151
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Affiliation(s)
- Robin Goland
- Naomi Berrie Diabetes Center, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA ; Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA ; Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Dieter Egli
- Naomi Berrie Diabetes Center, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA ; Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA ; The New York Stem Cell Foundation Research Institute (NYSCF), New York, NY 10032, USA
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152
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Cardini B, Watschinger K, Hermann M, Obrist P, Oberhuber R, Brandacher G, Chuaiphichai S, Channon KM, Pratschke J, Maglione M, Werner ER. Crucial role for neuronal nitric oxide synthase in early microcirculatory derangement and recipient survival following murine pancreas transplantation. PLoS One 2014; 9:e112570. [PMID: 25389974 PMCID: PMC4229216 DOI: 10.1371/journal.pone.0112570] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 10/08/2014] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Aim of this study was to identify the nitric oxide synthase (NOS) isoform involved in early microcirculatory derangements following solid organ transplantation. BACKGROUND Tetrahydrobiopterin donor treatment has been shown to specifically attenuate these derangements following pancreas transplantation, and tetrahydrobiopterin-mediated protective effects to rely on its NOS-cofactor activity, rather than on its antioxidant capacity. However, the NOS-isoform mainly involved in this process has still to be defined. METHODS Using a murine pancreas transplantation model, grafts lacking one of the three NOS-isoforms were compared to grafts from wild-type controls. Donors were treated with either tetrahydrobiopterin or remained untreated. All grafts were subjected to 16 h cold ischemia time and transplanted into wild-type recipients. Following 4 h graft reperfusion, microcirculation was analysed by confocal intravital fluorescence microscopy. Recipient survival was monitored for 50 days. RESULTS Transplantation of the pancreas from untreated wild-type donor mice resulted in microcirculatory damage of the transplanted graft and no recipient survived more than 72 h. Transplanting grafts from untreated donor mice lacking either endothelial or inducible NOS led to similar outcomes. In contrast, donor treatment with tetrahydrobiopterin prevented microcirculatory breakdown enabling long-term survival. Sole exception was transplantation of grafts from untreated donor mice lacking neuronal NOS. It resulted in intact microvascular structure and long-term recipient survival, either if donor mice were untreated or treated with tetrahydrobiopterin. CONCLUSION We demonstrate for the first time the crucial involvement of neuronal NOS in early microcirculatory derangements following solid organ transplantation. In this model, protective effects of tetrahydrobiopterin are mediated by targeting this isoform.
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Affiliation(s)
- Benno Cardini
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Katrin Watschinger
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Martin Hermann
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Peter Obrist
- Institute of Pathology, St. Vinzenz Krankenhaus, Zams, Austria
| | - Rupert Oberhuber
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Gerald Brandacher
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Surawee Chuaiphichai
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Keith M. Channon
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Johann Pratschke
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Manuel Maglione
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Ernst R. Werner
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
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153
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Fridell JA, Mangus RS, Chen JM, Goble ML, Mujtaba MA, Taber TE, Powelson JA. Late pancreas retransplantation. Clin Transplant 2014; 29:1-8. [DOI: 10.1111/ctr.12468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2014] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Jeanne M. Chen
- Department of Pharmacy; Indiana University Health - University Hospital; Indianapolis IN USA
| | | | | | - Tim E. Taber
- Medicine; Indiana University School of Medicine; Indianapolis IN USA
| | - John A. Powelson
- Surgery; Indiana University School of Medicine; Indianapolis IN USA
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154
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Lindahl JP, Reinholt FP, Eide IA, Hartmann A, Midtvedt K, Holdaas H, Dorg LT, Reine TM, Kolset SO, Horneland R, Øyen O, Brabrand K, Jenssen T. In patients with type 1 diabetes simultaneous pancreas and kidney transplantation preserves long-term kidney graft ultrastructure and function better than transplantation of kidney alone. Diabetologia 2014; 57:2357-65. [PMID: 25145544 DOI: 10.1007/s00125-014-3353-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 07/23/2014] [Indexed: 12/27/2022]
Abstract
AIMS/HYPOTHESIS In patients with type 1 diabetes and end-stage renal disease (ESRD) we aimed to determine whether long-term normoglycaemia, as achieved by successful simultaneous pancreas and kidney (SPK) transplantation, would preserve kidney graft structure and function better than live donor kidney (LDK) transplantation alone. METHODS Estimated GFR (eGFR) was calculated in SPK (n = 25) and LDK (n = 17) recipients in a stable phase 3 months after transplantation and annually during follow-up. Kidney graft biopsies were obtained at follow-up for measurement of glomerular volume (light microscopy), glomerular basement membrane (GBM) and podocyte foot process widths and mesangial volume fraction (electron microscopy). RESULTS SPK and LDK recipients were similar in age and diabetes duration at engraftment. Donor age was higher in the LDK group. Median follow-up time was 10.1 years. Mean HbA1c levels during follow-up were 5.5 ± 0.4% (37 ± 5 mmol/mol) and 8.3 ± 1.5% (68 ± 16 mmol/mol) in the SPK and LDK group, respectively (p < 0.001). Compared with SPK recipients, LDK recipients had wider GBM (369 ± 109 nm vs 281 ± 57 nm; p = 0.008) and increased mesangial volume fraction (median 0.23 [range 0.13-0.59] vs 0.16 [0.10-0.41]; p = 0.007) at follow-up. Absolute eGFR change from baseline was -11 ± 21 and -23 ± 15 ml min(-1) 1.73 m(-2) (p = 0.060), whereas eGFR slope was -1.1 (95% CI -1.7, -0.5) and -2.6 (95% CI -3.1, -2.1) ml min(-1) 1.73 m(-2) per year in the SPK and LDK group, respectively (p = 0.001). CONCLUSIONS/INTERPRETATION In patients with type 1 diabetes and long-term normoglycaemia after successful SPK transplantation, kidney graft ultrastructure and function were better preserved compared with LDK transplantation alone.
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Affiliation(s)
- Jørn P Lindahl
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway,
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155
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Rangel EB. Tacrolimus in pancreas transplant: a focus on toxicity, diabetogenic effect and drug–drug interactions. Expert Opin Drug Metab Toxicol 2014; 10:1585-605. [DOI: 10.1517/17425255.2014.964205] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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156
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Stratta RJ, Farney AC, Rogers J, Orlando G. Immunosuppression for pancreas transplantation with an emphasis on antibody induction strategies: review and perspective. Expert Rev Clin Immunol 2014; 10:117-32. [PMID: 24236648 DOI: 10.1586/1744666x.2014.853616] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A review of recent literature was performed to identify trends and evaluate outcomes with respect to immunosuppression in pancreas transplantation (PTX). In the past decade, the majority of PTXs were performed with depleting antibody induction, particularly in the setting of either calcineurin inhibitor minimization, corticosteroid withdrawal or both. Maintenance immunosuppression consisted of predominantly tacrolimus (TAC)/mycophenolatemofetil, TAC/mycophenolic acid or TAC/sirolimus with or without corticosteroids. Depending on PTX category, donor and recipient risk factors, case mix and immunosuppressive regimen, the 1-year incidence of acute rejection has decreased to 5-20%. Current 1-year rates of immunological pancreas graft loss range between 1.8 and 6%. Depleting antibody induction and either TAC/mycophenolatemofetil or TAC/sirolimus maintenance therapy with early steroid withdrawal have become the mainstay of immunosuppression in PTX. However, the development of non-nephrotoxic, nondiabetogenic, and nongastrointestinal toxic regimens is highly desirable to improve quality of life in all solid organ transplant recipients.
