Cytoablative therapy with combined resection and cryosurgery for limited bilobar hepatic colorectal metastases

BACKGROUND

Cryosurgery can be employed in patients with unresectable hepatic metastases when the tumor size and the number of metastases are limited. However, local recurrence can result from incomplete ablation. We proposed a trial of complete cytoablation with a combined approach of cryosurgery and hepatic resection for patients with bilobar hepatic metastases.

METHODS

Seven patients underwent cryosurgery alone (CRYO). Seven additional patients underwent combined resection and cryosurgery (CRYO+RES) for bilobar metastases.

RESULTS

In the CRYO group, 5 of 7 patients had at least one centrally located tumor. All 5 of these patients had early recurrence at the site of ablation. In the CRYO+RES group complete ablation was achieved in 7 of 7. Two (28.6%) of these patients developed local recurrence.

CONCLUSION

Cytoablation of hepatic metastases can be safely achieved with combined hepatic resection and cryosurgery in selected patients. Long-term survival data are necessary before advocating widespread application of this approach.

Distinctive clinical features of portopulmonary hypertension

STUDY OBJECTIVE

To differentiate the cardiopulmonary profile of portopulmonary hypertension (PPHTN) from that of primary pulmonary hypertension and chronic liver disease.

DESIGN

Retrospective survey.

SETTING

Tertiary care center.

PATIENTS

Thirty patients with cardiac catheterization-proven PPHTN were compared to 30 randomly selected patients with primary pulmonary hypertension alone and 30 patients with chronic liver disease alone necessitating consideration of liver transplantation (L-CONT).

INTERVENTIONS

All patients underwent right heart catheterization, echocardiography, ECG, chest radiography, pulmonary function tests, ventilation-perfusion scanning, and room air arterial blood gas measurements.

RESULTS

Patients with PPHTN exhibited elevated pulmonary pressures (mean pulmonary pressure, 48.6+/-2.1 mm Hg) and pulmonary vascular resistance (11.6+/-1.6 mm Hg/L/min/m2) with simultaneous elevation in the cardiac index (3.8+/-0.3 L/min/m2) and depression of systemic vascular resistance (24.9+/-1.7 mm Hg/L/min/m2). Arterial blood gas measurements indicate that PPHTN exhibits a significant accentuation of the chronic respiratory alkalosis (PCO2, 28.7+/-0.5 mm Hg) usually seen with chronic liver disease and pulmonary hypertension. In addition, patients with PPHTN have an increased alveolar-arterial gradient (27.0+/-2.7 mm Hg) when compared to patients with L-CONT, suggesting impaired gas exchange.

CONCLUSIONS

PPHTN is associated with a unique clinical profile that possesses characteristics common to and exclusive of liver disease and primary pulmonary hypertension.

Outcome after splenic vein thrombosis in the pancreas allograft

The outcome and management of isolated splenic vein thrombosis in the pancreas transplant is unknown. We retrospectively reviewed the records of 76 simultaneous pancreas-kidney transplantations (SPK) and 56 solitary pancreas transplantations (SPT) performed at the University of Maryland from January 1995 to December 1996. A total of 24 patients were identified (9 SPK and 15 SPT recipients). All were systemically anticoagulated for a period of 6-8 weeks after diagnosis. In the SPK thrombosis group, anticoagulation resulted in 1-year graft survival that was equivalent to that of SPK controls (86.1% vs. 95.3%). In contrast, in SPT, thrombosis and subsequent anticoagulation were associated with decreased graft survival compared with SPT controls (26.8% vs. 78.3%; P<0.01). Although the outcome of splenic vein thrombosis in the absence of anticoagulation is unknown, these data suggest that (1) in SPK, anticoagulation for splenic vein thrombosis maintains graft survival, and (2) in SPT, anticoagulation does not alter the ultimate progression of splenic vein thrombosis to complete graft thrombosis.

The evolution of a successful liver transplant program in 1996: the clinical and administrative role of the anesthesiologist

The establishment of a new liver transplant program requires enormous planning and resources. Extensive negotiations must take place to ensure institutional and departmental commitments to obtain the proper equipment, personnel, and other resources. The formation of a well-trained multidisciplinary team of physicians and nurses becomes the next step. Finally, ample time must be provided to adequately deploy resources, lobby referring physicians, recruit patients, and troubleshoot problems as they arise.

