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Boggi U, Vistoli F, Andres A, Arbogast HP, Badet L, Baronti W, Bartlett ST, Benedetti E, Branchereau J, Burke GW, Buron F, Caldara R, Cardillo M, Casanova D, Cipriani F, Cooper M, Cupisti A, Davide J, Drachenberg C, de Koning EJP, Ettorre GM, Fernandez Cruz L, Fridell JA, Friend PJ, Furian L, Gaber OA, Gruessner AC, Gruessner RW, Gunton JE, Han D, Iacopi S, Kauffmann EF, Kaufman D, Kenmochi T, Khambalia HA, Lai Q, Langer RM, Maffi P, Marselli L, Menichetti F, Miccoli M, Mittal S, Morelon E, Napoli N, Neri F, Oberholzer J, Odorico JS, Öllinger R, Oniscu G, Orlando G, Ortenzi M, Perosa M, Perrone VG, Pleass H, Redfield RR, Ricci C, Rigotti P, Paul Robertson R, Ross LF, Rossi M, Saudek F, Scalea JR, Schenker P, Secchi A, Socci C, Sousa Silva D, Squifflet JP, Stock PG, Stratta RJ, Terrenzio C, Uva P, Watson CJ, White SA, Marchetti P, Kandaswamy R, Berney T. First World Consensus Conference on pancreas transplantation: Part II - recommendations. Am J Transplant 2021; 21 Suppl 3:17-59. [PMID: 34245223 PMCID: PMC8518376 DOI: 10.1111/ajt.16750] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 02/07/2023]
Abstract
The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246.
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Lauria MW, Ribeiro-Oliveira A. Diabetes and other endocrine-metabolic abnormalities in the long-term follow-up of pancreas transplantation. Clin Diabetes Endocrinol 2016; 2:14. [PMID: 28702248 PMCID: PMC5471933 DOI: 10.1186/s40842-016-0032-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 07/03/2016] [Indexed: 12/12/2022] Open
Abstract
Pancreas transplantation (PTX) has been demonstrated to restore long-term glucose homeostasis beyond what can be achieved by intensive insulin therapy or islet transplants. Moreover, PTX has been shown to decrease the progression of the chronic complications of diabetes. However, PTX patients require chronic use of immunosuppressive drugs with potential side effects. The long-term follow-up of PTX patients demands special care regarding metabolic deviations, infectious complications, and chronic rejection. Diabetes and other endocrine metabolic abnormalities following transplantation are common and can increase morbidity and mortality. Previous recipient-related and donor-related factors, as well as other aspects inherent to the transplant, act together in the pathogenesis of those abnormalities. Early recognition of these disturbances is the key to timely treatment; however, adequate tools to achieve this goal are often lacking. In a way, the type of PTX procedure, whether simultaneous pancreas kidney or not, seems to differentially influence the evolution of endocrine and metabolic abnormalities. Further studies are needed to define the best approach for PTX patients. This review will focus on the most common endocrine metabolic disorders seen in the long-term management of PTX: diabetes mellitus, hyperlipidemia, and bone loss. The authors here cover each one of these endocrine topics by showing the evaluation as well as proper management in the follow-up after PTX.
