EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Organ transplantation is one of the most successful achievements in modern medicine. For patients with end-stage chronic renal failure, transplantation undeniably improves their quality of life. The purpose of the study was to discuss the latest scientific data on the state of kidney transplantation in the world and to give an idea of the advantages, opportunities, and problems of kidney transplantation in the world and in the Republic of Uzbekistan. Transplantation in Uzbekistan developed in 5 stages. Stage I (1972-1991) began with the first kidney transplant in Uzbekistan on September 14, 1972, on the basis of the legislation on organ and tissue transplantation of 1970. Stage II (1991-1998) represented a break in the field of transplantation due to its prohibition by law. Stage III (1998-2017) comprised a series of 48 kidney transplants from living related donors on the basis of an order of the Ministry of Health of the Republic of Uzbekistan. Stage IV (2017-2022) comprised a series of 849 kidney transplants and 22 liver transplants from living related donors on the basis of Cabinet of Ministers Resolution No. 859 of October 17, 2017. Stage V began on May 11, 2022, with the adoption of the a new of the Republic of Uzbekistan, On Transplantation of Human Organs and Tissues. According to this new law, the objects of transplantation can be human organs and (or) tissues taken from either a living donor or a deceased donor. This law will expand the range of donors for patients in need. Transplantology is a sphere of life activity that can no longer be ignored; therefore, it is necessary to develop and implement humanistic principles on the basis of which it will be regulated.

Key words : Donation problems, End-stage renal failure, Kidney transplantation

Organ transplantation is one of the most successful achievements in modern medicine. For patients with end-stage chronic renal failure, transplantation undeniably improves their quality of life. Thanks to breakthroughs in surgery and anesthesia, organ transplantation has become available worldwide. About 120?000 organ transplants are performed annually; however, the World Health Organization estimates that this number of transplants meets only 10% of the annual transplant needs worldwide. Many problems remain unresolved in this direction and provide fertile ground for research. In light of the progress made in the field of transplantation, this type of renal therapy has become routine, and organ transplant is now defined as the gold standard treatment for patients with chronic renal insufficiency with the best indicators, compared with other methods of replacement therapy.¹ At the present stage, transplantologists are faced with the challenge to achieve a 95% transplant survival rate within 5 years. Presently, the transplant survival rate during the first year has increased significantly, to 93.4% for kidney transplants from deceased donors and 97.2% for transplants from living donors.² The improvement of this indicator is due to the improvement of immunosuppression protocols.^3-6 According to the registry of transplanted patients in Uzbekistan (httpss://trans.nefro.uz/), there are currently 2330 patients who underwent kidney and liver transplantation and 1679 (73%) with a transplanted kidney and twice as many patients (approximately 3300) on renal replacement therapy.⁷

The purpose of our study was to discuss the latest scientific data on the state of kidney transplantation in the world and to provide a perspective on the advantages, opportunities, and problems of kidney transplantation in the world and in the Republic of Uzbekistan.

There are several studies aimed at improving organ availability and survival, including optimization of ex vivo graft perfusion and graft use protocols with expanded criteria, preoperative evaluation of candidates, comparison of graft and recipient, and pretreatment of recipients (using ischemic preconditioning) and donors (using mild hypothermia). To help alleviate the shortage of kidneys for transplantation, the United Network of Organ Sharing has implemented a kidney donor transplant program. This program helps people who have not yet identified a compatible living donor to find suitable a donor and receive a transplant. Similar organizations exist in many countries of the world.

Transplantation in Uzbekistan developed in 5 stages. Stage I (1972-1991) began with the first kidney transplant in Uzbekistan on September 14, 1972, on the basis of the legislation on organ and tissue transplantation of 1970. Stage II (1991-1998) represented a break in the field of transplantation due to its prohibition by law. Stage III (1998-2017) comprised a series of 48 kidney transplants from living related donors on the basis of an order of the Ministry of Health of the Republic of Uzbekistan. Stage IV (2017-2022) comprised a series of 849 kidney transplants and 22 liver transplants from living related donors on the basis of Cabinet of Ministers Resolution No. 859 of October 17, 2017. Stage V began on May 11, 2022, with adoption of a new law of the Republic of Uzbekistan, On Transplantation of Human Organs and Tissues. According to this new law, the objects of transplantation can be human organs and (or) tissues taken from a living donor or a deceased donor. This law will expand the range of donors for patients in need.

According to Global Observatory on Donation and Transplantation, in 2021 there were 144?302 organ transplants performed worldwide, and 92?532 of these were kidney transplants, which is a 14.3% increase compared with the same period in 2020, and 38% of kidney transplants were from a living donor.⁸ The greatest activity is observed in the United States, where 36?323 kidney transplants were performed in 2021, of which 8915 were from living donors with an upward trend compared with the previous year.⁹ According to the register of the Russian Society of Transplantologists, in 2019 there were more than 2400 transplants. It was the most productive year before the COVID-19 pandemic, and there was a motivation to increase the number of transplants by about 200 to anticipate and accommodate development of regions and an increase in the activity of transplant centers. However, in 2020, due to the pandemic, the number of organ transplant operations decreased to 2000. Then, in 2021, Russian doctors performed more than 2300 transplant operations. In 2023 (this year), nearly 1800 organ transplants have been completed so far, and 950 of these were kidney transplants.^10-12