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Affiliation(s)
- Robert J Stratta
- Department of General Surgery, Section of Transplantation, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC27157, USA
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157
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Stratta RJ, Rogers J, Orlando G, Farooq U, Al-Shraideh Y, Doares W, Kaczmorski S, Farney AC. Depleting antibody induction in simultaneous pancreas-kidney transplantation: a prospective single-center comparison of alemtuzumab versus rabbit anti-thymocyte globulin. Expert Opin Biol Ther 2014; 14:1723-30. [DOI: 10.1517/14712598.2014.953049] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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158
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Stratta RJ, Farney AC, Orlando G, Farooq U, Al-Shraideh Y, Rogers J. Similar results with solitary pancreas transplantation compared with simultaneous pancreas-kidney transplantation in the new millennium. Transplant Proc 2014; 46:1924-7. [PMID: 25131072 DOI: 10.1016/j.transproceed.2014.05.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The purpose of this study was to analyze our single-center outcomes according to pancreas transplant (PT) category in the new millennium by using standardized management protocols. PATIENTS AND METHODS We retrospectively studied 202 consecutive PTs (179 with portal-enteric drainage) in 192 patients; all received either rabbit antithymocyte globulin or alemtuzumab induction in combination with tacrolimus, mycophenolate mofetil, and tapered corticosteroids or early steroid withdrawal. Unlike simultaneous pancreas/kidney (SPK) transplant, solitary PT (SPT) recipients were managed with routine perioperative anticoagulation and surveillance pancreas biopsies. RESULTS From November 2001 to March 2013, we performed 162 SPK transplants, 35 pancreas after kidney transplants, and 5 pancreas-alone transplants (40 SPTs). Demographic characteristics were mostly comparable; however, the SPT group had younger donors, shorter waiting time, fewer HLA mismatches, and fewer African-American recipients but more retransplants (all, P < .05). With a mean follow-up of 5.5 versus 7.5 years, overall patient (86.4% SPK vs 86.8% SPT), kidney graft (74% SPK vs 80% SPT), and pancreas graft (both 65%) survival rates were comparable. Although mortality rates were similar, mortality patterns differed because no SPT recipients died early, whereas the 1-, 3-, and 5-year mortality rates after SPK transplant were 4%, 9% and 12%, respectively (P < .05). The most common causes of pancreas graft loss were death with functioning grafts in SPK recipients and acute/chronic rejection in SPT recipients. Rates of early thrombosis were 8.6% in SPK patients and 5% in SPT patients. Cumulative clinical acute rejection rates were similar between groups (SPK 29% vs SPT 27.5%; P = NS). CONCLUSIONS In the setting of depleting antibody induction and tacrolimus-based therapy, HLA matching, careful donor and recipient selection, portal-enteric drainage, selective perioperative anticoagulation, and surveillance SPT biopsy monitoring, similar medium-term outcomes can be achieved in SPK transplants and SPTs in the new millennium.
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Affiliation(s)
- R J Stratta
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - A C Farney
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - G Orlando
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - U Farooq
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Y Al-Shraideh
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - J Rogers
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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159
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Otsuki K, Yoshikawa K, Kenmoshi T, Akutsu N, Maruyama M, Asano T, Saigo K, Hasegawa M, Aoyama H, Matsumoto I, Ito T, Uchino Y. Evaluation of insulin independence using 11C-methionine positron emission tomography after living-donor and brain-dead donor pancreas transplantation. Transplant Proc 2014; 46:1913-6. [PMID: 25131069 DOI: 10.1016/j.transproceed.2014.05.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We recently reported that (11)C-methionine positron-emission tomography (PET) is clinically useful for the evaluation of the pancreatic function of the living donor. The objective of this study was to evaluate the postoperative insulin independence in 10 living donor (LD) and 10 brain-dead donor (BD) pancreas transplantations for 20 patients with type I diabetes mellitus by using (11)C-methionine PET. After 6 months, PET/computed tomography was performed 30 minutes after (11)C-methionine (370-740 MBq) injection. The uptake in the pancreas was expressed as the standardized uptake value (SUV). Patient survival rates were 100% at 5 years for LD transplantations and at 2 years for BD transplantations. Insulin independence was 60% for LD transplantations at 5 years and 75% for BD transplantations at 2 years. There were no major surgical complications such as vascular thrombosis, intra-abdominal abscess, and graft pancreatitis. The SUVs for LD and BD pancreas transplantations with insulin independence were 7.2 ± 1.8 and 10.4 ± 2.3, respectively. The SUVs for LD pancreas transplantations with insulin dependence and BD pancreas transplantations with graft failure were 3.6 ± 1.1 and 2.9 ± 1.0, respectively. At 5 years after transplantation, for the LD transplants, the insulin-independent rate was 100% for the graft recipients with an SUV higher than 5, and the median insulin independence duration of the graft recipients with an SUV less than 5 was 7 months (P < .01). The (11)C-methionine PET may be a potent modality to predict long-term insulin independence and the avoidance of pancreas graft failure.
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Affiliation(s)
- K Otsuki
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan.
