Bladder vs enteric drainage in simultaneous pancreas-kidney transplantation

Comparison of Outcomes and Survival of Two Cohorts of Patients with Simultaneous Pancreas-Kidney Transplantation: A Retrospective Cohort Study in a Latin American Hospital

Background

Simultaneous pancreas-kidney transplantation (SPKT) is a complex and demanding procedure with a considerable risk of morbidity and mortality. Advances in surgical techniques and organ preservation have introduced changes in care protocols. Two cohorts of patients receiving SPKT with two different protocols were compared to determine overall survival and pancreatic and renal graft failure-free survival.

Methods

This retrospective observational study was conducted in two cohorts of SPKT recipient patients that underwent surgery between 2001 and 2021. Outcomes were compared in transplant patients between 2001 and 2011 (cohort 1; initial protocol) and 2012-2021 (cohort 2; improved protocol). In addition to the temporality, the cohorts were defined by a protocolization of technical aspects and medical management in cohort 2 (improved protocol), compared to a wide variability in the procedures carried out in cohort 1 (initial protocol). Overall survival and pancreatic and renal graft failure-free survival were the primary outcomes. These outcomes were determined using Kaplan-Meier survival analysis and the log-rank test.

Results

Fifty-five SPKT were performed during the study period: 32 in cohort 1 and 23 in cohort 2. In the survival analysis, an average of 2546 days (95% CI: 1902-3190) was found in cohort 1, while in cohort 2, it was 2540 days (95% CI: 2100-3204) (p > 0.05). Pancreatic graft failure-free survival had an average of 1705 days (95% CI: 1037-2373) in cohort 1, lower than the average in cohort 2 (2337 days; 95% CI: 1887-2788) (p = 0.016). Similarly, renal graft failure-free survival had an average of 2167 days (95% CI: 1485-2849) in cohort 1, lower than the average in cohort 2 (2583 days; 95% CI: 2159-3006) (p = 0.017).

Conclusions

This analysis indicates that pancreatic and renal graft failure-free survival associated with SPKT decreased significantly in cohort 2, with results related to improvements in the treatment protocol implemented in that cohort.

Post-pancreatic transplant enteric leaks: The role of the salvage operation

Enteric drainage in pancreas transplantation is complicated by an enteric leak in 5%-8%, frequently necessitating pancreatectomy. Pancreatic salvage outcomes are not well studied. Risk factors for enteric leak were examined and outcomes of attempted graft salvage were compared to immediate pancreatectomy. Pancreas transplants performed between 1995 and 2018 were reviewed. Donor, recipient, and organ variables including demographics, donor type, ischemic time, kidney donor profile index, and pancreas donor risk index were analyzed. Among 1153 patients, 33 experienced enteric leaks (2.9%). Donors of allografts that developed leak were older (37.9y vs. 29.0y, p = .001), had higher KDPI (37% vs. 24%, p < .001), higher pancreas donor risk index (1.83 vs. 1.32, p < .001), and longer cold ischemic time (16.5 vs. 14.8 h, p = .03). Intra-abdominal abscess and higher blood loss decreased the chance of successful salvage. Enteric leak increased 6-month graft loss risk (HR 13.9[CI 8.5-22.9], p < .001). However, 50% (n = 12) of allografts undergoing attempted salvage survived long-term. After 6 months of pancreas graft survival, salvage and non-leak groups had similar 5-year graft survival (82.5% vs. 81.5%) and mortality (90.9% vs. 93.5%). Enteric leaks remain a challenging complication. Pancreatic allograft salvage can be attempted in suitable patients and accomplished in 50% of cases without significantly increased graft failure or mortality risk.

