1
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Ito T, Kenmochi T, Aida N, Matsushima H, Kurihara K, Ishihara T, Shintani A, Asaoka T, Ito T. Impact of Pancreas Transplantation on the Patient Survival-An Analysis of the Japanese Pancreas Transplants Registry. J Clin Med 2020; 9:jcm9072134. [PMID: 32640735 PMCID: PMC7408615 DOI: 10.3390/jcm9072134] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The impact of pancreas transplantation, including kidney transplantation on patients' life prognoses, is unclear in Japan. An analysis of the data of the Japan Pancreas Transplant Registry was performed to compare the patient survival between on the waiting list and after pancreas transplantation, and investigate the factors that affect the patient survival after pancreatic transplantation. METHODS The life prognoses of 361 patients who underwent pancreas transplantation from 2000 to December 2018 were examined. RESULTS The survival rates at 1, 5, and 10 years on the waiting list were 98.4%, 90.3%, and 78.1%, respectively, while those after transplantation were significantly improved (p = 0.029) at 100%, 97.5%, and 88.9%, respectively. Furthermore, the survival rates of patients waiting for simultaneous pancreas and kidney transplantation (SPK) at 1, 5, and 10 years were 98.2%, 89.4%, and 75.4%, respectively, while those after SPK were also significantly improved (p = 0.026) at 100%, 94.6%, and 88.8%. The multivariable analysis revealed that the duration of diabetes before surgery was the only independent risk factor (hazard ratio = 1.095, p = 0.012) that affected the patient survival after SPK. CONCLUSION Pancreas transplantation was found to improve the life prognosis of patients with type 1 diabetes, especially those with end-stage renal failure waiting for SPK.
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Affiliation(s)
- Taihei Ito
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, Dengakugakubo 1-98, Kutsukakecho, Toyoake-shi, Aichi 470-1192, Japan; (T.K.); (N.A.); (H.M.); (K.K.)
- Correspondence: ; Tel.: +5-62-93-2000; Fax: +5-62-93-7060
| | - Takashi Kenmochi
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, Dengakugakubo 1-98, Kutsukakecho, Toyoake-shi, Aichi 470-1192, Japan; (T.K.); (N.A.); (H.M.); (K.K.)
| | - Naohiro Aida
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, Dengakugakubo 1-98, Kutsukakecho, Toyoake-shi, Aichi 470-1192, Japan; (T.K.); (N.A.); (H.M.); (K.K.)
| | - Hajime Matsushima
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, Dengakugakubo 1-98, Kutsukakecho, Toyoake-shi, Aichi 470-1192, Japan; (T.K.); (N.A.); (H.M.); (K.K.)
| | - Kei Kurihara
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, Dengakugakubo 1-98, Kutsukakecho, Toyoake-shi, Aichi 470-1192, Japan; (T.K.); (N.A.); (H.M.); (K.K.)
| | - Takuma Ishihara
- Gifu University Hospital, Innovative and Clinical Research Promotion Center, Gifu University, Gifu 501-1193, Japan;
| | - Ayumi Shintani
- Department of Medical Statistics, Graduate School of Medicine, Osaka City University, Osaka 558-8585, Japan;
| | - Tadafumi Asaoka
- The Japan Pancreas Transplant Registry, Japan Society for Pancreas & Islet Transplantation, Osaka 565-0871, Japan; (T.A.); (T.I.)
| | - Toshinori Ito
- The Japan Pancreas Transplant Registry, Japan Society for Pancreas & Islet Transplantation, Osaka 565-0871, Japan; (T.A.); (T.I.)
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2
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Samoylova ML, Borle D, Ravindra KV. Pancreas Transplantation: Indications, Techniques, and Outcomes. Surg Clin North Am 2018; 99:87-101. [PMID: 30471744 DOI: 10.1016/j.suc.2018.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreas transplantation treats insulin-dependent diabetes with or without concurrent end-stage renal disease. Pancreas transplantation increases survival versus no transplant, increases survival when performed as simultaneous pancreas-kidney versus deceased-donor kidney alone, and improves quality of life. Careful donor and recipient selection are paramount to good outcomes. Several technical variations exist for implantation: portal versus systemic vascular drainage and jejunal versus duodenal versus bladder exocrine drainage. Complications are most frequently technical in the first year and immunologic thereafter. Graft rejection is challenging to diagnose and is treated selectively. Islet cell transplantation currently has inferior outcomes to whole-organ pancreas transplantation.
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Affiliation(s)
- Mariya L Samoylova
- Department of Surgery, Duke University School of Medicine, DUMC Box 3443, Room M114, Yellow Zone, Duke South, Durham, NC 27710, USA
| | - Deeplaxmi Borle
- Department of Surgery, Division of Abdominal Transplant Surgery, Duke University School of Medicine, DUMC Box 3443, Room M114, Yellow Zone, Duke South, Durham, NC 27710, USA
| | - Kadiyala V Ravindra
- Department of Surgery, Division of Abdominal Transplant Surgery, Duke University School of Medicine, 330 Trent Drive Room 217, DUMC Box 3512, Durham, NC 27710, USA.
