Posttransplant infection in enteric versus bladder-drained simultaneous pancreas-kidney transplant recipients

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.

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

Prevention and Treatment of Yeast and Endemic Fungal Infections

Invasive fungal infections (IFIs) remain an important complication of solid organ transplantation owing to their significant morbidity and mortality and include infections due to Candida, Cryptococcus, endemic mycosis, and other rare yeasts and molds. IFIs occur in different intervals posttransplantation and depend on a number of extrinsic and intrinsic risk factors, some of which are specific to the type of organs transplanted, surgical techniques, and type of immunosuppressive medications. Donor-derived IFIs and emergence of new multidrug-resistant yeasts have been reported in various healthcare settings. Clinical manifestations of yeast and endemic fungal infections vary in different types of organ transplants. Diagnosis of IFIs in SOT recipients is challenging due to their nonspecific signs and symptoms owing to the impaired inflammatory responses as a result of immunosuppression and the lack of highly sensitive and specific diagnostic modalities. Early diagnosis is key to successful therapy, and physicians should have a high index of suspicion based on risk factors and epidemiology of these pathogens. Antifungal treatment strategies for yeast infections have been outlined in various society guidelines. Management of complications that arise before or during antifungal therapy is critical for optimizing clinical response.

Risk factors for surgical site infection after kidney and pancreas transplantation

OBJECTIVE

To evaluate the incidence of surgical site infection (SSI) in a cohort of pancreas transplant recipients and assess predisposing risk factors for SSI DESIGN: Retrospective cohort study SETTING: Single transplant center in CanadaPatientsPatients who underwent any simultaneous pancreas and kidney (SPK) or pancreas after kidney (PAK) transplant procedures between January 2000 and December 2015 METHODS: In this retrospective cohort evaluation of SPK or PAK recipients, we assessed the incidence of SSI and risk factors associated with superficial, deep, and organ/space SSI. Multivariate logistic regression was used to identify independent risk factors for SSI in SPK and PAK recipients.

RESULTS

In total, 445 adult transplant recipients were enrolled. The median age of these patients was 51 years (range, 19-71 years), and 64.9% were men. SSIs were documented in 108 patients (24.3%). Organ/space SSIs predominated (59 patients, 54.6%), followed by superficial SSIs (47 patients, 43.5%) and deep SSIs (3 patients, 2.8%). Factors predictive of SSIs in the multivariate analysis were cold pancreas ischemic time (odds ratio [OR], 1.002; P=.019) and SPK transplant (compared to PAK transplant recipients; OR, 2.38; P=.038). Patients with SSIs developed graft loss more frequently (OR, 16.99; P<.001).

CONCLUSIONS

Organ/space SSIs remain a serious and common complication after SPK and PAK. Prolonged cold ischemic time and SPK transplant were the risk factors predictive of SSIs. Appropriate perioperative prophylaxis in high-risk patients targeting the potential pathogens producing SSIs in kidney and/or pancreas transplant recipients and a reduction in cold ischemia may prove beneficial in reducing these SSIs.

Bladder Versus Enteric Drainage of Exocrine Secretions in Pancreas Transplantation: A Retrospective Analysis of the United Network for Organ Sharing Database

OBJECTIVES

The method for drainage of exocrine secretions in pancreas transplantation remains a matter of debate. Different methods have evolved over time. Most data on these methods are from single-center studies with small sample sizes. Larger studies have yielded conflicting results.

METHODS

Data from the United Network for Organ Sharing database on all adult subjects who received pancreas and kidney-pancreas transplants between 1996 and 2012 were analyzed (n = 19,934). Subjects were divided into 3 groups: enteric drainage with Roux-en-Y (n = 4308), enteric drainage without Roux-en-Y (n = 11,145), and bladder drainage (n = 4481). Primary end points were patient and graft survival at 1, 3, 5, 10, and 15 years.

RESULTS

There was a patient and graft survival advantage with enteric drainage without Roux-en-Y reconstruction compared with the other methods. This was consistent at 1, 3, 5, 10, and 15 years.

CONCLUSIONS

Our study demonstrated increased graft and patient survival when comparing enteric drainage of the transplanted pancreas without Roux-en-Y reconstruction to enteric drainage with Roux-en-Y and bladder drainage at 1, 3, 5, 10, and 15 years. Based on this study, we recommend enteric drainage without Roux-en-Y reconstruction as the method of choice in pancreas transplantation.

Techniques of pancreas graft salvage/indications for allograft pancreatectomy

PURPOSE OF REVIEW

Despite improvements in pancreas allograft outcome, graft complications remain a significant cause of morbidity and mortality. This review analyses the issues involved in the management of conditions that may require graft pancreatectomy, including the indications and techniques for graft salvage.

RECENT FINDINGS

With early recognition of graft complications, liberal use of radiological interventions, improved infection control, access to critical care and innovative surgical techniques, graft salvage is now feasible in many circumstances where graft pancreatectomy would previously have been necessary.

SUMMARY

The outcome of pancreas transplantation continues to improve with advances in the management of graft-threatening complications.

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.

