Surgical aspects of the treatment of patients with the terminal stage of chronic renal failure

The dissertation addresses the surgical aspects of care for patients with end-stage chronic renal failure (ESCRF) in the Republic of Sakha (Yakutia). It covers the formation and long-term maintenance of permanent vascular access for maintenance hemodialysis, including arteriovenous fistulas, tunneled central venous catheters, and synthetic and biological vascular prostheses. The work also examines the methods of evaluation of potential donors (ultrasound, renal scintigraphy, intravenous urography, selective renal angiography, multislice computed tomographic angiography, and immunological assessment), as well as the technique of living-related kidney transplantation. On the basis of an analysis of immediate and long-term outcomes and a comparison of transplantations from living related and deceased donors, the author proposes optimized algorithms for the management of patients with ESCRF and for the selection of donor–recipient pairs.

Relevance of the topic. Modern medicine possesses sufficiently well-developed and effective methods for treating end-stage chronic renal failure (ESCRF). These include peritoneal dialysis, hemodialysis, and kidney transplantation. However, despite the achievements of medicine, the treatment of patients with ESCRF remains one of the most pressing problems of clinical medicine today, due, on the one hand, to the annual growth in the number of patients suffering from this pathology and, on the other hand, to the imperfection of the currently used methods of renal replacement therapy [27, 29, 39, 51, 89, 106, 131].

Adequate hemodialysis care for a patient suffering from ESCRF requires constant attention to the state of the permanent vascular access (PVA), but none of the proposed methods ensures its long-term functioning. This problem currently remains unsolved because of the limited duration of functioning of the arteriovenous fistula (AVF) and the rapid depletion of the vascular resource of patients [54, 55, 60, 68, 85, 114, 118, 166]. There is also no consensus among surgeons regarding the choice of the method for forming a PVA. Some authors recommend the wide use of synthetic vascular prostheses to accelerate the initiation of patients on hemodialysis treatment [57, 93, 101, 125, 136, 137, 171]. Other authors recommend the use of biological prostheses [46, 172]. The third line along which the problem of establishing a PVA is being addressed involves long-term tunneled central venous catheters [71, 84].

Meanwhile, even the most effective regimen of hemodialysis provides only 10 to 12% removal of low-molecular-weight substances relative to the norm achieved by two healthy kidneys, while the removal of high-molecular-weight compounds is even lower [9, 91, 128, 147]. Therefore, at present, the most preferable method of treating patients with end-stage chronic renal failure is kidney transplantation; however, the shortage of donor organs [63, 161], the problems of selecting "ideal" donors [67, 174], and the high financial costs prevent its wider use in clinical practice [1, 45, 53, 111, 124, 130, 143, 144, 151, 152, 153, 154, 156, 157, 160].

All of the above testifies to the relevance of the problem of treating patients with ESCRF, the need for its comprehensive study, and the further improvement of surgical care for this group of patients.

Aim of the work: to improve the results of treatment of patients with end-stage chronic renal failure.

Research objectives. To fulfil the aim of the work, the following tasks are to be solved:

1. to study the detection rate of patients with chronic renal failure among the population of the Republic of Sakha (Yakutia);

2. to carry out a comparative analysis of the results of formation and duration of functioning of permanent vascular access in patients with ESCRF in order to choose the optimal method;

3. to investigate the possibility of expanding the vascular resource in patients with end-stage chronic renal failure undergoing hemodialysis using an autovein;

4. to study the influence of renal vascular anomalies in potential donors on the results of kidney transplantation;

5. to perform an analysis of the long-term results of related kidney transplantation in the Republic of Sakha (Yakutia);

6. based on the results of the studies performed, to optimize the algorithms for the management of patients with end-stage chronic renal failure and the selection of donor–recipient pairs for related kidney transplantation.

Scientific novelty. As a result of the studies conducted, for the first time we have:

• carried out an analysis of the detection rate of chronic renal failure (CRF) in the Republic of Sakha (Yakutia) based on patient attendance records;

• carried out an analysis of the choice of permanent vascular access for maintenance hemodialysis (MHD) in patients with ESCRF;

• studied the influence of renal vascular anomalies in donors on the long-term results of kidney transplantation;

• improved the algorithms for the management of patients with ESCRF.

Statements submitted for defence:

1. A native arteriovenous fistula on the forearm is the method of choice for permanent vascular access in patients with end-stage chronic renal failure, since the duration of its functioning is the longest.

2. The long-term graft survival results after kidney transplantation from a living related donor are higher than after transplantation from a deceased donor.

3. Performing multislice computed tomographic angiography makes it possible to exclude excretory urography and selective renal angiography from the algorithm of potential donor examination, which accelerates the process of examination and preparation for surgery.

Practical significance. The choice of the optimal method of permanent vascular access formation and the prevention of complications will make it possible to carry out dialysis treatment of patients with end-stage chronic renal failure more effectively.

The introduction of related kidney transplantation operations in RS (Ya) has improved the results of treatment of patients with end-stage chronic renal failure and enhanced their quality of life.

I consider it my duty to express my deep gratitude and appreciation to my scientific supervisor, the Head of the Department of Hospital Surgery of the Medical Institute of YaSU, Doctor of Medical Sciences Aleksandr Vasilyevich Tobokhov, for giving me the opportunity to carry out this work and for his invaluable assistance and support in its preparation. I express my gratitude to the staff of the Department of Hospital Surgery of the Medical Institute of YaSU and to the teams of the departments of chronic hemodialysis, urology, and vascular surgery of the State Institution RB No. 1 — NCM RS (Ya), who participated in the development and clinical implementation of methods for the surgical treatment of patients with end-stage chronic renal failure.