Evaluation of pancreas transplant needle biopsy: reproducibility and revision of histologic grading system

BACKGROUND

Tissue samples for the diagnosis of pancreatic allograft rejection are now obtained routinely through the application of the percutaneous needle biopsy technique. The availability of biopsy material (89% adequate for diagnosis in our setting) presents a challenge for pathologists who are asked to provide a fast and accurate diagnosis of rejection and its severity, while at the same time being able to differentiate rejection from other causes of graft dysfunction.

METHODS

To differentiate rejection from other pathologic processes, 26 histologic features were assessed in 92 biopsies performed for confirmation of clinical diagnosis of rejection and the results were compared with 31 protocol biopsies, 12 allograft pancreatectomies with non-rejection pathology, and 30 native pancreas resections with various disease processes.

RESULTS

Based on these comparisons, a constellation of findings relating to the vascular, septal, and acinar inflammation was identified for the diagnosis of rejection. Application of these features led us to revise our scheme for grading rejection (ranging from 0-normal to V-severe rejection) to include the categories of "inflammation of undetermined significance" and "minimal rejection." The scheme was used by five pathologist to grade 20 biopsies independently of any clinical data and the interobserver level of agreement was highly significant (kappa=0.83, P<0.0001). This grading scheme was applied blindly to all (183) biopsies from 77 patients with 6-52 months of follow-up. The correlation of the highest degree of rejection on each patient and ultimate graft loss (0% for grades 0-I, 11.5% for grade II, 17.3% for grade III, 37.5% for grade IV, and 100% for grade V) was highly statistically significant (P<0.002). The fraction of grafts lost due to pure immunologic causes increased proportionally to the grade of rejection (0, 50, 66, and 100% for grades II, III, IV, and V, respectively).

CONCLUSIONS

This study provides strong support for the proposed pancreas rejection grading scheme and confirms its potential for practical use.

Safe pancreas transplantation in patients with coronary artery disease

BACKGROUND

This study was conducted to determine the risk of clinically significant posttransplant cardiac events (PCEs) in a cohort of diabetic patients referred for pancreas transplantation.

METHODS

Between April 1991 and December 1995, 316 insulin-dependent diabetics were evaluated for pancreas transplantation. Patients were assessed for risk factors for coronary artery disease (CAD), and underwent screening for significant CAD by a standardized algorithm that included selective coronary angiography. For the 3-year period following transplantation, PCEs were identified, and related to pretransplant cardiac risk factors.

RESULTS

Only four patients (1.3%) were turned down for cardiac contraindications. Coronary angiography was done in 74 patients (27% of the active transplant candidates) during the evaluation period because of the patient's history or a positive stress test. Significant coronary artery stenoses were found in 54% of the patients catheterized. Twenty-five of these 40 patients (63%) underwent revascularization with percutaneous transluminal coronary angioplasty and/or coronary artery bypass grafting. A total of 359 organs were subsequently transplanted into 194 of these patients. No deaths occurred within 30 days of any of the transplants; four percent of transplant recipients died of cardiac causes within the follow-up period (median 23 months). Those with no pretransplant evidence of CAD had significantly lower rates of PCE (2% and 8% at 1 and 3 years, respectively) than those with pretransplant evidence of CAD (11% and 29% at 1 and 3 years, P<0.01; relative risk, 4.3).

CONCLUSIONS

Routine cardiac screening of pancreas recipients with selective angiography and revascularization allows patients with significant CAD to safely undergo pancreas transplantation. Patients should rarely be excluded from pancreas transplantation for cardiac causes.