| | - K Yoshikawa
- National Institute of Radiological Sciences, Chiba, Japan
| | - T Kenmoshi
- Department of Transplantation Surgery, Fujita Health University, Nagoya, Japan
| | - N Akutsu
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan
| | - M Maruyama
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan
| | - T Asano
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan
| | - K Saigo
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan
| | - M Hasegawa
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan
| | - H Aoyama
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan
| | - I Matsumoto
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan
| | - T Ito
- Department of Transplantation Surgery, Fujita Health University, Nagoya, Japan
| | - Y Uchino
- Chiba Ryogo Center, PET Imaging Division, Chiba, Japan
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160
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Nagaraju S, Bottino R, Wijkstrom M, Trucco M, Cooper DKC. Islet xenotransplantation: what is the optimal age of the islet-source pig? Xenotransplantation 2014; 22:7-19. [DOI: 10.1111/xen.12130] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 06/26/2014] [Indexed: 12/24/2022]
Affiliation(s)
- Santosh Nagaraju
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - Rita Bottino
- Division of Immunogenetics; Department of Pediatrics; Children's Hospital of Pittsburgh; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - Martin Wijkstrom
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - Massimo Trucco
- Division of Immunogenetics; Department of Pediatrics; Children's Hospital of Pittsburgh; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - David K. C. Cooper
- Thomas E. Starzl Transplantation Institute; University of Pittsburgh Medical Center; Pittsburgh PA USA
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161
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Montiel-Casado MC, Pérez-Daga JA, Aranda-Narváez JM, Fernández-Burgos I, Sánchez-Pérez B, León-Díaz FJ, Cabello-Díaz M, Rodríguez-Burgos D, Hernández-Marrero D, Santoyo-Santoyo J. Pancreas graft survival in simultaneous pancreas-kidney versus pancreas-after-kidney and pancreas alone transplantations: a single institution experience. Transplant Proc 2014; 45:3609-11. [PMID: 24314973 DOI: 10.1016/j.transproceed.2013.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Pancreas transplantation offers excellent outcomes today in patients who have type-1 diabetes mellitus (DM) with difficult control in terms of increasing patient and pancreatic graft survival. Different factors in donors, recipients, and the perioperative period have been associated with long-term graft survival. The aim of this study was to compare pancreatic graft survival in simultaneous pancreas-kidney transplantation (SPK) and the other two modalities, pancreas-alone and pancreas-after-kidney transplantation (non-SPK), at our institution. METHODS This retrospective cohort study included 63 pancreas transplantation patients from January 2007 to May 2012 at our institution. The patients were divided into two groups: SPK and non-SPK transplantations. We excluded those patients who had transplants with vascular graft loss. The primary endpoint was 1-year and overall graft survival with consideration of multiple relevant variables. Non-parametric tests were calculated with the statistical package SPSS 20 (SPSS INC, Chicago, IL). RESULTS The 1-year and overall graft survival in this period was 87.3% and 82.5%, respectively. The median follow-up was 963 days. The causes of graft loss were vascular (64%) and immunologic (34%). Finally, we included 56 pancreas transplantations, 46 (82%) were SPK and 10 (18%) non-SPK. The donor and recipient characteristics were similar in both groups, except for the duration of DM (SPK 22 years vs. non-SPK 29 years) and recipient body mass index (SPK 23 vs. non-SPK 28); P = .042 and P = .003, respectively. The cold ischemia time was 563 minutes (standard deviation, 145). Bivariate analysis showed that long-term graft loss was only influenced by matching for gender (P = .023). Using the Kaplan-Meier method, the pancreas graft survival was better in SPK than in non-SPK transplants (log rank .038). CONCLUSIONS Patients who receive pancreas-alone or pancreas-after-kidney grafts have shorter long-term graft survival. Multiple strategies should be applied to improve immunologic surveillance and obtain an early diagnosis of graft rejection.
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Affiliation(s)
- M C Montiel-Casado
- Department of Digestive Surgery and Transplantation, Hospital Regional Universitario Carlos Haya, Málaga, Spain.
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162
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Voskuil MD, Mittal S, Sharples EJ, Vaidya A, Gilbert J, Friend PJ, Ploeg RJ. Improving monitoring after pancreas transplantation alone: fine-tuning of an old technique. Clin Transplant 2014; 28:1047-53. [PMID: 24990774 DOI: 10.1111/ctr.12416] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2014] [Indexed: 11/28/2022]
Abstract
Graft survival after pancreas transplantation alone (PTA) is significantly poorer than graft survival after simultaneous pancreas kidney (SPK) and is particularly affected by difficulty in monitoring rejection. Exocrine bladder drainage allows assessment of pancreas graft function as urinary amylase (UA). However, standards for UA collection and interpretation are not well defined. In this study, 21 bladder-drained PTA recipients were monitored with daily values for UA and urine creatinine (Creat) concentration from post-transplant 10-mL samples and 24-h collections. Clinical events were documented and correlated to UA measurements. UA values were found to increase post-transplant until day 15, and large interpatient variability was noted (median 12 676 IU/L, range 668-60 369 IU/L). A strong correlation was found total 24-h UA production and spot UA/Creat ratio (r = 0.80, p < 0.001). UA/Creat ratio showed less variation during episodes of impaired renal function; therefore, urinary amylase baseline was defined as the median UA/Creat ratio after day 15. A > 25% decrease of UA predicted 9/13 (69%) events. We conclude that individual baselines should be set once the values have stabilized after 15 d post-transplant and that spot UA/Creat measures are reliable, patient friendly and indicate potential events after PTA.
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Affiliation(s)
- Michiel D Voskuil
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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163
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Siskind E, Maloney C, Ashburn S, Akerman M, Siskind T, Goldberg L, Bhaskaran M, Basu A, Molmenti E, Ortiz J. The use of venous jump grafts in pancreatic transplantation - no difference in patient or allograft outcomes - an update of the UNOS database. Clin Transplant 2014; 28:883-8. [PMID: 24930804 DOI: 10.1111/ctr.12397] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2014] [Indexed: 12/17/2022]
Abstract
Venous jump grafts are used in pancreas transplantation to salvage a pancreas with a short portal vein or to facilitate an easier anastomosis. There have been no large studies evaluating the safety of venous jump grafts in pancreas transplantation. We analyzed the UNOS database to determine whether venous jump grafts are associated with graft loss or patient death. Data from UNOS on all adult pancreas transplant recipients 1996-2012 were analyzed. Venous extension grafts were used in 2657 cases; they were not in 18 124. Kaplan-Meier/product-limit estimates analysis demonstrated similar patient survival (p < 0.641) and death-censored graft survival (p < 0.351) at one, three, five,10, and 15 yr between subjects with and without venous jump grafts. There was a statistically significant difference in one-yr unadjusted patient survival between the venous extension graft (94.9%) and the no-venous extension graft (95.8%) groups (p < 0.045) and a borderline difference in one-yr graft survival between the venous extension graft (84.1%) and the no-venous extension graft (82.6%) groups (p < 0.055). There was no significant difference in patient survival or allograft survival at the three-, five-, 10-, and 15-yr intervals. The use of venous jump grafts is not associated with increased graft loss or mortality.
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Affiliation(s)
- Eric Siskind
- Department of Transplantation, North Shore Long Island Jewish Health System, Hofstra University School of Medicine, Manhasset, NY, USA
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164
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Stratta R, Rogers J, Orlando G, Farooq U, Al-Shraideh Y, Farney A. 5-Year Results of a Prospective, Randomized, Single-Center Study of Alemtuzumab Compared With Rabbit Antithymocyte Globulin Induction in Simultaneous Kidney–Pancreas Transplantation. Transplant Proc 2014; 46:1928-31. [DOI: 10.1016/j.transproceed.2014.05.080] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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165
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Porubsky M, Gruessner A, Rana A, Jie T, Gruessner R. Excellent Outcomes Can Be Achieved in Young Pancreas Transplant Alone Recipients by Addition of Sirolimus to Maintenance Immunosuppression Regimen. Transplant Proc 2014; 46:1932-5. [DOI: 10.1016/j.transproceed.2014.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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166
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Risk Factors of Pancreatic Graft Loss and Death of Receptor After Simultaneous Pancreas/Kidney Transplantation. Transplant Proc 2014; 46:1827-35. [DOI: 10.1016/j.transproceed.2014.05.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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167
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Chiang JL, Kirkman MS, Laffel LMB, Peters AL. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care 2014; 37:2034-54. [PMID: 24935775 PMCID: PMC5865481 DOI: 10.2337/dc14-1140] [Citation(s) in RCA: 589] [Impact Index Per Article: 58.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - M Sue Kirkman
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lori M B Laffel
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Anne L Peters
- Division of Endocrinology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
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168
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169
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Lindahl JP, Jenssen T, Hartmann A. Long-term outcomes after organ transplantation in diabetic end-stage renal disease. Diabetes Res Clin Pract 2014; 105:14-21. [PMID: 24698407 DOI: 10.1016/j.diabres.2014.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 02/27/2014] [Accepted: 03/06/2014] [Indexed: 01/28/2023]
Abstract
Patients with type 1 diabetic end-stage renal disease (ESRD) may be offered single kidney transplantation from a live donor (LDK) or a deceased donor (DDK) to replace the lost kidney function. In the latter setting the patient may also receive a simultaneous pancreas together with a kidney from the same donor (SPK). Also in some cases a pancreas after kidney may be offered to those who have previously received a kidney alone (PAK). The obvious benefit of a successful SPK transplantation is that the patients not only recover from uremia but also obtain normal blood glucose control without use of insulin or other hypoglycemic agents. Accordingly, this combined procedure has become an established treatment for type 1 diabetic patients with ESRD. Adequate long-term blood glucose control may theoretically lead to reduced progression or even reversal of microvascular complications. Another potential beneficial effect may be improvement of patient and kidney graft survival. Development of diabetic complications usually takes a decade to develop and accordingly any potential benefits of a pancreas transplant will not easily be disclosed during the first decade after transplantation. The purpose of the review is to assess the present literature of outcomes after kidney transplantation in patients with diabetic ESRD, with our without a concomitant pancreas transplantation. The points of interest given in this review are microvascular complications, graft outcomes, cardiovascular outcomes and mortality.
