amakuru

Guhindura ibihaha nubuvuzi bwemewe bwo kuvura indwara yibihaha. Mu myaka mike ishize, guhinduranya ibihaha byateye intambwe ishimishije mugusuzuma no gusuzuma abahawe transplant, guhitamo, kubungabunga no gutanga ibihaha by'abaterankunga, tekinike yo kubaga, gucunga nyuma yo kubagwa, gucunga ibibazo, no gukingira indwara.

Mu myaka irenga 60, guhinduranya ibihaha byavuye mu buvuzi bw'igerageza bugera ku buvuzi bwemewe bwo kuvura indwara y'ibihaha ishobora guhitana ubuzima. Nubwo ibibazo bikunze kugaragara nko gukora nabi kwa graft primaire, imikorere mibi yibihaha idakira (CLAD), kongera ibyago byo kwandura amahirwe, kanseri, nibibazo byubuzima budakira bijyanye na immunosuppression, harasezeranijwe kuzamura ubuzima bwumurwayi nubuzima bwiza binyuze muguhitamo uwakiriye neza. Mu gihe ibihaha bigenda byiyongera ku isi hose, umubare w’ibikorwa nturajyana n’ibisabwa kwiyongera. Iri suzuma ryibanda ku miterere iriho hamwe n’iterambere rya vuba mu guhinduranya ibihaha, ndetse n’amahirwe azaza yo gushyira mu bikorwa neza ubu buvuzi butoroshye ariko bushobora guhindura ubuzima.

Isuzuma no gutoranya abashobora kuzakira
Kuberako ibihaha byabaterankunga bibereye ari bike, ibigo byatewe birasabwa muburyo bwo kugenera abaterankunga abashobora kuba bashobora kubona inyungu zatewe no guhindurwa. Ibisobanuro gakondo kubantu bashobora guhabwa ni uko bafite ibyago birenga 50% byo guhitanwa nindwara yibihaha mugihe cyimyaka 2 kandi amahirwe arenga 80% yo kubaho nyuma yimyaka 5 nyuma yo guterwa, ukeka ko ibihaha byatewe bikora neza. Ibimenyetso bikunze kugaragara mu guhinduranya ibihaha ni fibrosis yo mu bihaha, indwara zidakira zifata ibihaha, indwara zifata imitsi, na fibrosis ya cystic. Abarwayi boherezwa hashingiwe ku kugabanuka kw'imikorere y'ibihaha, kugabanuka kw'imikorere y'umubiri, no gutera imbere kw'indwara nubwo hakoreshwa cyane imiti n'ubuvuzi bwo kubaga; Ibindi bipimo byihariye byindwara nabyo birasuzumwa. Inzitizi ziteganijwe zishyigikira ingamba zo koherezwa hakiri kare zitanga inama nziza-zunguka ibyago kugirango tunoze ibyemezo bisangiwe hamwe nuburyo bwo guhindura inzitizi zishobora guterwa no guterwa neza. Itsinda rinyuranye rizasuzuma ko hakenewe guhindurwa ibihaha ndetse n’umurwayi ashobora guhura n’ingaruka nyuma yo kwimurwa bitewe no gukoresha immunosuppressant, nk’ibyago byo kwandura ubuzima. Kwipimisha imikorere idasanzwe yumubiri, gukora neza kumubiri, ubuzima bwo mumutwe, ubudahangarwa bwa sisitemu na kanseri nibyingenzi. Isuzuma ryihariye ryimitsi yumutima nubwonko, imikorere yimpyiko, ubuzima bwamagufwa, imikorere ya esophageal, ubushobozi bwa psychosocial hamwe ninkunga yabantu nibyingenzi, mugihe hafashwe ingamba zo gukomeza gukorera mu mucyo kugirango hirindwe ubusumbane muguhitamo ibikwiye guterwa.