Increased living donor volunteer rates with a formal recipient family education program

We have generally encouraged living donation among our kidney recipients. However, an examination of our clinical practice revealed inconsistencies in the depth and content of information transmitted to kidney recipient families regarding living donation. We therefore initiated a structured education program, including an educational video, to ensure that all recipient families would receive a similar exposure to a standard block of information. After the program had been functioning for over a year, we compared the living donor (LD) volunteer rates between the 3-year period before (BEFORE) and the 18 months after (AFTER) initiation of the formal education program. There were 1,363 patients registered on our kidney transplantation waiting list during the 54-month study period (757 white [56%] and 580 black [43%]). We found that 33.4% of the kidney transplant candidates in the period BEFORE the LD education program had at least one potential LD tissue typed, compared with 39.4% in the period AFTER starting the program (P = 0.03). The increase in the proportion of patients with potential donors was greatest among the black (P < 0.05) and elderly (P < 0.01) registrants, which were the groups with the lowest volunteer rates before the program began. Among the registrants with at least one potential donor, the percentage of registrants who ultimately received an LD transplant was highly correlated with the number of donors (R = 0.98). The rate of LD kidney transplantation was significantly higher (P = 0.02) for the patients referred in the period AFTER initiation of the LD education program compared with the period BEFORE the program. The 1- and 3-year graft survival rates for the 170 LD transplants performed in these patients were 96.9% and 93.2%, respectively. These were significantly better than the corresponding 83.9% and 71.4% rates for the 341 kidney transplants from cadaver donors in these registrants (P < 0.001). Black recipients of LD transplants had graft survival rates comparable to whites; the 3-year graft survival rate for LD transplants was 93.9% in whites and 90.6% in blacks (P = NS). We conclude that living kidney donor volunteer rates can be improved by a formal family education program, especially for subgroups of patients with low volunteer rates. A substantial benefit is derived by black patients, who generally experience low graft survival rates with cadaver-donor kidneys. A local formal LD education program is a useful adjunct to national organ donation campaigns.

Successful emergency transplantation of a liver allograft from a donor maintained on extracorporeal membrane oxygenation

The critical shortage of cadaveric donors for organ transplantation has led many transplant centers to accept life-saving organs from donors who would have previously been refused for transplantation. We report a novel case of the use of a liver allograft from a donor whose oxygen delivery was maintained by extracorporeal membrane oxygenation (ECMO) for 29 days before suffering an anoxic brain injury from ECMO dysfunction. Liver transplantation was successfully performed in a patient with fulminant hepatic failure. Immediate graft function was obtained in the recipient, with full neurologic recovery and return to gainful employment 4 months after transplantation. ECMO may provide an intriguing option for the maintenance of organ function in the critically unstable brain-dead organ donor to salvage organs for transplantation. Further studies are currently underway.

Methemoglobinemia associated with dapsone treatment in solid organ transplant recipients: a two-case report and review

Dapsone, a sulfone antibiotic, has been increasingly used in solid-organ transplant recipients for the primary prevention of Pneumocystis carinii pneumonia, especially in patients with documented sulfa allergy. A known side effect of dapsone therapy, however, is methemoglobinemia, a condition leading to impaired tissue oxygen delivery. This report documents two cases of dapsone-induced methemoglobinemia in patients after solid organ transplantation with emphasis on the importance of clinical recognition and benefits of treatment. Further, the pathophysiology and causes of this condition are extensively reviewed.

Continuous intravenous infusion of epoprostenol for the treatment of portopulmonary hypertension

The association of pulmonary hypertension with portal hypertension, also called portopulmonary hypertension (PPHTN), is a known complication of chronic liver disease. Previously, the presence of PPHTN was considered to be a contraindication to orthotopic liver transplantation (OLT). Although there are selected case reports of successful OLT in the setting of PPHTN, an excessive mortality rate is associated with OLT and PPHTN. Heretofore, therapy for chronic management of PPHTN was lacking. Recently, continuous intravenous infusion of epoprostenol has been demonstrated to improve symptomatology and survival in the general population of patients with primary pulmonary hypertension. We now report the use of epoprostenol in the more specific instance of PPHTN. Over a period of 6-14 months, epoprostenol (10-28 ng/kg/min) therapy was associated with a 29-46% decrease in mean pulmonary artery pressure, a 22-71% decrease in pulmonary vascular resistance, and a 25-75% increase in cardiac output in a group of four patients. These results suggest that effective chronic therapy for PPHTN is available. In conjunction with inhaled nitric oxide as acute intraoperative therapy, epoprostenol infusion represents an additional therapeutic option for treatment of PPHTN in the liver transplant candidate.