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3
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Iemura T, Oba A, Matsui M, Mano C, Kawabata N, Horisawa Y, Miyahara Y, Itoh M. Substantial Improvement in a Nerve Conduction Study of Lymphoma-associated Demyelinating Neuropathy Treated by Intravenous Immunoglobulin and Chemotherapy. Intern Med 2018; 57:3467-3472. [PMID: 30101902 PMCID: PMC6306548 DOI: 10.2169/internalmedicine.0678-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
A 64-year-old woman with lymphoma-associated demyelinating neuropathy was treated by 6 cycles of R-CHOP with intravenous immunoglobulin in the first 2 cycles. We noted substantial improvement in the findings of a nerve conduction study (NCS) after the first cycle, followed by more protracted improvement during the second to sixth cycles. The improvement of the neurological symptoms paralleled the findings of the NCS. Our case provides important information for understanding the etiology and optimization of treatments for lymphoma-associated demyelinating neuropathy.
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Affiliation(s)
- Tomoki Iemura
- Department of Hematology, Kyoto City Hospital, Japan
| | - Akifumi Oba
- Department of Hematology, Kyoto City Hospital, Japan
| | | | - Chihiro Mano
- Department of Hematology, Kyoto City Hospital, Japan
| | | | | | | | - Mitsuru Itoh
- Department of Hematology, Kyoto City Hospital, Japan
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4
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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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5
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Saudek F, Cahová M, Havrdová T, Zacharovová K, Daňková H, Voska L, Lánská V, Üçeyler N, Sommer C. Preserved Expression of Skin Neurotrophic Factors in Advanced Diabetic Neuropathy Does Not Lead to Neural Regeneration despite Pancreas and Kidney Transplantation. J Diabetes Res 2018; 2018:2309108. [PMID: 30648113 PMCID: PMC6311823 DOI: 10.1155/2018/2309108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/27/2018] [Indexed: 01/11/2023] Open
Abstract
Diabetic peripheral neuropathy (DPN) is a common complication of diabetes with potential severe consequences. Its pathogenesis involves hyperglycemia-linked mechanisms, which may include changes in the expression of neurotrophic growth factors. We analyzed the expression of 29 factors potentially related to nerve degeneration and regeneration in skin biopsies from 13 type 1 diabetic pancreas and kidney recipients with severe DPN including severe depletion of intraepidermal nerve fibers (IENF) in lower limb skin biopsies (group Tx1 1st examination). The investigation was repeated after a median 28-month period of normoglycemia achieved by pancreas transplantation (group Tx1 2nd examination). The same tests were performed in 13 stable normoglycemic pancreas and kidney recipients 6-12 years posttransplantation (group Tx2), in 12 matched healthy controls (group HC), and in 12 type 1 diabetic subjects without severe DPN (group DM). Compared to DM and HC groups, we found a significantly higher (p < 0.05-0.001) expression of NGF (nerve growth factor), NGFR (NGF receptor), NTRK1 (neurotrophic receptor tyrosine kinase 1), GDNF (glial cell-derived neurotrophic factor), GFRA1 (GDNF family receptor alpha 1), and GFAP (glial fibrillary acidic protein) in both transplant groups (Tx1 and Tx2). Enhanced expression of these factors was not normalized following the median 28-month period of normoglycemia (Tx1 2nd examination) and negatively correlated with IENF density and with electrophysiological indices of DPN (vibration perception threshold, electromyography, and autonomic tests). In contrast to our expectation, the expression of most of 29 selected factors related to neural regeneration was comparable in subjects with severe peripheral nerve fiber depletion and healthy controls and the expression of six factors was significantly upregulated. These findings may be important for better understanding the pathophysiology of nerve regeneration and for the development of intervention strategies.
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Affiliation(s)
- František Saudek
- Diabetes Center, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Monika Cahová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Terezie Havrdová
- Diabetes Center, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Klára Zacharovová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Helena Daňková
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Luděk Voska
- Clinical and Transplant Pathology Department, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Věra Lánská
- Department of Statistics, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Nurcan Üçeyler
- University Hospital of Würzburg, Department of Neurology, 97080 Würzburg, Germany
| | - Claudia Sommer
- University Hospital of Würzburg, Department of Neurology, 97080 Würzburg, Germany
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6
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Shafi T, Mullangi S, Jaar BG, Silber H. Autonomic dysfunction as a mechanism of intradialytic blood pressure instability. Semin Dial 2017; 30:537-544. [PMID: 28730673 DOI: 10.1111/sdi.12635] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The autonomic nervous system (ANS) is the principal endogenous defense mechanism that maintains blood pressure in the setting of hypotension. Disruption of the ANS impairs this ability and can contribute to blood pressure instability, including hypotension and hypertension. In this narrative review, we provide an overview of the ANS and the consequences of its dysfunction in patients with end-stage kidney disease treated with dialysis. We also discuss possible mechanisms of this autonomic dysfunction that may need future investigation.