Impamvu nyinshi zishobora guteza ingaruka mbi kuruta ibintu bimwe bishobora guteza ingaruka. Inzitizi gakondo zibangamira guhindurwa zirimo gusaza, umubyibuho ukabije, amateka ya kanseri, indwara zikomeye, n'indwara zifatika, ariko izi ngingo ziherutse gukemurwa. Imyaka yabayahawe iragenda yiyongera gahoro gahoro, kandi muri 2021, 34% byabakira muri Amerika bazaba barengeje imyaka 65, byerekana ko hibandwa cyane kumyaka yibinyabuzima mugihe cyigihe. Noneho, usibye intera yiminota itandatu yo kugenda, hakunze kubaho isuzumabumenyi ryintege nke, ryibanda kubigega byumubiri hamwe nibisubizo byateganijwe kubibazo. Ubugizi bwa nabi bujyanye ningaruka mbi nyuma yo guhindurwa ibihaha, kandi ubusanzwe intege nke zifitanye isano numubiri. Uburyo bwo kubara umubyibuho ukabije hamwe nibigize umubiri bikomeje kugenda bihinduka, byibanda cyane kuri BMI nibindi byinshi kubyibinure hamwe nimitsi. Ibikoresho byizeza kugereranya guhungabana, oligomyose, no kwihangana birategurwa kugirango hamenyekane neza ubushobozi bwo gukira nyuma yo guterwa ibihaha. Hamwe no gusubiza mu buzima busanzwe ibihaha, birashoboka guhindura imiterere yumubiri no gucika intege, bityo bikazamura umusaruro.

Ku bijyanye n'indwara zikomeye, kumenya urugero rwo gucika intege n'ubushobozi bwo gukira biragoye cyane. Guhindurwa mu barwayi bahabwa imashini ya mashini byari bisanzwe, ariko ubu biragenda biba byinshi. Byongeye kandi, ikoreshwa ryubuzima bwa extraacorporeal nkubuvuzi bwinzibacyuho mbere yo kwimurwa bwiyongereye mumyaka yashize. Iterambere mu ikoranabuhanga no kugera ku mitsi byatumye bishoboka ko abarwayi batoranijwe, bitonze bitonze bafite ubuzima bw’inyongera kugira uruhare mu buryo bwo kubyemererwa ndetse no gusubiza mu buzima busanzwe, kandi bakagera ku musaruro nyuma yo guterwa nk’abarwayi badakeneye ubufasha bw’ubuzima budasanzwe mbere yo guterwa.
Indwara ya sisitemu isanzwe yabonwaga ko ari ukurwanya burundu, ariko ingaruka zayo ku musaruro nyuma yo kwimurwa zigomba gusuzumwa. Bitewe n’uko immunosuppression ijyanye no guhindurwa byongera amahirwe yo kongera kanseri, amabwiriza yambere yerekeranye na malariya mbi yabanje gushimangira icyifuzo cy’uko abarwayi batagira kanseri mu myaka itanu mbere yo gushyirwa ku rutonde rw’abategereje guhindurwa. Nyamara, uko kuvura kanseri bigenda neza, ubu birasabwa gusuzuma niba kanseri ishobora kongera kubaho ku barwayi. Indwara ya autoimmune sisitemu isanzwe ifatwa nkaho yanduye, igitekerezo kikaba ikibazo kuko indwara yibihaha yateye imbere ikunda kugabanya igihe cyo kubaho kwaba barwayi. Amabwiriza mashya arasaba ko guhindurwa ibihaha bigomba kubanzirizwa no gusuzuma no kuvura indwara hagamijwe kugabanya indwara zishobora kugira ingaruka mbi ku musaruro, nk'ibibazo bya Esophageal bijyana na scleroderma.
Gukwirakwiza antibodiyite zirwanya ibyiciro byihariye bya HLA birashobora gutuma bamwe mubashobora guhabwa allergique kubice byabaterankunga runaka, bikavamo igihe kinini cyo gutegereza, kugabanya amahirwe yo guterwa, kwangwa ningingo zikomeye, hamwe n’ibyago bya CLAD. Nyamara, guhinduranya bimwe hagati ya antibodi zabakandida nubwoko bwabaterankunga byageze ku musaruro usa nuburyo bwo gutangira desensisisation mbere yo gutangira, harimo guhinduranya plasma, immunoglobuline yinjira mu mitsi, hamwe no kuvura anti-B.

