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Grasberger J, Ortiz F, Ekstrand A, Sallinen V, Ahopelto K, Finne P, Gissler M, Lempinen M, Helanterä I. Infection-Related Hospitalizations After Simultaneous Pancreas-Kidney Transplantation Compared to Kidney Transplantation Alone. Transpl Int 2024; 37:12235. [PMID: 38444997 PMCID: PMC10912468 DOI: 10.3389/ti.2024.12235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024]
Abstract
The total burden of infections after transplantation has not been compared in detail between recipients of simultaneous pancreas-kidney transplantation (SPK) and kidney transplantation alone (KTA). We compared infection-related hospitalizations and bacteremias after transplantation during 1- and 5-year follow-up among 162 patients undergoing SPK. The control group consisted of 153 type 1 diabetics undergoing KTA with the inclusion criteria of donor and recipient age < 60, and BMI < 30. During the first year, SPK patients had more infection-related hospitalizations (0.54 vs. 0.31 PPY, IRR 1.76, p = <0.001) and bacteremias (0.11 vs. 0.01 PPY, IRR 17.12, p = <0.001) compared to KTA patients. The first infection-related hospitalizations and bacteremias occurred later during follow-up in KTA patients. SPK was an independent risk factor for infection-related hospitalization and bacteremia during the first year after transplantation, but not during the 5-year follow-up. Patient survival did not differ between groups, however, KTA patients had inferior kidney graft survival. SPK patients are at greater risk for infection-related hospitalizations and bacteremias during the first year after transplantation compared to KTA patients, however, at the end of the follow-up the risk of infection was similar between groups.
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Affiliation(s)
- Juulia Grasberger
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Fernanda Ortiz
- Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Agneta Ekstrand
- Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kaisa Ahopelto
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Patrik Finne
- Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Marko Lempinen
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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2
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Lange UG, Rademacher S, Zirnstein B, Sucher R, Semmling K, Bobbert P, Lederer AA, Buchloh D, Seidemann L, Seehofer D, Jahn N, Hau HM. Cardiovascular outcomes after simultaneous pancreas kidney transplantation compared to kidney transplantation alone: a propensity score matching analysis. BMC Nephrol 2021; 22:347. [PMID: 34674648 PMCID: PMC8529792 DOI: 10.1186/s12882-021-02522-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Coronary heart disease due to arteriosclerosis is the leading cause of death in type 1 diabetic patients with end-stage renal disease (ESRD). The aim of this study was to evaluate the effect of simultaneous pancreas kidney transplantation (SPKT) compared to kidney transplantation alone (KTA) on survival, cardiovascular function and metabolic outcomes. Methods A cohort of 127 insulin-dependent diabetes mellitus (IDDM) patients with ESRD who underwent either SPKT (n = 100) or KTA (n = 27) between 1998 and 2019 at the University Hospital of Leipzig were retrospectively evaluated with regard to cardiovascular and metabolic function/outcomes as well as survival rates. An additional focus was placed on the echocardiographic assessment of systolic and diastolic cardiac function pretransplant and during follow-up. To avoid selection bias, a 2:1 propensity score matching analysis (PSM) was performed. Results After PSM, a total of 63 patients were identified; 42 patients underwent SPKT, and 21 patients received KTA. Compared with the KTA group, SPKT recipients received organs from younger donors (p < 0.05) and donor BMI was higher (p = 0.09). The risk factor-adjusted hazard ratio for mortality in SPKT recipients compared to KTA recipients was 0.63 (CI: 0.49–0.89; P < 0.05). The incidence of pretransplant cardiovascular events was higher in the KTA group (KTA: n = 10, 47% versus SPKT: n = 10, 23%; p = 0.06), but this difference was not significant. However, the occurrence of cardiovascular events in the SPKT group (n = 3, 7%) was significantly diminished after transplantation compared to that in the KTA recipients (n = 6, 28%; p = 0.02). The cardiovascular death rate was higher in KTA recipients (19%) than in SPK recipients with functioning grafts (3.3%) and comparable to that in patients with failed SPKT (16.7%) (p = 0.16). In line with pretransplant values, SPKT recipients showed significant improvements in Hb1ac values (p = 0.001), blood pressure control (p = < 0.005) and low-density lipoprotein/high-density lipoprotein (LDL/HDL) ratio (p = < 0.005) 5 years after transplantation. With regard to echocardiographic assessment, SPKT recipients showed significant improvements in left ventricular systolic parameters during follow-up. Conclusions Normoglycaemia and improvement of lipid metabolism and blood pressure control achieved by successful SPKT are associated with beneficial effects on survival, cardiovascular outcomes and systolic left ventricular cardiac function. Future studies with larger samples are needed to make predictions regarding cardiovascular events and graft survival. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02522-8.
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Affiliation(s)
- U G Lange
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - S Rademacher
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - B Zirnstein
- Sana Hospital Borna, Clinic of Anaesthesia, Intensive Care and Palliative Medicine, Rudolf-Virchow-Strasse 2, 04552, Borna, Saxony, Germany
| | - R Sucher
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - K Semmling
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - P Bobbert
- Ev. Hubertus Hospital Berlin, Clinic of Internal Medicine and Angiology, Spanische Allee 10-14, 14129, Berlin, Berlin, Germany
| | - A A Lederer
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - D Buchloh
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - L Seidemann
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - D Seehofer
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - N Jahn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - H-M Hau
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany. .,Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Boggi U, Vistoli F, Andres A, Arbogast HP, Badet L, Baronti W, Bartlett ST, Benedetti E, Branchereau J, Burke GW, Buron F, Caldara R, Cardillo M, Casanova D, Cipriani F, Cooper M, Cupisti A, Davide J, Drachenberg C, de Koning EJP, Ettorre GM, Fernandez Cruz L, Fridell JA, Friend PJ, Furian L, Gaber OA, Gruessner AC, Gruessner RW, Gunton JE, Han D, Iacopi S, Kauffmann EF, Kaufman D, Kenmochi T, Khambalia HA, Lai Q, Langer RM, Maffi P, Marselli L, Menichetti F, Miccoli M, Mittal S, Morelon E, Napoli N, Neri F, Oberholzer J, Odorico JS, Öllinger R, Oniscu G, Orlando G, Ortenzi M, Perosa M, Perrone VG, Pleass H, Redfield RR, Ricci C, Rigotti P, Paul Robertson R, Ross LF, Rossi M, Saudek F, Scalea JR, Schenker P, Secchi A, Socci C, Sousa Silva D, Squifflet JP, Stock PG, Stratta RJ, Terrenzio C, Uva P, Watson CJ, White SA, Marchetti P, Kandaswamy R, Berney T. First World Consensus Conference on pancreas transplantation: Part II - recommendations. Am J Transplant 2021; 21 Suppl 3:17-59. [PMID: 34245223 PMCID: PMC8518376 DOI: 10.1111/ajt.16750] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 02/07/2023]
Abstract
The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246.
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Chudek J, Kolonko A, Ziaja J, Francuz T, Kamińska D, Owczarek AJ, Kuczera P, Kujawa-Szewieczek A, Kusztal M, Kowalik AP, Bożek-Pająk D, Kluz J, Choręza P, Król R, Krajewska M, Cierpka L, Więcek A. Beneficial Effect of Successful Simultaneous Pancreas-Kidney Transplantation on Plasma Profile of Metalloproteinases in Type 1 Diabetes Mellitus Patients. J Clin Med 2021; 10:jcm10173800. [PMID: 34501247 PMCID: PMC8432100 DOI: 10.3390/jcm10173800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 12/04/2022] Open
Abstract
It is not fully elucidated whether the restoring of normal glucose metabolism after successful simultaneous pancreas-kidney transplantation (SPK) improves vascular wall morphology and function in type 1 diabetic (T1D) patients. Therefore, we compared arterial stiffness, assessed by pulse wave velocity (PWV), carotid intima-media thickness (IMT), and biomarkers of arterial wall calcification in T1D patients after SPK or kidney transplantation alone (KTA). In 39 SPK and 39 KTA adult patients of similar age, PWV, IMT, circulating matrix metalloproteinases (MMPs) and calcification biomarkers were assessed at median 83 months post transplantation. Additionally, carotid plaques were visualized and semi-qualitatively classified. Although PWV and IMT values were similar, the occurrence of atherosclerotic plaques (51.3 vs. 70.3%, p < 0.01) and calcified lesions (35.9 vs. 64.9%, p < 0.05) was lower in SPK patients. There were significantly lower concentrations of MMP-1, MMP-2, MMP-3, and osteocalcin in SPK subjects. Among the analyzed biomarkers, only logMMP-1, logMMP-2, and logMMP-3 concentrations were associated with log HbA1c. Multivariate stepwise backward regression analysis revealed that MMP-1 and MMP-3 variability were explained only by log HbA1c. Normal glucose metabolism achieved by SPK is followed by the favorable profile of circulating matrix metalloproteinases, which may reflect the vasoprotective effect of pancreas transplantation.