Prevention of autoimmune islet allograft destruction by engraftment of donor T cells

The results of clinical islet transplantation have remained poor when compared with the consistent success of pancreas transplantation. Autoimmunity has usually been discounted as a cause of islet transplant failure. Previously, we demonstrated that pancreas transplants from the diabetes resistant BB rat (BB-DR) function indefinitely in autoimmune diabetic hosts, but islets from the same donor are vulnerable to recurrent autoimmunity. Addition of 100 million pancreatic lymph node cells (PLNC) to BB-DR islets restores resistance to autoimmunity and leads to repletion of a T cell subset (RT6.1) in the recipients. Autoimmune (BB-Ac) and streptozocin (BB-Sz) diabetic BB rats were recipients of Wistar Furth (WF) intraportal islet or islets plus PLNC transplants with cyclosporine 5 mg/kg/day recipient treatment. One cohort of Brown Norway (BN) islet transplants to BB-Ac with CsA was performed. At the termination of the experiment, recipient peripheral blood lymphocytes (PBL) were characterized by flow cytometry (FACS) for class I, CD4, CD8, RT6.1, and RT6.2, a T cell maturation marker found in WF but not BB rats. All (14/14) WF and 75% (6/8) BN islet transplants to BB-Ac recipients failed after a mean of 42 and 36 days, respectively, despite CsA immunosuppression. WF islets were successful in 6/8 (75%) transplants to BB-Sz recipients (P<0.001 vs. BB-Ac recipients), confirming that autoimmunity is the major cause of islet failure in BB-Ac rats. Addition of PLNC to WF islets increased the survival in BB-Ac to 82% (9/11) (P<0.0001 vs. WF islets alone). Recipients of islet+PLNC express 19.7% RT6.2 compared with 4.6% and 4.0% for WF islets alone in BB-Ac (P<0.01) and BB-Sz (P<0.01), respectively. Autoimmunity is an important factor leading to islet transplant failure in autoimmune diabetic BB rats. Addition of donor PLNC prevent islet allograft failure and leads to recipient chimerism for a donor T cell subset (RT6.2) associated with resistance to autoimmunity.

Simultaneous pancreas/kidney transplantation--a comparison of enteric and bladder drainage of exocrine pancreatic secretions

Simultaneous pancreas/kidney transplantation (SPK) has evolved to become a therapeutic option for patients with renal failure resulting from type 1 diabetes mellitus. However, the appropriate route for drainage of the exocrine secretions of the pancreas allograft remains unclear. While bladder drainage (BD) is the current state of the art, it is associated with a high frequency of urologic complications, including urinary tract infections, hematuria, metabolic acidosis, dehydration, and reflux pancreatitis. Although enteric drainage (ED) is the more physiologic route, it has been associated in the past with decreased graft survival and increased infectious complications. In addition, BD offered a technique for detection of rejection through measurement of urinary amylase. However, with the advent of improved immunosuppression and antibiotic therapy, percutaneous pancreas biopsy, improved radiologic imaging, and greater understanding of pancreas transplantation, we hypothesized that ED could be performed without increased morbidity or cost. A group of 23 consecutive SPK was performed with ED during the period from July 1995 to November 1995. Another 23 age- and sex-matched recipients of SPK with BD performed from November 1994 to June 1995 served as a historical control group. Because of the differing lengths of follow-up, data were analyzed with respect to the first six months posttransplant. ED and BD were associated with equivalent actuarial one-year patient and graft survival rates: 100% and 88% for ED, and 96% and 91% for BD, respectively. Hospital charges, length of stay, readmissions, rejection, sepsis-related procedures were also equivalent in ED and BD. However, ED was associated with significantly fewer urinary tract infections and urologic complications. In addition, no grafts were lost as the result of sepsis. In the setting of SPK, ED represents a viable alternative to BD for primary drainage of pancreas exocrine secretions. Further studies with extended lengths of follow-up are necessary to confirm our observations.

Solitary pancreas allografts. The role of percutaneous biopsy and standardized histologic grading of rejection

OBJECTIVE

To determine the potential impact of ultrasound-guided percutaneous pancreas allograft biopsy and standardized histologic grading on graft and patient survival in a solitary pancreas transplant program.

DESIGN

Retrospective case series survey.

SETTING

Tertiary care, university teaching hospital.