From insulin injections to islet transplantation: An overview of the journey

When, in 1869, Paul Langerhans detected the "islands of tissue" in the pancreas, he took the first step on a journey towards islet transplantation as a treatment for type 1 diabetes. The route has embraced developments across biosciences, surgery, gene therapy and clinical research. This review highlights major milestones along that journey involving whole pancreas transplantation, islet transplantation, the creation of surrogate insulin-secreting cells and novel islet-like structures using genetic and bio-engineering technologies. To obviate the paucity of human tissue, pluripotent stem cells and non-β-cells within the pancreas have been modified to create physiologically responsive insulin-secreting cells. Before implantation, these can be co-cultured with endothelial cells to promote vascularisation and with immune defence cells such as placental amnion cells to reduce immune rejection. Scaffolds to contain grafts and facilitate surgical placement provide further opportunities to achieve physiological insulin delivery. Alternatively, xenotransplants such as porcine islets might be reconsidered as opportunities exist to circumvent safety concerns and immune rejection. Thus, despite a long and arduous journey, the prospects for increased use of tissue transplantation to provide physiological insulin replacement are drawing ever closer.

Forty-Year Survival of Simultaneous Kidney and Duct-Injected Segmental Pancreas Transplants in a Recipient Maintained on Low-Dose Azathioprine and Prednisone

Here, we report on the remarkable survival of a simultaneous kidney-pancreas transplant recipient who has received minimal immunosuppression, has had normal kidney function, and has been insulin-free for 40 years since her transplant surgery.

First World Consensus Conference on pancreas transplantation: Part II - recommendations

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.

Pancreas transplant with enteric drainage at a single institute in Asia

BACKGROUND/OBJECTIVE

This study is to assess immunological and graft survival outcomes after pancreas transplant at a single institute in Asia.

METHODS

Patients undergoing pancreas transplant with enteric drainage were included. Clinical data and outcomes were evaluated and compared between each subgroup.

RESULTS

There were 165 cases of pancreas transplant, including 38 (23 %) simultaneous pancreas-kidney transplant (SPK), 24 (15 %) pancreas after kidney transplant (PAK), 75 (46 %) pancreas transplant alone (PTA), and 28 (17 %) pancreas before kidney transplant (PBK). The overall surgical complication rate was 46.1 %, with highest (62.5 %) in PAK and lowest (32.0 %) in PTA, P = 0.008. The late complications included 32.7 % infection and 3.6 % malignancy. Overall rejection of pancreas graft was 24.8 % including 18.2 % acute and 9.7 % chronic rejection. Rejection was highest in PTA group (36.0 %) and lowest in PBK (3.6 %). There were 56 cases (33.9 %) with graft loss in total, with highest graft loss rate in PTA (38.7 %). The 1-year, 5-year and 10-year pancreas graft survivals for total patients were 98.0 %, 87.7 % and 70.9 % respectively.

CONCLUSIONS

Enteric drainage in pancreas transplant could be applied safely not only in SPK but also in other subgroups. Enteric drainage itself would not compromise the immunological and graft survival outcomes.

A case report of percutaneous direct injection of N-butyl-2-cyanoacrylate (NBCA) to treat a pancreatic duodenal stump leak after a simultaneous pancreas and kidney transplantation

BACKGROUND

Simultaneous pancreas and kidney transplantation (SPK) is a treatment option for patients with end-stage renal disease due to type 1 diabetes mellitus. We report a patient with a refractory fistula due to leakage from the duodenal stump of the pancreas graft after an SPK with bladder drainage who was successfully treated with a percutaneous direct injection of N-butyl-2-cyanoacrylate (NBCA).

CASE PRESENTATION

A 60-year-old female with a 33-year history of type 1 diabetes mellitus and a 10-year history of renal replacement therapy underwent an SPK in 2015. At the time of transplantation, an abdominal aortic aneurysm with a high risk of rupture was treated by a Y-graft replacement prior to the SPK. Bladder drainage of the pancreas graft was chosen to avoid a vessel graft infection. The patient's postoperative course was uneventful. The patient was discharged on postoperative day 93 with good-functioning pancreas and kidney grafts. One and a half years after the operation, the patient was found to have acute graft pancreatitis and a leak from the duodenal stump of the pancreas graft due to a paralytic neurogenic bladder. The insertion of an indwelling catheter into the bladder and the endoscopic-guided insertion of a catheter into the graft pancreatic duct through the duodenum/bladder anastomosis did not result in the closure of the fistula. Therefore, NBCA was injected at the site of the leak point using CT-guided technique. The fistula was completely closed immediately after the injection, with no recurrences of leaks.