Pancreatic Transplantation: Evaluation and Management

More than 2 million people in the United States have type 1 diabetes mellitus. Pancreatic transplantation has emerged as the single most effective means of achieving normal glucose homeostasis in this patient population. Newer immunosuppressive agents and surgical techniques continue to evolve, resulting in improved long-term graft and patient survival. Herein, an understanding of the evaluation, technical aspects, and perioperative management of pancreas transplantation is outlined.

Conservative Pancreas Graft Preservation at the Extreme

Because of the value some patients place in remaining insulin-independent after pancreas transplantation, they may be reluctant to undergo graft pancreatectomy, even in the face of extreme complications, such as graft thrombosis and duodenal segment leak. Partly, for this reason, a variety of complex salvage techniques have been described to save the graft in such circumstances. We report a case of a series of extreme complications related to a leak from the duodenal segment after a simultaneous pancreas and kidney transplant. These included infected thrombosis of the inferior vena cava associated with a graft venous thrombosis and a retroperitoneal fistula. The patient retained graft function with insulin independence and repeatedly declined graft pancreatectomy against the advice of the transplant team. Conservative treatment with percutaneous drainage, antibiotics, and anticoagulation was eventually successful. This outcome is unique in our experience and may be instructive to teams caring for pancreas transplant recipients.

Emerging trends in infections among renal transplant recipients

Outcomes following renal and simultaneous kidney-pancreas transplants have improved significantly due to better surgical techniques and improved modalities of antirejection therapy. However, infection remains a significant cause of morbidity and mortality. The use of new modalities of immunosuppression and routine use of antimicrobial prophylaxis has changed the pattern of infections post-transplantation. Cytomegalovirus remains a significant problem and BK virus has emerged as an important pathogen. New antimicrobial agents are now available to treat infection, however, antimicrobial resistance remains a concern.

Outcome of surgical complications following simultaneous pancreas-kidney transplantation

BACKGROUND

Simultaneous pancreas-kidney (SPK) transplantation carries a higher risk of surgical complications than kidney transplantation alone. We aimed to establish the incidence of surgical complications after SPK transplantation and determine the effect on graft and patient survival.

METHODS

Outcomes of all SPK transplants performed at our centre were compared between patients who experienced a surgical complication (SC group) and those who did not (NSC group).

RESULTS

Our centre performed 193 SPK transplants in a 15-year period; 44 patients (23%) experienced a surgical complication. One-year and 5-year pancreatic graft survival was 89 and 80%, respectively; this was lower in the SC group. There was no significant difference in patient or kidney graft survival between the SC and NSC groups at 5 years (92 and 83%, respectively.)

CONCLUSION

Surgical complications following SPK transplantation can cause significant morbidity and adversely affect pancreas graft survival, but do not affect long-term kidney or patient survival.

Complications following pancreatic transplantations: imaging features

Whole organ vascularized pancreatic transplant is a recognized treatment for diabetes and is increasingly being performed worldwide. The procedure itself is complex and is associated with significant mortality and morbidity. Despite improvements in surgical techniques, postoperative complications of pancreatic transplantation are still common and include graft rejection, pancreatitis, peripancreatic fluid collections, exocrine leaks, vascular thrombosis, and hemorrhage. In this pictorial essay, we review clinical presentation and imaging features of these complications. We also briefly discuss technique and complications of islet cell transplants.

One thousand simultaneous pancreas-kidney transplants at a single center with 22-year follow-up

OBJECTIVE

Simultaneous pancreas-kidney transplantation (SPK) is a procedure which frees the diabetic patient with end-stage nephropathy from dialysis and daily insulin injections. The purpose of this study is to report long-term outcomes of this procedure, and describe surgical and medical complications.

METHODS

The analysis includes 1000 consecutive SPKs performed between 1985 and 2007. Bladder drainage was used in 390 patients and enteric drainage in 610 patients. In 362 patients, SPK transplantation was performed before initiation of dialysis.

RESULTS

Patient survival at 1, 10, and 20 years is 97%, 80%, and 58%; kidney survival is 91%, 63%, and 38%; and pancreas survival is 88%, 63%, and 36%, respectively. There was no difference (P > 0.19) for patient, kidney, and pancreas survival between bladder and enteric drainage. Major surgical complications for bladder-drained patients were anastomotic leaks, urological complications, and infections. For enteric-drained patients, major surgical complications were infection, bleeding, and enzyme leak. Principal causes of death were myocardial infarction (n = 23), cerebrovascular accident (n = 18), and renal failure (n = 15). Graft failure for the kidney was due to acute rejection (n = 48), chronic rejection (n = 146), and death with a functioning graft (n = 99). Graft failure for the pancreas was caused by chronic graft loss (n = 44), thrombosis (n = 31), rejection (n = 80), and death with a functioning graft (n = 125). A total of 113 patients were retransplanted with either living related or unrelated donor kidneys (n = 64) or deceased donor kidneys (n = 42). Survival for retransplanted kidneys is 84% at 1 year and 68% at 5 years. Surviving bladder-drained patients underwent enteric conversion (>50%) for severe recalcitrant metabolic or urologic complications, most commonly enzyme leaks, hematuria, and recurrent urinary tract infection.

CONCLUSIONS

Diabetic patients with end-stage renal failure have a poor prognosis without transplantation. Transplantation with SPK provides a marked extension of the patient's life and freedom from insulin injections. Enteric drainage is currently the surgical technique of choice. SPK transplantation should be considered the treatment of choice in this patient population.