PATIENTS

Thirty-five recipients of solitary pancreas transplants.

INTERVENTIONS

Percutaneous pancreas allograft biopsies were performed in solitary pancreas transplant recipients.

MAIN OUTCOME MEASURES

Actuarial graft and patient survival, cause of graft loss.

RESULTS

Initiation of ultrasound-guided percutaneous pancreas allograft biopsy with standardized histologic grading is associated with a 70% 1-year graft survival and 93% 1-year patient survival in solitary pancreas transplantation. Acute rejection was responsible for only 11% of cases of graft loss. The presence of endotheliitis, vasculitis, or confluent acinar necrosis is associated with decreased pancreas allograft survival, poor response to corticosteroid therapy, and shortened time interval to ultimate graft loss. Clinical criteria for acute rejection such as elevated serum amylase or lipase levels, 50% decrease in urinary amylase levels, unexplained fever, or hyperglycemia are associated with a positive predictive value of only 72%.

CONCLUSION

Pancreas allograft biopsy and standardized histologic grading are associated with significantly improved 1-year graft and patient survival in solitary pancreas transplantation.

Double renal allografts successfully increase utilization of kidneys from older donors within a single organ procurement organization

BACKGROUND

In 1994, a policy of double renal allografting (DUAL) was used at two centers within our local organ procurement organization to increase utilization of kidneys from older donors that would otherwise be discarded. Both kidneys from an older donor (age > 60 years) were selectively transplanted into a single adult recipient.

METHODS

The relative impact of a DUAL policy on the utilization of older donor kidneys is examined for the period of April 1994 to April 1996. Actual utilization is compared with the hypothetical case in which a DUAL policy is not present.

RESULTS

In the actual setting, a total of 75 kidneys from older donors (> 60 years) were accepted for transplantation. Thirty-six kidneys were transplanted as singlets, and 16 additional kidneys were transplanted as DUAL renal allografts. Thus, a 44% increase in transplantable kidneys, and a 22% increase in patients transplanted with kidneys from older donors, was realized. In the actual setting, 23 older kidneys were discarded; without the DUAL policy, 39 kidneys would have been deemed untransplantable. When compared with the actual (n = 52) and hypothetical number of kidneys transplanted without a policy of DUAL transplantation (n = 36), the DUAL policy significantly increased the utilization of older donor kidneys (P = 0.01). The actuarial 1-year graft survival rate of the dual kidneys was 100%, with a mean follow-up of 11.1 +/- 2.9 months. Mean 6-month and 1-year serum creatinine level were 1.76 +/- 0.4 and 1.63 +/- 0.6 mg/dl, respectively.

CONCLUSIONS

A DUAL policy significantly increased the number of older donor kidneys transplanted in a single organ procurement organization and reduced the rate of discard of older donor kidneys over a 2-year period. Long-term follow-up is necessary to substantiate satisfactory graft function in DUAL from older donors.

Utilization of the older donor for renal transplantation

BACKGROUND

The persistent shortage of ideal donor organs has resulted in increased transplantation of kidneys from older donors (age > 60 years). The overall experience with this donor subgroup indicates decreased graft survival.

METHODS

The records of 413 renal transplants performed between July 1991 and July 1995 were reviewed in a retrospective fashion to determine those patients who had received a cadaveric (CT > 60; n = 17) or living donor (LT > 60; n = 7) renal transplant from an older donor. Control groups consisted of randomly selected patients who received cadaveric (CT < 50; n = 20) or living related (LT < 50; n = 20) renal transplants from donors less than 50 years of age.

RESULTS

In the CT > 60 group, 1-year graft survival was 57.4%, significantly less than in those of the LT < 50 (100%), LT > 60 (100%), and CT < 50 (89%) groups. Mean recipient serum creatinine in the CT > 60 group was twofold greater than that of other groups at 1, 6, and 12 months following transplantation. Cold ischemia time and creatinine clearance correlated highly with graft survival. Stepwise regression analysis showed creatinine clearance to be the sole independent predictor of graft survival. A calculated donor creatinine clearance < 50 mL/minute was associated with ultimate graft loss.

CONCLUSION

Age alone should not be an exclusion criterion to renal organ donation. When considering the older renal donor, creatinine clearance should be included within the decision algorithm.