Organ donation creates many opportunities for people with end-stage organ failure. Organ donation is an important medical, economic, social, religious, and political issue. Unfortunately, the number of patients awaiting transplant worldwide exceeds the number of donated organs. About 120?000 organ transplants are performed annually; however, according to the World Health Organization this number is only 10% of the annual need for transplantation worldwide.¹³

Recently, this concept of donation after brain death has been adopted in developed countries, as many lives are saved by organs from donors after brain death.¹⁴

The legal aspects of brain death were first considered and accepted in the United States. For the first time, the legal aspects of brain death were considered and adopted in the United States and other Western countries, and after a long period of time, laws were ratified in some Asian countries.^15,16 In October 2017, after a long delay, surgeons in Uzbekistan were first able to perform kidney transplant procedures only from living related donors. Recent data on deceased organ donation are not available in Uzbekistan, because of the absence of legislation.¹ Resolution of the Cabinet of Ministers of the Republic of Uzbekistan No. 859 of October 23, 2017, approved the Temporary Regulation on the Procedure for Closely Related Kidney and (or) Liver Lobe Transplantation, which adopted the draft law of the Republic of Uzbekistan No. PZ-376, On Transplantation of Organs, Tissues and (or) Human Cells. On the basis of these documents, organ transplantation has resumed in 2 leading medical centers in Uzbekistan.

Special gratitude was expressed by the government and the Ministry of Health of the Republic of Uzbekistan to our Turkish colleagues and personally to Professor Mehmet Haberal, a pioneer in the field of transplantology and the founding rector of the largest and leading medical university in Turkey (Baskent University) for his comprehensive personal assistance and participation in all stages of the implementation of kidney transplant operations at the Republican Research Center for Emergency Medicine (RRCEM). Together with our Turkish colleagues under the leadership of Professor Mehmet Haberal, the first kidney transplant was performed at the RRCEM on April 7, 2018.

The number of patients with chronic kidney disease in Uzbekistan remains high at 12?567 people. There are 3067 patients on hemodialysis, and there are only 48 dialysis centers with 326 hemodialysis machines installed. In 2018, there were 3.7 kidney transplants per million population in Uzbekistan. Thus, the number of patients in need of donor organs is very large. In addition, many of these patients in need of transplant are severely or moderately disabled, and hemodialysis sessions are paid from the state budget. The potential cost of 1 patient undergoing hemodialysis is US $7500 to $15?000 (per year). However, state allocations for hemodialysis procedures (consumables) amount to US $8 million for coverage of hemodialysis procedures (equipment maintenance, purchase of spare parts, and salaries of medical personnel involved in hemodialysis), which is only one-third of the total financial cost.

The main contributory factors for the development of the system to provide patients with donor organs in Uzbekistan are legal and religious aspects. According to the global Religiosity and Atheism Index conducted by WIN-Gallup International in 2012, 79% of Uzbek respondents who took part in the survey consider themselves religious, another 16% consider themselves nonreligious, 2% consider themselves convinced atheists, and 3% chose the option “don’t know/no response.”17 Some factors that affect organ donation are related to the limited information received from society and the limited information received from medical professionals. Religious aspects, fear, and prejudice against organ donation were cited by participants as additional factors that prevent organ donation. Islam is the second-most widespread religion in the world, and the number of Muslim people in Western countries is growing due to recent migration trends. Studies show that Muslim people in Western countries have a more negative attitude toward organ donation and transplantation versus people with other religious beliefs.

A number of obstacles were cited as the reasons for the reluctance of Muslim people to engage in organ donation and transplantation. Among the main factors and problems are the lack of information about organ donation, distrust of the health care system, the opinion of the family, the sanctity of the body, the lack of a clear understanding of religious proscriptions, and the opinions of religious leaders. Studies have shown that cooperative engagement with religious leaders to address these issues can contribute to the formation of a positive attitude toward organ donation and transplantation. Transplant teams, organ donation coordinators, emergency care personnel, and nephrologists should be better informed about religious beliefs so that they may provide guidance to relatives in their decision about organ donation. For relatives to make an informed decision about organ donation, it is necessary to better educate transplant teams, organ donation coordinators, and nephrologists regarding religious beliefs. In addition, wider public awareness of the importance of organ donation to save the lives of others can contribute to a positive perception of this issue by relatives who have lost a loved one.

The results of our 2022 study, described in the report, Selection of Donors for Related Kidney Transplantation (unpublished observations) showed that most related donors for kidney transplant are siblings. Careful selection and detailed collection of anamnestic data showed that nearly 1 of every 4 potential kidney donors had contraindications to donor nephrectomy. Arterial hypertension was the most common reason for the exclusion of potential donors from kidney donation. The identification of contraindications in potential donors at the stage of initial examination can prevent postoperative complications, reduce the risk of kidney transplant loss, and reduce the negative effects of surgery on the donor’s health.

Transplantology is a sphere of life activity that can no longer be ignored; therefore, it is necessary to develop and implement humanistic principles on the basis of which it will be regulated. The release of the law of the Republic of Uzbekistan, On Organ and Tissue Transplantation, requires the creation of programs, funds, and organizations to increase the level of donation in the country.

Volume: 22 Issue: 1 January 2024 - Supplement - 1

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