Strangers as their own
Organ transplantation is put on stream
Andrey Subbotin, "Search" No. 20-2016
After the inclusion of the Russian Academy of Medical Sciences in the large Academy, the Presidium of the Russian Academy of Sciences increasingly discusses medical topics. So, recently the conversation was about organ transplantation – a modern, high-tech method of treating life-threatening diseases, used when other methods of treatment are already ineffective. The report "Organ transplantation in the XXI century: overcoming barriers" was made by the chief transplantologist of the Ministry of Health of Russia, Director of the Federal Scientific Center for Transplantology and Artificial Organs named after Academician V.I.Shumakov (FNCTIO) Academician Sergey Gauthier.
Transplantology is one of the young clinical disciplines using the latest achievements of medicine, natural and exact sciences. It is also an integral area of scientific research, accumulating and actively using the achievements of immunology, molecular biology and biochemistry, biotechnology, exact sciences (biomechanics, bioengineering, etc.).
An excursion into history
The history of Russian clinical transplantology began on April 16, 1965, when Academician Boris Petrovsky performed the first human kidney transplant. But back in 1946, Vladimir Demikhov successfully transplanted a second heart to a dog for the first time in the world, and soon he was able to completely replace the cardiopulmonary complex, which became a worldwide sensation that was not even noticed in the USSR. A few years later, for the first time in the world, he replaced a dog's heart with a donor one. This proved the possibility of carrying out such an operation on a person.
In 1969, on the initiative of B. Petrovsky, the Institute of Organ and Tissue Transplantation of the Academy of Medical Sciences of the USSR was established. The Institute was entrusted with the following tasks: overcoming immunological incompatibility of organs and tissues, immunological selection of "donor-recipient", development of drug immunosuppression, experimental development and introduction into clinical practice of transplantation of vital organs (kidneys, heart, liver). In 1986, the scientific specialty "Transplantology and artificial organs" appeared, combining biological and medical sciences. In 2009, the Institute was renamed the Federal Scientific Center of Transplantology and Artificial Organs named after Academician V.I.Shumakov.
Today in the world, S. Gauthier noted, more than 50 thousand organ transplants are performed annually. According to him, these operations are an indicator of the development of national health care and scientific and technological progress, an indicator of civil solidarity and public relations.
In Russia, organ transplantation operations are performed in 23 cities, in which more than 40 transplant centers operate. They perform kidney, heart, liver, pancreas and lung transplants. About 1,500 transplants are performed annually in the country, of which 1,000 are kidney operations, the rest are other types of organ transplants. A quarter of all operations are performed at the Shumakov center.
Heart, liver, lungs
According to S. Gauthier, throughout its history, transplantology has been associated with a number of problems: the shortage of donor organs, the need to preserve the viability of the donor organ and overcome the conflict of coexistence of "one's own" and "someone else's". Sergey Vladimirovich spoke in detail about the breakthrough aspects of modern transplantology, which made it possible to change the traditional ideas of "what is possible and what is not."
Since the national need in the Russian Federation for a heart transplant is still being met by less than 10%, the concept of the suitability of a donor heart has been changed. FNCTIO specialists were able to increase the age of the donor (now about 60% are over 40 years old). The concept of forming a waiting list was also changed: contraindications were minimized, options for mechanical support of blood circulation using ECMO devices (invasive extracorporeal method of blood oxygen saturation) were expanded, which allows the patient to survive until transplantation. In 2015, almost half of the patients received ECMO. This led to an increase in the number of patients on the waiting list (6.2 times since 2008), a decrease in mortality (decreased 11 times) and an increase in the number of operations.
– In 2013, our institution was the first in the world in terms of the number of heart transplantation operations. This year we are the second: we performed 103 operations, and the Americans 117, – said the academician. – In 1986-2007, 130 heart transplants were performed with an average hospital mortality of 30%. And in 2008-2015, there were already 483 heart transplants with an average hospital mortality of 8.6%. So with the accumulation of clinical experience and the improvement of treatment methods, the survival rates of patients also improve.
Another breakthrough, according to Sergey Gauthier, was the study of the molecular mechanisms that ensure the functioning of the transplant in the recipient's body – transplantomics. The study of special biomarkers made it possible to predict the scenario of intracellular rejection of the donor organ. The result was the creation of an electronic database of biomarkers, for which four patents were obtained. Organ transplantation technologies have been developed and improved in conditions of tissue incompatibility and from donors who are not compatible by blood type (ABO-incompatible).