Guhitamo no gushyira mu bikorwa ibihaha by'abaterankunga
Gutanga urugingo nigikorwa cyo kwinezeza. Kubona uruhushya rwabaterankunga no kubahiriza ubwigenge bwabo nibintu byingenzi byingenzi. Ibihaha by'abaterankunga birashobora kwangizwa no guhahamuka mu gatuza, CPR, kwifuza, embolisme, gukomeretsa cyangwa guhumeka biterwa na virusi, cyangwa ibikomere bya neurogene, bityo ibihaha byinshi by'abaterankunga ntibikwiriye guhindurwa. ISHLT (Sosiyete mpuzamahanga ishinzwe umutima no guhaha ibihaha)
Guhindura ibihaha bisobanura ibipimo byemewe by’abaterankunga, bitandukana bivuye mu kigo cyimurwa n’ibindi bimera. Mubyukuri, abaterankunga bake cyane bujuje ibisabwa "byiza" byo gutanga ibihaha (Ishusho 2). Kongera imikoreshereze y'ibihaha by'abaterankunga byagezweho binyuze mu koroshya ibipimo by'abaterankunga (ni ukuvuga abaterankunga batujuje ubuziranenge busanzwe), gusuzuma neza, kwita ku baterankunga, no mu isuzuma rya vitro (Ishusho 2). Amateka yo kunywa itabi cyane n’umuterankunga ni ibintu bishobora gutera ingaruka mbi z’ibanze mu bahabwa, ariko ibyago byo gupfa biturutse ku gukoresha izo ngingo ni bike kandi bigomba gupimwa n’ingaruka ziterwa n’impfu ziterwa no gutegereza igihe kirekire ibihaha by’abaterankunga batigeze banywa itabi. Gukoresha ibihaha biturutse ku baterankunga bakuze (barengeje imyaka 70) batoranijwe ku buryo bukomeye kandi nta zindi mpamvu zishobora gutera ingaruka zishobora kugera ku bakiriye ubuzima bwabo ndetse n’ibikorwa by’ibihaha nk’abaterankunga bato.

Kwita ku baterankunga benshi no gutekereza ku mpano zishobora gutangwa ni ngombwa kugira ngo ibihaha by’abaterankunga bigire amahirwe menshi yo guhindurwa. Mugihe bike mubihaha byatanzwe byujuje ibisobanuro gakondo byibihaha byiza byabaterankunga, kuruhura ibipimo birenze ibi bipimo gakondo bishobora gutuma ikoreshwa neza ryingingo zitabangamiye ibisubizo. Uburyo busanzwe bwo kubungabunga ibihaha bifasha kurinda ubusugire bwurugingo mbere yuko rushyirwa mubakira. Inzego zirashobora kujyanwa mubikorwa byo guhindurwa mubihe bitandukanye, nko kubika kristostatike cyangwa gutunganya imashini kuri hypothermia cyangwa ubushyuhe bwumubiri busanzwe. Ibihaha bidafatwa nkibikwiye guhindurwa byihuse birashobora gusuzumwa neza kandi birashobora kuvurwa hamwe na vitamine yo mu bihaha (EVLP) cyangwa bikabikwa igihe kirekire kugira ngo bikemure inzitizi zishyirwaho mu gutera. Ubwoko bwo guhinduranya ibihaha, uburyo, hamwe nubufasha bwa intraoperative byose biterwa nibyo umurwayi akeneye hamwe nubunararibonye bwa muganga. Kubantu bashobora guhabwa ibihaha indwara zabo zangirika cyane mugihe bagitegereje ko bahindurwa, ubufasha bwubuzima budasanzwe bushobora gufatwa nkubuvuzi bwinzibacyuho mbere yo guhindurwa. Ingorane zambere nyuma yo kubagwa zishobora kuba zirimo kuva amaraso, kubuza inzira zo guhumeka cyangwa anastomose y'amaraso, no kwandura ibikomere. Kwangiza imitsi ya frenic cyangwa vagus mu gituza birashobora gutera izindi ngorane, bikagira ingaruka kumikorere ya diafragma no gusiba gastric. Ibihaha by'abaterankunga birashobora gukomeretsa hakiri kare ibihaha nyuma yo guterwa no kwisubiraho, ni ukuvuga imikorere mibi y'ibanze. Nibyiza gushyira mubyiciro no kuvura ubukana bwimikorere mibi yambere, ifitanye isano nimpanuka nyinshi zo gupfa hakiri kare. Kuberako abaterankunga bashobora kwangirika kw ibihaha bibaho mugihe cyamasaha make ubwonko bwakomeretse ubwonko, gucunga ibihaha bigomba gushyiramo Igenamiterere ryiza, kwaguka kwa alveolar, bronchoscopy hamwe nicyifuzo hamwe na lavage (kumico y'icyitegererezo), gucunga amazi y'abarwayi, no guhindura imyanya yigituza. ଏବ PiCCO yerekana umutima wumutima wa pulse index waveform.
