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Transplantation: indications, preparation, technique of transplantation
Last reviewed: 04.07.2025

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Clinical transplantology is a complex of medical knowledge and skills that allow the use of transplantation as a method of treating various diseases that are not amenable to traditional treatment methods.
Main areas of work in the field of clinical transplantology:
- identification and selection of potential recipients of donor organs;
- performing the appropriate surgical intervention;
- conducting adequate immunosuppressive treatment to maximize the survival of the transplant and recipient.
Clinical transplantology is developing on the basis of the most modern methods of diagnostics, surgery, anesthesiology and resuscitation, immunology, pharmacology, etc. In turn, the practical needs of clinical transplantology stimulate the development of the indicated areas of medical science.
The development of clinical transplantology was facilitated by the experimental work of the Russian scientist V.P. Demikhov in the 40-60s of the last century. He laid the foundations for surgical methods of transplanting various organs, but the clinical development of his ideas took place abroad.
The first successfully transplanted organ was a kidney (Murray J., Boston, USA, 1954). It was a related transplant: the donor was an identical twin of the recipient, who suffered from chronic renal failure. In 1963, T. Starzl in Denver (USA) initiated clinical liver transplantation, but real success was achieved only in 1967. In the same year, H. Barryard in Cape Town (South Africa) performed the first successful heart transplant. The first transplantation of a cadaveric pancreas to a human was performed in 1966 by W. Kelly and R. Lillehey at the University Clinic of Minnesota (USA). A segment of the pancreas and a kidney were implanted in a patient with diabetes mellitus with chronic renal failure. As a result, almost complete rehabilitation of the patient was achieved for the first time - refusal of insulin and dialysis. The pancreas is the second solid organ after the kidney that has been successfully transplanted from a living related donor. A similar operation was also performed at the University of Minnesota in 1979. The first successful lung transplant was performed by J. Hardy in 1963 at a clinic in Mississippi (USA), and in 1981 B. Reitz (Stanford, USA) achieved success by transplanting a heart-lung complex.
The year 1980 is considered the beginning of the "cyclosporine" era in the history of transplantology, when, following the experiments of R. Calne in Cambridge (Great Britain), a fundamentally new immunosuppressant, cyclosporine, was introduced into clinical practice. The use of this drug significantly improved the results of organ transplantation and made it possible to achieve long-term survival of recipients with functioning transplants.
The late 1980s and early 1990s were marked by the emergence and development of a new direction in clinical transplantology - transplantation of liver fragments from living donors (Raya S, Brazil, 1988; Strong R.V., Australia, 1989; Brolsh H., USA, 1989).
In our country, the first successful kidney transplant was performed by Academician B.V. Petrovsky on April 15, 1965. This transplant from a living related donor (from mother to son) marked the beginning of the development of clinical transplantology in domestic medicine. In 1987, Academician V.I. Shumakov performed the first successful heart transplant, and in 1990, a group of specialists from the Russian Scientific Center of Surgery of the Russian Academy of Medical Sciences (RSCS RAMS) led by Professor A.K. Eramishantsev performed the first orthotopic liver transplant in Russia. In 2004, the first successful pancreas transplant was performed (using its distal fragment from a living related donor), and in 2006 - a small intestine. Since 1997, the RSCS RAMS has been performing related liver transplants (SV Gauthier).
Purpose of transplantation
Medical practice and numerous studies by domestic authors indicate the presence of a large number of patients suffering from incurable liver, kidney, heart, lung, and intestinal diseases, in which the commonly used treatment methods only temporarily stabilize the patients' condition. In addition to the humanitarian significance of transplantation as a radical form of assistance that allows preserving life and restoring health, its socio-economic effectiveness is also obvious compared to long-term, expensive, and futile conservative and palliative surgical treatment. As a result of using transplantation, society is returned to its full-fledged members with preserved ability to work, the ability to create a family, and have children.