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Affiliation(s)
- Jerzy Chudek
- Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia, 40-027 Katowice, Poland;
| | - Aureliusz Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland; (P.K.); (A.K.-S.); (A.W.)
- Correspondence: ; Tel.: +48-32-259-1429
| | - Jacek Ziaja
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, 40-027 Katowice, Poland; (J.Z.); (A.P.K.); (D.B.-P.); (R.K.); (L.C.)
| | - Tomasz Francuz
- Department of Biochemistry, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Dorota Kamińska
- Department of Nephrology and Transplantation Medicine, Wrocław Medical University, 50-556 Wrocław, Poland; (D.K.); (M.K.); (M.K.)
| | - Aleksander J. Owczarek
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Medical University of Silesia, 40-752 Katowice, Poland; (A.J.O.); (P.C.)
| | - Piotr Kuczera
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland; (P.K.); (A.K.-S.); (A.W.)
| | - Agata Kujawa-Szewieczek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland; (P.K.); (A.K.-S.); (A.W.)
| | - Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine, Wrocław Medical University, 50-556 Wrocław, Poland; (D.K.); (M.K.); (M.K.)
| | - Adrian P. Kowalik
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, 40-027 Katowice, Poland; (J.Z.); (A.P.K.); (D.B.-P.); (R.K.); (L.C.)
| | - Dominika Bożek-Pająk
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, 40-027 Katowice, Poland; (J.Z.); (A.P.K.); (D.B.-P.); (R.K.); (L.C.)
| | - Joanna Kluz
- Department of Angiology, Hypertension and Diabetology, University Clinical Hospital, 50-556 Wrocław, Poland;
| | - Piotr Choręza
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Medical University of Silesia, 40-752 Katowice, Poland; (A.J.O.); (P.C.)
| | - Robert Król
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, 40-027 Katowice, Poland; (J.Z.); (A.P.K.); (D.B.-P.); (R.K.); (L.C.)
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wrocław Medical University, 50-556 Wrocław, Poland; (D.K.); (M.K.); (M.K.)
| | - Lech Cierpka
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, 40-027 Katowice, Poland; (J.Z.); (A.P.K.); (D.B.-P.); (R.K.); (L.C.)
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland; (P.K.); (A.K.-S.); (A.W.)
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Lehner LJ, Öllinger R, Globke B, Naik MG, Budde K, Pratschke J, Eckardt KU, Kahl A, Zhang K, Halleck F. Impact of Early Pancreatic Graft Loss on Outcome after Simultaneous Pancreas-Kidney Transplantation (SPKT)-A Landmark Analysis. J Clin Med 2021; 10:jcm10153237. [PMID: 34362019 PMCID: PMC8347953 DOI: 10.3390/jcm10153237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 01/06/2023] Open
Abstract
(1) Background: Simultaneous pancreas-kidney transplantation (SPKT) is a standard therapeutic option for patients with diabetes mellitus type I and kidney failure. Early pancreas allograft failure is a complication potentially associated with worse outcomes. (2) Methods: We performed a landmark analysis to assess the impact of early pancreas graft loss within 3 months on mortality and kidney graft survival over 10 years. This retrospective single-center study included 114 adult patients who underwent an SPKT between 2005 and 2018. (3) Results: Pancreas graft survival rate was 85.1% at 3 months. The main causes of early pancreas graft loss were thrombosis (6.1%), necrosis (2.6%), and pancreatitis (2.6%). Early pancreas graft loss was not associated with reduced patient survival (p = 0.168) or major adverse cerebral or cardiovascular events over 10 years (p = 0.741) compared to patients with functioning pancreas, after 3 months. Moreover, kidney graft function (p = 0.494) and survival (p = 0.461) were not significantly influenced by early pancreas graft loss. (4) Conclusion: In this study, using the landmark analysis technique, early pancreas graft loss within 3 months did not significantly impact patient or kidney graft survival over 10 years.
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Affiliation(s)
- Lukas Johannes Lehner
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
- Correspondence: ; Tel.: +49-30-45-051-4002
| | - Robert Öllinger
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.Ö.); (B.G.); (J.P.)
| | - Brigitta Globke
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.Ö.); (B.G.); (J.P.)
| | - Marcel G. Naik
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
- Berlin Institute of Health (BIH), 10117 Berlin, Germany;
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.Ö.); (B.G.); (J.P.)
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
| | - Andreas Kahl
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
| | - Kun Zhang
- Berlin Institute of Health (BIH), 10117 Berlin, Germany;
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
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Buron F, Reffet S, Badet L, Morelon E, Thaunat O. Immunological Monitoring in Beta Cell Replacement: Towards a Pathophysiology-Guided Implementation of Biomarkers. Curr Diab Rep 2021; 21:19. [PMID: 33895937 DOI: 10.1007/s11892-021-01386-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW Grafted beta cells are lost because of recurrence of T1D and/or allograft rejection, two conditions diagnosed with pancreas graft biopsy, which is invasive and impossible in case of islet transplantation. This review synthetizes the current pathophysiological knowledge and discusses the interest of available immune biomarkers. RECENT FINDINGS Despite the central role of auto-(recurrence of T1D) and allo-(T-cell mediated rejection) immune cellular responses, the latter are not directly monitored in routine. In striking contrast, there have been undisputable progresses in monitoring of auto and alloantibodies. Except for pancreas recipients in whom anti-donor HLA antibodies can be directly responsible for antibody-mediated rejection, autoantibodies (and alloantibodies in islet recipients) have no direct pathogenic effect. However, their fluctuation offers a surrogate marker for the activation status of T cells (because antibody generation depends on T cells). This illustrates the necessity to understand the pathophysiology when interpreting a biomarker and selecting the appropriate treatment.
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Affiliation(s)
- Fanny Buron
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, 5 Place d'Arsonval, 69003, Lyon, France
| | - Sophie Reffet
- Department of Endocrinology and Diabetes, Lyon-Sud Hospital, Hospices Civils de Lyon, 69310, Pierre-Bénite, France
| | - Lionel Badet
- Department of Urology and Transplantation surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, 5 Place d'Arsonval, 69003, Lyon, France
- French National Institute of Health and Medical Research (Inserm) Unit 1111, Lyon, France
- Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, 5 Place d'Arsonval, 69003, Lyon, France.
- French National Institute of Health and Medical Research (Inserm) Unit 1111, Lyon, France.
- Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France.
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.
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Hau HM, Jahn N, Brunotte M, Wagner T, Rademacher S, Branzan D, Sucher E, Seehofer D, Sucher R. Pre-operative ankle-brachial index for cardiovascular risk assessment in simultaneous pancreas-kidney transplant recipients: a simple and elegant strategy! BMC Surg 2021; 21:156. [PMID: 33752640 PMCID: PMC7983212 DOI: 10.1186/s12893-021-01159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/15/2021] [Indexed: 12/24/2022] Open
Abstract
Background Patients with insulin-dependent diabetes mellitus type 1 (IDDM1) and end-stage kidney disease (ESKD) undergoing simultaneous pancreas kidney transplantation (SPKT) are a population with diffuse atherosclerosis and elevated risk of cardio- and cerebrovascular morbidity and mortality. We aimed to investigate the feasibility of preoperative screening for peripheral arterial disease (PAD), specifically ankle-brachial index (ABI) testing, to predict peri- and postoperative outcomes in SPKT recipients. Methods Medical data (2000–2016) from all patients with IDDM and ESKD undergoing SPKT at our transplant center were retrospectively analyzed. The correlation between PAD (defined by an abnormal ABI before SPKT and graft failure and mortality rates as primary end points, and the occurrence of acute myocardial infarction, cerebrovascular and peripheral vascular complications as secondary end points were investigated after adjustment for known cardiovascular risk factors. Results Among 101 SPKT recipients in our transplant population who underwent structured physiological arterial studies, 17 patients (17%) were diagnosed with PAD before transplantation. PAD, as defined by a low ABI index, was an independent and significant predictor of death (HR, 2.99 (95% CI 1.00–8.87), p = 0.049) and pancreas graft failure (HR, 4.3 (95% CI 1.24–14.91), p = 0.022). No significant differences were observed for kidney graft failure (HR 1.85 (95% CI 0.76–4.50), p = 0.178). In terms of the secondary outcomes, patients with PAD were more likely to have myocardial infarction, stroke, limb ischemia, gangrene or amputation (HR, 2.90 (95% CI 1.19–7.04), p = 0.019). Conclusions Pre-transplant screening for PAD and cardiovascular risk factors with non-invasive ABI testing may help to reduce perioperative complications in high-risk patients. Future research on long-term outcomes might provide more in depth insights in optimal treatment strategies for PAD among SPKT recipients.
