Hosť mesiaca APRÍL 2014 MUDr. Ľuboslav Beňa, PhD. | Medicínske právo
              

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Hosť mesiaca APRÍL 2014 MUDr. Ľuboslav Beňa, PhD.


 | 23.4.2014 | komentárov: 495

Je nám potešením, že pozvanie byť hosťom mesiaca APRÍL prijal MUDr. Ľuboslav Beňa, PhD., hlavný transplantačný koordinátor Slovenskej republiky, člen Transplantačnej komisie Ministerstva zdravotníctva SR, člen odborného konzília MZ SR pre transplantácie od geneticky nepríbuzných a vzdialene geneticky príbuzných darcov, primár Transplantačného oddelenia UNLP Košice a krajský odborník pre orgánové transplantácie pre košický a prešovský kraj. V rozhovore sa budeme venovať predovšetkým praktickým otázkam spojeným s vykonávaním transplantácií.

Obrazok

 

MEDIUS: Pán doktor, môžete priblížiť našim čitateľom svoju profesiu a  svoje aktuálne pôsobisko?

Vyštudoval som medicínu a venujem sa vnútornému lekárstvu, nefrológii a predovšetkým transplantačnej medicíne. Vediem Transplantačné oddelenie Univerzitnej nemocnice L. Pasteura v Košiciach a mojou hlavnou úlohou je koordinovať všetky aktivity v oblasti odberov orgánov a orgánových transplantácií v našej nemocnici a v regióne oboch krajov východného Slovenska. V našom centre sa už štvrťstoročie realizujú transplantácie obličiek, ktoré sú odobraté pacientom s diagnostikovanou smrťou mozgu alebo pacientom, ktorí darujú obličku počas života. Prvá skupina darcov (darcovia so stanovenou smrťou mozgu) si vyžaduje prepracovaný systém identifikácie potenciálnych darcov na oddeleniach anestéziológie a intenzívnej medicíny. Program transplantácií obličiek od žijúcich darcov je ďalším významným programom nášho transplantačného centra.

MEDIUS: Čo Vás motivovalo k voľbe transplantológie ako Vašej špecializácie a čo Vás najviac baví na tomto odbore a Vašej práci?

O transplantačnej medicíne sa hovorí ako o jednom zo zázrakov svetovej medicíny. V mojom prípade bolo ešte pred koncom gymnaziálneho štúdia jasné, že budem lekárom. O transplantáciách som toho veľa v tom čase nevedel a počas štúdia medicíny som bol stále silnejšie presvedčený o tom, že raz budem kardiológ. Neviem, či to bola náhoda alebo osud, ale na všetkých kľúčových skúškach z klinických predmetov som mal otázky z nefrológie. Keď som po ukončení lekárskej fakulty nastúpil ako mladý lekár do vtedajšej Fakultnej nemocnice na Triede SNP 1, dostal som ponuku profilovať sa ako koordinátor odberov obličiek na I. internej klinike. Takže popri profilácii v internej medicíne som sa hneď od začiatku mojej praxe dostal do priameho kontaktu s transplantáciami obličiek, manažovaním odberového programu regiónu a podieľal som  sa na starostlivosti o pacientov po transplantácii obličky. Spolu so svojimi kolegami som sa podieľal na vytváraní a zdokonaľovaní celého systému vrátane rôznych  vzdelávacích programov.  Čaro a zároveň sila orgánových transplantácií spočíva z môjho a nielen z môjho pohľadu v tom, že pacientom ponúkajú druhú šancu. V prípade transplantácie napr. srdca a pečene ide o druhú šancu na život a v prípade transplantácie obličky o druhú šancu na život bez závislosti na dialýze. Pacienti sa po úspešnej transplantácii vracajú do normálneho života a ako som to od viacerých z nich počul už veľakrát, oslavujú narodeniny dvakrát v roku.

MEDIUS: Aké charakterové vlastnosti, sú podľa Vášho názoru,  dôležité pre  transplantológa a prečo?