Mu bihugu bimwe na bimwe, ikoreshwa ry’ibihaha by’abaterankunga (DCD) ryazamutse kugera kuri 30-40% ku barwayi bapfa umutima, kandi ibipimo nk'ibyo byo kwangwa ingingo zikomeye, CLAD, no kubaho. Ubusanzwe, ingingo zituruka ku baterankunga banduye virusi zanduye zigomba kwirindwa kugira ngo zihindurwe ku batanduye; Mu myaka yashize ariko, imiti igabanya ubukana bwa virusi itera virusi ya hepatite C (HCV) yatumye ibihaha by’abaterankunga baterwa na HCV byatewe neza mu babakira nabi. Mu buryo nk'ubwo, virusi itera virusi itera SIDA (VIH) ibihaha by'abaterankunga barashobora kwanduzwa mu banduye virusi itera SIDA, naho virusi ya hepatite B (HBV) ibihaha by'abaterankunga irashobora kwimurirwa mu bahawe inkingo zatewe na HBV n'abafite ubudahangarwa. Habayeho amakuru yo guterwa ibihaha kubaterankunga bakora cyangwa mbere ya SARS-CoV-2. Dukeneye ibimenyetso byinshi kugirango tumenye umutekano wo kwanduza ibihaha abaterankunga na virusi zanduza zo guhindurwa.
Bitewe no kubona ingingo nyinshi, biragoye gusuzuma ubwiza bwibihaha byabaterankunga. Gukoresha sisitemu ya vitro y'ibihaha yo kwisuzumisha itanga isuzuma rirambuye kumikorere y'ibihaha y'abaterankunga hamwe n'ubushobozi bwo kuyisana mbere yo kuyikoresha (Ishusho 2). Kubera ko ibihaha by'abaterankunga bishobora kwibasirwa cyane no gukomeretsa, muri sisitemu yo mu bwoko bwa vitro ibihaha itanga urubuga rwo kuyobora imiti yihariye y’ibinyabuzima kugira ngo isane ibihaha by’abaterankunga byangiritse (Ishusho 2). Ibigeragezo bibiri byateganijwe byerekanye ko muri vitro ubushyuhe busanzwe bwumubiri ibihaha byuzuye ibihaha byabaterankunga byujuje ibisabwa bisanzwe bifite umutekano kandi ko itsinda ryatewe rishobora kongera igihe cyo kubungabunga muri ubu buryo. Kubungabunga ibihaha by'abaterankunga kuri hypothermia yo hejuru (6 kugeza 10 ° C) aho kuba 0 kugeza kuri 4 ° C ku rubura byavuzwe ko bizamura ubuzima bwa mitochondial, kugabanya ibyangiritse, no kunoza imikorere y'ibihaha. Kumunsi wo gutoranya igice cyo gutoranya, igihe kirekire cyo kubungabunga ijoro byavuzwe ko bigera ku musaruro mwiza nyuma yo guterwa. Ikigeragezo kinini cyumutekano kitari munsi ugereranije no kubungabunga kuri 10 ° C hamwe no kubungabunga kode isanzwe (nomero NCT05898776 kuri ClinicalTrials.gov). Abantu bagenda batezimbere gukira kwingingo mugihe binyuze mubigo byita ku baterankunga benshi no kunoza imikorere yingingo binyuze mubigo bisana urugingo, kugirango ingingo zujuje ubuziranenge zishobore gukoreshwa muguhindura. Ingaruka zizo mpinduka muri ecosystem ya transplant ziracyasuzumwa.
Kugirango ubungabunge ingingo za DCD zishobora kugenzurwa, gutwika kwubushyuhe bwumubiri busanzwe muburyo bwa ogisijeni ya extraacorporeal membrane (ECMO) birashobora gukoreshwa mugusuzuma imikorere yingingo zo munda no gushyigikira uburyo butaziguye no kubungabunga ingingo za thoracic, harimo nibihaha. Inararibonye hamwe no guhinduranya ibihaha nyuma yo gutwikwa kwaho ubushyuhe busanzwe bwumubiri mu gituza no munda ni bike kandi ibisubizo bivanze. Hari impungenge z'uko ubu buryo bushobora kwangiza abaterankunga bapfuye kandi bukarenga ku mahame remezo y’imyitwarire yo gusarura ingingo; Kubwibyo, parufe yaho mubushyuhe busanzwe bwumubiri ntibiremewe mubihugu byinshi.