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Affiliation(s)
- Jørn Petter Lindahl
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway.
| | - Trond Jenssen
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Anders Hartmann
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
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170
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Fourtounas C. Transplant options for patients with type 2 diabetes and chronic kidney disease. World J Transplant 2014; 4:102-110. [PMID: 25032099 PMCID: PMC4094945 DOI: 10.5500/wjt.v4.i2.102] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/20/2014] [Accepted: 05/14/2014] [Indexed: 02/05/2023] Open
Abstract
Chronic kidney disease (CKD) has become a real epidemic around the world, mainly due to ageing and diabetic nephropathy. Although diabetic nephropathy due to type 1 diabetes mellitus (T1DM) has been studied more extensively, the vast majority of the diabetic CKD patients suffer from type 2 diabetes mellitus (T2DM). Renal transplantation has been established as a first line treatment for diabetic nephropathy unless there are major contraindications and provides not only a better quality of life, but also a significant survival advantage over dialysis. However, T2DM patients are less likely to be referred for renal transplantation as they are usually older, obese and present significant comorbidities. As pre-emptive renal transplantation presents a clear survival advantage over dialysis, all T2DM patients with CKD should be referred for early evaluation by a transplant center. The transplant center should have enough time in order to examine their eligibility focusing on special issues related with diabetic nephropathy and explore the best options for each patient. Living donor kidney transplantation should always be considered as the first line treatment. Otherwise, the patient should be listed for deceased donor kidney transplantation. Recent progress in transplantation medicine has improved the “transplant menu” for T2DM patients with diabetic nephropathy and there is an ongoing discussion about the place of simultaneous pancreas kidney (SPK) transplantation in well selected patients. The initial hesitations about the different pathophysiology of T2DM have been forgotten due to the almost similar short- and long-term results with T1DM patients. However, there is still a long way and a lot of ethical and logistical issues before establishing SPK transplantation as an ordinary treatment for T2DM patients. In addition recent advances in bariatric surgery may offer new options for severely obese T2DM patients with CKD. Nevertheless, the existing data for T2DM patients with advanced CKD are rather scarce and bariatric surgery should not be considered as a cure for diabetic nephropathy, but only as a bridge for renal transplantation.
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171
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Sayed BA, Turgeon NA. Pancreas Transplantation of Non-Traditional Recipients. CURRENT TRANSPLANTATION REPORTS 2014. [DOI: 10.1007/s40472-014-0011-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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172
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Walter M, Jazra M, Kykalos S, Kuehn P, Michalski S, Klein T, Wunsch A, Viebahn R, Schenker P. 125 Cases of duodenoduodenostomy in pancreas transplantation: a single-centre experience of an alternative enteric drainage. Transpl Int 2014; 27:805-15. [PMID: 24750305 PMCID: PMC4497354 DOI: 10.1111/tri.12337] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 02/20/2014] [Accepted: 04/14/2014] [Indexed: 02/07/2023]
Abstract
Several exocrine drainage procedures have been successfully developed to perform pancreas transplantation (PT). Retroperitoneal graft placement allows exocrine drainage via direct duodenoduodenostomy (DD). This technique provides easy access for endoscopic surveillance and biopsy. A total of 241 PT procedures were performed in our centre between 2002 and 2012. DD was performed in 125 patients, and duodenojejunostomy (DJ) in 116 patients. We retrospectively compared our experience with these two types of enteric drainage, focusing on graft and patient survivals, as well as postoperative complications. With a mean follow-up of 59 months, both groups demonstrated comparable patient and graft survivals. 14 (11%) of 125 cases in the DD group and 21 (18%) of 116 cases in the DJ group had pancreatic graft loss (P = 0.142). Graft thrombosis [5 (4%) vs. 18 (16%) P = 0.002], anastomotic insufficiency [2 (1.6%) vs. 8 (7%) P = 0.052] and relaparotomy [52 (41%) vs. 56 (48%) P = 0.29] occurred more frequently in the DJ group, whereas gastrointestinal bleeding [14 (11%) vs. 4 (3%) P = 0.026] occurred more often in the DD group. DD is a feasible and safe technique in PT, with no increase in enteric complications. It is equivalent to other established techniques and extends the feasibility of anastomotic sites, especially in recipients who have undergone a second transplantation.
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Affiliation(s)
- Martin Walter
- Department of General, Visceral and Transplant Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
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173
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Krishnan R, Alexander M, Robles L, Foster CE, Lakey JRT. Islet and stem cell encapsulation for clinical transplantation. Rev Diabet Stud 2014; 11:84-101. [PMID: 25148368 DOI: 10.1900/rds.2014.11.84] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Over the last decade, improvements in islet isolation techniques have made islet transplantation an option for a certain subset of patients with long-standing diabetes. Although islet transplants have shown improved graft function, adequate function beyond the second year has not yet been demonstrated, and patients still require immunosuppression to prevent rejection. Since allogeneic islet transplants have experienced some success, the next step is to improve graft function while eliminating the need for systemic immunosuppressive therapy. Biomaterial encapsulation offers a strategy to avoid the need for toxic immunosuppression while increasing the chances of graft function and survival. Encapsulation entails coating cells or tissue in a semipermeable biocompatible material that allows for the passage of nutrients, oxygen, and hormones while blocking immune cells and regulatory substances from recognizing and destroying the cell, thus avoiding the need for systemic immunosuppressive therapy. Despite advances in encapsulation technology, these developments have not yet been meaningfully translated into clinical islet transplantation, for which several factors are to blame, including graft hypoxia, host inflammatory response, fibrosis, improper choice of biomaterial type, lack of standard guidelines, and post-transplantation device failure. Several new approaches, such as the use of porcine islets, stem cells, development of prevascularized implants, islet nanocoating, and multilayer encapsulation, continue to generate intense scientific interest in this rapidly expanding field. This review provides a comprehensive update on islet and stem cell encapsulation as a treatment modality in type 1 diabetes, including a historical outlook as well as current and future research avenues.
