Pancreas graft survival in simultaneous pancreas-kidney versus pancreas-after-kidney and pancreas alone transplantations: a single institution experience

Impact of pancreas transplantation alone on kidney function: A multicenter clinical cohort study

Pancreas transplantation alone (PTA) is a β cell replacement option for selected patients with type 1 diabetes mellitus; concerns have been raised regarding deterioration in kidney function (KF) after PTA. This retrospective multicenter study assessed actual impact of transplantation and immunosuppression on KF in PTA recipients at three Transplant Centers. The primary composite endpoint 10 years after PTA was >50% eGFR decline, eGFR < 30 mL/min/1.73 m2 , and/or receiving a kidney transplant (KT). Overall, 822 PTA recipients met eligibility. Median baseline and 10-year eGFR (mL/min/1.73 m2 ) were 76.3 (58.1-100.8) and 51.3 (35.3-65.9), respectively. Primary composite endpoint occurred in 98 patients (53.5%) with 45 experiencing a >50% decrease in eGFR by 10 years post-transplant, 38 eGFR < 30 mL/min/1.73 m2 and 49 requiring KT. KF declined most significantly within 6 months post-PTA, more often in females and patients with better preserved GFR up to 5 years with 11.6% kidney failure at 10 years. Patient survival and death-censored graft survival were both 68% at 10 years with overall graft thrombosis rate 8%. KF declined initially after PTA but stabilized with further slow progression. In conclusion, prospective intervention studies are needed to test renal sparing interventions while gathering more granular data.

Medical and Surgical Management of the Failed Pancreas Transplant

Despite the continued improvements in pancreas transplant outcomes in recent decades, a subset of recipients experience graft failure and can experience substantial morbidity and mortality. Here, we summarize what is known about the failed pancreas allograft and what factors are important for consideration of retransplantation. The current definition of pancreas allograft failure and its challenges for the transplant community are explored. The impacts of a failed pancreas allograft are presented, including patient survival and resultant morbidities. The signs, symptoms, and medical and surgical management of a failed pancreas allograft are described, whereas the options and consequences of immunosuppression withdrawal are reviewed. Medical and surgical factors necessary for successful retransplant candidacy are detailed with emphasis on how well-selected patients may achieve excellent retransplant outcomes. To achieve substantial medical mitigation and even pancreas retransplantation, patients with a failed pancreas allograft warrant special attention to their residual renal, cardiovascular, and pulmonary function. Future studies of the failed pancreas allograft will require improved reporting of graft failure from transplant centers and continued investigation from experienced centers.

Maximizing Utilization in Pancreas Transplantation: Phenotypic Characteristics Differentiating Aggressive From Nonaggressive Transplant Centers

BACKGROUND

Maximizing pancreas utilization requires a balance between judicious donor selection and transplant center aggressiveness. We sought to determine how such aggressiveness affects transplant outcomes.

METHODS

Using the Scientific Registry of Transplant Recipients, we studied 28 487 deceased-donor adult pancreas transplants. Donor and recipient demographic factors indicative of aggressiveness were used to score center aggressiveness. We compared outcomes of low (> 1 SD below mean), medium (± 1 SD from mean), and high (> 1 SD above mean) aggressiveness centers using bivariate and multivariable regressions.

RESULTS

Donor and recipient aggressiveness demonstrated a roughly linear relationship (R = 0.20). Center volume correlated moderately with donor (rs = 0.433) and recipient (rs = 0.270) aggressiveness. In bivariate analysis, there was little impact of donor selection aggressiveness on graft survival. Further, for simultaneous pancreas and kidney transplants, centers with greater recipient aggressiveness selection had better graft survival. High-volume centers had better graft survival than low-volume centers. In multivariable analysis, donor aggressiveness did not have an effect on graft survival, whereas graft survival for medium (hazard ratio [HR], 0.66, 95% confidence interval [95% CI], 0.53-0.83) and high (HR, 0.67; CI, 0.51-0.86) recipient aggressiveness performed better than low-aggressiveness centers. There was a clear volume effect, with high-volume centers (>20 transplants/year; HR, 0.69; CI, 0.61-0.79) performing better than low-volume centers.

CONCLUSIONS

Center practice patterns using higher-risk donors and recipients did not negatively affect outcomes. This effect is likely mediated through efficiencies gained with the increased transplant volumes at these centers.

Pancreas grafts for transplantation from donors with hypertension: an analysis of the scientific registry of transplant recipients database

BACKGROUND

With the rising demands for pancreas transplantation, surgeons are trying to extend the donors pool and set up a more appropriate assessment system. We aim to evaluate the effect of donor hypertension on recipient overall and graft survival rates.

METHODS

Twenty-four thousand one hundred ninety-two pancreas transplantation patients from the Scientific Registry of Transplant Recipients database were subdivided into hypertension group (HTN, n = 1531) and non-hypertension group (non-HTN, n = 22,661) according to the hypertension status of donors. Recipient overall and graft survival were analyzed and compared by log rank test, and hazard ratios of predictors were estimated using Cox proportional hazard models.

RESULTS

Patient overall and graft survival of non-HTN group were higher than that of the HTN group (both p < 0.001). The duration of hypertension negatively influenced both overall and graft survival rates (both p < 0.001). Multivariate analyses demonstrated that hypertension was an independent factor for reduced survival (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.01-1.18; p < 0.001). Other independent factors included recipient body mass index (HR, 1.02; 95% CI, 1.01-1.05; p < 0.001) and transplant type (pancreas after kidney transplants / pancreas transplant alone vs. simultaneous pancreas-kidney transplants; HR, 1.41; 95% CI, 134-1.55; p < 0.001).

CONCLUSIONS

Donor hypertension is an independent factor for recipient survival after pancreas transplantation and could be considered in donor selection as well as post-transplant surveillance in clinical practice.

What's new in clinical solid organ transplantation by 2013

Innovative and exciting advances in the clinical science in solid organ transplantation continuously realize as the results of studies, clinical trials, international conferences, consensus conferences, new technologies and discoveries. This review will address to the full spectrum of news in transplantation, that verified by 2013. The key areas covered are the transplantation activity, with particular regards to the donors, the news for solid organs such as kidney, pancreas, liver, heart and lung, the news in immunosuppressive therapies, the news in the field of tolerance and some of the main complications following transplantation as infections and cancers. The period of time covered by the study starts from the international meetings held in 2012, whose results were published in 2013, up to the 2013 meetings, conferences and consensus published in the first months of 2014. In particular for every organ, the trends in numbers and survival have been reviewed as well as the most relevant problems such as organ preservation, ischemia reperfusion injuries, and rejections with particular regards to the antibody mediated rejection that involves all solid organs. The new drugs and strategies applied in organ transplantation have been divided into new way of using old drugs or strategies and drugs new not yet on the market, but on phase Ito III of clinical studies and trials.