Prognostic risk factors for graft failure following pancreas transplantation: results of multivariate analysis of data from the International Pancreas Transplant Registry

Comparison of azathioprine and mycophenolate mofetil for the prevention of acute rejection in recipients of pancreas transplantation

The study was performed to compare the efficacy and side effects of azathioprine (AZA) and mycophenolate mofetil (MMF) in conjunction with cyclosporine or tacrolimus and steroids for the prevention of acute pancreas rejection during the first 6 months of pancreas transplantation. In this case-controlled study, MMF is compared with historical controls of AZA in the prevention of acute pancreas rejection. The primary measures of treatment efficacy were patient and pancreas survival rate at 6 months after transplantation. Secondary efficacy measures were the occurrence of biopsy-proven pancreas rejections and the use of antilymphocyte preparations for rejection treatment. A total of 111 pancreas transplant patients (57 in the AZA group and 54 in the MMF group) were evaluated. The 6-month patient survival rate was 96% in the AZA group versus 97% in the MMF group (p = 0.57). The 6-month pancreas graft survival rate was 88% in the AZA group versus 91% in the MMF group (p = 0.29). However, biopsy-proven rejection episodes during the first 6 months of transplantation were significantly lower with MMF (46%) than with AZA (69%) (p = 0.01). In addition, patients in the AZA group received a greater number of full courses of antilymphocyte therapy as a rejection treatment (p = 0.004). Overall, the frequency of adverse events was similar, although the MMF group experienced higher incidences of gastrointestinal adverse events. In conclusion, compared with AZA, MMF significantly reduces the rate of biopsy-proven pancreas rejection during the first 6 months of transplantation and is well tolerated, except for gastrointestinal adverse events.

Effect of blood group and HLA matching on pancreas graft survival with the use of UW solution

Pancreas graft survival is influenced by various donor and recipient factors. Factors that have posed serious problems to pancreas transplantation have included the limited cold ischemia time, early graft thrombosis, and rejection. A limited cold ischemia time not only causes problems in terms of logistics but also implies limitations with regard to HLA matching and organ exchange. Between August 1988 and August 1989 we performed a prospective, nonrandomized European multicenter study to evaluate the effect of University of Wisconsin (UW) solution on pancreas graft survival. In addition, donor and recipient factors were collected and their influence on graft survival analyzed. Overall pancreas graft survival at 1 and 4 years was 67% and 59%, respectively (n = 62). When only simultaneous pancreas and kidney transplants were included, the graft survival was 70% and 63% at 1 and 4 years, respectively. The incidence of pancreas graft thrombosis was 8%. Cold ischemia time was not found to significantly influence pancreas graft survival even when it exceeded 12 h. Factors that did were HLA-DR matching, simultaneous pancreas and kidney transplantation versus pancreas transplantation alone, and ABO blood group matching. We feel that the use of UW solution for pancreas preservation has contributed to improved pancreas graft survival and has reduced early graft thrombosis despite much longer cold ischemia times of over 12 h. Given this and the significant effect of HLA and blood group matching, we conclude that more attention should be paid to preoperative matching and organ exchange in order to further improve pancreas graft survival.

Report from the International Pancreas Transplant Registry

From December, 1966 through 1990, 3082 pancreas transplants were reported to the International Registry. A detailed analysis was performed on the 2087 transplants in the 1986-90 data base; during this time the overall one year recipient and graft functional survival rates were 89% and 62%. Univariate analyses showed graft survival rates to be significantly higher with bladder drainage than with other duct management techniques, with a simultaneous kidney transplant than without, and with preservation in UW than other solutions. Storage up to 30 hours did not adversely effect results. Graft survival rates were significantly higher in North America than Europe, a discrepancy that persisted in a Cox proportional hazard analysis that also included duct management, recipient category, HLA-DR mismatching, immunosuppression with anti-T cell agents, preservation solution and duration, and year of transplant as the other variables; three were identified to have a significant (p less than 0.05) impact on the relative risk (RR) of graft loss: 1) Recipient category, with an RR of 0.43 when placed simultaneously with a kidney; 2) Year, with an RR of 0.76 for transplants performed in 1989-90 versus 1986-88; and 3) Location, with an RR of 0.75 for transplants in North America versus Europe. The technical failure rate was significantly lower in North America than Europe, but this was not an explanation for the differences in outcome, since the same factors sorted out as significant in a Cox proportional hazard analysis of technically successful cases only. Furthermore, logistic regression analysis showed retransplantation, duct management, recipient category, preservation solution, and storage time to significantly influence the technical failure rate. The risk of technical failure was lowest for primary, bladder-drained, simultaneous pancreas/kidney, less than 12 hour UW stored grafts; year and location of transplant were not significant factors. Pancreas transplant results continue to improve and are in the range of those for other solid organs.