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Affiliation(s)
- Rahul Krishnan
- Department of Surgery, University of California Irvine, Orange, CA 92868, USA
| | - Michael Alexander
- Department of Surgery, University of California Irvine, Orange, CA 92868, USA
| | - Lourdes Robles
- Department of Surgery, University of California Irvine, Orange, CA 92868, USA
| | - Clarence E Foster
- Department of Surgery, University of California Irvine, Orange, CA 92868, USA
| | - Jonathan R T Lakey
- Department of Surgery, University of California Irvine, Orange, CA 92868, USA
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174
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Abstract
PURPOSE OF REVIEW Pigs have emerged as potential sources of islets for clinical transplantation. Wild-type porcine islets (adult and neonatal) transplanted into the portal vein have successfully reversed diabetes in nonhuman primates. However, there is a rapid loss of the transplanted islets on exposure to blood, known as the instant blood-mediated inflammatory reaction (IBMIR), as well as a T-cell response that leads to rejection of the graft. RECENT FINDINGS Genetically modified pig islets offer a number of potential advantages, particularly with regard to reducing the IBMIR-related graft loss and protecting the islets from the primate immune response. Emerging data indicate that transgenes specifically targeted to pig β cells using an insulin promoter (in order to maximize target tissue expression while limiting host effects) can be achieved without significant effects on the pig's glucose metabolism. SUMMARY Experience with the transplantation of islets from genetically engineered pigs into nonhuman primates is steadily increasing, and has involved the deletion of pig antigenic targets to reduce the primate humoral response, the expression of transgenes for human complement-regulatory and coagulation-regulatory proteins, and manipulations to reduce the effect of the T-cell response. There is increasing evidence of the advantages of using genetically engineered pigs as sources of islets for future clinical trials.
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175
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Dong GH, Li XF, Li JZ, Zhang ZD, Hu WM, Luo YH, Li ZD, Tian BL, He MX, Zhu XW. Intercellular adhesion molecular-1, Fas, and Fas ligand as diagnostic biomarkers for acute allograft rejection of pancreaticoduodenal transplantation in pigs. Dig Dis Sci 2014; 59:778-86. [PMID: 24162270 DOI: 10.1007/s10620-013-2904-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 10/03/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND The early diagnosis of pancreas allograft dysfunction is crucial for the management and long-term survival of transplanted pancreases. We investigated whether intercellular adhesion molecular-1 (ICAM-1), Fas, and Fas ligand (FasL) can be used as novel biomarkers of acute pancreaticoduodenal allograft dysfunction in pigs. METHODS Forty outbred landraces were randomly divided into three groups. In the control group (8 pigs), a sham operation was performed but no drugs were administered. In groups 1 and 2 (8 pairs each), pancreaticoduodenal transplantation was performed, with the latter administered immunosuppressive drugs and the former not administered drugs. The expression of ICAM-1, Fas, and FasL mRNA in the peripheral vein blood was assessed by flow cytometry and RT-PCR, pre-transplant and on days 1, 3, 5, and 7 after transplantation. Simultaneously, the levels of glucose, insulin, and glucagon in the serum of the recipients were evaluated. The allograft pancreas tissue was obtained to assess the pathological damage and the expression of Fas and FasL by immunohistochemistry. RESULTS On the first 7 days after transplantation, ICAM-1, Fas, and FasL mRNA expression in the blood leukocytes of the recipient increased significantly in groups 1 and 2 compared with the control group (P < 0.01). However, the levels in group 2 were significantly lower than those in group 1 (P < 0.05). Interestingly, the FasL expression increased but the Fas expression decreased gradually in the graft pancreas tissue during the first week after transplantation in both groups 1 and 2 compared with the control group (P < 0.05). The levels of serous glucose, insulin, and glucagon in groups 1 and 2 obviously changed on day 1 after transplantation but returned to normal on day 2. The recipient's pancreas pathological sections did not exhibit any rejection changes on days 1 and 3 after transplantation but showed rejection damage on days 5 and 7. CONCLUSION ICAM-1, Fas, and FasL were found to be sensitive biomarkers of acute pancreas allograft dysfunction after pancreaticoduodenal transplantation in pigs, and their monitoring could be used to evaluate the effectiveness of the immunosuppression therapy.
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Affiliation(s)
- Gao-hong Dong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
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176
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Therapeutic cell encapsulation techniques and applications in diabetes. Adv Drug Deliv Rev 2014; 67-68:74-83. [PMID: 24103903 DOI: 10.1016/j.addr.2013.09.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 09/19/2013] [Accepted: 09/25/2013] [Indexed: 12/27/2022]
Abstract
The encapsulation of therapeutic cells permits the implantation of allogeneic and xenogeneic cells for the regulation of certain physiological processes damaged by the death or senescence of host tissues. The encapsulation of pancreatic cells for the treatment of diabetes is emphasized; however, many of the techniques are applicable to a wide array of mammalian cell applications. The summary of both established and novel encapsulation techniques, clinical trials, and commercial product developments highlights the metered but steady pace of therapeutic cell encapsulation towards implementation.
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177
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Scharp DW, Marchetti P. Encapsulated islets for diabetes therapy: history, current progress, and critical issues requiring solution. Adv Drug Deliv Rev 2014; 67-68:35-73. [PMID: 23916992 DOI: 10.1016/j.addr.2013.07.018] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 07/10/2013] [Accepted: 07/22/2013] [Indexed: 02/07/2023]
Abstract
Insulin therapy became a reality in 1921 dramatically saving lives of people with diabetes, but not protecting them from long-term complications. Clinically successful free islet implants began in 1989 but require life long immunosuppression. Several encapsulated islet approaches have been ongoing for over 30 years without defining a clinically relevant product. Macro-devices encapsulating islet mass in a single device have shown long-term success in large animals but human trials have been limited by critical challenges. Micro-capsules using alginate or similar hydrogels encapsulate individual islets with many hundreds of promising rodent results published, but a low incidence of successful translation to large animal and human results. Reduction of encapsulated islet mass for clinical transplantation is in progress. This review covers the status of both early and current studies including the presentation of corporate efforts involved. It concludes by defining the critical items requiring solution to enable a successful clinical diabetes therapy.
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178
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Liver, pancreas and small bowel transplantation: current ethical issues. Best Pract Res Clin Gastroenterol 2014; 28:281-92. [PMID: 24810189 DOI: 10.1016/j.bpg.2014.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 02/07/2014] [Accepted: 02/21/2014] [Indexed: 01/31/2023]
Abstract
We describe the medical state of the art in liver, pancreas and small bowel transplantation, and portray the ethical issues. Although most ethical questions related to these transplantations are not specific for liver, pancreas and small bowel, they do challenge ethical analysis as well as new policies and clinical procedures. Firstly, outcomes continue to be of utmost concern, as information is only limited available, is developing over time and is surrounded by many uncertainties. Secondly, characteristics of donors and recipients should be carefully evaluated. The question of what qualifies a donor and a recipient should be considered against the background of a quest for extended criteria, embracing marginal cases, and a judgment with regard to what counts as a good enough outcome. Thirdly, ethical principles of autonomy and fairness are pushed, given the circumstance of severe scarcity, towards limits that can easily be crossed.
