Dancing from the kidney
Irina Krasnopolskaya, Rossiyskaya Gazeta, 02/14/2008
Photo: Sergey Kuksin
On the eve of the meeting in the editorial office, the head of the organ transplantation department of the Russian Scientific Center of Surgery named after Academician B.V. Petrovsky corresponding member of the Russian Academy of Medical Sciences Sergey Gauthier performed the 265th liver transplant operation. While this material was being prepared for printing, it became obvious: everything was successful. The recipient boy and his donor aunt feel fine, the rehabilitation process goes without complications.
No instructions, no transferRossiyskaya Gazeta: Sergey Vladimirovich, it is clear that every operation is a ride into the unknown.
No one is guaranteed against failures, involuntary mistakes. And yet, why is there such a difference in numbers in our country and in the USA? Why does the whole world often have to raise funds to send a child for an organ transplant abroad?
Sergey Gauthier: You asked a very painful question. It is impossible to answer it unequivocally. I will talk about what is closest to me, about the transplantation of donor liver to children. Of course, any person is free to choose a place for treatment, a specialist whom he trusts. However, if he has money for this, it's a lot of money. In Russia, liver transplantation is estimated at about 806 thousand rubles, that is, 32 thousand dollars. And its real price is 100 thousand euros.
RG: How do you get out of the situation?
Gauthier: It's difficult. Our patient pays nothing for the transplant. This is an absolutely budgetary procedure. Thank God, we managed to achieve this. I have never seen money collected for an adult patient. Only for children. Is there a need to send children for liver transplantation abroad? If it is possible to carry out a related transplant, then definitely not! We do everything ourselves.
Our department was a pioneer of liver transplantation. We have the greatest experience in Russia, good – seventeen–year-old - long-term results. Many patients have crossed the ten-year mark.
We started the related transplantation in 1997. Your newspaper wrote about that first operation. Then they transplanted a fragment of the liver from the mother to her three-year-old daughter. Eleven years have passed. Both are alive. Everything is fine. Previously, we took children for such operations after three years, when they gained more than ten kilograms of weight. Now we take all those in need, even those who weigh no more than four kilograms. We take care of them, they recover.
But if there is no related donor, then we try to arrange for the child to be sent abroad – for cadaveric transplantation. The fact is that we do not have instructions for the diagnosis of brain death in children. Without the same in Russia, the removal of an organ from a deceased child is impossible, and, therefore, it is impossible to carry out cadaveric transplantation of the heart or liver to children. That's the whole problem.
The adoption of such an instruction has long been exaggerated. But no more than that. Of course, from the point of view of kidney and liver transplantation, this is not a very important matter. Although, of course, it should be. After all, often a child does not have the possibility of related donation, for example, sick relatives, incompatibility by blood type and other circumstances. Sometimes there are no relatives at all. Nevertheless, the patient has the right to help. And then, of course, cadaver donation is needed. And if we are talking about heart transplantation, then there is no way to do without cadaveric donation. There can be no related heart transplantation.
Let's do without dopeRG: If the instructions on cadaver donation are adopted tomorrow, will the situation change?
Gauthier: Not right away. I would not say that the law on transplantation adopted in 1992 works well. This requires an appropriate concept of the social necessity of the development of transplantology. Society needs to realize that organ transplantation is not a bad thing, but a good thing. That it saves lives. Only on this basis will the instructions work. Well, imagine the parents whose child died. They, of course, will assume that the baby was poorly treated. That he was not treated specifically to take his organs away from him. This is a natural reaction. Here we are socially, mentally lagging behind developed countries.
RG: And in principle children's organs can be used? Can a child become, for example, a kidney donor?
Gautier: Cadaveric heart, intestines, liver can be used. And the kidneys – which is so often reported in the media – are not. Our center is the only place where babies are transplanted kidneys. But only adults! Children's kidneys are unable to take over normal functions. Therefore, all the talk about stealing a child in order to take a kidney from him is complete nonsense.
RG: Public opinion to this day, to put it mildly, is not favorable to transplantology. Every now and then there are "horror stories" about organ trafficking and so on...