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Affiliation(s)
- Tariq Shafi
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Surekha Mullangi
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Bernard G Jaar
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| | - Harry Silber
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
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7
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Normand G, Brunner F, Badet L, Buron F, Catton M, Massardier J, Esposito L, Grimbert P, Mourad G, Serre JE, Caillard S, Karam G, Cantarovich D, Morelon E, Thaunat O. Pregnancy outcomes in simultaneous pancreas and kidney transplant recipients: a national French survey study. Transpl Int 2017; 30:893-902. [DOI: 10.1111/tri.12983] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/20/2016] [Accepted: 05/08/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Gabrielle Normand
- Department of Transplantation, Nephrology and Clinical Immunology; Hospices Civils de Lyon; Lyon France
| | - Flora Brunner
- Department of Transplantation, Nephrology and Clinical Immunology; Hospices Civils de Lyon; Lyon France
| | - Lionel Badet
- Department of Urology and Transplant Surgery; Hospices Civils de Lyon; Lyon France
| | - Fanny Buron
- Department of Transplantation, Nephrology and Clinical Immunology; Hospices Civils de Lyon; Lyon France
| | - Marielle Catton
- Department of Gynecology and Obstetrics; Femme-Mère Enfants Hospital; Hospices Civils de Lyon; Lyon France
| | - Jérôme Massardier
- Department of Gynecology and Obstetrics; Femme-Mère Enfants Hospital; Hospices Civils de Lyon; Lyon France
| | - Laure Esposito
- Department of Nephrology and Organ Transplantation; CHU Rangueil; Toulouse France
| | - Philippe Grimbert
- Nephrology and Renal Transplantation and CIC-BT 504 Department; Henri Mondor Hospital; APHP; Créteil France
- INSERM U955; Paris Est University; Créteil France
| | - Georges Mourad
- Department of Nephrology; Hospital Lapeyronie; CHU Montpellier; Montpellier France
| | - Jean E. Serre
- Department of Nephrology; Hospital Lapeyronie; CHU Montpellier; Montpellier France
| | - Sophie Caillard
- Department of Nephrology-Transplantation; Strasbourg University Hospital; Strasbourg France
| | - Georges Karam
- Institute of Transplantation Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
| | - Diego Cantarovich
- Institute of Transplantation Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology; Hospices Civils de Lyon; Lyon France
- International Center for Infectiology Research (CIRI); French National Institute of Health and Medical Research (INSERM) Unit 1111; Ecole Normale Supérieure de Lyon; CNRS, UMR 5308; Claude Bernard Lyon 1 University; Lyon France
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology; Hospices Civils de Lyon; Lyon France
- International Center for Infectiology Research (CIRI); French National Institute of Health and Medical Research (INSERM) Unit 1111; Ecole Normale Supérieure de Lyon; CNRS, UMR 5308; Claude Bernard Lyon 1 University; Lyon France
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8
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Fensom B, Harris C, Thompson SE, Al Mehthel M, Thompson DM. Islet cell transplantation improves nerve conduction velocity in type 1 diabetes compared with intensive medical therapy over six years. Diabetes Res Clin Pract 2016; 122:101-105. [PMID: 27825059 DOI: 10.1016/j.diabres.2016.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/02/2016] [Accepted: 10/12/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Neuropathy is a common diabetic complication that can result in significant disability. Few treatment options exist to reverse this process. METHODS We conducted a one-way crossover cohort study comparing intensive medical treatment and islet cell transplantation for type 1 diabetes on the change in nerve conduction velocity over six years. FINDINGS For subjects with some neuropathy at baseline (Z score below -1), nerve conduction velocity significantly improved post-transplant (slope (0.073±0.042) while it worsened in medically treated patients (-0.136±0.081) (p<.05). INTERPRETATION Islet cell transplantation improves nerve conduction velocity and could be further investigated as a treatment for neuropathy in type 1 diabetes.
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Affiliation(s)
- Blake Fensom
- Department of Medicine, Vancouver General Hospital and University of British Columbia, Canada
| | - Claire Harris
- Department of Medicine, Vancouver General Hospital and University of British Columbia, Canada
| | - Sharon E Thompson
- Department of Medicine, Vancouver General Hospital and University of British Columbia, Canada
| | - Mohammed Al Mehthel
- Department of Medicine, Vancouver General Hospital and University of British Columbia, Canada
| | - David M Thompson
- Department of Medicine, Vancouver General Hospital and University of British Columbia, Canada.
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9
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Havrdova T, Boucek P, Saudek F, Voska L, Lodererova A, Üçeyler N, Vondrova H, Skibova J, Lipar K, Sommer C. Severe Epidermal Nerve Fiber Loss in Diabetic Neuropathy Is Not Reversed by Long-Term Normoglycemia After Simultaneous Pancreas and Kidney Transplantation. Am J Transplant 2016; 16:2196-201. [PMID: 26751140 DOI: 10.1111/ajt.13715] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 12/16/2015] [Accepted: 01/02/2016] [Indexed: 01/25/2023]
Abstract
Whether nerve fiber loss, a prominent feature of advanced diabetic neuropathy, can be reversed by reestablishment of normal glucose control remains questionable. We present 8-year follow-up data on epidermal nerve fiber (ENF) density and neurological function in patients with type 1 diabetes after simultaneous pancreas and kidney transplantation (SPK) with long-term normoglycemia. Distal thigh skin biopsies with ENF counts, vibration perception thresholds (VPTs), autonomic function testing (AFT) and electrophysiological examinations were performed at time of SPK and 2.5 and 8 years after SPK in 12 patients with type 1 diabetes. In comparison to controls, baseline ENF density, VPT and AFT results of patients indicated severe neuropathy. At follow-up, all SPK recipients were insulin independent with excellent glycemic control and kidney graft function; however, the severe ENF depletion present at baseline had not improved, with total ENF absence in 11 patients at 8-year follow-up. Similarly, no amelioration occurred in the VPT and AFT results. Numerical improvement was seen in some electrophysiological parameters; however, statistical significance was achieved only in median motor nerve conduction velocity. ENF loss and functional deficits in advanced diabetic peripheral neuropathy are rarely reversible, even by long-term normoglycemia, which underscores the importance of neuropathy prevention by early optimal glycemic control.