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179
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Martins LS, Henriques AC, Fonseca IM, Rodrigues AS, Oliverira JC, Dores JM, Dias LS, Cabrita AM, Silva JD, Noronha IL. Pancreatic autoantibodies after pancreas-kidney transplantation - do they matter? Clin Transplant 2014; 28:462-9. [PMID: 24655222 DOI: 10.1111/ctr.12337] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 02/05/2023]
Abstract
Type 1 diabetes recurrence has been documented in simultaneous pancreas-kidney transplants (SPKT), but this diagnosis may be underestimated. Antibody monitoring is the most simple, noninvasive, screening test for pancreas autoimmune activity. However, the impact of the positive autoimmune markers on pancreas graft function remains controversial. In our cohort of 105 SPKT, we studied the cases with positive pancreatic autoantibodies. They were immunosuppressed with antithymocyte globulin, tacrolimus, mycophenolate, and steroids. The persistence or reappearance of these autoantibodies after SPKT and factors associated with their evolution and with graft outcome were analyzed. Pancreatic autoantibodies were prospectively monitored. Serum samples were collected before transplantation and at least once per year thereafter. At the end of the follow-up (maximum 138 months), 43.8% of patients were positive (from pre-transplant or after recurrence) for at least one autoantibody - the positive group. Antiglutamic acid decarboxylase was the most prevalent (31.4%), followed by anti-insulin (8.6%) and anti-islet cell autoantibodies (3.8%). Bivariate analysis showed that the positive group had higher fasting glucose, higher glycated hemoglobin (HbA1c), lower C-peptide levels, and a higher number of HLA-matches. Analyzing the sample divided into four groups according to pre-/post-transplant autoantibodies profile, the negative/positive group tended to present the higher HbA1c values. Multivariate analysis confirmed the significant association between pancreas autoimmunity and HbA1c and C-peptide levels. Positivity for these autoantibodies pre-transplantation did not influence pancreas survival. The unfavorable glycemic profile observed in the autoantibody-positive SPKT is a matter of concern, which deserves further attention.
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Affiliation(s)
- La Salete Martins
- Nephrology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal; Transplantation Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal
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180
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Little SA, Leelarathna L, Barendse SM, Walkinshaw E, Tan HK, Lubina Solomon A, de Zoysa N, Rogers H, Choudhary P, Amiel SA, Heller SR, Evans M, Flanagan D, Speight J, Shaw JAM. Severe hypoglycaemia in type 1 diabetes mellitus: underlying drivers and potential strategies for successful prevention. Diabetes Metab Res Rev 2014; 30:175-90. [PMID: 24185859 DOI: 10.1002/dmrr.2492] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 02/03/2023]
Abstract
Hypoglycaemia remains an over-riding factor limiting optimal glycaemic control in type 1 diabetes. Severe hypoglycaemia is prevalent in almost half of those with long-duration diabetes and is one of the most feared diabetes-related complications. In this review, we present an overview of the increasing body of literature seeking to elucidate the underlying pathophysiology of severe hypoglycaemia and the limited evidence behind the strategies employed to prevent episodes. Drivers of severe hypoglycaemia including impaired counter-regulation, hypoglycaemia-associated autonomic failure, psychosocial and behavioural factors and neuroimaging correlates are discussed. Treatment strategies encompassing structured education, insulin analogue regimens, continuous subcutaneous insulin infusion pumps, continuous glucose sensing and beta-cell replacement therapies have been employed, yet there is little randomized controlled trial evidence demonstrating effectiveness of new technologies in reducing severe hypoglycaemia. Optimally designed interventional trials evaluating these existing technologies and using modern methods of teaching patients flexible insulin use within structured education programmes with the specific goal of preventing severe hypoglycaemia are required. Individuals at high risk need to be monitored with meticulous collection of data on awareness, as well as frequency and severity of all hypoglycaemic episodes.
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Affiliation(s)
- S A Little
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
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181
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182
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Chhabra P, Brayman KL. Overcoming barriers in clinical islet transplantation: current limitations and future prospects. Curr Probl Surg 2014; 51:49-86. [PMID: 24411187 DOI: 10.1067/j.cpsurg.2013.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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183
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Gioviale MC, Bellavia M, Damiano G, Lo Monte AI. Beyond islet transplantation in diabetes cell therapy: from embryonic stem cells to transdifferentiation of adult cells. Transplant Proc 2014; 45:2019-24. [PMID: 23769099 DOI: 10.1016/j.transproceed.2013.01.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 01/24/2013] [Indexed: 12/22/2022]
Abstract
Exogenous insulin is, at the moment, the therapy of choice of diabetes, but does not allow tight regulation of glucose leading to long-term complications. Recently, pancreatic islet transplantation to reconstitute insulin-producing β cells, has emerged as an alternative promising therapeutic approach. Unfortunately, the number of donor islets is too low compared with the high number of patients needing a transplantation leading to a search for renewable sources of high-quality β-cells. This review, summarizes more recent promising approaches to the generation of new β-cells from embryonic stem cells for transdifferentiation of adult cells, particularly a critical examination of the seminal work by Lumelsky et al.
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Affiliation(s)
- M C Gioviale
- Transplant Unit, AOUP P. Giaccone, School of Medicine, Università degli Studi di Palermo, Palermo, Italy
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184
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Perosa M, Noujaim H, Ianhez LE, Oliveira RA, Mota LT, Branez JR, Paredes MM, Giacaglia L, Genzini T. Experience with 53 portal-duodenal drained solitary pancreas transplants. Clin Transplant 2014; 28:198-204. [PMID: 24382212 DOI: 10.1111/ctr.12297] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 11/27/2022]
Abstract
Systemic-enteric drainage is currently the most common technique for pancreas transplantation (PT). A novel alternative technique, portal-duodenal drainage (PDD), has potential physiological benefits and provides improved monitoring of the pancreatic graft. The current study describes 53 solitary PT procedures (43 pancreas after kidney and 10 pancreas transplant alone) using the PDD technique over the last three yr. This method resulted in one-yr patient survival at 96% and 83% graft survival. There were five cases (9.4%) of thrombosis, in which transplantectomy and two-layer closure of the native duodenum were performed. No fistulas were observed. Here, we demonstrate that the PDD technique in PT was as safe and effective as current techniques in clinical use.
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Affiliation(s)
- Marcelo Perosa
- HEPATO - Hepatology and Organ Transplantation, Bandeirantes Hospital, São Paulo, Brazil
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185
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Jacewicz M, Marino CR. Neurologic complications of pancreas and small bowel transplantation. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1277-1293. [PMID: 24365419 DOI: 10.1016/b978-0-7020-4088-7.00087-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In the past decade, substantial improvements in patient and graft survival for pancreas and small bowel transplants have been achieved. Despite this progress, many patients still develop neurologic complications in the course of their illness. Small bowel transplants produce more neurologic complications because of the complex metabolic environment in which the procedure is performed and because of the intense immune suppression necessitated by the greater immunogenicity of the intestinal mucosa. Pancreas transplants stabilize and/or improve the signs and symptoms of diabetic neuropathy over time. Because transplantation of the pancreas is often coupled with a kidney transplant and small intestine with liver, neurologic complications in these patients sometimes reflect problems involving the organ partner or both organs. The spectrum of neurologic complications for pancreas and small bowel transplant recipients is similar to other organ transplants but their frequency varies depending on the type of transplant performed.