According to the chief transplantologist of the Ministry of Health of the Russian Federation, the country's need for liver transplantation is fully satisfied. In 2015, 325 operations were performed in 17 centers of 13 subjects of the Russian Federation. In 192 cases, the liver was transplanted from a posthumous donor, and in 133 – from a living one. Up to 93% of liver transplants to children are performed in FNCTIO.
But lung transplantation started in Russia recently, in September 2014. This new direction is being dealt with today in two institutions: the FNCTIO and the N.V. Sklifosovsky Research Institute of Emergency Medicine.
Challenges and Responses
Sergey Vladimirovich also spoke about technical circulatory support systems. The first domestic artificial left ventricle of the heart (AVK-N) has been created, its serial production has been established. Today it is implanted in Moscow, St. Petersburg, Novosibirsk and Omsk. An axial pump for two-stage heart transplantation in children is being developed. A technique of biventricular bypass of the heart using axial pumps in an experiment is being developed.
Another area of work is the creation of bio–artificial organs: bioactive and biodegradable 3D matrices with regulated physico-chemical and biological properties for the regeneration of soft and bone tissues, bioengineered structures, bio-artificial organ. Today, the FNCTIO is actively working on the creation of an artificial liver (a bioengineered liver design based on a biopolymer heterogeneous hydrogel, allogeneic liver tissue cells and mesenchymal bone marrow stem cells). The institute has obtained an original formula of a preservative solution, which is being "brought to mind" today.
– The main result of our work is that in the future patients can play sports, work, create a family, live a full life. Sick children not only survive, but also grow up and become citizens. This is what we are all working for," Academician Gauthier stressed.
Answering questions from colleagues, Sergey Vladimirovich also touched upon the commercial component of organ transplantation operations.
– Of course, preparing a patient for surgery requires costs, – he said. – Everything is paid from the state budget. There are no commercial transplants in Russia, although they are not prohibited by law. I believe that transplantation, like many other high technologies, should be a state program, as, for example, it happens in France or Italy. We stand on this position, and it is extremely important to us, as ideologists of this approach. In general, the cost of organ transplantation surgery varies from 900,000 to 1,200,000 rubles (heart transplantation is more expensive, kidneys are cheaper). With a normal formulation of the process, this is enough.
The role of mechanical devices for long-term support of blood circulation in heart failure was devoted to the speech of the head of the Center for Coronary Heart Disease of the Novosibirsk Research Institute of Pathology of Blood Circulation. Academician E.N. Meshalkin Alexander Chernyavsky. He spoke about the experience of clinical application of the EXCOR complex and the first Russian axial pump AVK-N.
– Excellent development. Now we practically do not use foreign analogues, – said Alexander Mikhailovich.
Novosibirsk Research Institute of Pathology of Blood Circulation named after Academician E.N.Meshalkin and the Institute of Theoretical and Applied Mechanics named after S.A.Khristianovich SB RAS is currently developing a new type of domestic disk pump for mechanical heart support based on Tesla turbine technology.
And the director of the Institute of Laser and Information Technology Problems of the Russian Academy of Sciences, Academician Vladislav Panchenko, presented biocompatible implants and additive technologies in reconstructive medicine to colleagues, told about 3D printing of hydrogel matrices (work is being carried out jointly with FNCTIO) on the domestic three-dimensional printer IPLIT-02G.
Colleagues asked Sergey Gauthier many more questions, but the most lively discussion was caused by the problem of acceptance of posthumous donation by society.
– I've been answering such questions lately, – said S. Gauthier. – All the talk about the underground organ trade is complete nonsense, yellow nonsense, which should be prosecuted by law.
What do I think about the presumption of consent? This is a normal expression of human will and desire to help another. A person should understand that not only can he die, but he can also serve as a savior of the lives of several people. This is possible only with the unity of professionals-doctors and the entire population for whom we work, sorry for the pathos! This requires an appropriate worldview, conscience and education."
According to Andrey Vasiliev, Director of the M.K.Koltsov Institute of Developmental Biology of the Russian Academy of Sciences, Doctor of Biological Sciences, the whole world is on the threshold of a new transplantology, which should bring deliverance from many barriers. The Government of the Russian Federation is currently considering a new law on organ transplantation, he said, which is likely to lead to changes in this area in our country.
Portal "Eternal youth" http://vechnayamolodost.ru
23.05.2016