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Affiliation(s)
- Hans-Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany. .,Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Department of Surgery, University Hospital of Dresden, Fetscherstrasse 74, 03107, Dresden, Germany.
| | - Nora Jahn
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Leipzig, Germany
| | - Max Brunotte
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Tristan Wagner
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Daniela Branzan
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Elisabeth Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Robert Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
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Perdue JM, Ortiz AC, Parsikia A, Ortiz J. Kidney-Pancreas Transplant Recipients Experience Higher Risk of Complications Compared to the General Population after Undergoing Coronary Artery Bypass Grafting. Int J Angiol 2021; 30:107-116. [PMID: 34054268 DOI: 10.1055/s-0040-1721680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This retrospective analysis aims to identify differences in surgical outcomes between pancreas and/or kidney transplant recipients compared with the general population undergoing coronary artery bypass grafting (CABG). Using Nationwide Inpatient Sample (NIS) data from 2005 to 2014, patients who underwent CABG were stratified by either no history of transplant, or history of pancreas and/or kidney transplant. Multivariate analysis was used to calculate odds ratio (OR) to evaluate in-hospital mortality, morbidity, length of stay (LOS), and total hospital charge in all centers. The analysis was performed for both nonemergency and emergency CABG. Overall, 2,678 KTx (kidney transplant alone), 184 PTx (pancreas transplant alone), 254 KPTx (kidney-pancreas transplant recipients), and 1,796,186 Non-Tx (nontransplant) met inclusion criteria. KPTx experienced higher complication rates compared with Non-Tx (78.3 vs. 47.8%, p < 0.01). Those with PTx incurred greater total hospital charge and LOS. On weighted multivariate analysis, KPTx was associated with an increased risk for developing any complication following CABG (OR 3.512, p < 0.01) and emergency CABG (3.707, p < 0.01). This risk was even higher at transplant centers (CABG OR 4.302, p < 0.01; emergency CABG OR 10.072, p < 0.001). KTx was associated with increased in-hospital mortality following emergency CABG, while PTx and KPTx had no mortality to analyze. KPTx experienced a significantly higher risk of complications compared with the general population after undergoing CABG, in both transplant and nontransplant centers. These outcomes should be considered when providing perioperative care.
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Affiliation(s)
- Jordyn M Perdue
- Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio
| | | | - Afshin Parsikia
- Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio
| | - Jorge Ortiz
- Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio
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9
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Tang J, Gulyani A, Hewawasam E, McDonald S, Clayton P, Webster AC, Kanellis J, Jesudason S. Pregnancy outcomes for simultaneous Pancreas-Kidney transplant recipients versus kidney transplant recipients. Clin Transplant 2020; 35:e14151. [PMID: 33179349 DOI: 10.1111/ctr.14151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 10/25/2020] [Accepted: 11/02/2020] [Indexed: 12/01/2022]
Abstract
Data about pregnancy outcomes for simultaneous pancreas-kidney transplant recipients (SPKR) are limited. We compared pregnancy outcomes in SPKR to Kidney Transplant Recipients (KTR) from 2001-17 using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and the Australian and New Zealand Pancreas Islet Transplant Registry (ANZPITR). A total of 19 pregnancies to 15 SPKR mothers, and 348 pregnancies to 235 KTR mothers were reported. Maternal ages were similar (SPKR 33.9 ± 3.9 years; KTR 32.1 ± 4.8 years, p = .10); however, SPKR had a shorter transplant to first-pregnancy interval compared to KTR (SPKR 3.3 years, IQR (1.7, 4.1); KTR 5 years, IQR (2.6, 8.7), p = .02). Median difference in creatinine pre- and post-pregnancy was similar between the groups (KTR -3 µmol/L, IQR (-15, 6), SPKR -3 µmol/L, IQR (-11, 3), p = .86). Maternal, fetal and kidney transplant outcomes were similar despite higher rates of pre-existing peripheral vascular and coronary artery diseases in SPKR. Live birth rates (>20 weeks) were comparable (SPKR 93.8% vs. KTR 96.8%, p = .06). KTR with either type 1 or type 2 diabetes mellitus (24 births) had similar outcomes compared to SPKR. In this national cohort, pregnancy outcomes were similar between SPKR and KTR mothers; however, findings should be interpreted with caution due to small sample sizes.
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Affiliation(s)
- Joanne Tang
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aarti Gulyani
- Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and Australian and New Zealand Organ Donation Registry (ANZOD), South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Erandi Hewawasam
- Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and Australian and New Zealand Organ Donation Registry (ANZOD), South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Stephen McDonald
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and Australian and New Zealand Organ Donation Registry (ANZOD), South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Phil Clayton
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and Australian and New Zealand Organ Donation Registry (ANZOD), South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Angela C Webster
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Shilpanjali Jesudason
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and Australian and New Zealand Organ Donation Registry (ANZOD), South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
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10
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Parajuli S, Arunachalam A, Swanson KJ, Aziz F, Garg N, Redfield RR, Kaufman D, Djamali A, Odorico J, Mandelbrot DA. Outcomes after simultaneous kidney‐pancreas versus pancreas after kidney transplantation in the current era. Clin Transplant 2019; 33:e13732. [PMID: 31628870 DOI: 10.1111/ctr.13732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/28/2019] [Accepted: 10/14/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Annamalai Arunachalam
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Kurtis J. Swanson
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Fahad Aziz
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Neetika Garg
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Robert R. Redfield
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Dixon Kaufman
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Arjang Djamali
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Jon Odorico
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Didier A. Mandelbrot
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
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11
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Pancreas Retransplant After Pancreas Graft Failure in Simultaneous Pancreas-kidney Transplants Is Associated With Better Kidney Graft Survival. Transplant Direct 2019; 5:e473. [PMID: 31576369 PMCID: PMC6708628 DOI: 10.1097/txd.0000000000000919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/06/2019] [Accepted: 06/08/2019] [Indexed: 11/30/2022] Open
Abstract
Background. Simultaneous pancreas-kidney (SPK) transplant is usually the best option for the diabetic end-stage renal disease patient. There is limited information about kidney graft outcomes in SPK recipients with isolated pancreas graft failure who do versus do not undergo pancreas retransplantation. Methods. Patients were divided into 2 groups based on whether they underwent pancreas retransplant (ReTx+) or not (ReTx−). Kidney graft function and survival were the primary endpoints. Results. One hundred and nine patients satisfied our selection criteria, 25 in ReTx+ and 84 in ReTx−. Mean interval from SPK to pancreas failure was significantly shorter in the ReTx+ compared with the ReTx− group, 19.3 ± 36.7 versus 45.7 ± 47.0 months (P = 0.01), respectively. There was no significant difference in kidney graft follow-up post SPK between 2 groups (P = 0.48). At last follow-up, 15 of the 25 (60%) of the repeat pancreas graft had failed, with a mean graft survival among these failed pancreas graft of 2.6 ± 2.7 years, ranging from 0 to 8.1 years. Uncensored kidney graft failure was significantly lower in the ReTx+ group compared with the ReTx− group, 44% versus 67% (P = 0.04). Death-censored kidney graft failure was also lower in the ReTx+ group, 24% versus 48% (P = 0.04). The difference in patient survival did not reach statistical significance. In adjusted Cox regression analysis, rejection as a cause of pancreas failure was associated with increased risk of death-censored kidney graft failure, and pancreas retransplantation was associated with decreased risk of kidney graft failure. A similar pattern was seen after 1:1 matching for the interval between SPK and pancreas graft failure. Conclusions. Even though ReTx+ patients accept the risks associated with repeat pancreas surgery, providers should consider this option in suitable otherwise healthy patients.
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12
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Abstract
PURPOSE OF REVIEW In patients with type 1 diabetes with extreme glycemic variability, the restoration of pancreas endocrine function is potentially and completely achieved with islets of Langerhans (tissue derived from whole organ) or pancreas (whole organ) transplantation. The aim of our review is to report on the latest studies and to highlight the benefits and risks of the two procedures, providing clearer, more selective, evidence-based clinical indications that also consider the impact on the degenerative complications of diabetes as a potential benefit. RECENT FINDINGS Clinical experience in this field has been dynamic over the last three decades, and has been characterized by the development of more standardized protocols and a clearer definition of clinical outcome. On the contrary, the recommendations thus far are not well delineated and tend to overlap, and the past ADA position statement for pancreas transplant alone has also been applied to islet transplant alone, without differentiation. Both outcome-driven and non-outcome-driven criteria are considered in the conclusions, in an attempt to streamline indications for islet-alone or pancreas-alone transplantation.