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.

Evolution of pancreas transplant surgery

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.

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.

Epidemiology of infections requiring hospitalization during long-term follow-up of pancreas transplantation

BACKGROUND.: Pancreas transplantation (PT) provides the best glycemic control option for diabetes mellitus but is associated with significant morbidities related to infectious disease. METHODS.: We performed a retrospective study of a cohort of consecutive PT recipients in whom PT was performed from 1998 to 2006 (n=216) and followed up them until July 2008. Data regarding infections, rejection, infection chemoprophylaxis, graft failure, absolute lymphocyte counts (ALCs), and mortalities were collected. RESULTS.: Simultaneous pancreas and kidney, pancreas transplantation alone, and pancreas after kidney (PAK) transplantations were performed in 42, 67, and 107 patients, with a mean (standard deviation) age at transplantation of 46.8 (8.03), 40.6 (10.1), and 43.7 (8.19) years. Of the simultaneous pancreas and kidney, pancreas transplantation alone, and PAK transplant recipients, 54.7%, 37.3%, and 58.8% were men. Overall, 63% developed a serious infection during the median follow-up of 6.4 years. Mean (range) number of infectious episodes was 2.3 (1-12), with mostly bacterial infections both within (68%) and after 1 year (78%). Incidence of bacterial and viral infections was greatest in the first 3 months after transplantation. Fungal infections were more constant. Bladder exocrine drainage was associated with higher risk of infection (hazard ratio=2.5, P<0.001). Infection within the first 3 months after transplantation was related to higher mortality after the first 3 months (hazard ratio=3.19). ALC was associated with the risk of first infections (P=0.005) and bacterial infections (P<0.001). CONCLUSIONS.: Incidence of infections after PT was 63% and mostly bacterial. Bladder drainage increases infection risk and low ALC partially predicts episodes. Limitations include retrospective design, unequal composition of PT groups, and lack of data between kidney and PT for PAK.

Urinary tract infections in renal transplant recipients

Urinary tract infection (UTI) is the most common infectious complication after renal transplantation. Although Escherichia coli remains the most common cause of UTI, Enterococcus spp and drug-resistant Enterobacteriaceae have emerged as important uropathogens in these patients. As a result, symptomatic UTIs warrant pathogen-specific antibiotic therapy guided by culture and susceptibility data. In the early transplant period, prophylaxis of UTI with trimethoprim-sulfamethoxazole is generally effective. Until the natural history and optimal management of asymptomatic bacteruria are better defined, therapy of asymptomatic bacteruria is generally unnecessary.

One hundred pancreas transplants performed in a Brazilian institution

After decades of controversy surrounding the therapeutic validity of pancreas transplantation, the procedure has become accepted as the preferred treatment for selected patients with type 1 diabetes mellitus. Between January 2001 and January 2008, 100 patients underwent pancreatic transplantation at our center: 88 simultaneous pancreas-kidney transplantation and 12 pancreas transplantations alone. Pancreas graft management of the exocrine drainage technique involved enteric drainage in 8 (all simultaneous pancreas-kidney) and the bladder in 92 cases. The recipient systemic venous system was used for the pancreas graft venous effluent in all cases. Our overall results have shown that the number of functioning pancreatic grafts was 64 of 100. Graft losses were: rejection (n = 8), venous thrombosis (n = 9), arterial thrombosis (n = 1), or surgical complications such as anastomotic leak (n = 3), perigraft infection (n = 10), pancreatitis of the graft (n = 5). Most cases of pancreatitis (80%) had preservation times exceeding 18 hours. Despite surgical and immunosuppressive complications, our impression was that pancreas transplantation was a highly effective therapy for diabetes mellitus. After 7 years of the program and 100 transplantations, we believe that there is a major role for transplantation in diabetes management.

Experiência obtida em 100 transplantes de pâncreas

OBJETIVO: Relatar nossa experiência com 100 transplantes de pâncreas realizados em um período de sete anos. MÉTODOS: Entre janeiro de 2001 e janeiro de 2008, 100 pacientes foram submetidos a transplante de pâncreas em nosso serviço, sendo 88 transplantes de pâncreas e rim simultâneo (TPRS) e 12 transplantes de pâncreas isolado (TPI). Todos foram transplantes primários. O manejo da porção exócrina do enxerto pancreático envolveu drenagem entérica em oito casos (todos TPRS) e a bexiga em 92 casos. O sistema venoso sistêmico do receptor foi utilizado para a drenagem venosa do enxerto em todos os casos. Nossos últimos 30 pacientes submetidos à TPRS não receberam terapia de indução independentemente do painel imunológico.Os pacientes TPRS receberam basiliximab e TPI receberam timoglobulina nos casos induzidos. Imunossupressão de manutenção foi realizada com tacrolimus, micofenolato mofetil e corticóides. O volume de perfusão do enxerto pancreático foi limitado a 800ml da solução de Celsior ou UW. RESULTADOS: Demonstram que os enxertos ainda funcionantes são atualmente 64 dos 100 realizados. Perda do enxerto foi causada por: rejeição (oito pacientes), trombose venosa (nove pacientes), trombose arterial (um paciente) Complicações cirúrgicas encontradas: fístula anastomótica (tres pacientes), infecção peri-enxerto (10 pacientes), pancreatite do enxerto (cinco pacientes). A Rejeição foi observada com menos freqüência nos TPRS (5/92) que nos TPI (3/12). A morte ocorreu em 24 pacientes. CONCLUSÃO: Nossa impressão é que o transplante de pâncreas é altamente efetivo como terapia para o diabetes mellitus apesar da morbidade do procedimento.