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Affiliation(s)
- T Havrdova
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - P Boucek
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - F Saudek
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - L Voska
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - A Lodererova
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - N Üçeyler
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - H Vondrova
- Department of Neurology, Thomayer Hospital, Prague, Czech Republic
| | - J Skibova
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - K Lipar
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - C Sommer
- Department of Neurology, University of Würzburg, Würzburg, Germany
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10
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Dholakia S, Sharples EJ, Friend PJ. Impact of Pancreas Transplant on Diabetic Complications: Retinoparhy, Gastroparesis and Automatic Dysregulation. CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0101-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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11
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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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12
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Kim SM, Youn WY, Kim DJ, Kim JS, Lee S. Simultaneous pancreas-kidney transplantation: lessons learned from the initial experience of a single center in Korea. Ann Surg Treat Res 2015; 88:41-7. [PMID: 25553324 PMCID: PMC4279990 DOI: 10.4174/astr.2015.88.1.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/04/2014] [Accepted: 08/07/2014] [Indexed: 01/26/2023] Open
Abstract
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.
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Affiliation(s)
- Suh Min Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Woo Young Youn
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Doo Jin Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joo Seop Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Samuel Lee
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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13
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Lindahl JP, Jenssen T, Hartmann A. Long-term outcomes after organ transplantation in diabetic end-stage renal disease. Diabetes Res Clin Pract 2014; 105:14-21. [PMID: 24698407 DOI: 10.1016/j.diabres.2014.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 02/27/2014] [Accepted: 03/06/2014] [Indexed: 01/28/2023]
Abstract
Patients with type 1 diabetic end-stage renal disease (ESRD) may be offered single kidney transplantation from a live donor (LDK) or a deceased donor (DDK) to replace the lost kidney function. In the latter setting the patient may also receive a simultaneous pancreas together with a kidney from the same donor (SPK). Also in some cases a pancreas after kidney may be offered to those who have previously received a kidney alone (PAK). The obvious benefit of a successful SPK transplantation is that the patients not only recover from uremia but also obtain normal blood glucose control without use of insulin or other hypoglycemic agents. Accordingly, this combined procedure has become an established treatment for type 1 diabetic patients with ESRD. Adequate long-term blood glucose control may theoretically lead to reduced progression or even reversal of microvascular complications. Another potential beneficial effect may be improvement of patient and kidney graft survival. Development of diabetic complications usually takes a decade to develop and accordingly any potential benefits of a pancreas transplant will not easily be disclosed during the first decade after transplantation. The purpose of the review is to assess the present literature of outcomes after kidney transplantation in patients with diabetic ESRD, with our without a concomitant pancreas transplantation. The points of interest given in this review are microvascular complications, graft outcomes, cardiovascular outcomes and mortality.
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Affiliation(s)
- Jørn Petter Lindahl
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway.
| | - Trond Jenssen
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Anders Hartmann
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
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14
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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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15
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Jacewicz M, Marino CR. Neurologic complications of pancreas and small bowel transplantation. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1277-1293. [PMID: 24365419 DOI: 10.1016/b978-0-7020-4088-7.00087-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In the past decade, substantial improvements in patient and graft survival for pancreas and small bowel transplants have been achieved. Despite this progress, many patients still develop neurologic complications in the course of their illness. Small bowel transplants produce more neurologic complications because of the complex metabolic environment in which the procedure is performed and because of the intense immune suppression necessitated by the greater immunogenicity of the intestinal mucosa. Pancreas transplants stabilize and/or improve the signs and symptoms of diabetic neuropathy over time. Because transplantation of the pancreas is often coupled with a kidney transplant and small intestine with liver, neurologic complications in these patients sometimes reflect problems involving the organ partner or both organs. The spectrum of neurologic complications for pancreas and small bowel transplant recipients is similar to other organ transplants but their frequency varies depending on the type of transplant performed.
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Affiliation(s)
- Michael Jacewicz
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Christopher R Marino
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Pretransplantation GAD-autoantibody status to guide prophylactic antibody induction therapy in simultaneous pancreas and kidney transplantation. Transplantation 2013; 96:745-52. [PMID: 23912172 DOI: 10.1097/tp.0b013e3182a012cc] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Daclizumab and antithymocyte globulin (ATG) have been shown to reduce allograft rejection. We assessed the safety and efficacy of daclizumab or ATG prophylaxis in combination with triple immunotherapy in simultaneous pancreas-kidney transplant (SPKT) recipients. METHODS Thirty-nine type 1 diabetic patients scheduled for primary SPKT were randomized to receive prophylactic therapy with either daclizumab or ATG. A group of 27 patients without prophylactic antibodies was used for retrospective comparison. All patients received cyclosporine and mycophenolate mofetil and gradually tapered prednisone. Autoantibodies and cellular autoreactivity were measured to assess recurrent autoreactive responses. RESULTS Baseline and transplant characteristics were comparable among groups. Both daclizumab and ATG therapy resulted in a significant reduction in acute rejection episodes. The incidence of rejection episodes was significantly higher in pretransplantation GAD autoantibody-positive daclizumab-treated recipients compared with GAD autoantibody-negative or ATG-treated recipients. IA-2 islet autoantibodies showed no association with rejection. There were no significant differences between the groups for in vitro autoreactivity, clinical outcome, or functional parameters. CONCLUSIONS Daclizumab or ATG combined with a maintenance immunosuppressive regime consisting of cyclosporine, mycophenolate mofetil, and prednisolone were well tolerated and equally effective in reducing the incidence of acute rejection episodes in SPKT recipients. Up to 3 years, no adverse sequelae of the immunoprophylaxis or clinical and ex vivo recurrent autoimmunity were observed. We propose that the pretransplantation existence of GAD65 autoantibodies serves as a marker guiding the choice for prophylactic therapy in pancreas transplantation.