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Affiliation(s)
- Paola Maffi
- Diabetes Research Institute - Internal Medicine and Transplant Unit, IRCCS Scientific Institute Ospedale San Raffaele, Milan, Italy.
| | - Antonio Secchi
- Internal Medicine and Transplant Unit, Vita-Salute San Raffaele University, Milan, Italy
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13
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Kratochvílová S, Brunová J, Wohl P, Lánská V, Saudek F. Retrospective Analysis of Bone Metabolism in Patients on Waiting List for Simultaneous Pancreas-Kidney Transplantation. J Diabetes Res 2019; 2019:5143021. [PMID: 31218231 PMCID: PMC6536959 DOI: 10.1155/2019/5143021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 03/14/2019] [Accepted: 03/25/2019] [Indexed: 11/17/2022] Open
Abstract
Posttransplant osteoporosis, which evolves from preexisting bone pathologies, represents a serious complication with deteriorating consequences. The aim of our study was to evaluate epidemiological data on bone mineral density (BMD) in subjects with type 1 diabetes (T1DM) in advanced stages of diabetic nephropathy indicated for simultaneous pancreas-kidney transplantation (SPK). We retrospectively compiled biochemical and densitometrical data from 177 patients with T1DM at CKD (chronic kidney disease) stages G4-G5 (115 men, 62 women, median age 40 yr, diabetes duration 23 yr) enrolled on waiting list for SPK for the first time between the years 2011 and 2016. Median Z-scores were as follows: lumbar spine (LS): -0.8 [interquartile range -1.75 to 0.1]; total hip (TH): -1.2 [-1.75 to -0.6]; femoral neck (FN): -1.2 [-1.9 to -0.7]; and distal radius (DR): -0.8 [-1.4 to -0.1]. We noted a gender difference in LS, with worse results for men (-1.1 vs. -0.3) even after adjusting for BMI (body mass index) and glomerular filtration (p < 0.001). Osteoporotic and osteopenic ranges (based on T-scores) for all major sites were 27.7% and 56.5%, respectively, with similar results across both genders. Women had a significantly higher proportion of normal BMD in LS than men (67.7 vs. 49.4%, p < 0.05). Patients with T1DM at CKD stages G4-G5 exhibited serious BMD impairment despite their young age. Men surprisingly displayed lower Z-scores and higher percentages of pathological BMD values in LS than women did. The introduction of adequate preventive measures during the advanced stages of diabetic nephropathy to prevent bone loss is recommended.
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Affiliation(s)
- Simona Kratochvílová
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
| | - Jana Brunová
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
| | - Petr Wohl
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
| | - Věra Lánská
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
| | - František Saudek
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
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14
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Jagdale A, Cooper DKC, Iwase H, Gaston RS. Chronic dialysis in patients with end-stage renal disease: Relevance to kidney xenotransplantation. Xenotransplantation 2018; 26:e12471. [PMID: 30456901 DOI: 10.1111/xen.12471] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/09/2018] [Accepted: 10/19/2018] [Indexed: 01/08/2023]
Abstract
Renal allotransplantation clearly offers better survival and quality of life for end-stage renal disease (ESRD) patients than chronic dialysis. The median waiting time for a deceased donor kidney in a suitable ESRD patient is 3.9 years. The initial candidates for pig kidney xenotransplantation will be those with ESRD unlikely to receive an allograft within a reasonable period of time. It is thus reasonable to ascertain whether clinical trials of xenotransplantation might likewise offer superior outcomes. Chronic dialysis in patients with ESRD is associated with poor quality of life, significant morbidity, and relatively high mortality, with only 56% surviving 3 years and 42% at 5 years. However, a significant number of these patients, because of comorbidities, frailty, etc, would not be considered for renal allotransplantation and likely not for xenotransplantation. As genetically engineered pig kidneys have satisfactorily supported life in immunosuppressed nonhuman primates for many months or even more than a year, consideration in carefully selected patients could be given to pig kidney xenotransplantation. We suggest that, in order to give a patient the best possible outcome, the pig kidney could be transplanted pre-emptively (before dialysis is initiated). If it fails at any stage, the patient would then begin chronic dialysis and continue to await an allograft. The present (limited) evidence is that failure of a pig graft would not be detrimental to a subsequent allograft.
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Affiliation(s)
- Abhijit Jagdale
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - David K C Cooper
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hayato Iwase
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert S Gaston
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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15
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Czerwińska M, Gniewkiewicz MS, Gozdowska J, Wyzgał J, Grochowiecki T, Nazarewski S, Kosieradzki M, Durlik M. Analysis of Hospitalizations in Simultaneous Pancreas-Kidney Transplant Recipients: A Single-center Experience in Poland. Transplant Proc 2018; 50:2132-2135. [PMID: 30177124 DOI: 10.1016/j.transproceed.2018.02.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND End-stage renal disease due to type 1 diabetes mellitus appears to be a regular indication for simultaneous pancreas and kidney transplantation (SPKT). Although transplantation improves a patient's health condition, it does not mean that all complications will be eliminated. METHODS We performed a retrospective analysis of 73 patients who underwent SPKT and follow-up between 1988 and 2015 at our institute. The number, duration, and reasons for hospitalization at 1, 5, 10, and 15 years after SPKT were analyzed. RESULTS The average number of hospitalizations at 1, 5, 10, 15 years after SPKT were 1.66, 0.39, 0.36, and 0.33, respectively. The main reason for hospitalization over the 15-year period was infections, at 32.4% (SD, 6.8%). Within the first year after SPKT, 6.8% of hospital admissions were caused by cytomegalovirus (CMV) infection. Over time, the percentage of hospitalizations for cardiovascular complications increased from 0.6% at 1 year to 29% at 12-15 years. Incidence of hospitalization due to cardiovascular complications correlated with a longer period of dialysis and a diagnosis of ischemic heart disease before transplant (r = 0.56, P = .004; r = 0.54, P < .0001, respectively). At 12-15 years after transplantation, 18.2% of hospitalizations were caused by secondary complications of diabetes. CONCLUSION The most common reason for hospitalization after SPKT is infectious complications. In the first year posttransplant, there is a high percentage of CMV infections. Hospitalization associated with cardiovascular complications was found to be most common in the latter follow-up period and showed a correlation with longer dialysis period.
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Affiliation(s)
- M Czerwińska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - M S Gniewkiewicz
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - J Gozdowska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - J Wyzgał
- Department of Nephrology Nursing, Medical University of Warsaw, Warsaw, Poland
| | - T Grochowiecki
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - S Nazarewski
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Kosieradzki
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Durlik
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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16
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[Transplantation strategy in type 1 diabetic patients]. Nephrol Ther 2018; 14 Suppl 1:S23-S30. [PMID: 29606260 DOI: 10.1016/j.nephro.2018.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/01/2018] [Indexed: 11/23/2022]
Abstract
Beta cell replacement by pancreas or Langerhans islets transplantation is the only way to restore glucose homeostasis in type 1 diabetic patients. The counterpart is the need for long-term immunosuppression. These transplantations are therefore mainly indicated for patients candidates for kidney transplantation and for patients with poor quality of life due to unstable diabetes with life-threatening hypoglycemic events. Both beta cell replacement techniques have different benefits and risks and should be adapted to each type 1 diabetic patient. The transplant strategy must be personalized according to parameters assessed in the pre-transplant period, validated by a multidisciplinary team and reassessed regularly until transplantation.
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17
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Abstract
BACKGROUND Successful pancreas transplantation requires surgical expertise and multidisciplinary medical management. The impact of transplant center volume on pancreas allograft survival remains unclear. METHODS We examined Organ Procurement and Transplantation Network data on 11 568 simultaneous pancreas-kidney (SPK) and 4308 solitary pancreas (pancreas transplant alone and pancreas after kidney) transplants between 2000 and 2013. RESULTS Average annual transplant center volume was categorized by tertiles into low, medium, and high volume, respectively, as follows: 1 to 6 (n = 3861), 7 to 13 (n = 3891), and 14 to 34 (n = 3888) for SPK, and 1 to 3 (n = 1417), 4 to 10 (n = 1518), and 11 to 33 (n = 1377) for solitary pancreas transplants. Favorable donor characteristics were seen in low-volume centers. For SPK transplantation, low (adjusted hazard ration [aHR], 1.55, 95% confidence interval [CI], 1.34-1.8) and medium (aHR, 1.24; 95% CI, 1.07-1.44) center volumes were associated with a higher risk of early pancreas graft failure at 3 months. The increased risk associated with low center volume extended to 1, 5, and 10 years. For solitary pancreas transplants, low, but not medium, center volume was associated with a higher risk of early pancreas graft failure at 3 months (aHR, 1.56; 95% CI, 1.232-1.976), and this risk persisted over 10 years. Patients transplanted at high-volume centers had better pancreas survival rates across all categories of the Pancreas Donor Risk Index. CONCLUSION On average, low center volume were associated with higher risk for pancreas failure. Future studies should seek to identify care processes that support optimal outcomes after pancreas transplantation irrespective of center volume.
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18
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Abstract
The potential to reverse diabetes has to be balanced against the morbidity of long-term immunosuppression associated with transplantation. For a patient with renal failure, the treatment of choice is often a simultaneous transplant of the pancreas and kidney or pancreas after kidney. For a patient with glycaemic instability, choices between a solid organ or islet transplant have to be weighed against benefits and risks of remaining on insulin. Results of simultaneous transplant of the pancreas and kidney transplantation are comparable to other solid-organ transplants, and there is evidence of improved quality of life and life expectancy. There is some evidence of benefit with respect to the progression of secondary diabetic complications in patients with functioning transplants for several years.