Indications for transplantation
World experience in transplantation shows that the results of the intervention largely depend on the correctness of the assessment of indications, contraindications and the choice of the optimal time for the operation in a specific potential recipient. The course of the disease requires analysis from the point of view of the life prognosis both in the absence and after transplantation, taking into account the need for lifelong drug immunosuppression. Ineffectiveness of therapeutic or surgical treatment methods is the main criterion in the selection of potential recipients of donor organs.
When determining the optimal time for transplantation in children, the child's age is of great importance. The observed improvement in the results of organ transplantation with increasing age and body weight is not a reason for delay, for example, with liver transplantation in biliary atresia or acute liver failure. On the other hand, a relatively stable condition of the child, for example, with cholestatic liver lesions (biliary hypoplasia, Caroli disease, Byler's disease, etc.), chronic renal failure with effective peritoneal or hemodialysis allows postponing the operation until the child achieves a more stable condition against the background of conservative treatment. At the same time, the period for which the transplantation is postponed should not be unreasonably long, so that the delay in the physical and intellectual development of the child does not become irreversible.
Thus, the following principles and criteria for the selection of potential recipients for organ transplantation are postulated:
- Indications for transplantation:
- irreversibly progressive organ damage, manifested by one or more life-threatening syndromes;
- ineffectiveness of conservative therapy and surgical treatment methods.
- No absolute contraindications.
- Favorable life prognosis after transplantation (depending on the nosological form of the disease).
Indications for transplantation are very specific for each specific organ and are determined by the spectrum of nosological forms. At the same time, contraindications are quite universal and should be taken into account when selecting and preparing recipients for transplantation of any organ.
Preparing for transplantation
Preoperative preparation is carried out with the aim of possible improvement of the health condition of the potential recipient and elimination of factors that can negatively affect the course of the operation and the postoperative period. Thus, we can talk about two components of preoperative treatment of potential recipients of donor organs:
- treatment aimed at eliminating or minimizing relative contraindications to transplantation;
- treatment aimed at maintaining the patient's life while awaiting transplantation and optimizing his physical condition at the time of the operation.
Waiting list - a document for registering patients who need a transplant of a particular organ. It contains passport data, diagnosis, date of its establishment, severity of the disease, presence of complications, as well as data necessary for selecting a donor organ - blood type, anthropometric parameters, HLA typing results, level of pre-existing antibodies, etc. The data is constantly updated due to the inclusion of new patients in the list, changes in their status, etc.
The patient is not put on the waiting list for a donor organ if there are any foci of infection outside the organ to be replaced, as they may cause serious complications against the background of immunosuppressive therapy in the post-transplant period. In accordance with the nature of the infectious process, its treatment is carried out, the effectiveness is monitored by serial bacteriological and virological studies.
Drug immunosuppression, traditionally carried out to minimize autoimmune manifestations of chronic diseases of the liver, kidneys, heart, lungs and providing for the administration of large doses of corticosteroids, creates favorable conditions for the development of various infectious processes and the existence of pathogenic flora, which can be activated after transplantation. As a result, corticosteroid therapy is canceled during preoperative preparation, after which all foci of bacterial, viral and/or fungal infection are sanitized.
During examination of patients, especially children, nutritional status disorders of varying severity are revealed, the correction of which with high-calorie mixtures containing a large amount of protein is difficult in patients with liver and kidney diseases. For this reason, it is advisable to use nutritional preparations consisting mainly of amino acids with branched chains, keto analogues of essential amino acids and vegetable protein, with replenishment of the deficiency of fat-soluble vitamins and minerals. Patients with intestinal insufficiency syndrome awaiting small intestine transplantation should undergo complete parenteral nutrition.
An important component of preoperative care of a potential recipient is psychological preparation.
An integrated assessment of the patient's status indicators allows us to determine the prognosis of the disease and assign the patient to one or another group according to the degree of urgency of transplantation:
- Patients requiring continuous intensive care require emergency surgery.