CONCLUSIONS

A percutaneous direct injection of NBCA is one of the treatment options to treat intractable fistulas.

Sleeve gastrectomy enables simultaneous pancreas and kidney transplantation in severely obese recipients

BACKGROUND

Obesity adversely affects wait-listing and precludes patients with concomitant end-stage renal disease and type 1 diabetes mellitus from getting a simultaneous pancreas and kidney transplantation (SPK).

OBJECTIVE

To analyze safety and efficacy of laparoscopic sleeve gastrectomy (LSG) before SPK in severely obese type I diabetics.

METHODS

We assessed weight curve, complications, and graft function of three patients who underwent LSG before SPK.

RESULTS

LSG was uneventful in all patients. Body mass index dropped from 38.4 (range 35.7 - 39.9) before LSG to 28.5 (26.8 - 30.9) until SPK, with a mean loss of 25.8% (22.4 - 32.3). Interval between LSG and SPK was 364.3 (173 - 587) days. Pancreas and kidney graft function was excellent, with 100% insulin-free and dialysis-free survival over a mean follow-up of 3.6 (2.9 - 4.5) years. A1C dropped from 7% (6.3 - 8.2) before LSG to 4.9% (4.7 - 5.3) and 4.8% (4.5 - 5.1) 1 and 2 years after SPK, respectively.

CONCLUSION

LSG before SPK is safe and effective to enable severely obese type I diabetics to receive a lifesaving transplant. This is the first study analyzing the role of bariatric surgery before simultaneous pancreas and kidney transplantation.

Simultaneous Kidney-Pancreas Transplantation With an Original "Transverse Pancreas" Technique: Initial 9 Years' Experience With 56 Cases

An innovative technique for pancreas transplantation is described. The main aspect consists of the horizontal positioning of the pancreas, which allows a better venous outflow, thus preventing thrombosis and graft loss. The program of pancreas transplantation in this national reference center for pancreatic and liver surgery was started in 2007; the initial results were considered poor, resulting in the loss of half of the grafts due to venous thrombosis. After analyzing the possible causes, this technique was proposed and successfully implemented, reducing the postoperative complications, particularly the problem of venous thrombosis. A detailed description of the new surgical technique is provided. The main clinical and demographic characteristics of the 56 patients who underwent the surgery are analyzed. The incidence of venous thrombosis was 5.3% (3 patients) and graft loss was 3.5% (2 patients). Due to the good results, this technique became the standard surgery for transplantation of the pancreas in our center. The technique proved to be safe and successful. Due to the unique pancreas graft implantation, we called it "transverse pancreas surgery."

Preserving the Pancreas Graft: Outcomes of Surgical Repair of Duodenal Leaks in Enterically Drained Pancreas Allografts

BACKGROUND

Duodenal leak remains a major cause of morbidity and graft loss in pancreas transplant recipients. The role and efficacy of surgical and image-guided interventions to salvage enterically drained grafts with a duodenal leak has yet to be defined.

METHODS

We investigated the incidence, treatment, and outcome of duodenal leak in 426 pancreas transplantation recipients from 2000 to 2015.

RESULTS

Duodenal leak developed in 33 (7.8%) recipients after a median follow-up of 5.3 (range, 0.5-15.2) years. Most leaks occurred during the first year (n = 22; 67%), and most were located near the proximal and distal duodenal staple line. Graft pancreatectomy was performed in 8 patients as primary therapy because of unfavorable local and/or systemic conditions. Salvage was attempted in 25 patients using percutaneous drainage (n = 4), surgical drainage (n = 4), or surgical repair (n = 17). Percutaneous or surgical drainage failed to control the leak in 7 of these 8 patients, and all 7 ultimately required graft pancreatectomy for persistent leak and sepsis. Surgical repair salvaged 14 grafts, and 13 grafts continue to function after a median follow-up of 2.9 (range, 1.1-6.3) years after repair.

CONCLUSIONS

Our study shows that in selected patients a duodenal leak can be repaired successfully and safely in enterically drained grafts.