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Affiliation(s)
- Shamik Dholakia
- Imperial College Healthcare NHS Trust, West London Renal and Transplant Centre, London W12 0HS, UK
| | - Youssof Oskrochi
- Department of Public Health and Primary Care, Imperial College, London W6 8RP, UK
| | - Graham Easton
- Department of Public Health and Primary Care, Imperial College, London W6 8RP, UK
| | - Vassilios Papalois
- Imperial College Healthcare NHS Trust, West London Renal and Transplant Centre, London W12 0HS, UK
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19
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Dholakia S, Mittal S, Quiroga I, Gilbert J, Sharples EJ, Ploeg RJ, Friend PJ. Pancreas Transplantation: Past, Present, Future. Am J Med 2016; 129:667-73. [PMID: 26965300 DOI: 10.1016/j.amjmed.2016.02.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 01/07/2023]
Abstract
Diabetes is the pandemic disease of the modern era, with 10% of these patients having type 1 diabetes mellitus. Despite the prevalence, morbidities, and associated financial burden, treatment options have not changed since the introduction of injectable insulin. To date, over 40,000 pancreas transplants have been performed globally. It remains the only known method for restoring glycemic control and thus curing type 1 diabetes mellitus. The aim of this review is to bring pancreatic transplantation out of the specialist realm, informing practitioners about this important procedure, so that they feel better equipped to refer suitable patients for transplantation and manage, counsel, and support when encountering them within their own specialty. This study was a narrative review conducted in October 2015, with OVID interface searching EMBASE and MEDLINE databases, using Timeframe: Inception to October 2015. Articles were assessed for clinical relevance and most up-to-date content, with articles written in English as the only inclusion criterion. Other sources used included conference proceedings/presentations and unpublished data from our institution (Oxford Transplant Centre). Pancreatic transplantation is growing and has quickly become the gold standard of care for patients with type 1 diabetes mellitus and renal failure. Significant improvements in quality of life and life expectancy make pancreatic transplant a viable and economically feasible intervention. It remains the most effective method of establishing and maintaining euglycemia, halting and potentially reversing complications associated with diabetes.
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Affiliation(s)
- Shamik Dholakia
- Nuffield Department of Surgical Sciences and Oxford Transplant Centre, University of Oxford and Oxford University Hospitals NHS Trust, UK.
| | - Shruti Mittal
- Nuffield Department of Surgical Sciences and Oxford Transplant Centre, University of Oxford and Oxford University Hospitals NHS Trust, UK
| | - Isabel Quiroga
- Nuffield Department of Surgical Sciences and Oxford Transplant Centre, University of Oxford and Oxford University Hospitals NHS Trust, UK
| | - James Gilbert
- Nuffield Department of Surgical Sciences and Oxford Transplant Centre, University of Oxford and Oxford University Hospitals NHS Trust, UK
| | - Edward J Sharples
- Nuffield Department of Surgical Sciences and Oxford Transplant Centre, University of Oxford and Oxford University Hospitals NHS Trust, UK
| | - Rutger J Ploeg
- Nuffield Department of Surgical Sciences and Oxford Transplant Centre, University of Oxford and Oxford University Hospitals NHS Trust, UK
| | - Peter J Friend
- Nuffield Department of Surgical Sciences and Oxford Transplant Centre, University of Oxford and Oxford University Hospitals NHS Trust, UK
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20
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Lindahl JP, Hartmann A, Aakhus S, Endresen K, Midtvedt K, Holdaas H, Leivestad T, Horneland R, Øyen O, Jenssen T. Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation. Diabetologia 2016; 59:844-52. [PMID: 26713324 DOI: 10.1007/s00125-015-3853-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/14/2015] [Indexed: 01/30/2023]
Abstract
AIMS/HYPOTHESIS Mortality due to cardiovascular disease (CVD), particularly coronary artery disease (CAD), is high in type 1 diabetic patients with end-stage renal disease (ESRD). We aimed to determine whether normoglycaemia, as achieved by successful simultaneous pancreas and kidney (SPK) transplantation, could improve long-term outcomes compared with living donor kidney-alone (LDK) transplantation. METHODS We studied 486 type 1 diabetic patients with ESRD who underwent a first SPK (n = 256) or LDK (n = 230) transplant between 1983 and 2012 and were followed to the end of 2014. Data were retrieved from the Norwegian Renal Registry and hospital records. Kaplan-Meier plots and multivariate Cox regression, with correction for recipient, donor and transplant factors, were used to examine potential associations between transplant type and all-cause and CVD- and CAD-related mortality. RESULTS Median follow-up time was 7.9 years (interquartile range 4.3, 12.9). The adjusted HR for CVD-related deaths in SPK recipients compared with LDK recipients was 0.63 (95% CI 0.40, 0.99; p = 0.047), while the HRs for all-cause and CAD-related mortality were 0.81 (95% CI 0.57, 1.16; p = 0.25) and 0.63 (95% CI 0.36, 1.12; p = 0.12), respectively. Compared with the LDK group, SPK recipients were younger and received grafts from younger donors. Cardiovascular mortality was higher in patients transplanted between 1983 and 1999 compared with those who received their grafts in subsequent years. CONCLUSIONS/INTERPRETATION In patients with type 1 diabetes and ESRD, SPK transplantation was associated with reduced long-term cardiovascular mortality compared with LDK transplantation.
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Affiliation(s)
- Jørn P Lindahl
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway.
| | - Anders Hartmann
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Svend Aakhus
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Hallvard Holdaas
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Torbjørn Leivestad
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Rune Horneland
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Ole Øyen
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Trond Jenssen
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
- Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
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Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015; 30 Suppl 2:ii1-142. [PMID: 25940656 DOI: 10.1093/ndt/gfv100] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Mittal S, Gough SCL. Pancreas transplantation: a treatment option for people with diabetes. Diabet Med 2014; 31:512-21. [PMID: 24313883 DOI: 10.1111/dme.12373] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 10/23/2013] [Accepted: 11/17/2013] [Indexed: 11/29/2022]
Abstract
Since the first pancreas transplants in the early 1960s, whole-organ pancreas transplantation, either alone or combined with kidney transplantation, has become commonplace in many countries around the world. Whole-organ pancreas transplantation is available in the UK, with ~200 transplants currently carried out per year. Patient survival and pancreas graft outcome rates are now similar to other solid organ transplant programmes, with high rates of long-term insulin independence. In the present review, we will discuss whole-pancreas transplantation as a treatment for diabetes, focusing on indications for transplantation, the nature of the procedure performed, graft survival rates and the consequences of pancreas transplantation on metabolic variables and the progression of diabetes-related complications.
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Affiliation(s)
- S Mittal
- Nuffield Department of Surgical Sciences, Oxford, UK; Oxford Centre of Diabetes, Endocrinology and Metabolism, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
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Mittal S, Johnson P, Friend P. Pancreas transplantation: solid organ and islet. Cold Spring Harb Perspect Med 2014; 4:a015610. [PMID: 24616200 DOI: 10.1101/cshperspect.a015610] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Transplantation of the pancreas, either as a solid organ or as isolated islets of Langerhans, is indicated in a small proportion of patients with insulin-dependent diabetes in whom severe complications develop, particularly severe glycemic instability and progressive secondary complications (usually renal failure). The potential to reverse diabetes has to be balanced against the morbidity of long-term immunosuppression. For a patient with renal failure, the treatment of choice is often a simultaneous transplant of the pancreas and kidney (SPK), whereas for a patient with glycemic instability, specifically hypoglycemic unawareness, the choice between a solid organ and an islet transplant has to be individual to the patient. Results of SPK transplantation are comparable to other solid-organ transplants (kidney, liver, heart) and there is evidence of improved quality of life and life expectancy, but the results of solitary pancreas transplantation and islets are inferior with respect to graft survival. There is some evidence of benefit with respect to the progression of secondary diabetic complications in patients with functioning transplants for several years.
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Affiliation(s)
- Shruti Mittal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, United Kingdom
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Mangus RS, Powelson J, Kinsella SB, Farar DT, Creal CA, Fridell JA. Pretransplant coronary artery disease associated with worse clinical outcomes in pancreas transplantation. Clin Transplant 2014; 27:E442-7. [PMID: 23923972 DOI: 10.1111/ctr.12185] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) is common in patients with type I diabetes and may be associated with worse outcomes in patients undergoing pancreas transplantation (PT). This study evaluates PT patients to determine the pre transplant prevalence of CAD and assesses the post-transplant outcomes including complications and survival. METHODS This study is a retrospective review of PTs from 2003 to 2011. Diagnosis of CAD required cardiac catheterization. Outcomes included: myocardial infarction (MI), stroke, and survival. RESULTS There were 405 transplants in 389 patients with median follow-up of 56 months. Pre transplant prevalence of CAD was 19% (n = 74). There was no increased risk of perioperative, 90-d or one-yr mortality for patients with CAD. The CAD group did have increased risk of MI (11% vs. 1%, p < 0.001) and stroke (8% vs. 3%, p = 0.02). Controlling for patient and donor age, and history of CAD, the CAD group had decreased patient survival at five yr (82% vs. 90%, p = 0.09, HR 1.77) by Cox regression. CONCLUSIONS Patients with type I diabetes and CAD have increased risk of MI and stroke post-pancreas transplant, with decreased five-yr survival. Patients without CAD and a negative pre transplant cardiac evaluation carry a low risk of post-transplant MI.
