate below 60ml/ minutes/1,73m2 skin that requires two kidneys (bigreft) as described in the medical literature Creatinine level in the blood, on average, at the Footer Page 26 of 161 4.2 SELECTION PREPARATION OF RECIPIENTS AND PREOPERATIVE In a period from 5/2010- 12/2010, we had patients who had kidney transplantation immediately at night For these patients, not all the tests were conducted as a kidney transplant recipient from wellprepared living donors Due to new application, the crossmatching usually takes to hours and there were three transplant candidates with HLA nonmatching, transplant candidate having different blood type (donor blood type was O but recipient blood type was A) Afterwards, number of brain death patients underwent the organs harvesting operations more often In 2010, there were three patients; patients in 2011; patients in 2012, and patients in 2013 We started to build a waiting list of chronic renal failure patients whose preoperative evaluation was similar to the kidney transplantation from living donors By enrolling in the patient list from deceased donors, the transplant candidates must undergo all the tests to determine compatibility of the transplanted organ between the donor and the recipient (compatibility of blood type ABO, HLA matching, crossmatchin negative, pre-sensitivity) In case of HLD nonmatching, the blood type matching is compulsory However, those patients were still in waiting list of operation and prepared like an emergency operation Depending on typical features of each speciality, different diagnosis methods shall be applied but final selection of kidney transplant recipients should be decided and notified as soon as possible, the best within the first hours so that all have enough time to prepare 4.3 APPLY THE PROCESS OF KIDNEY HARVESTING, STORING FROM DECEASED DONORS 4.3.1 Application of multiple-organ harvesting, storing process: In conditions of well preparation (heart, liver, kidney) for the recipient, we applied the multiple-organ harvesting model in sequence by removing heart at first, and then removing liver and finally removing the kidney In the event no patient need heart transplantation, we gave priority to the recipients of other organs (mostly the liver and Header Page 27 of 161 21 22 the kidney) At such time, we did not rip the chest but implanted a cleansing path and discharged the fluid while the heart was still beating, which did not prolong process of organ cleansing fluid inside the body but ensured good functions of harvested organs For good quality of donation organ(s), cutting and cleansing the organ are not as good as insitu perfusion with the organ still lying in the body The insitu perfusion began when the liver failure patient had his liver removed successfully To harvest the kidney easily, we performed in two types by either removing the whole kidney and placing it outside the body (4 patients at 20%) or cut each single kidney (16 patients at 80%) Removing kidney took 15 minutes on average As Lechaux stated, when many surgerical teams join in the organ harvesting process on the same patient, anatomical boundary are more difficult to fix In a short time, they may get difficulty to determine the extent of artery, vein for the liver removing team, which part belongs to task of the pancreas team or the kidney team Therefore, we gave priority to dissect the renal artery and vein by threading to make it available to avoid any possible trauma on renal vessel system because the renal vein shall be flattened, white, not beating that make it difficult to find when arterial perfusion ends 4.3.2 Applications of renal transplantation techniques: the same as normal rule of kidney transplant The kidney of the recipients shall be transplanted into the right pelvis Vena connecting mouths are grafted end-side to the external iliac vein Transplanted renal artery is end-side grafted to the external pelvic artery of the recipient The left kidney is reversed front and behind of the kidney while the kidney is reversed upper and lower positions to ensure the vena connecting mouths not to be short, tense and oblique to the pelvic vein; the connecting mouths of renal artery - pelvic artery were not folded; axis of the kidney was in parallel with the big vessel, upper renal polar is not above and adjacent to the pelvic artery and the pelvic vein It is of the urinary surgical team's own experience from the transplantation The ureter is implanted into the bladder by the Lich - Grộgoir method with JJ catheter There is no intra- and post-operative complication 4.4.1 Results of multiple-organ harvesting process , kidney preservation After cleanse, the kidney was measured in three directions in 30 transplanted kidneys with their average length: 11.31.3cm, width 5.7 1.25cm , thickness 4.3 0.74cm For the deceased donors, the harvested kidney was evaluated via ultrasonography that made it impossible to evaluate functions of each kidney The renal functions are, in general, evaluated on the basis of creatinine level in the blood, urine amount in the last hours the bigger kidney was chosen for the patient of high body mass index based on the measured dimensions from the kidney cleansing Therefore, such selection is just relative and subject to practical experiences of the transplant team Duration of cold blood shortage: The patient group in this study has low duration of cold blood shortage in comparison with study results in the centres over the world Duration of cold blood shortage average is 136.589.80 minutes; the shortest for 73 minutes and the longest for 200 minutes The main cause comes from insitu