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Affiliation(s)
- Michael Jacewicz
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Christopher R Marino
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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186
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Abstract
Transplantation of the whole vascularized pancreas can provide insulin secretion in patients with insulin-dependent, type 1 diabetes mellitus (T1D). It restores euglycemia in most patients, with the potential to impact the chronic diabetic complications and quality of life. Pancreas transplantation (PT) is presently controversial for type 2 diabetes mellitus (T2D). For those patients with severe glycemic dysregulation, T2D can be associated with the same life-threatening sequelae as T1D such as severe hypoglycemia and kidney failure that could be corrected by pancreas (and kidney) transplantation. Thus, clinical indications and patient selection criteria are very important. This chapter will review the current status of PT for T2D and discuss the options and evolution of transplant perspectives.
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Affiliation(s)
- Gaetano Ciancio
- The DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA,
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187
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Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft. Case Rep Transplant 2013; 2013:171807. [PMID: 24455393 PMCID: PMC3886212 DOI: 10.1155/2013/171807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/05/2013] [Indexed: 12/13/2022] Open
Abstract
We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population.
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188
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189
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Examination of carbohydrate metabolism parameters after simultaneous pancreas-kidney transplantation. Transplant Proc 2013; 45:3698-702. [PMID: 24315001 DOI: 10.1016/j.transproceed.2013.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
End-stage renal failure, a frequent complication of type 1 diabetes mellitus, requires renal replacement therapy. Our team examined the laboratory parameters of carbohydrate metabolism in 18 patients with type 1 diabetes at 10 to 89 months after simultaneous pancreas-kidney transplantation. We compared these results with those of 17 patients with type 1 diabetes who had formerly received kidney-alone transplantations, and were undergoing insulin treatment, as well as with those of 16 metabolically healthy controls. The hemoglobin A1c (HbA1c) and blood glucose levels of the pancreas-kidney transplant recipients were within the normal ranges, not differing significantly from those of the healthy controls. In contrast, the HbA1c and glucose levels were significantly elevated among kidney transplanted diabetic subjects. However, fasting and 2-hour insulin levels of pancreas-kidney transplant patients were significantly higher than those of the controls, indicating insulin resistance. According to these results, the insulin secretion by the pancreas graft sufficiently compensated for insulin resistance. Thus 10 to 89 months after successful pancreas-kidney transplantation, carbohydrate metabolism by type 1 diabetic patients was well controlled without antidiabetic therapy.
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190
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Rogers J, Farney AC, Orlando G, Farooq U, Al-Shraideh Y, Stratta RJ. Pancreas transplantation with portal venous drainage with an emphasis on technical aspects. Clin Transplant 2013; 28:16-26. [PMID: 24410731 DOI: 10.1111/ctr.12275] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 12/17/2022]
Abstract
Advances in surgical techniques and clinical immunosuppression have led to improving results in vascularized pancreas transplantation. Most pancreas transplants are performed with enteric exocrine drainage and systemic venous delivery of insulin (systemic-enteric technique) although bladder drainage (systemic-bladder technique) remains a viable option. To improve the physiology of pancreas transplantation, an innovative technique of portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric technique) was developed and refined over the past 27 yr. However, the potential of portal-enteric pancreas transplantation has never been fully realized as it is currently performed in only 18% of simultaneous pancreas-kidney/sequential pancreas after kidney and 10% of pancreas-alone transplants with enteric drainage. A number of studies have demonstrated no major or consistent differences in outcomes for bladder-drained or enteric-drained pancreas transplants with either portal or systemic venous drainage although some studies suggest purported metabolic and immunologic advantages associated with portal venous delivery of insulin. The purpose of this study is to review the existing literature on portal-enteric pancreas transplantation with an emphasis on surgical aspects and technical modifications/nuances that have been introduced with time and experience.
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Affiliation(s)
- Jeffrey Rogers
- Section of Transplantation, Department of General Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
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191
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Abstract
Pancreas transplants are performed in multiple centres across the UK with good graft survival rates. This places an increasing demand on radiology services, particularly as the complication rates are not insignificant. The imaging appearances of pancreas transplants and their complications can be difficult to interpret. This review provides an illustrative journey through the anatomical appearances of a graft and the imaging appearances of complications, as a reference tool for radiologists.
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Affiliation(s)
- A Yates
- Department of Radiology, University Hospital of Wales, Cardiff, UK.
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Clinically significant peripancreatic fluid collections after simultaneous pancreas-kidney transplantation. Transplantation 2013; 95:1263-9. [PMID: 23507700 DOI: 10.1097/tp.0b013e318289c978] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Peripancreatic fluid collections (PPFC) are a serious complication after simultaneous pancreas-kidney transplantation (SPKTx). METHODS Retrospective study for all 223 SPKTx performed from December 8, 1996, to October 10, 2011, to evaluate the risk factors (RF) and impact of PPFCs on outcomes was conducted. RESULTS Clinically significant PPFCs were seen in 36 (16%) cases, all within 3 months after transplantation. Radiologic drainage resolved 2 (6%) cases, and 34 required laparotomy (mean [SD], 4 [7]). Compared with the non-PPFC group (n=186), the PPFC group had similar patient and total kidney graft survivals but significantly lower total pancreas survival (68% vs. 85%) and greater incidence of infections (75% vs. 46%, all P<0.05) at 5 years. PPFCs were associated with early graft pancreatitis in 18 (50%), pancreatic fistula in 20 (56%, 9 with obvious duodenal stump leak) and infection in the collection in 20 (56%) cases. Comparison of PPFCs with pancreas graft loss to the PPFCs with surviving grafts showed that the incidence of pancreatic fistula was greater in the former (90% pancreas graft loss vs. 42% pancreas graft survival, P<0.01). Binary logistic regression analysis of RF for developing PPFC showed a donor age >30 years to be significant (P=0.03; odds ratio, 3.4; confidence interval, 1.1-10.5) and a trend of association with donor body mass index >30 and pancreas cold ischemia time greater than 12 hr. CONCLUSIONS PPFCs are associated with significant reduction in pancreas allograft survival and impact resource use. Donor age >30 years is a significant RF for their development. PPFCs associated with pancreatic fistula carry a greater risk for pancreas graft loss.
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193
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Abdel-Aal AK, Elsayed A, Saddekni S, Hamed MF, Young C. Endovascular Treatment of Pancreatic Allograft Transplant Arteriovenous Fistula Using Amplatzer Vascular Plug 2. Cardiovasc Intervent Radiol 2013; 37:819-24. [DOI: 10.1007/s00270-013-0682-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 05/25/2013] [Indexed: 12/28/2022]
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Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (AMR) is acknowledged and defined in kidney transplantation, but where do we stand as far as pancreas transplantation is concerned? Here we appraise the most recent findings in pancreatic AMR and give suggestions for future research in the field by addressing currently unresolved issues. RECENT FINDINGS Five main topics are discussed: chronological assessment of all literature on biopsy-proven pancreatic AMR; role of C4d and recent development in other markers; the use of sentinel organs, such as kidney biopsies and duodenal patch biopsies for diagnosis of pancreatic AMR; studies addressing islet pathology and its relevance in AMR; and protocol and follow-up pancreas biopsy practice in relation to pancreas transplant management and survival. SUMMARY Antibody-mediated processes play a role in pancreas transplantation. However, sensitive markers, pathophysiological understanding, and adequate interventions have not yet been established. Much data are still lacking and we believe that studying protocol and follow-up biopsies along with serial donor-specific antibody data may improve pancreas transplant patient management and outcomes.