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Affiliation(s)
- Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202-5250, USA.
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25
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Greffe de pancréas et d’îlots de Langerhans. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
For many patients with type 1 diabetes mellitus and selected patients with type 2 diabetes mellitus, a successful pancreas transplant is the only definitive long-term treatment that both restores euglycaemia without the risk of severe hypoglycaemia and prevents, halts or reverses secondary complications. These benefits come at the cost of major surgery and lifelong immunosuppression. Nevertheless, pancreas transplants are safe and effective, with patient survival rates currently >95% at 1 year and >88% at 5 years; graft survival rates are almost 85% at 1 year and >60% at 5 years. The estimated half-life of a pancreas graft is now 7-14 years. The improvements in graft survival are attributable to considerable reductions in technical failures and in immunologic graft losses. Pancreas recipients have reduced mortality compared with waiting candidates or patients with diabetes mellitus who undergo a kidney transplant alone. Pancreas transplants should be more frequently offered to nonuraemic patients with brittle diabetes mellitus to prevent the development of secondary diabetic complications and to avoid the need for a kidney transplant. Although the results of islet transplantation have also improved, islet recipients rarely maintain long-term insulin independence despite the use of multiple organ donor pancreases. Pancreas transplants and islet transplants should be considered complementary, not mutually exclusive, procedures that are chosen on the basis of the individual patient's surgical risk.
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Affiliation(s)
- Rainer W G Gruessner
- Department of Surgery, University of Arizona, 1501 N. Campbell Avenue, Room 4410, PO Box 245066, Tucson, AZ 85724, USA. rgruessner@ surgery.arizona.edu
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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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Wiseman AC, Huang E, Kamgar M, Bunnapradist S. The impact of pre-transplant dialysis on simultaneous pancreas–kidney versus living donor kidney transplant outcomes. Nephrol Dial Transplant 2013; 28:1047-58. [DOI: 10.1093/ndt/gfs582] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Boggi U, Vistoli F, Egidi FM, Marchetti P, De Lio N, Perrone V, Caniglia F, Signori S, Barsotti M, Bernini M, Occhipinti M, Focosi D, Amorese G. Transplantation of the pancreas. Curr Diab Rep 2012; 12:568-79. [PMID: 22828824 DOI: 10.1007/s11892-012-0293-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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Abstract
SPK transplant is the definitive treatment of type 1 diabetes combined with end-stage renal disease. Long-term graft function can lead to improvement in diabetes-related complications and, in patients younger than 50 years, can lead to improved overall survival. PAK transplant and PA transplant do not result in similar improvements in patient survival, but with appropriate patient selection, they can improve quality of life by rendering patients insulin-free. Pancreas transplant is associated with more surgical complications and higher perioperative morbidity and mortality than KTA. Therefore, careful donor and recipient selection along with meticulous surgical technique are mandatory for optimal outcomes.
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Affiliation(s)
- Kiran K Dhanireddy
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Ruparelia N, Bhindi R, Sabharwal N, Mason P, Klucniks A, Sinha S, Friend P, Ormerod O. Myocardial Perfusion Is a Useful Screening Test for the Evaluation of Cardiovascular Risk in Patients Undergoing Simultaneous Pancreas Kidney Transplantation. Transplant Proc 2011; 43:1797-800. [DOI: 10.1016/j.transproceed.2011.02.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 02/16/2011] [Indexed: 11/15/2022]
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Maffi P, Scavini M, Socci C, Piemonti L, Caldara R, Gremizzi C, Melzi R, Nano R, Orsenigo E, Venturini M, Staudacher C, Del Maschio A, Secchi A. Risks and benefits of transplantation in the cure of type 1 diabetes: whole pancreas versus islet transplantation. A single center study. Rev Diabet Stud 2011; 8:44-50. [PMID: 21720672 DOI: 10.1900/rds.2011.8.44] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Pancreas and islet transplantation are the only available options to replace beta-cell function in patients with type 1 diabetes. Great variability in terms of rate of success for both approaches is reported in the literature and it is difficult to compare the respective risks and benefits. OBJECTIVES The aim of this study was to analyze risks and benefits of pancreas transplantation alone (PTA) and islet transplantation alone (ITA) by making use of the long-term experience of a single center where both transplantations are performed. We focused on the risks and benefits of both procedures, with the objective of better defining indications and providing evidence to support the decision-making process. The outcomes of 33 PTA and 33 ITA were analyzed, and pancreas and islet function (i.e., insulin independence), perioperative events, and long-term adverse events were recorded. RESULTS We observed a higher rate of insulin independence in PTA (75%) versus ITA (59%), with the longer insulin independence among PTA patients receiving tacrolimus. The occurrence of adverse events was higher for PTA patients in terms of hospitalization length and frequency, re-intervention for surgical and immunological acute complications, CMV reactivation, and other infections. CONCLUSIONS In conclusion, these results support the practice of listing patients for PTA when the metabolic control and the progression of chronic complications require a rapid normalization of glucose levels, with the exception of patients with cardiovascular disease, because of the high surgical risks. ITA is indicated when replacement of beta-cell mass is needed in patients with a high surgical risk.
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Affiliation(s)
- Paola Maffi
- Diabetes Research Institute, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milano, Italy.
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Ponticelli C, Moroni G, Glassock RJ. Recurrence of secondary glomerular disease after renal transplantation. Clin J Am Soc Nephrol 2011; 6:1214-21. [PMID: 21493742 DOI: 10.2215/cjn.09381010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The risk of a posttransplant recurrence of secondary glomerulonephritis (GN) is quite variable. Histologic recurrence is frequent in lupus nephritis, but the lesions are rarely severe and usually do not impair the long-term graft outcome. Patients with Henoch-Schonlein nephritis have graft survival similar to that of other renal diseases, although recurrent Henoch-Schonlein nephritis with extensive crescents has a poor prognosis. Amyloid light-chain amyloidosis recurs frequently in renal allografts but it rarely causes graft failure. Amyloidosis secondary to chronic inflammation may also recur, but this is extremely rare in patients with Behcet's disease or in those with familial Mediterranean fever, when the latter are treated with colchicine. Double organ transplantation (liver/kidney; heart/kidney), chemotherapy, and autologous stem cell transplantation may be considered in particular cases of amyloidosis, such as hereditary amyloidosis or multiple myeloma. There is little experience with renal transplantation in light-chain deposition disease, fibrillary/immunotactoid GN, or mixed cryoglobulinemic nephritis but successful cases have been reported. Diabetic nephropathy often recurs but usually only after many years. Recurrence in patients with small vessel vasculitis is unpredictable but can cause graft failure. However, in spite of recurrence, patient and graft survival rates are similar in patients with small vessel vasculitis compared with those with other renal diseases. Many secondary forms of GN no longer represent a potential contraindication to renal transplantation. The main issues in transplantation of patients with secondary GN are the infectious, cardiovascular, or hepatic complications associated with the original disease or its treatment.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, Scientific Institute Humanitas, Rozzano, Milano, Italy
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Jahansouz C, Kumer SC, Ellenbogen M, Brayman KL. Evolution of β-Cell Replacement Therapy in Diabetes Mellitus: Pancreas Transplantation. Diabetes Technol Ther 2011; 13:395-418. [PMID: 21299398 DOI: 10.1089/dia.2010.0133] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus remains one of the leading causes of morbidity and mortality worldwide. According to the Centers for Disease Control and Prevention, approximately 23.6 million people in the United States are affected. Of these individuals, 5-10% have been diagnosed with type 1 diabetes mellitus (TIDM), an autoimmune disease. Although it often appears in childhood, T1DM may manifest at any age. The effects of T1DM can be devastating, as the disease often leads to significant secondary complications, morbidity, and decreased quality of life. Since the late 1960s, surgical treatment for diabetes mellitus has continued to evolve and has become a viable alternative to chronic insulin administration. In this review, the historical evolution, current status, graft efficacy, benefits, and complications of pancreas transplantation are explored.
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Affiliation(s)
- Cyrus Jahansouz
- University of Virginia School of Medicine, Charlottesville, Virginia, USA.