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Thwaites SE, Lam VWT, Yao J, Kable K, Jenkins L, Chen C, Robertson P, Hawthorne WJ, Ryan BJ, Pleass HC, Allen RDM. Surgical Morbidity of Simultaneous Kidney and Pancreas Transplantation: A Single-Centre Experience in the Tacrolimus Era. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/685850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction. Simultaneous pancreas and kidney (SPK) transplantation is performed to restore normoglycaemia and renal function in patients with Type I diabetes mellitus and end-stage renal failure. We aimed to evaluate the impact of major postoperative complications to patient and graft survival outcomes. Method. Using a prospectively collected database over a 10-year period, major postoperative complications requiring return to operating theatre as well as patient and graft survival outcomes were analysed retrospectively. Results. Between January 2001 and May 2010, 165 patients underwent first-time SPK transplantation. Median age of recipients was 39.8 years (range, 16.9–53.2). Enteric drainage was used in 149 patients, and bladder drainage was used in 16. Median follow-up time was 5.2 years (range 1.1–10.3). Fifty-six patients (34%) returned to operating theatre at least once. Pancreatic allograft loss secondary to vascular thrombosis occurred in 12 patients (7%), and 2 patients (1.2%) required transplant pancreatectomy due to debilitating pancreatic enzyme leaks. At 1 and 5 years, patient survival was 98% and 94%; pancreas graft survival, 86% and 77%; kidney graft survival 96% and 89%, respectively. Conclusion. SPK is a safe and effective treatment for Type I diabetes mellitus and end-stage renal failure although surgical reintervention is required in approximately one-third of patients. Preventing vascular thrombosis remains a major challenge.
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Affiliation(s)
- Stephen E. Thwaites
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Vincent W. T. Lam
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Jinna Yao
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Kathy Kable
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Lillian Jenkins
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Cheng Chen
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Paul Robertson
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Wayne J. Hawthorne
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Brendan J. Ryan
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Henry C. Pleass
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Richard D. M. Allen
- National Pancreas Transplant Unit, Westmead Hospital, Westmead, NSW 2145, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
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Abstract
Solid organ transplantations save lives in patients affected by terminal organ failures and improve quality of life. Organ transplantations have gradually ameliorated in the last two decades and usually provide excellent results in children and young adults, and are increasingly challenged by the growing proportion of elderly transplant patients with comorbidities. Renal transplantation increases patient survival over dialysis, and lifesaving transplants are indispensible to treat patients with liver, heart, or lung irreversible diseases. Solid organ transplant programs activity has been steadily growing but is still far from global needs, with great differences among countries. Solid organ transplantations are essential for developed and mature health care systems.
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Affiliation(s)
- Josep M Grinyó
- Department of Nephrology, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, Barcelona 08907, Spain.
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19
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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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Viglietti D, Serrato T, Abboud I, Antoine C, Pillebout E, Busson M, Desgrandchamps F, Meria P, Godin M, Hurault de Ligny B, Thervet E, Legendre C, Suberbielle C, Verine J, Glotz D, Peraldi MN. Kidney graft dysfunction in simultaneous pancreas-kidney recipients after pancreas failure: analysis of early and late protocol biopsies. Clin Transplant 2013; 27:E249-55. [DOI: 10.1111/ctr.12095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 02/02/2023]
Affiliation(s)
| | - Tomas Serrato
- Service de Néphrologie et Transplantation; Hôpital Saint-Louis; Paris
| | - Imad Abboud
- Service de Néphrologie et Transplantation; Hôpital Saint-Louis; Paris
| | - Corinne Antoine
- Service de Néphrologie et Transplantation; Hôpital Saint-Louis; Paris
| | | | - Marc Busson
- Unité INSERM U 940; Hôpital Saint-Louis; Paris
| | | | - Paul Meria
- Service d'Urologie; Hôpital Saint-Louis; Paris
| | - Michel Godin
- Service de Néphrologie; Hôpital Bois-Guillaume; Rouen
| | | | - Eric Thervet
- Service de Néphrologie; Hôpital Européen Georges Pompidou; Paris
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Tavakoli M, Mitu-Pretorian M, Petropoulos IN, Fadavi H, Asghar O, Alam U, Ponirakis G, Jeziorska M, Marshall A, Efron N, Boulton AJ, Augustine T, Malik RA. Corneal confocal microscopy detects early nerve regeneration in diabetic neuropathy after simultaneous pancreas and kidney transplantation. Diabetes 2013; 62:254-60. [PMID: 23002037 PMCID: PMC3526062 DOI: 10.2337/db12-0574] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetic neuropathy is associated with increased morbidity and mortality. To date, limited data in subjects with impaired glucose tolerance and diabetes demonstrate nerve fiber repair after intervention. This may reflect a lack of efficacy of the interventions but may also reflect difficulty of the tests currently deployed to adequately assess nerve fiber repair, particularly in short-term studies. Corneal confocal microscopy (CCM) represents a novel noninvasive means to quantify nerve fiber damage and repair. Fifteen type 1 diabetic patients undergoing simultaneous pancreas-kidney transplantation (SPK) underwent detailed assessment of neurologic deficits, quantitative sensory testing (QST), electrophysiology, skin biopsy, corneal sensitivity, and CCM at baseline and at 6 and 12 months after successful SPK. At baseline, diabetic patients had a significant neuropathy compared with control subjects. After successful SPK there was no significant change in neurologic impairment, neurophysiology, QST, corneal sensitivity, and intraepidermal nerve fiber density (IENFD). However, CCM demonstrated significant improvements in corneal nerve fiber density, branch density, and length at 12 months. Normalization of glycemia after SPK shows no significant improvement in neuropathy assessed by the neurologic deficits, QST, electrophysiology, and IENFD. However, CCM shows a significant improvement in nerve morphology, providing a novel noninvasive means to establish early nerve repair that is missed by currently advocated assessment techniques.