Transplantačná medicína je špičkovou oblasťou medicíny, na východe Slovenska sú orgánové transplantácie realizované iba v Univerzitnej nemocnici L. Pasteura Košice. To najdôležitejšie pre zdarné fungovanie odberového a transplantačného programu je multidisciplinárna tímová práca v každom momente všetkých procesov – od primárnej identifikácie potenciálneho darcu, cez manažment darcu, koordináciu procesu multiorgánového odberu, alokáciu orgánu, prípravu recipienta, ktorej predchádza manažment jeho pobytu na čakacej listine, cez operačný výkon až po moduláciu imunosupresívnej liečby po transplantácii. Na každom vymenovanom kroku sa podieľajú profesionáli, ktorí sú v tom pozitívnom slova zmysle „odsúdení na spoluprácu“. Jedine tak a pochopiteľne pri ich profesionálnom prístupe je možné zabezpečiť  úspech transplantácie.

MEDIUS: Prejdime už k samotnej praxi. Majú, podľa Vás,  Slováci strach z darcovstva? Aké sú  dôvody, ktoré vedú k, povedzme, rezervovanému postoju k darcovstvu orgánov?

Nemyslím si, že by to bol strach a priznám sa, že nie som ani celkom stotožnený s tým, čo spomínate s tým rezervovaným postojom k darovaniu orgánov. V našej krajine platí predpokladaný súhlas s darovaním orgánov po stanovení smrti, čo znamená, že pokiaľ človek počas života jednoznačne nevysloví nesúhlas s darovaním orgánov, predpokladá sa, že súhlasil. V našich registroch je skutočne iba zanedbateľný počet osôb, ktoré tak za života urobili, bežne sa v praxi stretávame skôr s pozitívnym prístupom príbuzných v rozhovoroch a odberoch orgánov. Podľa štatistických prehľadov, ktoré zverejňuje pravidelne Európska komisia zo všetkých oblastí života a hospodárstva z krajín EÚ, sa v oblasti prístupu k darovaniu orgánov Slováci pohybujú v priemere. V reálnom svete však s Európou významne zaostávame v darovaní obličky počas života (podľa našej legislatívy je možné darovať obličku geneticky príbuznej osobe alebo osobe emočne spriaznenej) a významné rezervy máme v prvotnej identifikácii potenciálneho orgánového darcu s kraniocerebrálnym poškodením, ktoré nie je zlúčiteľné so životom.

MEDIUS: Ako prebieha celý proces transplantácie - od oznámenia o vhodnom darcovi až po samotnú operáciu?

V prípade, že sa na ktoromkoľvek oddelení anestéziológie a resuscitačnej medicíny nachádza pacient s poškodením hlavy a mozgu, ktoré nie je zlúčiteľné so životom, lekár z daného pracoviska informuje transplantačné centrum o potenciálnom darcovi. Koordinátor transplantačného centra overí v registri Národnej transplantačnej organizácie, či potenciálny darca za života preukázateľne nevyslovil nesúhlas s odberom orgánov po stanovení smrti mozgu. V prípade, že sa potenciálny darca v takomto registri nenachádza, začína sa celý proces diagnostiky smrti mozgu a manažovania darcu do momentu prekladu do transplantačného centra. Komunikácia s príbuznými darcu je realizovaná v darcovskej nemocnici alebo priamo v transplantačnom centre. Po definitívnom stanovení smrti mozgu a zrealizovaní všetkých krokov predpísaných legislatívou pristupujeme k multiorgánovému odberu. Ešte predtým sú však kontaktované koordinátorom transplantačného centra, ktoré realizuje odber,  príslušné  transplantačné centrá príjemcov mimoobličkových parenchýmových orgánov (srdce, pľúca, pečeň) na Slovensku resp. v zahraničí. V priebehu odberu je realizovaný výber príjemcov obličiek na Slovensku. Srdce musí byť voperované do tela príjemcu najneskôr do štyroch hodín od jeho odberu – keď si predstavíte, že je odobraté v Košiciach a transplantované v Bratislave, musí Vám byť jasné, ako presne musí byť všetko zorganizované ... každý krok procesu, všetky transporty, odovzdávanie informácií, príprava príjemcu, koordinácia operačných tímov. O niečo dlhší čas majú lekári pri transplantácii pľúc a pečene a v prípade obličiek je tento čas tzv. studenej ischémie prijateľný až do 24 hodín. Za tento čas sú realizované náročné imunologické testy medzi darcom a potenciálnymi príjemcami, na základe sofistikovaného softwarového alokačného systému sú vybratí dvaja príjemcovia obličiek darcu. Príprava potenciálnych príjemcov spočíva v hemodialýze (pokiaľ je indikovaná) a úvodnej medikamentóznej aplikácii  imunosupresie, ktorá zabráni rejekcii (odvrhnutiu) orgánu po transplantácii. Po adekvátnej príprave je pacient podrobený operačnému výkonu a následne realizovaná intenzívna podporná a imunosupresí vna liečba. V optimálnom prípade je pacient po dvoch týždňoch prepustený do domácej rekonvalescencie s dobre fungujúcou transplantovanou obličkou a bez závislosti od pravidelnej dialyzačnej liečby.  
Celý proces je extrémne náročný na správnu koordináciu  a vyžaduje spoluprácu celého tímu.