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Medina-Polo J, Domínguez-Esteban M, Morales J, Pamplona M, Andrés A, Jiménez C, Manrique A, Moreno E, Díaz R. Cardiovascular Events After Simultaneous Pancreas-Kidney Transplantation. Transplant Proc 2010; 42:2981-3. [DOI: 10.1016/j.transproceed.2010.07.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Folli F, Guzzi V, Perego L, Coletta DK, Finzi G, Placidi C, La Rosa S, Capella C, Socci C, Lauro D, Tripathy D, Jenkinson C, Paroni R, Orsenigo E, Cighetti G, Gregorini L, Staudacher C, Secchi A, Bachi A, Brownlee M, Fiorina P. Proteomics reveals novel oxidative and glycolytic mechanisms in type 1 diabetic patients' skin which are normalized by kidney-pancreas transplantation. PLoS One 2010; 5:e9923. [PMID: 20360867 PMCID: PMC2848014 DOI: 10.1371/journal.pone.0009923] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 02/19/2010] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In type 1 diabetes (T1D) vascular complications such as accelerated atherosclerosis and diffused macro-/microangiopathy are linked to chronic hyperglycemia with a mechanism that is not yet well understood. End-stage renal disease (ESRD) worsens most diabetic complications, particularly, the risk of morbidity and mortality from cardiovascular disease is increased several fold. METHODS AND FINDINGS We evaluated protein regulation and expression in skin biopsies obtained from T1D patients with and without ESRD, to identify pathways of persistent cellular changes linked to diabetic vascular disease. We therefore examined pathways that may be normalized by restoration of normoglycemia with kidney-pancreas (KP) transplantation. Using proteomic and ultrastructural approaches, multiple alterations in the expression of proteins involved in oxidative stress (catalase, superoxide dismutase 1, Hsp27, Hsp60, ATP synthase delta chain, and flavin reductase), aerobic and anaerobic glycolysis (ACBP, pyruvate kinase muscle isozyme, and phosphoglycerate kinase 1), and intracellular signaling (stratifin-14-3-3, S100-calcyclin, cathepsin, and PPI rotamase) as well as endothelial vascular abnormalities were identified in T1D and T1D+ESRD patients. These abnormalities were reversed after KP transplant. Increased plasma levels of malondialdehyde were observed in T1D and T1D+ESRD patients, confirming increased oxidative stress which was normalized after KP transplant. CONCLUSIONS Our data suggests persistent cellular changes of anti-oxidative machinery and of aerobic/anaerobic glycolysis are present in T1D and T1D+ESRD patients, and these abnormalities may play a key role in the pathogenesis of hyperglycemia-related vascular complications. Restoration of normoglycemia and removal of uremia with KP transplant can correct these abnormalities. Some of these identified pathways may become potential therapeutic targets for a new generation of drugs.
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Affiliation(s)
- Franco Folli
- Diabetes Division, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
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Abstract
PURPOSE OF REVIEW Type 1 diabetes is a chronic disease that can impact patient survival and quality of life because of acute and chronic complications. Although intensive insulin scheme treatment has been shown to reduce the incidence of diabetes-related complications, only pancreas transplantation has been shown to be able to alter them and in some cases to revert them. In this review, an extensive view of the effect of pancreas transplantation on diabetes-related complication will be described. RECENT FINDINGS This review will focus on patients survival, diabetic nephropathy, neuropathy, cardiovascular event, comparing their incidence in type 1 diabetic patients treated with insulin and in type 1 diabetic patients receiving kidney, kidney-pancreas or pancreas alone graft. The review will focus mostly on the papers published in the last decade, with a particular attention to those on new aspects of graft function analysis like spectroscopy. Moreover, a comparison with islet transplantation procedure will be performed. SUMMARY This review will give an update on the potential of pancreas transplantation, give a guide for clinical practice and help to consider pancreas transplantation as an alternative to insulin treatment for selected patients.
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Morath C, Schmied B, Mehrabi A, Weitz J, Schmidt J, Werner J, Buchler M, Morcos M, Nawroth P, Schwenger V, Doehler B, Opelz G, Zeier M. Simultaneous pancreas-kidney transplantation in type 1 diabetes. Clin Transplant 2009; 23 Suppl 21:115-20. [DOI: 10.1111/j.1399-0012.2009.01116.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Mäkinen VP, Forsblom C, Thorn LM, Wadén J, Kaski K, Ala-Korpela M, Groop PH. Network of vascular diseases, death and biochemical characteristics in a set of 4,197 patients with type 1 diabetes (the FinnDiane Study). Cardiovasc Diabetol 2009; 8:54. [PMID: 19804653 PMCID: PMC2763862 DOI: 10.1186/1475-2840-8-54] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 10/06/2009] [Indexed: 12/26/2022] Open
Abstract
Background Cardiovascular disease is the main cause of premature death in patients with type 1 diabetes. Patients with diabetic kidney disease have an increased risk of heart attack or stroke. Accurate knowledge of the complex inter-dependencies between the risk factors is critical for pinpointing the best targets for research and treatment. Therefore, the aim of this study was to describe the association patterns between clinical and biochemical features of diabetic complications. Methods Medical records and serum and urine samples of 4,197 patients with type 1 diabetes were collected from health care centers in Finland. At baseline, the mean diabetes duration was 22 years, 52% were male, 23% had kidney disease (urine albumin excretion over 300 mg/24 h or end-stage renal disease) and 8% had a history of macrovascular events. All-cause mortality was evaluated after an average of 6.5 years of follow-up (25,714 patient years). The dataset comprised 28 clinical and 25 biochemical variables that were regarded as the nodes of a network to assess their mutual relationships. Results The networks contained cliques that were densely inter-connected (r > 0.6), including cliques for high-density lipoprotein (HDL) markers, for triglycerides and cholesterol, for urinary excretion and for indices of body mass. The links between the cliques showed biologically relevant interactions: an inverse relationship between HDL cholesterol and the triglyceride clique (r < -0.3, P < 10-16), a connection between triglycerides and body mass via C-reactive protein (r > 0.3, P < 10-16) and intermediate-density cholesterol as the connector between lipoprotein metabolism and albuminuria (r > 0.3, P < 10-16). Aging and macrovascular disease were linked to death via working ability and retinopathy. Diabetic kidney disease, serum creatinine and potassium, retinopathy and blood pressure were inter-connected. Blood pressure correlations indicated accelerated vascular aging in individuals with kidney disease (P < 0.001). Conclusion The complex pattern of links between diverse characteristics and the lack of a single dominant factor suggests a need for multifactorial and multidisciplinary paradigms for the research, treatment and prevention of diabetic complications.
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Affiliation(s)
- Ville-Petteri Mäkinen
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Finland.
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41
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de Sá JR, Monteagudo PT, Rangel ÉB, Melaragno CS, Gonzalez AM, Linhares MM, Salzedas A, Neves MDF, Stela C, Medina-Pestana JO. The evolution of diabetic chronic complications after pancreas transplantation. Diabetol Metab Syndr 2009; 1:11. [PMID: 19825148 PMCID: PMC2762460 DOI: 10.1186/1758-5996-1-11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 09/28/2009] [Indexed: 12/16/2022] Open
Abstract
Pancreas transplantation is an invasive procedure that can restore and maintain normoglycemic level very successfully and for a prolonged period in DM1 patients. The procedure elevates the morbimortality rates in the first few months following the surgery if compared to kidney transplants with living donors, but it offers a better quality of life to patients.Although controversial, several studies have shown the stabilization or the improvement of some of the chronic complications related to diabetes, as well as the extra number of years of life that patients submitted to a double pancreas-kidney transplantation may gain.Recent studies have demonstrated clashing outcomes regarding isolated pancreas transplantations, a fact which reinforces the need for a more discerning selection of patients for this procedure.
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Affiliation(s)
- João R de Sá
- Department of Medicine, Division of Endocrinology of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - Patricia T Monteagudo
- Department of Medicine, Division of Endocrinology of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - Érika B Rangel
- Department of Medicine, Division of Nephrology of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - Cláudio S Melaragno
- Department of Medicine, Division of Nephrology of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - Adriano M Gonzalez
- Department of Surgery, Division of Gastrosurgery of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - Marcelo M Linhares
- Department of Surgery, Division of Gastrosurgery of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - Alcides Salzedas
- Department of Surgery, Division of Gastrosurgery of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - Maria-Deolinda F Neves
- Department of Medicine, Division of Endocrinology of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - Camila Stela
- Department of Medicine, Division of Endocrinology of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
| | - José O Medina-Pestana
- Department of Medicine, Division of Nephrology of Federal University of Sᾶo Paulo, Sᾶo Paulo, Brazil
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Nikeghbalian S, Bahador A, Salahi H, Kakaei F, Kazemi K, Dehghani M, Ghaffaripour S, Malek-Hosseini S. Non–Marginal Donor C-Loop Ulcers as a Cause of Gastrointestinal Bleeding After Pancreas Transplantation: Three Case Reports. Transplant Proc 2009; 41:2930-2. [DOI: 10.1016/j.transproceed.2009.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rangel ÉB, de Sá JR, Melaragno CS, Gonzalez AM, Linhares MM, Salzedas A, Medina-Pestana JO. Kidney transplant in diabetic patients: modalities, indications and results. Diabetol Metab Syndr 2009; 1:2. [PMID: 19825194 PMCID: PMC2758579 DOI: 10.1186/1758-5996-1-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 08/26/2009] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Diabetes is a disease of increasing worldwide prevalence and is the main cause of chronic renal failure. Type 1 diabetic patients with chronic renal failure have the following therapy options: kidney transplant from a living donor, pancreas after kidney transplant, simultaneous pancreas-kidney transplant, or awaiting a deceased donor kidney transplant. For type 2 diabetic patients, only kidney transplant from deceased or living donors are recommended. Patient survival after kidney transplant has been improving for all age ranges in comparison to the dialysis therapy. The main causes of mortality after transplant are cardiovascular and cerebrovascular events, infections and neoplasias. Five-year patient survival for type 2 diabetic patients is lower than the non-diabetics' because they are older and have higher body mass index on the occasion of the transplant and both pre- and posttransplant cardiovascular diseases prevalences. The increased postransplant cardiovascular mortality in these patients is attributed to the presence of well-known risk factors, such as insulin resistance, higher triglycerides values, lower HDL-cholesterol values, abnormalities in fibrinolysis and coagulation and endothelial dysfunction. In type 1 diabetic patients, simultaneous pancreas-kidney transplant is associated with lower prevalence of vascular diseases, including acute myocardial infarction, stroke and amputation in comparison to isolated kidney transplant and dialysis therapy. CONCLUSION Type 1 and 2 diabetic patients present higher survival rates after transplant in comparison to the dialysis therapy, although the prevalence of cardiovascular events and infectious complications remain higher than in the general population.
