CAMAGÜEY- Since 1978, 580 transplants have been performed in the territory's nephrology service. “We have transplants who have been like this for more than 20 years, but if you ask me, the graft has a survival period of 15 years because when it is lost they go back to dialysis. Right now in this treatment we have 180 patients, here the machines do not stop, never, there are no waiting lists or quotas, they work as long as there is a person who needs it ”.
This is how Dr. Leonardo Curbelo Rodríguez, a second degree specialist in Nephrology with more than 20 years of work, presents the work of the Nephrology Center, attached to the Manuel Ascunce Domenech hospital service.
“In 1978 there were only 13 hospital beds and 8 artificial kidneys. Today we have a unit where we can provide various forms of care.
"In the nephrological clinic, patients with kidney diseases of different types and stages are admitted for study, we also receive some with chronic kidney diseases secondary to high blood pressure, diabetic nephropathy - the first cause of chronic kidney diseases in Cuba--, and with glomerular diseases. In addition, kidney infections with complications in the functions and some systemic ones that affect the kidney, among the most frequent, systemic lupus erythematosus.
“Patients attend the ambulatory hemodialysis area daily, each three times a week, with specialized doctors and nurses on each shift. During the four hours that the treatment usually lasts, the Cubataxi service awaits them, which previously brought them. Almost 100 patients are seen daily in the five work shifts.
“The transplant room has all the exceptional isolation cleanliness conditions that the transplant recipient, who is in fact an immunosuppressed patient, needs. There they spend the immediate postoperative period unaccompanied for the first 72 hours, only with a nurse who changes every 24 hours, a period in which they are administered the highest dose of immunosuppressants to avoid rejection. After the first few days, they are left with a companion as it must be at least a month until they regain kidney function ”.
A procedure that is carried out in this room is the kidney biopsy that allows a histological study to be carried out to know precisely the cause of the kidney disease.
“It is done only when there are doubts as to what the cause is or when there is a glomerular disease. We focus on treatment, therapeutics and being able to explain the patient's future prognosis to the family. Transplant patients are also performed when the recovery of kidney function is delayed ”.
Another form of treatment for these conditions is ambulatory peritoneal dialysis. “Instead of hemodialysis, catheter dialysis is performed in the peritoneal cavity. The advantage is that the patient can be at home, it allows them not to go to the hospital constantly. Here the patients learn to do the changes and intraperitoneal fluid exchange every 4 hours or 6 hours; a good method as long as the sepsis and antisepsis measures are maintained. The supplies for this treatment are imported and are given free of charge to each patient every month ”.
THANKS FOR LIFE
The longest-term solution with less wear and tear for the patient and financial expense is kidney transplantation. In Argentina this operation costs 125,000, in Mexico 200,000, in the United States you have to wait almost five years, in which the treatment reaches 350,000, and the proceeding costs 150,000.
The 580 cases attended in Camagüey have only “paid” with “thanks”.
“We work according to a national program with three categories of care: the kidney program where all the cases suitable for the operation are, dialysis for dialysis or permanent dialysis, with which they remain in this treatment, and anticipated transplantation.
“The latter allows us to remove from dialysis those patients who already have a filtration below 30 milliliters before they go into dialysis. It is the global trend, to try not to resort to dialysis because that way the patient arrives in better conditions to the operation than the one who has already been in hemodialysis ”.
A team of anesthetists and surgeons, with several generations at work, are in charge of carrying out these acts in the same room created for the purposes at the Center. “I was trained with the best, with those who have been doing it for many years,” commented Dr. Ramón Estopiñán Cánovas. To recover a kidney, to extract it and make the graft, we have gone to Morón, wherever it is, at any time. I have done it for six years, I consider it one of the most rewarding surgeries ”.
The global trend is an increase in cases of chronic kidney disease. Not only in Cuba, artificial kidneys are not enough, that is why it is a priority of the program to encourage the practice of transplantation especially in the early and living donor variants.
“To date, only four have been with a living donor, says Dr. Curbelo. We did the first to Carlos Peón Casas. His son gave him the kidney in 2017. Historically, cadaveric donation abounds more but right now we are facing a complex situation: given medical advances, fewer and fewer cases of brain death are decreed, especially in young people. Therefore, the cases that arrive are older than 50 who suffered a cerebrovascular accident and the comorbidities can affect the state of the kidney and the life span of the graft.
“In addition, cadaveric donation has a time limit for organ viability, 24 hours at the most, and the entire system must be deployed to preserve the kidney and prepare the recipient. There will always be hours of ischemia because when you take it out, infuse it, put it in a bag and place it, what is called cold ischemia occurs, which can increase the delay time in which kidney function is achieved ”.
-Is that why you insist on the related donation?