Compative study of bladder versus enteric drainage in pancreas transplantation

INTRODUCTION

There is some controversy concerning the choice of best technique for drainage of exocrine secretions in pancreas transplantation. We compared patients with bladder drainage (BD) versus those with enteric drainage (ED).

PATIENTS AND METHODS

From March 1995 to September 2008, 118 patients (68 men and 50 women) of overall mean age of 37.8 +/- 7.8 years underwent pancreas transplantation. There were 109 simultaneous pancreas-kidney, and 9 pancreas after kidney procedures. Recipients were divided in a BD (n = 66 patients) and an ED group (n = 52).

RESULTS

Donor characteristics were similar in both groups. Thirty-two patients (48.5%) of the BD group versus none in the ED group experienced urinary tract infections (UTI; P < .001), and 16 patients (24.2%) BD versus 15 (29.4%) ED developed intraabdominal infections (P = NS). The overall rate of relaparotomies was 33.9% (n = 40): 34.8% (n = 23) in the BD versus 32.7% (n = 17) in the ED group (P = NS). Thirty patients (25.4%) lost their pancreas grafts: 21 (31.8%) in the BD group versus 9 (17.3%) in the ED group (P = .055). The acute rejection rates were 12.7%; namely, 15.2% in the BD versus 9.8% in the ED (P = NS). Three-year patient and graft survivals were equivalent in both groups: 96.1% and 65.3% in the BD versus 89.0% and 74.0% in the ED group, respectively (P = NS).

CONCLUSIONS

ED is a good alternative to BD for drainage of pancreatic graft exocrine secretions because both techniques have the same patient and graft survival, but BD is associated with a significantly higher rate of UTI and urologic complications.

Portal and systemic venous drainage in pancreas and kidney-pancreas transplantation: early surgical complications and outcomes

OBJECTIVE

The objective of this study was to perform a retrospective analysis of the clinical evolution and surgical complications comparing pancreas transplantation with systemic-enteric (SE) drainage versus portal-enteric (PE) drainage.

METHODS

This review of 48 consecutive pancreas transplantation includes 39 simultaneous kidney and pancreas (SKP) and 9 pancreas after kidney (PAK) grafts as well as 2 retransplantations. Venous drainage was systemic (n = 29) or portal (n = 19).

RESULTS

There were no significant differences in patient, kidney, or pancreas allograft survival rates. There were no significant differences in levels of creatinine, fasting glucose, C-peptide, cholesterol, and homeostatic model assessment (HOMA) of beta cells, namely HOMA-s and HOMA-IR index. HbA1c was lower at 6 months and 1 year in the PE group (P < .05). Twenty-two patients displayed early postoperative complications at a mean time of presentation of 12.8 days. All of these patients but 2 needed relaparotomy. The other two were treated either conservatively (1 enteric fistula) or by interventional radiology (arteriovenous fistula). There were 10 graft losses, 5 in each group, due to thrombosis, pancreatitis, and enteric fistulae.

CONCLUSION

Early graft losses were related to pancreatitis and thrombosis. Intermediate-term endocrine function was similar in both groups.

C4d-positive interacinar capillaries correlates with donor-specific antibody-mediated rejection in pancreas allografts

BACKGROUND

The deposition of the complement split fragment C4d and its association with acute antibody-mediated rejection (AMR) in pancreas transplant (PTx) is not well defined. To characterize the deposition of C4d in PTx, we analyzed 27 PTx biopsies from 18 patients transplanted between 2004 and 2007 at the University of Wisconsin.

METHODS

The presence of C4d was graded in interacinar capillaries (IAC), islets, interstitium, and small- and medium-size vessels. Sera obtained at the time or within 5 days of the biopsy were tested for antidonor-specific antibodies (DSA).

RESULTS

16 biopsies (59.26%) showed at least 5% C4d+ IAC (range 5%-90%). Of those, five biopsies (18.5%) revealed diffuse labeling (>50% C4d+ IAC) and 11 (40.74%) showed focal staining (5%-50% C4d+ IAC). C4d+ IAC (>5%) was significantly associated with the presence of strong DSA for class I or class II (P<0.018). C4d staining of the media or endothelium of small and medium-size vessels was a common finding in all biopsies without any association with DSA. Similarly, staining of islets and parenchymal interstitium was not statistically associated with AMR. The majority of patients received intravenous corticosteroid bolus and taper, with specific cases requiring thymoglobulin, IVIg, rituximab, or plasmapheresis. Forty-six percent of patients who demonstrated AMR returned to insulin therapy because of chronic graft damage and loss of C-peptide.

CONCLUSION

Our findings support the potential role of C4d labeling of PTx biopsies in the diagnosis of AMR and emphasize the staining of IAC as a valuable histologic tool for the diagnosis.