Simultaneous pancreas-kidney transplant for type I diabetes with renal failure: Anaesthetic considerations

Pancreatic grafts have been successfully used in patients with diabetes and are combined with kidney transplantation in patients with renal failure. The propagation of awareness in organ donation in India has increased the donor pool of transplantable organs in the last few years making multi visceral transplants feasible in our country. We present the anaesthetic management of a 32-year-old male with diabetes mellitus and end-stage renal failure who was successfully managed with a combined pancreas and kidney transplantation.

Early Hospital Readmission After Simultaneous Pancreas-Kidney Transplantation: Patient and Center-Level Factors

Early hospital readmission is associated with increased morbidity, mortality, and cost. Following simultaneous pancreas-kidney transplantation, rates of readmission and risk factors for readmission are unknown. We used United States Renal Data System data to study 3643 adult primary first-time simultaneous pancreas-kidney recipients from December 1, 1999 to October 31, 2011. Early hospital readmission was any hospitalization within 30 days of discharge. Modified Poisson regression was used to determine the association between readmission and patient-level factors. Empirical Bayes statistics were used to determine the variation attributable to center-level factors. The incidence of readmission was 55.5%. Each decade increase in age was associated with an 11% lower risk of readmission to age 40, beyond which there was no association. Donor African-American race was associated with a 13% higher risk of readmission. Each day increase in length of stay was associated with a 2% higher risk of readmission until 14 days, beyond which each day increase was associated with a 1% reduction in the risk of readmission. Center-level factors were not associated with readmission. The high incidence of early hospital readmission following simultaneous pancreas-kidney transplant may reflect clinical complexity rather than poor quality of care.

Duodenal leaks after pancreas transplantation with enteric drainage - characteristics and risk factors

Pancreas-kidney transplantation with enteric drainage has become a standard treatment in diabetic patients with renal failure. Leaks of the graft duodenum (DL) remain a significant complication after transplantation. We studied incidence and predisposing factors of DLs in both simultaneous pancreas-kidney (SPK) and pancreas after kidney (PAK) transplantation. Between January 2002 and April 2013, 284 pancreas transplantations were performed including 191 SPK (67.3%) and 93 PAK (32.7%). Patient data were analyzed for occurrence of DLs, risk factors, leak etiology, and graft survival. Of 18 DLs (incidence 6.3%), 12 (67%) occurred within the first 100 days after transplantation. Six grafts (33%) were rescued by duodenal segment resection. Risk factors for a DL were PAK transplantation sequence (odds ratio 3.526, P = 0.008) and preoperative immunosuppression (odds ratio 3.328, P = 0.012). In the SPK subgroup, postoperative peak amylase as marker of preservation/reperfusion injury and recipient pretransplantation cardiovascular interventions as marker of atherosclerosis severity were associated with an increased incidence of DLs. CMV-mismatch constellations showed an increased incidence in the SPK subgroup, however without significance probability. Long-term immunosuppression in PAK transplantation is a major risk factor for DLs. Early surgical revision offers the chance of graft rescue.

Simultaneous pancreas-kidney transplantation: lessons learned from the initial experience of a single center in Korea

Purpose

The purpose of this study is to report the results of simultaneous pancreas-kidney (SPK) transplantations and describe the lessons learned from the early experiences of a single center.

Methods

Between January 2002 and June 2013, a total of 8 patients underwent SPK transplantation. Clinical and radiologic data were reviewed retrospectively.

Results

Seven patients were diagnosed with type I diabetes mellitus and one patient became insulin-dependent after undergoing a total pancreatectomy because of trauma. Pancreas exocrine drainage was performed by enteric drainage in 4 patients and bladder drainage in 4 patients. Three patients required conversion from initial bladder drainage to enteric drainage due to urinary symptoms and duodenal leakage. Four patients required a relaparotomy due to hemorrhage, ureteral stricture, duodenal leakage, and venous thrombosis. There was no kidney graft loss, and 2 patients had pancreas graft loss because of venous thrombosis and new onset of type II diabetes mellitus. With a median follow-up of 76 months (range, 2-147 months), the death-censored graft survival rates for the pancreas were 85.7% at 1, 3, and 5 years and 42.9% at 10 years. The patient survival rate was 87.5% at 1, 3, 5, and 10 years.