Gauthier: To our clinic, to the Research Institute of Transplantology, to other transplant centers, they often call and offer to buy an organ. There are a lot of ads on the Internet: "I'm looking for a donor for a kidney transplant." Or: "I'll sell a kidney." I know that in some cases it is possible to sell a kidney. I can assume that they also offer a fragment of the liver. This is used by people who need money. There is information, for example, that there is a flow of such applicants from Moldova. People come to Turkey, they have a kidney removed, they are paid some money for it. Not so much, by the way, how big. There is no underground organ trading market in Russia.
In my opinion, the 1992 law on transplantation is quite adequate, puts all the dots over the "I". He is especially adapted to our society, to our mentality. It clearly states that organ trafficking is prohibited, that only his relative can be a living donor for any patient. And a genetically proven adult relative. It is from these two positions that we proceed when we talk about transplantation in general.
I understand that in exceptional cases unrelated donation can be allowed. After all, there are not only relatives who love their relatives and want to save them. But there are also not relatives, but close people who are ready to give their organ for the sake of saving a person who is dear to them. Quite a few of them come to our clinic. We have to refuse. For such a stage of development of living donation, our society must grow.
Grow up to donationRG: When?
Gauthier: When will it grow up? Don't know. We do not consider a person as a collection of different "meat products" that can be used for transplantation. If a person wants to earn money, then, probably, it can be done in a different way. Without risking your health. We are very careful about live donation, we select donors very precisely, excluding possible risks for him. I don't even mean surgical things, but unexpected, for example, a collapse of the ceiling, a power outage. We had no complications, there was not a single death of a donor.
RG: It's a shame that in the field of transplantology we are so far behind the West. After all, it was in Russia that the great Vladimir Demikhov was the first in the world to perform an organ transplant... And he died in a one-room "Khrushchev" in complete oblivion...
Gauthier: This is the lot of many great ones, especially those who are ahead of their time. So, Demikhov was the first, but clinical transplantation did not begin here, but in the USA, where a kidney was transplanted from twin to twin for the first time in Boston. Boris Vasilyevich Petrovsky performed the first kidney transplant in our country on April 15, 1965. Ten years later than the Americans.
RG: What does clinical transplantation mean?
Gauthier: Boris Vasilyevich said this: transplantation – "it's not otsobachil and prisobachil." It is necessary that the transplanted organ works. And this requires certain diagnostics, antibiotics, nutrition, and the art of nursing. This is a whole complex. This is a special medical discipline.
RG: Is she taught anywhere?
Gauthier: The only department of transplantology is at the Medical and Dental University of Moscow, which was headed by Academician Valery Ivanovich Shumakov. Valery Ivanovich, whom we buried in January, has done an invaluable lot for the development of transplantology. It was he who performed the first successful heart transplant in our country in 1987.
He was awarded many titles, awards, regalia. But despite all this, his path was not strewn with roses. The so-called case of transplant doctors, which lasted more than two years, accelerated his passing away. The persecution of transplantology, superimposed on its ten–year initial delay, led to the fact that in the same USA there are 200 transplant centers that transplant the liver, and in Russia they are carried out only in our center, in the Shumakov Center, in the Sklifosovsky Research Institute and in the village of Pesochny in St. Petersburg.
RG: One department for the whole of Russia. And where to study? Where, for example, did you study?
Gauthier: If we talk about liver transplantation, then in 1990 we started literally from scratch. Moreover, despite everything: there was no state support, there was no funding. There was no public opinion support, which is very important. There were no people who could provide, if you like, the infrastructure of this operation. We studied and taught ourselves. At first we read books. Then we went to Spain, then to the USA...
Passport for kidneyRG: Usually, when they talk, they write about the so-called black transplantologists, they are talking about kidneys.
Gauthier: This is understandable. Taking a kidney is the least traumatic operation. It can be carried out quickly, the donor recovers quickly.
RG: Catch a homeless man in the alley, take his kidney from him...