Postoperative infectious complications of abdominal solid organ transplantation

There is a rapidly growing population of immunocompromised organ transplant recipients. These patients are at risk of a large variety of infections that have significant consequences on mortality, graft dysfunction, and graft loss. The diagnosis and treatment of these infections are facilitated by an understanding of the preoperative, perioperative, and postoperative risk factors; the typical pathogens; and their characteristic time of presentation. On the basis of these factors, we put forth an algorithm for diagnosing and treating suspected infections in solid organ transplant recipients.

Antibody-mediated rejection of the kidney after simultaneous pancreas-kidney transplantation

The prevalence, risk factors, and outcome of antibody-mediated rejection (AMR) of the kidney after simultaneous pancreas-kidney transplantation are unknown. In 136 simultaneous pancreas-kidney recipients who were followed for an average of 3.1 yr, 21 episodes of AMR of the kidney allograft were identified. Eight episodes occurred early (</=90 d) after transplantation, and 13 occurred later. Histologic evidence of concomitant acute cellular rejection was noted in 12 cases; the other nine had evidence only of humoral rejection. In 13 cases, clinical rejection of the pancreas was diagnosed simultaneously, and two of these were biopsy proven and were positive for C4d immunostaining. Multivariate analysis identified only one significant risk factor: Female patients were three times more likely to experience AMR. Nearly all early episodes resolved with treatment and did not predict graft loss, but multivariate Cox models revealed that late AMR episodes more than tripled the risk for kidney and pancreas graft loss; therefore, new strategies are needed to prevent and to treat late AMR in simultaneous pancreas-kidney transplant recipients.

Invasive fungal infections and antifungal therapies in solid organ transplant recipients

This manuscript will review the risk factors, prevalence, clinical presentation, and management of invasive fungal infections (IFIs) in solid organ transplant (SOT) recipients. Primary literature was obtained via MEDLINE (1966-April 2007) and EMBASE. Abstracts were obtained from scientific meetings or pharmaceutical manufacturers and included in the analysis. All studies and abstracts evaluating IFIs and/or antifungal therapies, with a primary focus on solid organ transplantation, were considered for inclusion. English-language literature was selected for inclusion, but was limited to those consisting of human subjects. Infectious complications following SOT are common. IFIs are associated with high morbidity and mortality rates in this patient population. Determining the best course of therapy is difficult due to the limited availability of data in SOT recipients. Well-designed clinical studies are infrequent and much of the available information is often based on case-reports or retrospective analyses. Transplant practitioners must remain aware of their therapeutic options and the advantages and disadvantages associated with the available treatment alternatives.

Infections Complicating Solid Organ Transplantation

The requirements for immune suppression after solid organ transplantation increases the risk of infection with a myriad of organisms. There are many unique and evolving aspects of infection after solid organ transplantation. Advances in immunosuppressive therapy and improved protocols for infection prophylaxis have resulted in changes in the timing and clinical presentation of opportunistic infections. Vigilance in the diagnostic evaluation of suspected infection in the solid organ transplant recipient is essential. This article reviews the basic evaluation and treatment options for many of the infectious conditions peculiar to the immunosuppressed patient.

Bloodstream infection following 217 consecutive systemic-enteric drained pancreas transplants

Background

Combined kidney pancreas transplantation (PTx) evolved as excellent treatment for diabetic nephropathy. Infections remain common and serious complications.

Methods

217 consecutive enteric drained PTxs performed from 1997 to 2004 were retrospectively analyzed with regard to bloodstream infection. Immunosuppression consisted of antithymocyteglobuline induction, tacrolimus, mycophenolic acid and steroids for the majority of cases. Standard perioperative antimicrobial prophylaxis consisted of pipercillin/tazobactam in combination with ciprofloxacin and fluconazole.

Results

One year patient, pancreas and kidney graft survival were 96.4%, 88.5% and 94.8%, surgical complication rate was 35%, rejection rate 30% and rate of infection 59%. In total 46 sepsis episodes were diagnosed in 35 patients (16%) with a median onset on day 12 (range 1–45) post transplant. Sepsis source was intraabdominal infection (IAI) (n = 21), a contaminated central venous line (n = 10), wound infection (n = 5), urinary tract infection (n = 2) and graft transmitted (n = 2). Nine patients (4%) experienced multiple episodes of sepsis. Overall 65 pathogens (IAI sepsis 39, line sepsis 15, others 11) were isolated from blood. Gram positive cocci accounted for 50 isolates (77%): Coagulase negative staphylococci (n = 28, i.e. 43%) (nine multi-resistant), Staphylococcus aureus (n = 11, i.e. 17%) (four multi-resistant), enterococci (n = 9, i.e. 14%) (one E. faecium). Gram negative rods were cultured in twelve cases (18%). Patients with blood borne infection had a two year pancreas graft survival of 76.5% versus 89.4% for those without sepsis (p = 0.036), patient survival was not affected.

Conclusion

Sepsis remains a serious complication after PTx with significantly reduced pancreas graft, but not patient survival. The most common source is IAI.