Conclusion

The long-term grafts and patient survival in the current series are comparable to previous studies. A successful pancreas transplant program can be established in a single small-volume institute. A meticulous surgical technique and early anticoagulation therapy are required for further improvement in the outcomes.

DXA variations and fractures after simultaneous pancreas-renal transplantation: results of a long-term follow-up

Simultaneous pancreas-kidney transplant (SPKT) has been associated with an increased risk of fracture. We prospectively evaluated the long-term effects of SPKT on bone mineral density (BMD) and fracture risk. During 1998 to 1999, 29 participants were consecutively monitored, and 18 completed the 10-year follow-up. Laboratory blood parameters, lumbar-dorsal radiography, and DEXA were determined at baseline, 1 year, and 10 years. The medical record was reviewed for peripheral fragility fractures. The BMD revealed no changes between baseline and 1 or 10 years after SPKT. Lumbar-dorsal radiography showed 0% asymptomatic vertebral fractures at baseline and after 1 year with 16.7% at 10 years. Vertebral asymptomatic fractures were correlated with acute rejection episodes (P = 0.025). During the first year, no nonvertebral fractures were identified. At the end of the follow-up, 5 nonvertebral fractures in 4 patients were reported. Dorsal and lumbar spine fractures correlated with lumbar spine t score (r = -0.591, P =0.022) and peripheral fractures with femoral neck t score (r = -0.633, P = 0.013). Patients with SPKT did not show long-term significant loss of BMD. The incidence of vertebral fractures was low and related to steroid treatment; the incidence of peripheral fractures was higher and independent of clinical or biochemical parameters.

Imaging in pancreatic transplants

Pancreatic transplantation, performed alone or in conjunction with kidney transplantation, is an effective treatment for advanced type I diabetes mellitus and select patients with type II diabetes mellitus. Following advancements in surgical technique, postoperative management, and immunosuppression, pancreatic transplantation has significantly improved the length and quality of life for patients suffering from pancreatic dysfunction. While computed tomography (CT) and magnetic resonance imaging (MRI) have more limited utility, ultrasound is the preferred initial imaging modality to evaluate the transplanted pancreas; gray-scale assesses the parenchyma and fluid collections, while Doppler interrogation assesses vascular flow and viability. Ultrasound is also useful to guide percutaneous interventions for the transplanted pancreas. With knowledge of the surgical anatomy and common complications, the abdominal radiologist plays a central role in the perioperative and postoperative evaluation of the transplanted pancreas.

Prevention and management of graft thrombosis in pancreatic transplant

Pancreatic transplant effectively cures type 1 diabetes mellitus and maintains consistent long-term euglycemia. However, technical failure, and in particular graft thrombosis, accounts for the vast majority of transplants lost in the early postoperative period. The pancreas' inherently low microvascular flow state makes it vulnerable to vascular complications, as does the hypercoagulable blood of diabetic patients. Ultimately, the phenomenon is most definitely multifactorial. Prevention, as opposed to treatment, is key and should focus on reducing these multiple risk factors. This will involve tactical donor selection, optimal surgical technique and some form of anticoagulation. Close monitoring and early intervention will be crucial when treating thrombosis once preventative methods have failed. This may be achieved by further anticoagulation, graft salvage, or pancreatectomy with retransplant. This article will explore the multiple factors contributing to graft thrombus formation and the ways in which they may be addressed to firstly prevent, or more likely, reduce thrombosis. Secondly, we will consider the management strategies which can be implemented once thrombosis has occurred.

Pancreatic transplant in diabetes

Whole organ pancreas transplantation is increasingly being performed for the treatment of diabetes mellitus. To date, over 32,000 pancreas transplants have been performed worldwide. The procedure is associated with significant mortality and morbidity in early transplant period. However, the successful pancreas transplantation has the potential to render patients insulin-independent and halt the progression of complications of diabetes, thereby improving both quality of life and patient survival.