- Patients requiring inpatient medical support usually need surgery within a few weeks.
- Patients in stable condition may wait several months for transplantation, with periodic hospitalization to prevent progression of chronic disease complications.
Donor organs for transplantation
Related transplantation became possible due to the presence of paired organs (kidneys, lungs) and special anatomical and physiological properties of some unpaired solid human organs (liver, pancreas, small intestine), as well as due to the steady improvement of surgical and parasurgical technologies.
At the same time, the relationships within the triangle “patient-living donor-doctor” are built not only on generally accepted deontological positions, when the prerogative is completely given to the patient, but with the informed and voluntary decision-making of the donor.
Features of surgical intervention during transplantation
The ideological basis of the operation on a living donor is the combination of minimizing donor risk and obtaining a high-quality transplant. These interventions have a number of distinctive features that do not allow them to be classified as general surgical manipulations:
- the operation is performed on a healthy person;
- complications pose a threat to the life and health of two people at once - the donor and the recipient;
- mobilization of an organ or separation of its fragment is carried out under conditions of continuous blood circulation of the given organ.
The main tasks of surgical technique and anesthetic care in living donors:
- minimizing surgical trauma;
- minimizing blood loss;
- exclusion of ischemic organ damage during surgical procedures;
- reduction of thermal ischemia time during transplantation.
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Perfusion and preservation of fragmented graft
Regardless of the type of the transplant obtained, immediately after its removal from the donor's body, the transplant is placed in a tray with sterile ice, where after cannulation of the afferent vessel, perfusion with a preservative solution is started at a temperature of +40 °C. Currently, in the practice of related transplantation, the preservative solution "Custodiol" is most often used. The criterion for sufficiency of perfusion is the flow of pure (without blood admixture) preservative solution from the mouth of the transplant vein. Then the transplant is placed in a preservative solution at a temperature of +40 °C, where it is stored until implantation.
Operating characteristics
Transplantation may be complicated by the consequences of previous operations on abdominal or thoracic organs, so the decision to include such patients among potential recipients is made depending on the individual experience of the transplant surgeon.
Contraindications to transplantation
Contraindications to transplantation are understood to mean the presence of any diseases or conditions in the patient that pose an immediate threat to life and not only cannot be eliminated by transplantation, but can also be aggravated as a result of its implementation or subsequent immunosuppressive therapy, leading to a fatal outcome. There is a certain group of conditions in which transplantation, even if there are indications, seems obviously meaningless or harmful from the point of view of the life prognosis for a particular patient.
Contraindications to organ transplantation are divided into absolute and relative. The following are considered absolute contraindications:
- uncorrectable dysfunctions of vital organs, including the central nervous system;
- an infectious process outside the organ to be replaced, such as the presence of tuberculosis, AIDS, or any other incurable systemic or local infections;
- oncological diseases outside the organ to be replaced;
- the presence of developmental defects associated with the underlying disease, which cannot be corrected and are incompatible with longevity.
In the process of accumulating experience in clinical transplantology, methods of preparing recipients and maintaining their vital functions while waiting for surgery have been improved. Accordingly, some contraindications previously considered absolute have become relative contraindications, i.e. conditions that increase the risk of intervention or complicate its technical implementation, but in case of success do not worsen the favorable prognosis after surgery.
Improvement of surgical and anesthetic techniques has allowed optimizing the conditions for transplantation even in the neonatal period. For example, early age of the child has been excluded from the list of contraindications. The boundaries of the maximum age of a potential recipient are gradually being pushed back, since contraindications are determined not so much by it as by concomitant diseases and the possibility of preventing complications.
In the process of preparing a patient for transplantation of a particular organ, successful correction of the status is possible with minimization and even elimination of a number of relative contraindications (infections, diabetes mellitus, etc.).