MEDIUS: Aké zdravotné či právne kritériá musí spĺňať živý darca?

Pacient, ktorý chce darovať za života obličku, musí byť zdravý a musí byť geneticky príbuzný alebo emočne spriaznený s pacientom, ktorému chce obličku darovať (rodič, dieťa, súrodenec, životný druh, priateľ). Každý, kto zamýšľa pomôcť svojmu príbuznému, by mal navštíviť  našu ambulanciu, kde mu dáme odpoveď na každú otázku, ktorú nám položí. Pri transplantácii obličky od žijúceho darcu hovoríme ešte o jednej skupine transplantácií – sú to tzv. transplantácie obličky preemptívne, čo znamená, že transplantácia je realizovaná ešte pred nutnosťou začať dlhodobý dialyzačný program. Pacientov, ktorí čakajú na zaradenie do dialýzy je veľa, nie všetci ale vedia, že môžu byť ešte predtým transplantovaní, a tak sa dialýze môžu vyhnúť.

MEDIUS: V prípade darovania obličky môže darca viesť aj po vykonaní zákroku plnohodnotný život?

Existujú minimálne riziká vyššieho krvného tlaku alebo zvýšeného odpadu bielkovín močom mnoho rokov po darovaní obličky, avšak všetci žijúci darcovia sú po odbere u nás pravidelne sledovaní, a teda pod neustálou lekárskou kontrolou. V minulosti bola publikovaná veľká epidemiologická štúdia z krajín Scandiatransplantu, kde je darovanie obličky počas života mnohonásobne vyššie v porovnaní so Slovenskom, a v tejto štúdii bolo dokázané, že darcovia obličky na transplantáciu žijú paradoxne dlhšie v porovnaní s bežnou populáciou ... podľa záverov štúdie je tento záver výsledkom pravidelných  lekárskych kontrol.

MEDIUS: Na druhej strane, sa často (aj na našich stránkach) stretávame s ochotou darovať svoje orgány po smrti na výskum alebo „ďalšie použitie“. Mohli by ste prosím vysvetliť zásady tzv. opt-out systému, a taktiež postup pre tých,  ktorí majú aktívny prístup a sú rozhodnutí svoje orgány po smrti darovať?

Opting-out princíp resp. princíp predpokladaného súhlasu som vysvetlil v jednej z predchádzajúcich otázok a ľudia, ktorí sú s týmto princípom stotožnení, nemusia v súlade s našou legislatívou dávať písomný súhlas ani žiadne iné vyjadrenie. Ako národ by sme sa o týchto veciach mali podľa môjho názoru v rodinách viac rozprávať, aby naši príbuzní poznali náš názor na túto problematiku. Ide o vysoko humánnu záležitosť, ktorá zachraňuje životy a naši blízki by mali poznať náš postoj. Nikdy nevieme, čo sa nám môže stať.

MEDIUS: Aké sú aktuálne trendy v transplantológii a kde vidíte jej možnosti o takých 10 rokov?