Infectious complications following 72 consecutive enteric-drained pancreas transplants

New immunosuppressive protocols and advanced surgical technique resulted in an improved outcome of pancreatic transplantation (PTx) with infection remaining the most common complication. Seventy-two enteric-drained whole PTxs performed at the Innsbruck University Hospital between September 2002 and October 2004 were retrospectively analyzed. Prophylactic immunosuppression consisted of either the standard protocol consisting of single bolus antithymocyteglobulin (ATG) (Thymoglobulin, Sangstat or ATG Fresenius) induction (9 mg/kg), tacrolimus (TAC), mycophenylate mofetil (MMF) and steroids (38 patients) or a 4-day course of ATG (4 mg/kg) tacrolimus and steroids with MMF (n = 19), or Sirolimus (n = 15). Perioperative antimicrobial prophylaxis consisted of Piperacillin/Tazobactam (4.5 g q 8 h) in combination with ciprofloxacin (200 mg q 12 h) and fluconazole (400 mg daily). Ganciclovir was used for cytomegalovirus (CMV) prophylaxis if donor was positive and recipient-negative. Patient, pancreas, and kidney graft survival at 1 year were 97.2%, 88.8%, and 93%, respectively, with no difference between the groups. All retransplants (n = 8) and single transplants (n = 8) as well as all type II diabetics and nine of 11 patients older 55 years received standard immunosuppression (IS). The rejection rate was 14% and infection rate 46% with no difference in terms of incidence or type according to the three groups. Severe infectious complications included intra-abdominal infection (n = 12), wound infection (n = 7), sepsis (n = 13), respiratory tract infection (n = 4), urinary tract infection (n = 12), herpes simplex/human herpes virus 6 infection (n = 5), CMV infection/disease (n = 7), post-transplant lymphoproliferative disorder (PTLD, n = 3), invasive filamentous fungal infection (n = 4), Clostridial/Rotavirus colitis (n = 1), and endocarditis (n = 1). All four patients in this series died of infectious complications (invasive aspergillosis n = 2) (one with Candida glabrata superinfection), invasive zygomycosis (n = 1), PTLD (n = 1). Five grafts were lost (vascular thrombosis n = 3, pancreatitis n = 1, noncompliance n = 1). Infection represented the most frequent complication in this series and all four deaths were of infectious origin. Better prophylaxis and management of infections now should be the primary target to be addressed in the field of pancreas transplantation.

Pancreas transplantation: advantages of both enteric and bladder drainage combined in a two-step approach

BACKGROUND

Although there is a tendency to perform enteric drainage of pancreas transplants in simultaneous pancreas-kidney (SPK) transplantation, bladder drainage is still preferable in pancreas transplantation alone (PTA) or after a previous kidney transplantation (PAK). Our hypothesis was that enteric conversion of a bladder drained pancreas is an effective and safe procedure. We studied the complication rate and physiological effects of enteric conversion in patients with primary bladder-drained SPK transplantation.

PATIENTS

We performed 51 enteric conversions in bladder-drained SPK transplant recipients. As we observed a low complication rate, with time enteric conversions were also performed for less strict and severe indications.

RESULTS

The main indications for conversion were urological problems, metabolic complications and reflux-pancreatitis. The median transplantation-conversion interval was 12 months (range 2-40 months). Post-operative complications consisted of seven urinary tract infections, two low-grade superficial wound infections, one minor bleeding, one phlebitis and one paralytic ileus. In two patients, a relaparotomy was necessary. No graft rejection following enteric conversion was found. Long-term renal and pancreatic function were not affected by the enteric conversion. Three-year patient, kidney and pancreas survival rates after enteric conversion were 93, 97 and 93%, respectively (censored data).

CONCLUSION

Enteric conversion after pancreas transplantation is an effective and safe procedure. Therefore, we suggest a policy of a two-step approach of primary bladder drainage followed by an enteric conversion of the pancreas in a selected group of SPK patients.

An evidence-based analysis of simultaneous pancreas-kidney and pancreas transplantation alone

While pancreas transplantation has evolved within two decades from a frustrating and poorly-accepted therapeutic option to a highly successful procedure, the respective benefits of the successive surgical and immunosuppressive developments have remained unclear. The aim of this study was to determine using an evidence-based methodology, which novel approaches have contributed to the current results and whether pancreas transplantation is cost-effective. Out of 2481 articles, 102 analyzed either surgical or immunosuppressive aspects of pancreas transplantation. Urological complications were more frequent in bladder over enteric drainage (range: 62-63% vs. 12-20%, p = 0.0001), but without significant difference in patient or graft survival. Portal drainage was associated with a trend toward fewer complications and better hyperinsulinemia control over systemic drainage in retrospective studies. Immunosuppression combining induction therapy, a calcineurin inhibitor, mycophenolate mophetil (MMF) and corticosteroids were associated with a 40% decreased incidence of rejection (p = 0.01) and an increase in graft survival above 90% at 1 year (p < 0.05). Pancreas transplantation is highly cost-effective compared to conservative alternatives. We conclude that despite a paucity of large studies, enteric drainage should be recommended but the benefits of portal venous drainage remain debated. Quadruple immunosuppression protocols including induction therapy should be the standard regimen.