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Affiliation(s)
- Érika B Rangel
- Division of Nephrology, Universidade Federal de São Paulo, Brazil
| | - João R de Sá
- Division of Endocrinology, Universidade Federal de São Paulo, Brazil
| | | | | | | | - Alcides Salzedas
- Departament of Sugery, Universidade Federal de São Paulo, Brazil
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Wiseman AC. Simultaneous pancreas kidney transplantation: a critical appraisal of the risks and benefits compared with other treatment alternatives. Adv Chronic Kidney Dis 2009; 16:278-87. [PMID: 19576558 DOI: 10.1053/j.ackd.2009.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Advances in technical aspects of pancreas transplantation and improvements in immunosuppression over the last decade have led to significant improvements in pancreas transplant outcomes in the short-term. Simultaneous kidney pancreas transplantation remains an attractive option for patients with type 1 diabetes (T1DM) and late chronic kidney disease (CKD), with 1-year pancreas graft survival rates of 86% in 2004. For the individual patient with T1DM and CKD, the various transplant options must be considered carefully, with attention to the timing of surgery relative to the need for dialysis, the challenge in managing diabetes with noninvasive medical therapy, and the assumption of risks attendant to each surgical option. This review summarizes the current status of simultaneous pancreas kidney transplantation and compares and contrasts outcomes with other potential treatment options.
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Abstract
Since the introduction of pancreas transplantation more than 40 years ago, efforts to develop more minimally invasive techniques for endocrine replacement therapy have been in progress, yet this surgical procedure still remains the treatment of choice for diabetic patients with end-stage renal failure. Many improvements have been made in the surgical techniques and immunosuppressive regimens, both of which have contributed to an increasing number of indications for pancreas transplantation. This operation can be justified on the basis that patients replace daily injections of insulin with an improved quality of life but at the expense of a major surgical procedure and lifelong immunosuppression. The various indications, categories, and outcomes of patients having a pancreas transplant are discussed, particularly with reference to the effect on long-term diabetic complications.
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Affiliation(s)
- Steve A White
- Department of Hepatopancreatobiliary and Transplantation Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.
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Weiss AS, Smits G, Wiseman AC. Twelve-month pancreas graft function significantly influences survival following simultaneous pancreas-kidney transplantation. Clin J Am Soc Nephrol 2009; 4:988-95. [PMID: 19406961 DOI: 10.2215/cjn.04940908] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Simultaneous pancreas-kidney transplantation (SPK) is regarded as the treatment of choice for type 1 diabetes (T1DM) and kidney dysfunction, despite the morbidity associated with pancreas transplantation. These morbidities often influence selection of SPK versus living-donor kidney alone (LD KA) transplant. This study quantifies the impact of pancreas graft function on outcomes following SPK. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the SRTR database, SPK wait-listed patients transplanted from 1997 to 2005 were evaluated and segregated as: (1) SPK recipients with functioning pancreas graft 12 mo posttransplant (SPK, P+); (2) SPK recipients with loss of pancreas graft function within 12 mo posttransplant (SPK, P-); (3) recipients of deceased donor (DD) KA; (4) recipients of LD KA. The study compared patient and kidney graft survival to 84 mo posttransplant. RESULTS Patient survival for SPK, P+ was significantly better than the LD KA; SPK, P-; and DD KA cohorts (88.6% versus 80.0%, 73.9% and 64.8%, respectively [P < 0.001]), a finding confirmed by multivariate analysis and not influenced by pancreas-after-kidney transplantation (PAK) rates and outcomes. Unadjusted graft survival was also highest in the SPK, P+ cohort (72.0% versus 63.6%, 59.8%, 49.7%, P = 0.015 versus LD KA). CONCLUSIONS SPK recipients with functioning pancreas grafts have superior survival compared with LD KA and DD KA, including in the setting of PAK. Early pancreas graft failure results in kidney and patient survival rates similar to KA. These data help further clarify the decision-making of SPK versus KA transplant options for patients and providers.
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Affiliation(s)
- Andrew S Weiss
- Division of Renal Diseases and Hypertension, Transplant Center, University of Colorado Health Sciences Center, Aurora, CO 80045, USA
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Jaeckel E, Lehner F. [Pancreas and islet transplantation]. Internist (Berl) 2009; 50:536-49. [PMID: 19390835 DOI: 10.1007/s00108-008-2272-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pancreas transplantation is a successful and effective procedure resulting in tight glucose control. Due to the postoperative morbidity and the need for immunosuppression pancreas transplantation should be considered in patients with type I diabetes at the time of kidney transplantation. Besides this pancreas transplantation alone can be taken into consideration for patients with very poor metabolic control and quality of life despite optimal medical treatment. Recently, islet transplantation became a less invasive alternative to pancreas transplantation. Due to the lack of long-term follow-up and due to the need of multiple donor grafts for one recipient, islet transplantation should be performed under experimental settings in experienced centers. New developments in protecting transplanted islets and in the induction of donor-specific tolerance could increase the indication to perform the procedure. Therefore alternative sources of beta-cells have to be identified.
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Affiliation(s)
- E Jaeckel
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover.
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Abstract
PURPOSE OF REVIEW Pancreas transplantation has emerged as an effective treatment for patients with diabetes mellitus, especially those with established end-stage renal disease. Surgical and immunosuppressive advances have significantly improved allograft survival. With more recipients enjoying normoglycemia for longer periods of time, the opportunity to study more closely the effects of pancreas transplantation has arisen. This review will focus on these long-term benefits. RECENT FINDINGS The field of pancreas transplantation has been limited by a lack of randomized, controlled trials and relatively poor graft survival rates historically, however we can still glean many important points from the existing literature. The procedure reduces mortality compared with diabetic kidney transplant recipients and waitlisted patients. Improvements in diabetic nephropathy and retinopathy have also been demonstrated. Pancreas transplantation can improve cardiovascular risk profiles, improve cardiac function and decrease cardiovascular events. Lastly, improvements in diabetic neuropathy and quality of life can result from pancreas transplantation. SUMMARY Pancreas transplantation remains the most effective method to establish durable normoglycemia for patients with diabetes mellitus. Well designed clinical studies to assess outcomes and adverse events will be of paramount importance in providing optimal care to patients with diabetes mellitus.
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Luan FL, Miles CD, Cibrik DM, Ojo AO. Impact of simultaneous pancreas and kidney transplantation on cardiovascular risk factors in patients with type 1 diabetes mellitus. Transplantation 2007; 84:541-4. [PMID: 17713440 DOI: 10.1097/01.tp.0000270617.43811.af] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We retrospectively investigated the impact of pancreas transplantation on cardiovascular disease risk factors in patients with type 1 diabetic end-stage renal disease (ESRD). Two cohorts of patients, 44 simultaneous pancreas and kidney transplant patients (SPK) and 30 kidney transplant-alone patients (KTA), were included. Univariate and multivariate analyses were performed. Compared with KTA patients, SPK patients had significantly lower mean arterial pressure (88.5+/-12.7 vs. 98.2+/-13.0 mmHg, P=0.002), lower pulse pressure (51.6+/-15.1 vs. 61.4+/-15.6 mmHg, P=0.008), lower low-density lipoprotein cholesterol (83.5+/-20.6 vs. 99.2+/-32.5 mg/dl, P=0.02), and required fewer lipid-lowering medications (31.8% vs. 60.0%, P=0.02). Compared with pretransplant values, only SPK patients showed significant improvement in both blood pressure and total cholesterol. We conclude that SPK significantly improves blood pressure and dyslipidemia compared with KTA in type 1 diabetic ESRD patients.
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Affiliation(s)
- Fu L Luan
- Internal Medicine, Division of Nephrology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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