Rejection reaction and immunosuppressive treatment
When entering the recipient's body, the transplant becomes the cause and object of an immunological response. The reaction to the donor organ includes a whole complex of sequential cellular and molecular processes, which together determine the clinical picture of rejection syndrome. The main components of its occurrence are considered to be pre-existing donor-specific HLA antibodies and "recognition" by the immune system of genetically foreign HLA antigens. According to the mechanism of action on the tissues of the donor organ, rejection with a predominance of antibody activity (humoral, hyperacute rejection) and acute cellular rejection are distinguished. It should be taken into account that both mechanisms can be involved in the development of this reaction. In the late stages after transplantation, chronic rejection of the donor organ may develop, which is based mainly on immune complex mechanisms.
The choice of immunosuppressive treatment protocol depends on many factors: the type of donor organ, blood group match, tissue compatibility, transplant quality, and the initial condition of the recipient. Immunosuppression at different stages of the post-transplant period changes in accordance with the manifestations of the rejection reaction and the general status of the patient.
The use of related transplants significantly simplifies the implementation of drug immunosuppression. This is especially noticeable when the recipient's closest relatives become donors: parents or siblings. In such cases, a match is observed for three or four HLA antigens out of six standardly diagnosed. Despite the fact that the rejection reaction is certainly present, its manifestations are so insignificant that they can be stopped with smaller doses of immunosuppressants. The probability of a rejection crisis of a related transplant is very small and can only be provoked by unauthorized drug withdrawal.
It is well known that organ transplantation involves immunosuppressive treatment for the entire period of functioning of the donor organ in the recipient's body. Compared to other transplantable organs, such as the kidney, pancreas, lung, heart and small intestine, the liver occupies a special position. It is an immunocompetent organ that is tolerant to the recipient's immune response. More than 30 years of transplantation experience have shown that with proper immunosuppression, the average survival time of a liver transplant significantly exceeds that of other transplantable organs. About 70% of liver donor recipients demonstrate a ten-year survival. Long-term interaction of the liver transplant with the recipient's body creates so-called microchimerism, which provides favorable conditions for a gradual reduction in the doses of immunosuppressants up to the discontinuation of corticosteroids, and then, in some patients, to the complete discontinuation of drug immunosuppression, which is more realistic for recipients of related transplants due to the obviously greater initial tissue compatibility.
Methodology and aftercare
Principles of obtaining transplants from brain-dead donors
Donor organs are removed from the body of the deceased during a complex surgical intervention, which involves obtaining the maximum possible number of cadaveric organs suitable for transplantation to patients awaiting transplantation (multi-organ retrieval). The heart, lungs, liver, pancreas, intestines, and kidneys are obtained as part of a multi-organ retrieval. The distribution of donor organs is carried out by the regional organ donation coordination center in accordance with the general waiting list of all transplant centers operating in the region based on individual compatibility indicators (blood group, tissue typing, anthropometric parameters) and information on the imperativeness of the patient's indications for transplantation. The procedure for multi-organ organ retrieval has been developed by global transplant practice. There are various modifications to it that allow for maximum preservation of organ quality. Cold perfusion of organs with a preservative solution is performed directly in the body of the deceased, after which the organs are removed and placed in containers in which they are transported to their destination.
The final preparation of donor organs for implantation is performed directly in the operating room where the recipient is located. The purpose of the preparation is to adapt the anatomical features of the transplant to those of the recipient. Simultaneously with the preparation of the donor organ, the operation is performed on the recipient in accordance with the chosen implantation option. Modern clinical transplantology in transplantation of the heart, liver, lungs, heart-lung complex and small intestine involves the removal of the affected organ with subsequent implantation of the donor organ in its place (orthotopic transplantation). At the same time, the kidney and pancreas are implanted heterotopically, without the obligatory removal of the recipient's own organs.
Obtaining organs or their fragments from living (related) donors
Organs that can be obtained from a living donor without causing harm to his health are a kidney, liver fragments, a distal fragment of the pancreas, a section of the small intestine, and a lobe of the lung.