V transplantačnej medicíne sa v posledných rokoch udialo veľmi veľa v oblasti vývoja nových imunosupresív, ktoré sú stále selektívnejšie a cielenejšie, menej toxické a efektívnejšie. Akýmsi svätým grálom by bolo v transplantačnej medicíne navodenie imunotolerancie podľa možností jednou infúziou na začiatku procesu. Množstvo tímov po celom svete pracuje na vývoji a overovaní nových imunosupresívnych protokolov. Problémom po transplantácii sú rejekčné (odvrhovacie) reakcie, ich manažovanie a liečba je cieľom, ktorý si vyžaduje špičkových odborníkov a laboratórne vybavenie, ktoré sú možné jedine v nemocnici so silným ľudským i technickým potenciálom.
Dôležitým momentom je neustále nedostatok orgánov  na transplantácie. Ide o globálny problém, pre nás je však dôležité, že na Slovensku je ešte obrovský priestor pre zlepšenie v identifikácii potenciálnych darcov orgánov, takže trend v transplantológii u nás vidím v tejto oblasti v neustálom zlepšovaní systému. Práve v tejto oblasti očakávame silnú garanciu a podporu zo strany štátnych zdravotníckych orgánov.
Tento rok v decembri uplynie 60 rokov od prvej úspešnej transplantácie obličky. Vtedy si niečo podobné ako transplantáciu obličky dokázalo predstaviť iba zopár nadšencov a dnes, po uplynutí relatívne krátkeho obdobia, je transplantácia obličky dnes metódou voľby liečby chronického obličkového zlyhania. Podobne si dnes nevieme predstaviť v praxi klonované orgány, transplantáty od iných živočíšnych druhov. Som však presvedčený o tom, že nás v tejto oblasti transplantačná medicína v priebehu 10 rokov vyvedie z tejto názorovej neistoty.

MEDIUS: V súčasnosti je v médiách často spomínaná  tzv. medicínska turistika. Vyskytuje sa takýto „turizmus“ aj za účelom podstúpenia transplantácie? 

„Transplantačná turistika“, ktorú máte isto na mysli, bola zo strany svetovej transplantačnej spoločnosti jednoznačne a definitívne zavrhnutá tzv. istanbulským protokolom v roku 2010. Slovensko sa k uvedenej iniciatíve pochopiteľne pridalo.

MEDIUS: Je aktuálna legislatíva vykonávania transplantácií na Slovensku vyhovujúca podmienkam praxe? Ak nie, tak prečo?

Aktuálna legislatíva je vyhovujúca, i keď z pohľadu poskytovateľov trochu komplikovaná v tom zmysle, že sa jednotlivé oblasti transplantačnej medicíny riešia na viacerých miestach v zákonoch, vyhláškach a odborných usmerneniach. Možno treba začať uvažovať nad transplantačným zákonom, ktorý je vo viacerých európskych krajinách štandardom. Na druhej strane treba uviesť, že v poslednom čase boli do našej legislatívy zapracované všetky odporúčania a direktívy, ktoré sme ako člen Európskej únie povinní rešpektovať.  

MEDIUS: Podieľajú sa odborníci z oblasti transplantológie na príprave právnych predpisov regulujúcich túto oblasť?

Určite. Mienkotvorní odborníci z jednotlivých slovenských transplantačných centier sú členmi všetkých „transplantačných“ výkonných orgánov, odbornej spoločnosti, grémií, konzílií, komisií a poradných orgánov ministerky zdravotníctva. Spolupracujú pri navrhovaní a schvaľovaní všetkých legislatívnych úprav v rámci transplantológie na Slovensku.

MEDIUS: Poznáte presný počet  transplantácií  realizovaných v Košiciach? Má toto číslo stúpajúcu alebo klesajúcu tendenciu? Aké sú príčiny?

V našom centre je ročne realizovaných celkovo cca 50 transplantácií obličiek od mŕtvych i žijúcich darcov. Transplantácie od žijúcich darcov predstavujú iba malý zlomok celkového počtu transplantácií, ktorý má v poslednom čase klesajúci trend. Dôvod je prozaický – nedostatok darcov. Veľmi intenzívne pracujeme na tom, aby sa situácia zlepšila v oboch kľúčových programoch.

Ďakujem za rozhovor.
Ďakujem.

 

Rozhovor spracovala Zuzana Zoláková




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