GAUTHIER: Where? In the alley? Who would do that? Such arguments about the acquisition of donor organs do not stand up to any criticism. The donor organ must meet certain criteria. The donor himself must undergo a special examination. His organ should be evaluated. Any donor kidney received from a deceased person has a passport. The kidney enters a medical institution where it will be used for transplantation, with a passport containing all the data about it. There is no way without it. Without this, the transplant loses its meaning.
RG: There is an opinion that donors eventually become disabled.
GAUTHIER: No. Our credo: a very thorough examination of a potential donor. Exclusion of all possible risk factors. Often, for example, people come to us with obesity. For them, any surgical intervention – appendicitis, gastric resection, especially liver resection – is a risk. They have a tendency to various complications, in particular to thromboembolism. We are conducting a special course of treatment. It sometimes takes months. Until we get the rehabilitation of the body so much that, say, a woman weighing 90 kilograms, for the sake of saving her child, loses 25-30 kilograms, becomes suitable for performing an organ transplant operation. But he loses weight under the strictest supervision of specialists.
Or, for example, a man who gained excess weight under the influence of addiction to alcohol. He has peptic ulcer disease, he has gastric erosion. And he first needs to be cured, fully rehabilitated, otherwise he cannot become a donor. We remove all risk factors and only after that we take some organ.
127 hearts of ShumakovRG: And if you take an organ from a corpse?
How do cadaveric organs come to you?
Gauthier: There is a Moscow City organ donation center. There is a team of specialists who leave to examine a dying patient. A potential donor must be treated. A person dies from injury, a lot of blood loss. So in order for the organs to be used for transplantation later, this blood loss must be replenished, normal conditions for the organs must be created. For this, there must be a very qualified rehabilitation service. Yes, brain death has already been confirmed, it is no longer possible to save a person, but it is necessary to save his organs. Otherwise, they are not suitable for transplantation.
RG: How is brain death diagnosed?
Gauthier: There is a certain set of tests that allow us to say that this brain has died. In particular, there is absolutely irrefutable objective evidence when there is no blood circulation in the brain. It just doesn't exist. This is stated by the computer. Only after that, this corpse with a beating heart is considered a potential donor. And then the question is decided – whether to take organs from him or not. Concomitant diseases, the condition of a particular organ are taken into account. Why did Valery Ivanovich Shumakov transplant 127 hearts instead of 500? Yes, because not every heart fits. Why did we transplant 32 cadaveric livers, although we performed 256 transplants? Yes, because not every liver is suitable. And not only the fact of the transplant is needed. It is necessary for a person to live after that.
RG: Is the consent of relatives to the removal of cadaveric organs mandatory?
Gauthier: Our law speaks about the presumption of consent. That is, special consent of relatives is not required. So, if brain death is detected, then you can not ask your relatives about anything. Which, in my opinion, is controversial. But everything depends on the degree of preparedness of society, on its mentality.
Here in the USA, the consent of relatives is mandatory. But there is about 70 percent confidence that there will be such an agreement. The society is prepared. Ukraine recently adopted an amendment to the law on transplantation, introduced the presumption of informed consent. That is, they ask for the consent of relatives. And ... the transplantation in Ukraine has ended – no one gives consent. Transplantology is an extremely delicate matter. We have an ethics committee in the clinic that keeps the situation under its control.
RG: If the committee says no?
Gauthier: So, no. However, this has never happened, because our specialists are fully aware of the measure of responsibility.
"Don't take organs to heaven"RG: When they talk about organ transplantation, as a rule, they refer to Spain, to the fact that even religious representatives there urge not to take their organs to heaven after death, since they are needed on Earth to save lives...
Gauthier: I myself witnessed how the state propaganda of transplantology was conducted in Spain. On all television channels, they told and showed publicly how organ transplantation was going, there were live reports from the operating rooms. On the streets of Madrid, those who wished could donate blood to transfuse it to a donor or recipient. A transplant mentality was created, if you will. And the result is known: Spain is one of the world leaders in organ transplantation. We are talking about transplantation – only with a minus sign. We do not notice that people with transplanted organs live and feel normal.
The pig is our friendRG: What organs are being transplanted in the world now?
Gauthier: Kidney, liver, pancreas, heart, lungs, intestines.