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Affiliation(s)
- Mitra Tavakoli
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Maria Mitu-Pretorian
- Transplantation Unit, Manchester Royal Infirmary, Central Manchester University Hospitals Foundation Trust, Manchester, U.K
| | - Ioannis N. Petropoulos
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Hassan Fadavi
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Omar Asghar
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Uazman Alam
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Georgios Ponirakis
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Maria Jeziorska
- Tissue Injury and Repair Group, School of Medicine, The University of Manchester, U.K
| | - Andy Marshall
- Department of Clinical Neurophysiology, Manchester Royal Infirmary, Central Manchester University Hospitals Foundation Trust, U.K.; and
| | - Nathan Efron
- Institute of Health and Biomedical Innovation and School of Optometry and Vision Science, Queensland University of Technology, Brisbane, Australia
| | - Andrew J. Boulton
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Titus Augustine
- Transplantation Unit, Manchester Royal Infirmary, Central Manchester University Hospitals Foundation Trust, Manchester, U.K
| | - Rayaz A. Malik
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
- Corresponding author: Rayaz A. Malik,
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Affiliation(s)
- Roni M. Shtein
- Department of Ophthalmology, University of Michigan, Ann Arbor, Michigan
| | - Brian C. Callaghan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
- Corresponding author: Brian C. Callaghan,
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Girman P, Saudek F. The IKEM pancreas and islet transplant program as part of healthcare for type 1 diabetes patients: retrospective analysis of outcome from 1983 to 2010. Rev Diabet Stud 2011; 8:35-43. [PMID: 21720671 DOI: 10.1900/rds.2011.8.35] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Currently, 25-30 pancreas transplantations per year are carried out in type 1 diabetes (T1D) recipients residing in Czech Republic. Most of the recipients are transplanted together with kidney allografts, but pancreas is also transplanted alone in selected patients with brittle diabetes. Since 2005, the Institute for Clinical and Experimental Medicine (IKEM) islet transplant program was initiated as complementary therapeutic modality. The aim of this paper was to analyze the transplant program at our clinical center, and to examine the survival of recipients, and their pancreas, kidney, and islet grafts. Patient and graft survival rates were evaluated in the following three categories using Kaplan-Meier test: simultaneous pancreas and kidney transplantation (SPKTx), pancreas transplantation alone (PTA), and islet transplantation (ITx). Three hundred and ninety SPKTx, 34 PTA and 44 ITx were carried out between 1983 and 2010. One- and 5-year patient survival rates were 92 % and 81% in SPKTx, respectively. In SPKTx, the 1-year survival rate of pancreas grafts was 78%, and the 5-year rate was 66%. Kidney graft survival rates were 89% and 79%, respectively, after the same follow-up periods. In the PTA category, recipient survivals were 100% after 1 year, and 92% after 3 years. 70% and 65% of pancreatic grafts were working properly at 1 and 3-year follow-ups, respectively. To date, we have carried out 44 islet transplantations in 31 recipients. Islet function (C-peptide ≥ 0.2 ng/ml) was documented in 60% of recipients after 12 months. So far, only 3 patients remained free of exogenous insulin. While SPKTx is a well established treatment for uremic T1D patients, ITx represents an emerging complementary treatment modality. The latter is especially suitable for high-risk recipients, but routine clinical application is still hampered by the limited availability of usable organ transplants and viability of transplanted islets.
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Affiliation(s)
- Peter Girman
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague 14300, Czech Republic.
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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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26
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Lam VWT, Pleass HCC, Hawthorne W, Allen RDM. Evolution of pancreas transplant surgery. ANZ J Surg 2010; 80:411-8. [PMID: 20618193 DOI: 10.1111/j.1445-2197.2010.05309.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Type 1 diabetes mellitus is a chronic condition often leading to disabling complications including retinopathy, neuropathy and cardiovascular disease which can be modified by intensive treatment with insulin. Such treatment, however, is associated with a restrictive lifestyle and risk of hypoglycaemic morbidity and mortality. METHODS This review examines the role of pancreas transplantation in patients with Type 1 diabetes mellitus. RESULTS Pancreas transplantation is currently the only proven option to achieve long-term insulin independence, resulting in an improvement or stabilization of those diabetic related complications. The hazards of pancreas transplantation as a major operation are well known. Balancing the risks of a surgical procedure, with the benefits of restoring normoglycaemia remains an important task for the pancreas transplant surgeon. Pancreas transplantation is not an emergency operation to treat poorly managed and non-compliant patients with debilitating complications. It is a highly specialized procedure which has evolved both in terms of the surgical technique, patient selection and assessment. CONCLUSION Pancreas transplantation has emerged as the single most effective way to achieve normal glucose homeostasis in patients with Type 1 diabetes mellitus.