- Living donor transplantation shows many advantages. First, greater compatibility is achieved in the antigens by being a family, you can prepare both, donor and recipient, do the two programmed operations without time pressure and simultaneously, so the ischemia time is minimal and many times they leave the room with renal function, so it does not need dialysis support in the immediate postoperative period.
“A very important figure in the process is the psychologist because many times, even if you want to, you cannot donate, either because you are not compatible or because of comorbidities. We have the case of two twins, one resident in Anesthesiology and the other, my patient, a specialist in Pathology; the mother wanted to give the kidney but due to the hypertension she could not, that depressed her greatly. We are going to continue with the living donor procedure because her sister will do it, she shares all the antigens with her, the histocompatibility is perfect and we will do an early transplant.
“In this type of donation, the donor, who has to be a close relative or a spouse of many years, should not have any complications for his life. You cannot sacrifice the health of one person for the benefit of another. To carry out the process, a whole study is carried out, the situation of the other kidney is evaluated and after an analysis of the informed consent that is made with a lawyer, the surgical act is carried out ”.
An essential part of the treatment of chronic kidney diseases are immunosuppressants. “Before and after transplantation, a balance must be achieved so as not to put them at risk of infection or rejection. Here we use them from the first world like neoral cyclosporine, very expensive, at first we only had steroids and azathioprine.
“Many drugs that are already produced in Cuba are used in the activity, such as azathioprine, prednisone, polyclonal drugs and methylprednisolone. Everything before and after is guaranteed free of charge, as it is the expendable material for hemodialysis and peritonial dialysis ”.
“In this case there are 13 patients, says Dr. Jenny Rodríguez Lino, they are given the boxes with the bags for the exchange that only lasts 30 minutes. In hemodialysis, the filters in some patients can be recovered about three times but it is not always feasible. These are procedures that if charged would be above 700 pesos each time, that is why transplantation is intended as a more profitable long-term method ”.
THE “PAYMENT” OF PATIENTS
Willian Soca Estrada has spent “a whole life in the infirmary, 36 years, and of them two in the service and one in transplantation, the most beautiful part because they leave with a better quality of life. The important thing here is to be well prepared ”.
This idea is reinforced by the nurse Luisa Biggs Arbolay, “there are good days and bad days, but you must always be well prepared to take on the challenges. Here we are also very jealous with the protocols, our patients cannot be infected with anything, we must keep the area clean and free from outside personnel ”.
Yan Carlos Moreno Ce was 14 years old on June 19, 2018 when he received his kidney. “At two years he was diagnosed with resistant nephrotic syndrome, at five with chronic renal failure and at 10 years he was on hemodialysis, says his sister Anisleydis Estrada Ce. We all took the tests and were not compatible, the transplant was from a donor corpse".
Yan Carlos lives in Vertientes and we could only communicate by WhatsApp. He has large, very black eyes and thick eyebrows that stand out in the middle of his face that is revealed behind the nasobuco. “He finished the ninth grade and could not continue studying because the schools are too far away and he had a severe hearing loss due to infections that he suffered at the time of hemodialysis. He is very cheerful and sociable, he plays a lot and helps around the house. He has follow-up every three months, the care now and before, throughout the treatment and the two months of postoperative admission, has always been wonderful ”.
Children are a priority in the program. Up to now, five have been carried out in pediatric ages. "The first was in 2016, now we have a compatibility pending," says Dr. Leonardo.
"Look, says Eraase Acosta López vehemently, admitted for an infection due to his polycystic kidney disease, from my heart I tell you, the doctors and nurses are very concerned. They are attentive all the time and they are very affectionate towards us, we do not lack anything essential in the service, including all medications ”.
In addition to the Nephrology Center and its hemodialysis service, another two operate in the province in Florida and Nuevitas, as well as one in Ciego de Ávila and another in Morón due to the regionalized care assumed by the unit.
The lights don't go out here, when the first shift comes in, at 6:00 a.m. The last ones almost go out, their maxim is to win days to life in what appears the compatible kidney, in what they investigate causes and consequences, in what they do "miraculous operations" to insert catheters in the vena cava because there is venous compromise…
"Anywhere in the world, only the consultation costs more than 400 pesos and the treatment is cold, says 70-year-old lawyer Rogelio Vega Conde at the exit. Here they accompany you, they talk and they are attentive for the duration of the hemodialysis, they are a team for assistance, everyone runs if you feel bad and they become family. The same happens with the drivers who bring us and wait for us — we were witnesses of the latter, as three raised their hands to greet him.
“Mija, inside there is a banner with the prices of all the treatments and services we receive, it should be visible to anyone who enters. In 20 years I have not had to pay anything, and you cannot imagine with the simplicity and dedication that everyone does their work. What else can we do than thank them for such dedication! Talk about it journalist, write it down, here they fight for life until the end ”.
Translated by Linet Acuña Quilez