Single-Shot Antithymocyte Globulin (ATG) Induction for Pancreas/Kidney Transplantation: ATG-Fresenius Versus Thymoglobulin

Single-shot antithymocyte globulin (ATG) prior to reperfusion followed by tacrolimus (TAC), mycophenolate mofetil (MMF), and prednisolone (PRD) is an established induction therapy in simultaneous pancreas kidney transplant (SPK) recipients. We retrospectively analyzed 6-month data from 105 patients who received their first SPK. From January 1996 to December 2000, ATG-Fresenius was used. Since January 2001, Thymoglobulin has been administered. In the first group, 58 patients were treated with ATG-Fresenius (4-6 mg/kg body weight). In the second group, 47 patients received Thymoglobulin (1.5-2.5 mg/kg body weight). HLA-mismatch was comparable. After an observation period of 6 months, patients, kidney, and pancreas graft survival is 98.3%, 96.6%, and 93.1% in group I and 97.9%, 97.9%, and 85.1% in group II, respectively. In each group, one death with functioning graft (DWFG) was observed. Twenty (34.5%) acute rejection episodes (AR) were observed (18 patients) in group I. They were treated with steroids (n = 16) or steroids/OKT3 (n = 4). One kidney graft failure was observed due to rejection and one due to DWFG. Four pancreas grafts were lost (thrombosis, n = 2; AR, n = 1; DWFG, n = 1). In group II, 15 AR (31.9%) were seen in 12 patients and were treated with steroids (n = 12), steroids/ATG (n = 1), or steroids/OKT3 (n = 2). Seven pancreas (thrombosis, n = 5; rejection, n = 1; DWFG, n = 1) and one kidney (DWFG, n = 1) graft losses occurred. These data clearly establish that single-shot ATG prior to reperfusion, followed by TAC, MMF, and PRD results in a low incidence of AR (34.5% in group I and 31.9% in group II) after SPK. Only 6.9% (group I) and 6.4% (group II) of the patients received antibodies for rejection treatment.

Pancreas transplantation: indications and consequences

Pancreas transplantation continues to evolve as a strategy in the management of diabetes mellitus. The first combined pancreas-kidney transplant was reported in 1967, but pancreas transplant now represents a number of procedures, each with different indications, risks, benefits, and outcomes. This review will summarize these procedures, including their risks and outcomes in comparison to kidney transplantation alone, and how or if they affect the consequences of diabetes: hyperglycemia, hypoglycemia, and microvascular and macrovascular complications. In addition, the new risks introduced by immunosuppression will be reviewed, including infections, cancer, osteoporosis, reproductive function, and the impact of immunosuppression medications on blood pressure, lipids, and glucose tolerance. It is imperative that an endocrinologist remain involved in the care of the pancreas transplant recipient, even when glucose is normal, because of the myriad of issues encountered post transplant, including ongoing management of diabetic complications, prevention of bone loss, and screening for failure of the pancreas graft with reinstitution of treatment when indicated. Although long-term patient and graft survival have improved greatly after pancreas transplant, a multidisciplinary team is needed to maximize long-term quality, as well as quantity, of life for the pancreas transplant recipient.

[Pancreatic Transplantation: 2. Surgical technique and post-operative complications]

Since the first pancreatic allograft in 1966, pancreatic transplantations have been performed by numerous surgical teams throughout the world. Initial results were disappointing with a high percentage of technical failures and rejection. Over-optimistic enthusiasm for islet-cell allografts also retarded the development of pancreatic transplantation. Despite this slow start, results of pancreatic transplantation from 1995 onward have been very satisfactory and equivalent to or even better than the results of other solid organ transplants. This success has been due to better graft selection, improved surgical techniques and preservation solutions, and especially to improvements in immunosuppressive protocols. More than 19,000 pancreatic transplantations have now been performed throughout the world including both combined kidney-pancreas transplantations and pancreas-only transplantations. The most satisfactory results occur in the setting of dialysis-dependent renal failure due to diabetes; simultaneous combined kidney and pancreas transplantation is performed with the total pancreas implanted into the bowel and with venous drainage into the portal system. The long-term risks and constraints of chronic diabetes with renal failure must be weighed against the risks of a complex surgical procedure, significant post-operative complications, and the need for long-term immunosuppressive therapy.

Simultaneous pancreas-kidney transplantation: infectious complications and microbiological aspects

OBJECTIVE

The purpose of this study was to describe the clinical and microbiological characteristics of the infectious complications among simultaneous pancreas-kidney transplantations (SPKT).

MATERIALS AND METHODS

Among the first 45 SPKT the mean age was 34 years (range, 21 to 49) and the mean duration of follow-up 13 months (range, 2 to 27 months).

RESULTS

Twenty-three patients (51%) presented at least one to three episodes (1.7 mean) of infectious complications that needed hospitalization. The etiology of the infections included 71% bacterial (44% gram-negative rods and 27% gram-positive cocci), 16% viral (12% from CMV and 4% from Herpes sp) and 13% fungal (8% by Candida sp and 4% by others fungus). Wound and urinary infections were most frequent, occurring in 22% and 28% of the patients, respectively. All patients who were submitted to vesical drainage developed infections in contrast a rate of only 44% among patients undergoing enteric drainage.

CONCLUSION

Infectious complications are the main cause of morbidity and mortality following simultaneous pancreas-kidney transplantation, especially with vesical drainage. The use of enteric drainage combined with administration of broad spectrum prophylactic antibiotics is recommended.