Current concepts in the simultaneous transplantation of kidney and pancreas

Diabetes mellitus (DM) represents an enormous health care concern for the United States and other countries. According to the American Diabetes Association in 2007, there were more than 23 million Americans living with diabetes. This is a 13.5% increase from 2005, likely representing increases in Type II DM (DMII). Diabetes mellitus results when the beta cells of the pancreas are unable to produce sufficient insulin to prevent hyperglycemia. Simultaneous pancreas and kidney transplantation, or SPK, may be indicated for patients that have experienced renal failure as a complication of DM (either type I or type II). Until recently, technical failure represented a significant impediment to the success of pancreas transplantation. At the turn of the century, however, both renal and pancreatic graft survival dramatically improved. Immunologic and nonimmunologic causes of graft failure continue to challenge inpatient and outpatient management. With vigilance in the ICU postoperatively and in the clinic, SPK can provide significant benefit both in patient survival and quality of life.

Human fibrinogen patches application reduces intra-abdominal infectious complications in pancreas transplant with enteric drainage

PURPOSE

The purpose of the study was to analyze the incidence of intra-abdominal infectious complications after the application of a fibrinogen sealant to the duodenojejunal anastomosis in simultaneous pancreas-kidney transplants (SPK) with enteric drainage.

METHODS

Results of 68 SPKs with enteric drainage were prospectively assessed. A fibrinogen and thrombin sheet was applied to the duodenojejunal anastomosis in 34 patients, who were compared to a control group of 34 patients. The incidence and severity of intra-abdominal infectious complications and the 1-year patient and grafts survival were analyzed.

RESULTS

Eighteen patients experienced intra-abdominal infectious complications. Grade 1a complications occurred in the study group, whereas surgery was required only in patients from the control group: complications grade 3a (15%) and complications grade 3b (18%) (p = 0.003 vs. study group, respectively). The overall rate of anastomotic leakage (complications grade 2b and 3b) was 10%, all of which occurred in the control group. The length of hospital stay was higher in the control group was 34.6 ± 11.3 days vs. 22.8 ± 11.1 days (p = 0.03). There were no significant differences in 1-year patient and graft survival between groups.

CONCLUSIONS

In our study, the application of fibrinogen and thrombin sheets was associated to a decrease in the number and severity of intra-abdominal infectious complications.

Evolution of β-Cell Replacement Therapy in Diabetes Mellitus: Pancreas Transplantation

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.

Enteric conversion after pancreatic transplantation: resolution of symptoms and long-term results

PURPOSE

Bladder drainage (BD) of pancreatic transplants is associated with a unique set of complications. We intended to analyze the incidence, indications, complications and long-term results of enteric conversion procedures (EC).

METHODS

Using a prospective database, 32 EC patients out of 433 simultaneous pancreas-kidney-transplant (SPK) recipients were identified. Graft and patient survival rates were compared with those after primary enteric drainage (ED).

RESULTS

The mean SPK-EC interval was 5.0 yr, and the mean patient follow-up was 13.8 yr. Indications for EC were genitourinary symptoms (62.5%), duodenal complications (15.6%), graft pancreatitis (12.5%), pyelonephritis (6.3%), and metabolic acidosis (3.1%). All patients reported significant long-term resolution of symptoms. Surgical complications, reoperations, early graft loss, and 30-d mortality occurred in 31.3%, 25.0%, 6.3%, and 3.1% of cases, respectively. Pancreatic graft and patient survival rates at 1, 5, and 10 yr after SPK were comparable between EC patients and ED patients at the same institution.

CONCLUSION

For the treatment of symptoms associated with BD, EC results in excellent long-term graft function and significant resolution of symptoms even years after SPK. Postoperative morbidity after EC including early reoperation and graft loss, however, has to be considered.

Consolidation of enteric drainage for exocrine secretions in simultaneous pancreas-kidney transplant

INTRODUCTION

Management of the exocrine drainage of the pancreatic graft in simultaneous pancreas kidney (SPK) transplantation has been a matter of debate for years. There is currently a trend toward a more physiological enteric drainage (ED). This study compared short- and long-term complications and graft survival in patients with enteric versus bladder exocrine secretion drainage.

PATIENTS AND METHODS

Between January 1995 and November 2005, we performed 75 SPK transplants: 55 with ED and 20 with bladder drainage (BD). The rates of complications and graft survival were monitored over at least 36 months after transplantation.