Significance of the Banff borderline biopsy

In the Banff classification of kidney transplant pathology the "borderline changes" category falls short of a diagnosis of mild acute rejection, with the recommendation that no treatment is a possible clinical approach. We reviewed the clinical course of patients whose renal allograft biopsies showed "borderline changes" to determine how often these histologic findings actually represented acute rejection. Between January 1992 and June 1994, 351 biopsy specimens were obtained from 170 renal allografts and graded according to the Banff criteria. Eighty-one biopsy specimens were classified as "borderline changes" (23%). Of these, 59 had Banff scores of i1, t1, and vO; the remaining 22 had scores of i2, t1, and vO (i = interstitial infiltrate, t = tubulitis, and v = vasculitis). Medical record review showed that nearly all the "borderline" biopsies had been performed because of an elevated creatinine (Cr; 78 of 81 [96%]), with a mean increase of 1.1 +/- 0.1 mg/dL (+/- SE) over baseline. Most of the patients with "borderline changes" and elevated Cr were treated for acute rejection (61 of 78 [78%]); some with pulse steroids alone (29 of 61 [48%]), the rest with antilymphocyte antibody (32 of 61 [52%]). Among all 61 patients with "borderline" biopsies treated for rejection, 26 had a complete response (43%), 17 had a partial response (28%), and 18 had no response (30%). Interpretation of these changes in Cr, however, was confounded by intercurrent conditions in 28 of the patients. A group of 33 patients was therefore identified in whom a "borderline changes" biopsy was obtained, who were treated for rejection, and in whom all other identifiable causes of elevated Cr other than possible acute rejection had been systematically eliminated from consideration. In this group the mean Cr was 2.0 +/- 0.1 mg/dL at baseline, 3.3 +/- 0.2 mg/dL at the time of biopsy, and 2.2 +/- 0.1 mg/dL 1 month after treatment (P < 0.001 Cr at biopsy v Cr 1 month later). Among these 33 patients, 19 had a complete response (58%), 10 had a partial response (30%), and four had no response (12%). Therefore, the Cr in 88% of the patients in this group was lower 1 month after treatment for rejection than it was at the time of the biopsy. Follow-up biopsies were performed within 1 month of the "borderline" biopsy in 24 cases; these showed "borderline changes" (five of 24 [21%]), mild acute rejection (eight of 24 [33%]), or moderate to severe acute rejection (11 of 24 [46%]). We conclude that in the clinical setting of deteriorating renal graft function with mild elevation of serum Cr, the "borderline changes" biopsy frequently represents acute rejection. Antirejection treatment is therefore appropriate in the majority of cases. The reader should bear in mind that the current study is retrospective, with no control group. The risk of loosely interpreting these data is that some patients will be treated without due cause. Banff "borderline changes" should be used as part of an algorithm, but not the sole criterion, for therapeutic decision making.

Double adult renal allografts: a technique for expansion of the cadaveric kidney donor pool

BACKGROUND

A major impediment to kidney transplantation is the current shortage of donor organs. Currently approximately 22,500 candidates are awaiting kidney transplantation, while the number of donors remains stable at approximately 3500 each year in the United States. Alternative approaches to traditional organ donor selection are necessary. In this setting we hypothesized that kidneys with reduced nephron mass from adult donors may provide satisfactory renal function if both donor kidneys are placed into a single recipient.

METHODS

Eighteen paired adult renal allografts were transplanted into nine adult recipients (DUAL). Recipient graft outcome variables were examined and compared with outcomes from single kidneys transplanted from randomly selected "ideal" donors younger than 50 years of age (CONT < 50) and "expanded" donors older than 60 years of age (CONT > 60) who underwent transplantation at our center.

RESULTS

Six-month serum creatinine levels in the three groups, DUAL (n = 9), CONT < 50 (n = 20), and CONT > 60 (n = 12), were 1.6 +/- 0.3, 2.3 +/- 0.3, and 4.1 +/- 0.9 mg/dl, respectively, (p < 0.0001) between CONT > 60 and the other two groups. Mean estimated creatinine clearance (ml/min/1.73 m2) was 43.2 +/- 3.4, 62.5 +/- 5.4, and 24.5 +/- 5.3 (p < 0.02). Graft and patient survival at last follow-up in DUAL was 100% compared with 95% in CONT < 50 and 75% graft and 83% patient survival in CONT > 60. Delayed graft function occurred in one of nine patients (11%) in DUAL group compared with 4 of 20 (20%) in CONT < 50 group and 6 of 12 (50%) in CONT > 60 group. Mean follow-up of patients in DUAL group was 6.6 months (range, 2 to 14 months).