RG: But they recently transplanted a face.
Gauthier: Such attempts are being made. Are they justified? The face, hands are muscles, it's bone, it's skin, fiber, all sorts of tendons. I read that a patient with a transplanted face is now getting senile skin. Should I transplant my arm? Only as a last resort if both hands are missing. And so... It requires such a powerful suppression of the rejection reaction, such suppression of immunity that the most severe complications, up to cancer, can develop. A person becomes completely unprotected against infections. Need it? Very doubtful.
RG: And organ transplantation from animals?
Gauthier: Such attempts are being made all over the world. They are also made in the center, which was headed by Valery Ivanovich. The closest donor to a human was a pig. Valery Ivanovich also worked on the creation of artificial organs. In the future, it will probably be possible to use cloning... International experience shows that, for example, the frequency of transplants of the same kidney from related donors over the past ten years has equaled cadaveric transplantation.
Liver by blatRG: You've done a lot of transplants.
You track the fate of your patients. Have you noticed that with a transplanted organ, some character traits are transmitted, human behavior changes?
Gauthier: Character traits are not transmitted. But the behavior becomes somewhat different – more careful in relation to his own person. Almost all of our patients acquire the habit of washing their hands when they come from the street, take care of themselves from street infection. There is a habit of not sucking your fingers, not grabbing sour cream in your mouth, standing on the windowsill, washing more often, being less in crowded classrooms.
RG: Is the life span of patients after transplantation different in Russia and abroad or approximately the same?
Gauthier: The average term is the same. But do not forget, different factors affect the life span. Including the fact that in our country life expectancy leaves much to be desired... Now the whole world is struggling to create more reliable immunosuppressants with the least number of side effects.
RG: Is there a queue for a transfer? Is the waiting list full? Is it possible to move someone in it and pass without waiting in line?
Gauthier: There is a queue. I think we can't do without it. Now we are doing 60 liver transplants a year. The queue is small. But even if they did a hundred, there would still be a queue. We do not know exactly how many people there would be in it, because there are not always opportunities to identify those who need a transplant on the ground.
The same applies to kidney transplantation. There are still few dialysis centers in the country that support the lives of people suffering from kidney failure. And people just don't live up to the transplant. And about the blat? Sorry! If we are talking about a related transplant, then this is out of the question at all. And if a person is waiting for a cadaveric organ, then permutations are possible in the waiting list – they are caused by the fact that at the moment an organ has been received that fits one and cannot fit another. It's not the queue numbers that are in force here, but expediency. Just like that!
RG: Some of those present at this table have been to your clinic. At different times of the day. The impression is that you just live there...
Gauthier: Such a job. Otherwise it is impossible. The operations themselves take a long time. Preparation for them, nursing – everything is difficult. Therefore, we cannot boast of the number of people who want to work in transplantology.
RG: And material incentives?
Gauthier: Do you mean the payment of our labor? Nurses receive about 12 thousand rubles, a doctor – 15. I myself – about 40-45 thousand rubles. Eleven times less than my colleagues in the USA.
Why pull a tiger's mustacheRG: Are you, Sergey Vladimirovich, a superstitious person?
Gauthier: To some extent. I had such a case once. One of the first liver transplants to a young child was coming. I stop by, and then I went to the "Zaporozhets", to Abrikosovsky Lane, where our clinic is. And I see how this very alley is decorously crossed by a fat black cat who lived at our dining room. Being a man devoid of any superstitions, I went... That child died. The operation went perfectly, but something happened in the postoperative period, someone missed something. It hurt so much! So insulting!
In short, I never cross the path of a black cat. Never! I'm waiting for someone to overtake me. Recently we are going home with my wife Olga. Too late. And – a black cat. In front of me is a jeep, it stops. And I stop in parallel with him. We – two Jeeps – are standing. We are looking. Someone else is coming from behind, starting to honk in bewilderment. I'm standing closer to the center, they're driving around us. And we started moving together. That's all my superstitions. But this is ironclad. And why pull a tiger's mustache?..
Portal "Eternal youth" www.vechnayamolodost.ru14.02.2008