RESULTS

Mean posttransplant follow-up was 119.5 +/- 6.6 months. Urinary infection, hematuria, reflux pancreatitis, and repeat surgery rates were all significantly higher among the BD area. There was no intergroup difference in rejection rates or in the incidence of graft thrombosis, transplantectomy, anastomotic dehiscence, or intra-abdominal abscesses. Pancreas and kidney graft survival rates were similar in the two groups.

CONCLUSIONS

In our experience, ED was more physiological than BD, and was associated with fewer complications.

The current state of pancreas-kidney transplantation in China: the indications, surgical techniques and outcome

It is currently estimated that 50 million Chinese have diabetic mellitus (DM) with more than 90% of these being afflicted with type 2 DM. Concomitantly, the socio-economic improvements in China are supporting the adoption of pancreas-kidney transplantations as a treatment option for these patients. Recipient candidate pool has yet to be expanded and the final effect to be improved in clinical practice. To date, more than 250 pancreas-kidney transplants have been performed on patients with type 1 and type 2 DM. To improve the outcome, a new surgical technique that involves anastomosis of the graft duodenum to recipient jejunum side-to-side but not Roux-en-Y, has been devised for enteric drainage. Furthermore, the systemic venous drainage (SVD) has been used as the method of choice for endocrine secretions. Graft and recipient long-term survival in China was similar to that in America and Europe. Three-year survival rate of pancreas and kidney grafts was 92.2% and 90.2%, respectively, in our center. No difference in survival and graft function between type 1 and type 2 DM recipients was noted. It is concluded that pancreas-kidney transplantation is an effective way for the treatment of type 1 DM and some type 2 DM complicated with uremia.

Twelve-month pancreas graft function significantly influences survival following simultaneous pancreas-kidney transplantation

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.

Acute urinary retention secondary to a urethral calculus in a bladder-drained kidney pancreas transplant patient - a metallic clip nidus

Urological expertise is usually required for the management of any urological complications of bladder-drained pancreatic allografts whether they are the result of simultaneous pancreas-kidney transplants, pancreas after kidney transplants, or pancreas transplants alone. This study presents a case of urinary retention secondary to prostatic urethra calculus impaction, the nidus of which was found to be metallic staples from the donor duodenal segment of a pancreatic allograft. Knowledge of the pre-transplant benchwork gave a high index of suspicion to the urological sequelae of this case and, in particular, the presence of calculi should suggest a metal clip nidus. We examine the methods of exocrine pancreatic drainage, donor duodenum preparation and case management.

Pancreas-kidney transplantations with primary bladder drainage followed by enteric conversion: graft survival and outcomes

BACKGROUND

In the Leiden University Medical Centre, a two-step approach is routinely used in simultaneous pancreas-kidney (SPK) transplantations: primary bladder drainage (BD) followed by elective enteric conversion. The rationale for this approach is to prevent the short-term disadvantages of primary enteric drainage (intra-abdominal abscesses, pancreas graft loss) and the long-term urological complications related to bladder drainage. Aim of the present study is to evaluate survival and (urological) complications of this approach compared to enteric drainage (ED).

METHODS

Patient records of all 98 SPK transplantations in the period 1997-2004 were reviewed for complications during the initial hospitalization until 30 days after discharge, and to assess urological complications and graft survival until the last hospital visit. Median duration of follow-up was 4.3 years for pancreas graft survival, 4.7 years for kidney graft survival, and 4.8 years for patient survival.

RESULTS

Patient survival was significantly better in BD patients than in ED patients (chi2=9.89 P<0.01). Pancreas graft survival was also better in BD patients after adjustment for the longer pancreas warm ischemia time in BD patients (P=0.05). The survival rates in our patient population seem higher than reported by the International Pancreas Transplant Registry, particularly in BD patients. Urological complications occurred in nine BD patients (10.3%), comparable to the rates reported for enteric-drained grafts.

CONCLUSIONS

This two-step approach of SPK transplantation results in excellent survival rates, with urological complication rates comparable to those reported for enteric-drained grafts, and may thus be viewed as a safe and effective procedure of SPK transplantation.