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Affiliation(s)
- Vincent W T Lam
- National Pancreas Transplant Unit, Westmead Hospital, New South Wales, Australia
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Perkins BA, Dholasania A, Buchanan RA, Bril V. Short-term metabolic change is associated with improvement in measures of diabetic neuropathy: a 1-year placebo cohort analysis. Diabet Med 2010; 27:1271-9. [PMID: 20950385 DOI: 10.1111/j.1464-5491.2010.03110.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
AIMS Randomized clinical trials have frequently shown improvement in diabetic sensorimotor polyneuropathy in placebo-treated participants, counter to the prevailing concept that it deteriorates with time. We aimed to determine the variables associated with this paradoxical nerve function improvement. METHODS Participants with diabetic sensorimotor polyneuropathy randomized to placebo in a multi-centre, double-blind study were evaluated for the primary outcome of 1-year change in the summed sensory nerve conduction velocity of the bilateral sural and non-dominant median nerves. Association with clinical and biochemical variables measured at 13 time points were examined. RESULTS The 134 participants had mild to moderate diabetic sensorimotor polyneuropathy of 4.6 years' duration and mean 1-year improvement of 2.0 ± 8.0 m/s. Primary outcome measures were available for 122 participants (91%). In multivariate analyses, the change in HbA(1c) and serum triglycerides from baseline to 2 months demonstrated the strongest association, even independent of baseline and end-of-study levels. According to quintiles of change, we determined thresholds: participants with salutary improvement in HbA(1c) (exceeding a drop of -0.8%) or whose triglycerides did not increase (by 0.32 mmol/l or more) experienced significant improvement (2.9 m/s), while those with salutary levels of both these variables had an exaggerated improvement (5.1 m/s). In comparison, those with non-salutary changes in both variables experienced a loss of -4.9 m/s (ANOVA P=0.0014). CONCLUSIONS In mild to moderate diabetic sensorimotor polyneuropathy, short-term improvements in glycaemic control and serum triglyceride levels have an independent, additive and durable effect on restoration of nerve function.
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Affiliation(s)
- B A Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, Canada.
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Abstract
For patients with type 1 diabetes, innovations in insulin formulations and delivery have improved the ability to achieve excellent blood glucose control. However, it is uncommon to achieve euglycemia, particularly while avoiding complications arising from hypoglycemia. Pancreas transplantation remains the only broadly applied treatment strategy that can result in normalization of blood glucose, but this must be weighed against the risks of a surgical procedure and subsequent immunosuppression. To improve this risk/benefit ratio, pancreas transplantation is typically performed in patients with kidney failure who are to undergo kidney transplantation and immunosuppression (simultaneous pancreas-kidney transplant) or who have undergone kidney transplant and are obligated to the use of immunosuppressive medications (pancreas after kidney transplant). The purpose of this review is to clarify the benefit of an added pancreas transplant in these clinical settings and formulate an approach to the patient with type 1 diabetes as they approach kidney failure.
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Affiliation(s)
- Alexander C Wiseman
- Transplant Center, University of Colorado Denver, 1635 North Aurora Court, Aurora, CO 80045, USA.
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Abstract
Whole pancreas has been used successfully for transplantation for more than 30 years, and islets have been used reproducibly with success for 10 years; both procedures require drugs for immunosuppression. Success is judged by discontinuation of exogenous insulin-based treatment and maintenance of normal or nearly normal hemoglobin A1c. Successful pancreas transplantation has beneficial effects on retinopathy, nephropathy, neuropathy, macrovascular disease, and quality of life. Such findings are suggested for islet transplantation, but insufficient information is available to draw firm conclusions. Because of the paucity of annual pancreas donations, research for human beta cell surrogates is essential to provide a transplantation approach to therapy for a greater number of recipients.
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Affiliation(s)
- R Paul Robertson
- Division of Endocrinology and Metabolism, Pacific Northwest Diabetes Research Institute, University of Washington, 720 Broadway, Seattle, WA 98122, USA.