Incidence, timing and site of infections among pancreas transplant recipients

The incidence, timing and site of infections among the different categories of pancreas transplant recipients were investigated. Patients were divided into three groups: pancreas transplant alone (PTA), pancreas after kidney transplant (PAK), or simultaneous pancreas and kidney (SPK) transplants. Length of follow-up, time to death, pancreas graft survival, incidence, timing and site of bacterial infections were noted. Our study showed that at least 75% of pancreas transplant recipients experienced at least one infection (range from 77.8% in the PTA group to 86.7% in the PAK group). The SPK group presented the highest rate of infections with 35.1 infections per 1000/patient-days. Symptomatic urinary tract infections were the most common cause of infection in all patients. The incidence of infections was higher during the first month after transplantation, except for the SPK transplant group, where infections occurred over a longer time period.

Urological complications after simultaneous renal and pancreatic transplantation

OBJECTIVE

To report the urological complications after simultaneous renal and pancreatic transplantation.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Italy.

SUBJECTS

143 consecutive patients having simultaneous renal and pancreatic transplantation by one of three techniques. 33 segmental pancreas with duct occlusion, 77 whole pancreas with bladder diversion, and 33 enteric diversion with systemic (n = 26) or portal venous drainage (n = 7). Urological complications were related to the pancreatic transplant, to the renal transplant, or unrelated to the transplant.

MAIN OUTCOME MEASURES

Morbidity.

RESULTS

After occlusion of the duct and enteric diversion, there were no urological complications related to the pancreatic transplant. On the other hand, among the 77 patients with pancreatic drainage into the bladder, urological complications were common (56/77; 73%). Complications related to the renal transplant were recorded in 6/33 (18%), 26/77 (34%) and 12/33 (36%), respectively. Complications unrelated to the transplant occurred in 6/77 patients (8%) in the bladder drainage group. Five patients after bladder drainage required cystoenteric conversion.

CONCLUSIONS

Enteric diversion is a safe alternative to bladder diversion and results in significantly fewer urological complications.

Hazardous crossing: immunosuppression and nosocomial infections in solid organ transplant recipients

BACKGROUND

During the past decade, ever-increasing numbers of patients have undergone renal, pancreatic, small bowel, hepatic, cardiac, or lung transplantation as therapy for various types of renal disease requiring dialytic therapy. Indications for solid organ transplantation include type I and, rarely, type II diabetes mellitus; hyperalimentation-dependent short gut syndrome; and formerly fatal liver, cardiac, or pulmonary failure. Significant improvements in patient and allograft survival have been observed in all categories. Unfortunately, despite such improved results, the risks of infection related to immunosuppression continue to be substantial.

METHODS

Review of pertinent studies from the English literature.

RESULTS

Suppression of host defenses by exogenous immunosuppressive agents renders patients susceptible to invasion by either resident or environmental bacterial, fungal, viral, and protozoal microbes or parasites. In such patients, invasion of organisms that produce mild infection in nonimmunosuppressed individuals can produce severe, lethal disease. Moreover, even low-virulence microbes may invade, proliferate, and cause disease in the immunosuppressed host; such organisms are referred to as "opportunistic" pathogens when they cause disease under these conditions.

CONCLUSION

Advances in the field of transplantation have been substantial, particularly in the regulation of therapeutic immunosuppression, in prophylactic measures to prevent infection, and in more effective diagnosis and treatment modalities.

Urinary Tract Infections in Renal Transplant Recipients

Infection of the urinary tract is the most common infectious complication of renal transplantation. The microbiology of post-transplant urinary tract infections is similar to what is seen in the general population, although transplant patients may develop infections due to unusual or opportunistic pathogens. The optimal management of urinary tract infections in renal transplant recipients is poorly studied, but recommendations for treatment are available. Antibiotic prophylaxis can reduce the risk of bacterial infection of the urinary tract post-transplant but is not used in all transplant centers. The influence of urinary tract infection on graft survival requires further study.

Technical and immunologic progress in simultaneous pancreas-kidney transplantation

BACKGROUND

During the past few years the use of new immunosuppressants and refinements in surgical technique of simultaneous pancreas-kidney (SPK) transplantation have resulted in markedly improved outcomes. This is a retrospective study of 208 SPK transplants performed at Northwestern University, demonstrating the advances made at a single center that are reflective of the field at large.

METHODS

An 8.5-year time span was split into 4 distinct eras marking sequential changes in immunosuppression and surgical technique that ensued. SPK transplant outcomes of patient and graft survival and rejection rates were compared. Also examined were end points related to the changing risk profile of the recipients, as well as quality of allograft function and rates of rehospitalizations.

RESULTS

Recipients receiving tacrolimus/mycophenolate mofetil-based immunosuppression had patient, kidney, and pancreas survival rates significantly higher than those of earlier cohorts. The elimination of corticosteroids did not reduce survival rates or increase rejection risk. The use of pancreatic exocrine enteric drainage technique over bladder drainage reduced rehospitalizations.

CONCLUSIONS

Advances in immunosuppression management combined with technical refinements have made SPK transplantation a safer and more effective treatment option for the diabetic, uremic patient.