Kanseri
Umubare wa kanseri mu baturage nyuma yo guhindurwa ibihaha ni mwinshi ugereranije no mu baturage muri rusange, kandi ibimenyesha bikunze kuba bibi, bingana na 17% by'impfu. Kanseri y'ibihaha n'indwara ya lymphoproliferative nyuma yo guhindurwa (PTLD) ni byo bitera impfu ziterwa na kanseri. Ubudahangarwa bw'igihe kirekire, ingaruka ziterwa no kunywa itabi mbere, cyangwa ibyago byo kwandura indwara y'ibihaha byose bitera ibyago byo kurwara kanseri y'ibihaha mu gihaha kimwe cy'uwahawe ibihaha, ariko mu bihe bidasanzwe, kanseri y'ibihaha yanduza abaterankunga ishobora no kugaragara mu bihaha byatewe. Kanseri y'uruhu itari melanoma ni kanseri ikunze kugaragara mu bahabwa transplant, bityo rero gukurikirana kanseri y'uruhu buri gihe ni ngombwa. B-selile PTLD iterwa na virusi ya Epstein-Barr nimpamvu ikomeye itera indwara nurupfu. Nubwo PTLD ishobora gukemura hamwe na immunosuppression nkeya, B-selile igamije kuvura hamwe na rituximab, chimiotherapie sisitemu, cyangwa byombi birakenewe.
Kurokoka nibisubizo birebire
Kurokoka nyuma yo guhindurwa ibihaha bikomeza kuba bike ugereranije no guhinduranya izindi ngingo, hamwe n’umuhuza wimyaka 6.7, kandi nta terambere ryigeze rigerwaho mubisubizo by’igihe kirekire by’abarwayi mu myaka mirongo itatu. Nyamara, abarwayi benshi bagize iterambere ryinshi mubuzima, ubuzima bwumubiri, nibindi byavuzwe nabarwayi; Kugirango hakorwe isuzuma ryimbitse ku ngaruka zo kuvura ziterwa no guhindurwa ibihaha, ni ngombwa kwita cyane ku bisubizo byatangajwe n'aba barwayi. Ikintu cyingenzi kidakenewe mu mavuriro ni ugukemura urupfu rwabakiriye biturutse ku ngaruka zica ziterwa no gutinda kwangirika cyangwa gukingirwa igihe kirekire. Ku bahabwa ibihaha, hakwiye kwitabwaho igihe kirekire, bisaba gukorera hamwe kugirango barinde ubuzima rusange bwuwo bahabwa mugukurikirana no gukomeza imikorere yimikorere kuruhande rumwe, kugabanya ingaruka mbi ziterwa na immunosuppression no gushyigikira ubuzima bwumubiri nubwenge kurundi ruhande (Ishusho 1).
Icyerekezo cy'ejo hazaza
Guhindura ibihaha nubuvuzi bugeze kure mugihe gito, ariko butaragera kubushobozi bwabwo bwose. Ibura ry'ibihaha bikwiye abaterankunga bikomeje kuba ingorabahizi, kandi uburyo bushya bwo gusuzuma no kwita ku baterankunga, kuvura no gusana ibihaha by'abaterankunga, no kunoza uburyo bwo kubungabunga abaterankunga biracyategurwa. Birakenewe kunoza politiki yo kugabura ibice tunoza guhuza abaterankunga nabahawe kugirango turusheho kongera inyungu. Hariho ubushake bwo gusuzuma kwangwa cyangwa kwandura binyuze mu gusuzuma indwara ya molekuline, cyane cyane hamwe na ADN ikomoka ku baterankunga ku buntu, cyangwa mu kuyobora kugabanya ubudahangarwa bw'umubiri; Nubwo bimeze bityo ariko, akamaro k’ibi bisuzumwa nkumugereka wuburyo bugezweho bwo kugenzura ibihingwa ngandurarugo biracyamenyekana.
Umwanya wo guhinduranya ibihaha wateye imbere binyuze mu gushiraho consortiums (urugero, ClinicalTrials.gov kwiyandikisha nomero NCT04787822; ALAD na CLAD uburyo. Kugabanya ingaruka mbi no kugabanya ingaruka za ALAD na CLAD binyuze mubuvuzi bwihariye bwa immunosuppressive, ndetse no gusobanura ibyavuye mu barwayi no kubishyira mu ngamba zavuyemo, bizaba urufunguzo rwo kunoza intsinzi ndende yo gutera ibihaha.