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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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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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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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O’Connell PJ. Chapter 6: Patient selection for pilot clinical trials of islet xenotransplantation. Xenotransplantation 2009; 16:249-54. [DOI: 10.1111/j.1399-3089.2009.0545.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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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: 65] [Impact Index Per Article: 4.3] [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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Reese PP, Israni AK. Best Option for Transplant Candidates with Type 1 Diabetes and a Live Kidney Donor: A Bird in the Hand is Worth Two in the Bush. Clin J Am Soc Nephrol 2009; 4:700-2. [DOI: 10.2215/cjn.00890209] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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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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Morath C, Zeier M, Döhler B, Schmidt J, Nawroth PP, Opelz G. Metabolic control improves long-term renal allograft and patient survival in type 1 diabetes. J Am Soc Nephrol 2008; 19:1557-63. [PMID: 18495965 DOI: 10.1681/asn.2007070804] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
It is a matter of debate whether pancreas allografts independently contribute to renal allograft and patient survival in individuals who have type 1 diabetes and receive a simultaneous pancreas and kidney transplant (SPK). Using data from the Collaborative Transplant Study, we studied patients who had type 1 diabetes and were recipients of deceased-donor kidneys (DDK), living-donor kidneys (LDK), or SPK. We analyzed graft and patient survival rates with a maximum of 18 yr of follow-up. DDK recipients had inferior graft and patient survival compared with LDK and SPK recipients. LDK recipients had superior graft and patient survival rates initially, but SPK recipients demonstrated equal survival rates toward the end of follow-up. Multivariate analysis, adjusting for pretransplantation cardiovascular risk, showed that patient survival of SPK recipients was superior to that of LDK recipients beyond the 10th year after transplantation (hazard ratio 0.55; P = 0.005). In summary, the early survival advantage of LDK over SPK is lost during long-term follow-up, probably as a result of improved glycemic control in SPK recipients.
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Affiliation(s)
- Christian Morath
- Department of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120 Heidelberg, Germany.
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Sá JRD, Gonzalez AM, Melaragno CS, Saitovich D, Franco DR, Rangel EB, Noronha IL, Pestana JOM, Bertoluci MC, Linhares M, Miranda MPD, Monteagudo P, Genzini T, Eliaschewitz FG. Transplante de pâncreas e ilhotas em portadores de diabetes melito. ACTA ACUST UNITED AC 2008; 52:355-66. [DOI: 10.1590/s0004-27302008000200024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 01/08/2008] [Indexed: 02/12/2023]
Abstract
O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.
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Sutherl DER, Gruessner RWG. Current Status of Pancreas Transplantation in Diabetic Renal Allograft Recipients. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1997.tb00499.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chartier-Kastler E, Robain G, Mozer P, Ruffion A. Chapitre E - Troubles vésico-sphinctériens et diabète sucré. Prog Urol 2007; 17:371-8. [PMID: 17622061 DOI: 10.1016/s1166-7087(07)92332-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Diabetic neuropathy can induce multi-organ functional disease including lower urinary tract dysfunction. After a review of the various neurological lesions associated with diabetes mellitus, the authors describe the voiding disorders observed in diabetics and their specificity. These disorders, usually characterized by a large, flaccid, underactive bladder, must always be interpreted as a function of other diseases of the male or female pelvis that alter an often precarious balance. The management problems raised by this neuropathy are related to the fact that it may not be correctly diagnosed prior to a surgical procedure, for example. A better knowledge of the risk factors and natural history of diabetic bladder must therefore be promoted.
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Matricali GA, Bammens B, Kuypers D, Flour M, Mathieu C. High rate of Charcot foot attacks early after simultaneous pancreas-kidney transplantation. Transplantation 2007; 83:245-6. [PMID: 17264831 DOI: 10.1097/01.tp.0000244730.95416.c6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Beta-cell transplantation can be either a whole organ pancreas transplant or an islet cell transplant; both have resulted in restoration of a normoglycemic state. These transplants can be performed in conjunction with kidney transplants or as solitary grafts. In general, whole organ transplants have more sustained and durable function and are more widely available than their islet counterparts, but entail a much more invasive procedure. Beta-cell transplantation continues to evolve, with considerable improvement in results over the past two decades, and is a cost-effective option for select patients with type 1 diabetes.
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Affiliation(s)
- Martha Pavlakis
- Beth Israel Deaconess Medical Center, The Transplant Center, 110 Francis Street, 7th Floor, Boston, MA 02215, USA.
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Abstract
In this review, an in-depth anatomic and molecular pathogenesis of diabetic neuropathy is provided. Classifications and clinical manifestations of diabetic neuropathy are discussed. The current modalities of treatment and clinical research on this disorder are summarized.
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Affiliation(s)
- Christopher Bibbo
- Department of Orthopaedics, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449, USA.
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Abstract
Diabetes mellitus (DM) is a major health problem worldwide, which affects 18.2 million individuals (6.3% of the population) in the United States. Currently, the prevalence of Type 1 DM in the United States is estimated to be 1,000,000 individuals, and 30,000 new cases are diagnosed each year. In addition to end-stage renal disease (ESRD), DM is associated with blindness, accelerated atherosclerosis, dyslipidemia, cardio- and cerebrovascular disease, amputation, poor quality of life, and overall lifespan reduction. It accounts for more than 160,000 deaths per year in the United States alone. In 2002, the annual national direct and indirect costs of Types 1 and 2 DM exceeded $130 billion, which included hospital and physician care, laboratory tests, pharmaceutical products, and patient workdays lost because of disability or premature death. Hyperglycemia alone or in concert with hypertension is the primary factor influencing the development of major diabetic complications. From 1990 to 2001, the number of existing ESRD cases to DM increased by more than 300%, while the rate per million populations increased from 167% to 491%. The number is expected to grow 10-fold by 2030 to 1.3 million accounting for 60% of ESRD population. To date, DM is the leading indication for transplantation and is the cause of ESRD in more than 40% of all transplant recipients each year.
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Affiliation(s)
- Martin L Mai
- Department of Transplantation, Mayo Clinic, Jacksonville, FL 32216, USA
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