The indisputable advantage of transplantation from a living donor is independence from the system of supplying cadaveric organs, and, accordingly, the possibility of planning the timing of the operation depending on the condition of the recipient.
The main advantage of a transplant from a living donor is the predictable quality of the organ by selection and, in some cases, preparation of related donors. This is due to the fact that with related donation, negative hemodynamic and drug effects at the perioperative stage are practically excluded for the donor. For example, when using a cadaveric liver, the probability of more severe initial damage to the parenchyma is always greater than with related transplantation. The current level of liver surgery and organ preservation methods allows obtaining a high-quality transplant from a living donor with minimal ischemic and mechanical damage.
Unlike transplantation of an organ obtained posthumously, the use of an organ or organ fragment from a close relative allows one to expect its more favorable immunological adaptation in the recipient's body due to similar HLA characteristics of haplotypes. Ultimately, the results of the world's leading transplant centers indicate better long-term survival of recipients and transplants after related transplantation than after transplantation of cadaveric organs. In particular, the "half-life" of a cadaveric kidney transplant is about 10 years, while for related transplants it exceeds 25 years.
Post-transplant period
The post-transplant period is the life of a recipient with a functioning transplanted organ. Its normal course in an adult recipient implies recovery from the underlying disease, physical and social rehabilitation. In children, the post-transplant period should guarantee additional conditions, such as physical growth, intellectual development and sexual maturation. The severity of the initial condition of potential recipients of donor organs, the trauma and duration of surgery in combination with the need for post-transplant immunosuppressive treatment determine the specifics of managing this contingent of patients. This implies active prevention, diagnosis and elimination of complications, replacement therapy aimed at compensating for previously impaired functions, as well as monitoring the rehabilitation process.
Peculiarities of postoperative management in recipients
The presence of multiple risk factors, such as prolonged extensive surgery, the presence of drains, drug immunosuppression, and prolonged use of central venous catheters, is the basis for massive and prolonged antibiotic prophylaxis. For this purpose, intraoperative intravenous administration of third- or fourth-generation cephalosporin drugs is continued at a dose of 2000-4000 mg/day [in children - 100 mg/kg x day)]. Antibacterial drugs are changed depending on the clinical and laboratory picture and in accordance with the sensitivity of the microflora revealed by bacteriological testing. All patients are prescribed fluconazole at a dose of 100-200 mg/day from the first day after transplantation to prevent fungal infections and ganciclovir at a dose of 5 mg (D kg x day) to prevent cytomegalovirus, herpes and Epstein-Barr infections. The period of fluconazole use corresponds to the period of antibiotic therapy. The prophylactic course of ganciclovir is 2-3 weeks.
Correction of nutritional status with maximally adequate replenishment of energy expenditure and timely compensation of protein metabolism disorders is achieved by balanced parenteral and enteral nutrition. In the first 3-4 days, all recipients receive complete parenteral nutrition [35 kcal/(kg x day)], which is included in the infusion therapy protocol. Replacement therapy is carried out by infusion of fresh frozen plasma in combination with albumin solution.
The need for constant administration of corticosteroids, as well as the tendency to develop erosive and ulcerative lesions of the upper gastrointestinal tract against the background of a stressful situation in the early postoperative period, require the mandatory administration of H2-histamine receptor blockers, antacids and enveloping agents.
Organ transplantation allows to save life and restore health to a large number of patients with serious diseases that cannot be cured by other methods. Clinical transplantology requires from the transplant doctor extensive knowledge not only in surgery, but also in the field of parasurgical specialties, such as intensive care and extracorporeal detoxification, immunology and drug immunosuppression, prevention and treatment of infections.
Further development of clinical transplantology in Russia implies the establishment, organization and uninterrupted functioning of the system of providing organs according to the concept of brain death. The successful solution of this problem depends, first of all, on the level of awareness of the population in the field of real possibilities of organ transplantation and the high humanism of organ donation.