kidney harvesting and transplanting without carriage to other hospital 4.4 EVALUATE THE AFORESAID PROCESSES Footer Page 27 of 161 Renal biosy to evaluate the renal functions: In this study, biosy was performed on 7/38 removed kidneys Biosy results showed no cell necrosis Kidney harvesting results to the standard show good results at 97.37%, average at 2.63% 100% tests of kidney cleansing liquid show no red blood cell No removed kidney was not transplanted Intraoperative accidents of organ harvesting were solved on the organ cleansing table, and thus created no influence on the transplantation process 4.4.2 Results of kidney transplant After brain death, the heart usually suspends for 48 hours without cardiac aid 25% potential donor cannot donate their organs because their dynamic blood becomes bad in spite of extreme treatment Many organs cannot be used due to high-dose administration of tetrahydrozoline to maintain the blood flow pressure Transplant candidates from brain dead donor has significant slow rate of transplanted renal functions, which is the primary difference between the kidney transplant from brain dead donor and from living donors Header Page 28 of 161 23 24 In most of cases, the transplanted kidneys recover well after operating activity and the renal functions survive for a long term pursuant to the observation results The urine volume is 7.74.45 liters for the first 24 hours of transplantation, 5.4 3.4 liters for the first three days and 3.8 1.62 liters after a week The creatinine level in the blood, before discharge from hospital, is 143.3 85.03 àmol/l, a bit higher but permissible In the first year, The creatinine level in the blood is 120.825.61 àmol/l on average, meaningfully decreased Furthermore, rejection treatment is still a main target with administration of Methylprednisolon 500mg three days after operation and Simulect based on the therapy Right from the first days, the patients were administered with prograf and MMF together with antiinfection antigen and stomach ulcer medication They were specially monitored and nurtured under the vena tract In this study, complications and fatality are still high Reading some medical literature of the world, this issue is not rare In Asian countries, the study lot with similar quantity manifest the same rate of complications and fatality Long-term monitoring following transplantation aims at regular assessment on blood flow of transplanted kidney through Doppler ultrasonography on renal vessels and creatinine level in the blood Any change in the renal functions on basis of creatinine level and Doppler ultrasonography may help to diagnose any rejection or renal failure early from any surgical causes (arterial thrombosis, angiosclerosis, urine leakage, ureteric stricture, fluid inflammation from the outside) Assistant tests should be conducted by each specific indication Up to now, by long-term monitoring, the patients in the studt group have not ever showed any complications to the functions caused by the internal pathology For long-monitored hepatitis C, enzyme virus levels are stable without recurring the pervious diseases Results from this study reflect a reality of applying the multipleorgan harvesting process in Vietnam - German Hospital, our efforts to obtain the source of organ that, otherwise, is really difficult in respect to the donation and waiting list Recommendation: For better results, it is necessary to enhance the dissemination and encourage the brain death patients, especially to raise efficiency of organ coordination so as not to waste any possible source of organ Footer Page 28 of 161 CONCLUSION Research and application of process of harvesting, storing and transplanting a kidney from deceased donors - Perform the multiple-organ harvesting process with combination of surgical teams in charge of cardiovascular, liver, kidney and then cleanse the kidney before transplantation for 14 recipients, without delay Model of liver - kidney harvesting: cases From 20 donors, 48 kidneys were harvested to transplant for 38 ERSD patients The renal artery was grafted to the external iliac artery The ureter was inserted into the bladder by Lich- Grộgoir method 100% - Kidney harvesting show good results at 97.37% All the removed kidneys have good functions to be transplanted 100% tests of kidney cleansing liquid show no red blood cell No removed kidney was not transplanted Intraoperative accidents of organ harvesting were solved on the organ cleansing table, and thus created no influence on the transplantation process Evaluate the results of kidney transplantation - All possible cases are renal recovery of renal function over the Header Page 29 of 161 25 - - long-term monitoring well The amount of urine in the first 24 hours of 4:45 7.7 liters Serum creatinine before discharge 143.3 85.03 mol / l increase in light level allows In the first year average serum creatinine : 120.8 25.61 mol Renal functions: kidney dysfunction (3 patients) by acute rejection 35/38 kidney transplant : 92.10% patients, months following transplantation, got ureteric stricture in need of inserting the JJ catheter (1 patient), cutting the narrow section and then reinserting the ureter-bladder (1 patien) patient returns to hemodialysis caused by tuberculosis year following transplantation Time for monitoring lasts for months at minimum and 43 months at maximum The creatinine level in the blood, after months was: 115.5825.06 àmol/l, 122.833.1 àmol/l after year Renal functions are good after three years of transplantation: 89.48% Footer Page 29 of 161 ... 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