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195
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Finger EB, Radosevich DM, Dunn TB, Chinnakotla S, Sutherland DER, Matas AJ, Pruett TL, Kandaswamy R. A composite risk model for predicting technical failure in pancreas transplantation. Am J Transplant 2013; 13:1840-9. [PMID: 23711225 PMCID: PMC3696030 DOI: 10.1111/ajt.12269] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 03/13/2013] [Accepted: 03/14/2013] [Indexed: 01/25/2023]
Abstract
Technical failure (TF) continues to have a significant impact on the success of pancreas transplantation. We assessed risk factors for TF in 1115 pancreas transplants performed at a single center between 1998 and 2011. The overall TF rate was 10.2%. In a multivariable model, donor BMI ≥ 30 (HR 1.87, p = 0.005), donor Cr ≥ 2.5 (HR 3.16, p = 0.007), donor age >50 (HR 1.73, p = 0.082) and preservation time >20 h (HR 2.17, p < 0.001) were associated with TF. Bladder drainage of exocrine secretions was protective (HR 0.54, p = 0.002). We incorporated these factors in a Composite Risk Model. In this model the presence of one risk factor did not significantly increase risk of TF (HR 1.35, p = 0.346). Two risk factors in combination increased risk greater than threefold (HR 3.65, p < 0.001) and three risk factors increased risk greater than sevenfold (HR 7.66, p = <0.001). The analysis also identified many factors that were not predictive of TF, including previous transplants, immunosuppressive agent selection, and almost all recipient demographic parameters. While the model suggests that two or more risk factors predict TF, strategies to reduce preservation time may mitigate some of this risk.
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Affiliation(s)
| | | | | | | | | | | | | | - Raja Kandaswamy
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455
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196
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Lindahl JP, Hartmann A, Horneland R, Holdaas H, Reisæter AV, Midtvedt K, Leivestad T, Oyen O, Jenssen T. Improved patient survival with simultaneous pancreas and kidney transplantation in recipients with diabetic end-stage renal disease. Diabetologia 2013; 56:1364-71. [PMID: 23549518 DOI: 10.1007/s00125-013-2888-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/25/2013] [Indexed: 01/20/2023]
Abstract
AIMS/HYPOTHESIS We aimed to determine whether simultaneous pancreas and kidney (SPK) transplantation would improve patient and kidney graft survival in diabetic end-stage renal disease (ESRD) compared with kidney transplantation alone (KTA). METHODS Follow-up data were retrieved for all 630 patients with diabetic ESRD who had received SPK or KTA at our centre from 1983 to the end of 2010. Recipients younger than 55 years of age received either an SPK (n = 222) or, if available, a single live donor kidney (LDK; n = 171). Older recipients and recipients with greater comorbidity received a single deceased donor kidney (DDK; n = 237). Survival was analysed by the Kaplan-Meier method and in multivariate Cox regression analysis adjusting for recipient and donor characteristics. RESULTS Patient survival was superior in SPK compared with both LDK and DDK recipients in univariate analysis. Follow-up time (mean ± SD) after transplantation was 7.1 ± 5.7 years. Median actuarial patient survival was 14.0 years for SPK, 11.5 years for LDK and 6.7 years for DDK recipients. In multivariate analyses including recipient age, sex, treatment modality, time on dialysis and era, SPK transplantation was protective for all-cause mortality compared with both LDK (p = 0.02) and DDK (p = 0.029) transplantation. After the year 2000, overall patient survival improved compared with previous years (HR 0.40, 95% CI 0.30, 0.55; p < 0.001). Pancreas graft survival also improved after 2000, with a 5 year graft survival rate of 78% vs 61% in previous years (1988-1999). CONCLUSIONS/INTERPRETATION Recipients of SPK transplants have superior patient survival compared with both LDK and DDK recipients, with improved results seen over the last decade.
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Affiliation(s)
- J P Lindahl
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway.
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Abstract
Solid organ transplantations save lives in patients affected by terminal organ failures and improve quality of life. Organ transplantations have gradually ameliorated in the last two decades and usually provide excellent results in children and young adults, and are increasingly challenged by the growing proportion of elderly transplant patients with comorbidities. Renal transplantation increases patient survival over dialysis, and lifesaving transplants are indispensible to treat patients with liver, heart, or lung irreversible diseases. Solid organ transplant programs activity has been steadily growing but is still far from global needs, with great differences among countries. Solid organ transplantations are essential for developed and mature health care systems.
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Affiliation(s)
- Josep M Grinyó
- Department of Nephrology, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, Barcelona 08907, Spain.
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198
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Niederhaus SV, Kaufman DB, Odorico JS. Induction therapy in pancreas transplantation. Transpl Int 2013; 26:704-14. [DOI: 10.1111/tri.12122] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/11/2013] [Accepted: 04/25/2013] [Indexed: 01/24/2023]
Affiliation(s)
- Silke V. Niederhaus
- Division of Transplantation; Department of Surgery; University of Maryland Medical Center; Baltimore; MD; USA
| | - Dixon B. Kaufman
- Department of Surgery; Division of Transplantation; University of Wisconsin School of Medicine and Public Health; Madison; WI; USA
| | - Jon S. Odorico
- Department of Surgery; Division of Transplantation; University of Wisconsin School of Medicine and Public Health; Madison; WI; USA
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Combined Pancreas-Kidney Transplantation for Patients With End-Stage Nephropathy Caused by Type-2 Diabetes Mellitus. Transplantation 2013; 95:1030-6. [DOI: 10.1097/tp.0b013e3182861945] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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200
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Follow-up of secondary diabetic complications after pancreas transplantation. Curr Opin Organ Transplant 2013; 18:102-10. [PMID: 23283247 DOI: 10.1097/mot.0b013e32835c28c5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Successful pancreas transplantation restores physiologic glycemic and metabolic control. Its effects on overall patient survival (especially for simultaneous pancreas-kidney transplantation) are clear-cut. We herein review the available literature to define the impact of pancreas transplantation on chronic complications of diabetes mellitus. RECENT FINDINGS With longer-term follow-up, wider patient populations, and more accurate investigational tools (clinical and functional tests, noninvasive imaging, histology, and molecular biology), growing data show that successful pancreas transplantation may slow the progression, stabilize, and even favor the regression of secondary complications of diabetes, both microvascular and macrovascular, in a relevant proportion of recipients. SUMMARY Patients who are referred for pancreas transplantation usually suffer from advanced chronic complications of diabetes, which have classically been deemed irreversible. A successful pancreas transplantation is often able to slow the progression, stabilize, and even reverse many microvascular and macrovascular complications of diabetes. Growing clinical evidence shows that the expected natural history of long-term diabetic complications can be significantly modified by successful pancreas transplantation.
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