CONCLUSIONS

Double adult kidney transplants (DUAL) are associated with acceptable short-term graft function, graft survival, and patient survival when compared with transplanted kidneys from an ideal donor group (CONT < 50). Double renal allografts are a preferred use for donor kidneys with suboptimal nephron mass. Long-term follow-up is required to validate further the proposed approach.

Equivalent success of simultaneous pancreas kidney and solitary pancreas transplantation. A prospective trial of tacrolimus immunosuppression with percutaneous biopsy

OBJECTIVE

This study was designed to evaluate the results of solitary pancreas transplantation in a protocol that uses the new immunosuppressant tacrolimus (FK) and liberally applies ultrasound-guided percutaneous pancreas biopsy to diagnose rejection.

SUMMARY BACKGROUND DATA

Pancreas graft survival in patients who simultaneously receive a kidney transplant (SPK) historically has been 75% to 90% at 1 year, approaching that of cadaveric kidney transplantations. In sharp contrast, graft survival rates in patients who receive a pancreas atone (PA) have remained static over the past decade, with approximately 50% functional at 1 year. It was hypothesized that the results of PA transplantations would improve with newer maintenance immunosuppressants and biopsy techniques.

METHODS

Twenty-seven PA recipients prospectively were treated with FK-based immunosuppression (PA-FK). Percutaneous biopsy was performed for hyperamylasemia, hyperlipasemia, hypoamylasuria, or unexplained fever. One year pancreas graft survival in these patients was compared to 15 cyclosporine treated PA cases (PA-CsA) and 113 SPK recipients.

RESULTS

The 1-year pancreas graft survival rate of 90.1% in technically successful PA-FK patients was significantly better than the 53.4% rate in PA-CsA recipients (p = 0.002) and no different than the 87.4% rate in SPK recipients. The only graft lost to acute rejection in the PA-FK group was because of acknowledged patient noncompliance. Percutaneous biopsy substantially improved the diagnostic certainty in cases of suspected rejection and was associated with a low complication rate (3/178 = 1.5%).

CONCLUSIONS

Modern immunosuppression and biopsy techniques have improved the success of solitary pancreas transplantations to the point where outcome is now equivalent to that of SPKs.

Late pancreas allograft rejection. Preliminary experience with factors predisposing to rejection

A case series of 31 cadaveric pancreas transplant recipients who were insulin-independent at least for one year was analyzed for the factors predisposing to late acute rejection (> 12 months posttransplant). Sixty-two pancreas transplants were performed in 61 patients, of whom 53 had functioning allografts 3 months posttransplant; 31 of these had a follow-up > 12 months. Twenty had no evidence of late rejection, whereas 11 had evidence of acute rejection after 12 months. All patients received quadruple induction immunosuppression. No demographic or clinical factors-including donor age, organ cold time, HLA mismatch, age, sex, or race-could distinguish the late acute rejection group. The presence of acute rejection in the first year posttransplant was similar in the late rejectors (21 episodes in 9 of 11 patients) compared with patients without late rejection (31 episodes in 16 of 20 patients). Antilymphocyte induction therapy type had no influence, but the amount of immunosuppression with prednisone and cyclosporine (CsA) at 3 months posttransplant was significantly lower in those patients who experienced late rejection. After the first year posttransplant, CsA 12-hr trough levels were significantly lower in late rejection months (121 +/- 7 ng/ml) compared with each patient's own stable months (183 +/- 5 ng/ml, P < 0.0001). Neither prednisone nor azathioprine dosages differed between teh two groups after the first year posttransplant. Our preliminary results suggest that early under immunosuppression with prednisone and CsA in the first year and 12-hr trough CsA levels less than approximately 180 ng/ml after the first year posttransplant predispose to late pancreatic rejection.