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Affiliation(s)
- Marcio W Lauria
- Department of Internal Medicine (Endocrinology section and Transplantation unit), Federal University of Minas Gerais, Rua Alfredo Balena, 190, 30130-100 Belo Horizonte, MG Brazil
| | - Antonio Ribeiro-Oliveira
- Department of Internal Medicine (Endocrinology section and Transplantation unit), Federal University of Minas Gerais, Rua Alfredo Balena, 190, 30130-100 Belo Horizonte, MG Brazil
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Chakkera HA, Kudva YC, Chang YHH, Heilman RL, Singer AL, Mathur AK, Hewitt WR, Khamash HA, Huskey JL, Katariya NN, Moss AA, Behmen S, Reddy KS. Glucose homeostasis after simultaneous pancreas and kidney transplantation: a comparison of subjects with C-peptide-positive non-type 1 diabetes mellitus and type 1 diabetes mellitus. Clin Transplant 2015; 30:52-9. [DOI: 10.1111/ctr.12658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2015] [Indexed: 11/30/2022]
Affiliation(s)
| | - Yogish C. Kudva
- Division of Endocrinology and Metabolic Diseases; Mayo Clinic; Rochester MN USA
| | - Yu-Hui H. Chang
- Department of Research Biostatistics; Mayo Clinic; Phoenix AZ USA
| | | | | | - Amit K. Mathur
- Division of Transplant Surgery; Mayo Clinic; Phoenix AZ USA
| | | | | | | | | | - Adyr A. Moss
- Division of Transplant Surgery; Mayo Clinic; Phoenix AZ USA
| | | | - Kunam S. Reddy
- Division of Transplant Surgery; Mayo Clinic; Phoenix AZ USA
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Oliver JB, Beidas AK, Bongu A, Brown L, Shapiro ME. A comparison of long-term outcomes of portal versus systemic venous drainage in pancreatic transplantation: a systematic review and meta-analysis. Clin Transplant 2015; 29:882-92. [PMID: 26172035 DOI: 10.1111/ctr.12588] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2015] [Indexed: 12/29/2022]
Abstract
Pancreas transplantation venous effluent can be drained via the portal vein or the systemic circulation; however, no recommendation exists for the ideal technique. A systematic review of the literature from 1989 through 2014 using PubMed, CINHAL, and Cochrane Library for portal versus systemic venous drainage was undertaken. Only studies on humans and published in English were considered. Measures of glycemic control and total cholesterol were synthesized for meta-analysis utilizing random-effects models. Of 166 articles retrieved, 15 articles were included for meta-analysis. Patient and graft survival were comparable in a large database study as well as in the only randomized control study. No differences in complications were seen when exocrine drainage was enteric for the systemic venous group. Fasting insulin (-34.13 pmol/mL, p < 0.001) was significantly lower within the portal drained group; however, fasting blood glucose levels (-3.4 mg/dL, p = 0.32) and hemoglobin A1C levels (mean difference 0.124%, p = 0.25) were comparable. Total cholesterol levels (-3.62 mg/dL, p = 0.447), as well as other measures of lipids, showed no difference. Based on this systematic review and meta-analysis, there is no evidence of differences in outcomes or metabolic control in patients undergoing pancreatic transplant with portal venous drainage compared to the systemic venous drainage.
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Affiliation(s)
- Joseph B Oliver
- Department of Surgery, Rutgers University - New Jersey Medical School, Newark, NJ, USA
| | - Abdel-Kareem Beidas
- Department of Surgery, Rutgers University - New Jersey Medical School, Newark, NJ, USA
| | - Advaith Bongu
- Department of Surgery, Rutgers University - New Jersey Medical School, Newark, NJ, USA
| | - Lloyd Brown
- Department of Surgery, Rutgers University - New Jersey Medical School, Newark, NJ, USA
| | - Michael E Shapiro
- Department of Surgery, Rutgers University - New Jersey Medical School, Newark, NJ, USA
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Rangel EB. Tacrolimus in pancreas transplant: a focus on toxicity, diabetogenic effect and drug–drug interactions. Expert Opin Drug Metab Toxicol 2014; 10:1585-605. [DOI: 10.1517/17425255.2014.964205] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Boggi U, Vistoli F, Egidi FM, Marchetti P, De Lio N, Perrone V, Caniglia F, Signori S, Barsotti M, Bernini M, Occhipinti M, Focosi D, Amorese G. Transplantation of the pancreas. Curr Diab Rep 2012; 12:568-79. [PMID: 22828824 DOI: 10.1007/s11892-012-0293-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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Rangel EB. The metabolic and toxicological considerations for immunosuppressive drugs used during pancreas transplantation. Expert Opin Drug Metab Toxicol 2012; 8:1531-48. [DOI: 10.1517/17425255.2012.724058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Long-Term (5 Years) Efficacy and Safety of Pancreas Transplantation Alone in Type 1 Diabetic Patients. Transplantation 2012; 93:842-6. [DOI: 10.1097/tp.0b013e318247a782] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Boggi U, Vistoli F, Amorese G, Giannarelli R, Coppelli A, Mariotti R, Rondinini L, Barsotti M, Piaggesi A, Tedeschi A, Signori S, De Lio N, Occhipinti M, Mangione E, Cantarovich D, Del Prato S, Mosca F, Marchetti P. Results of pancreas transplantation alone with special attention to native kidney function and proteinuria in type 1 diabetes patients. Rev Diabet Stud 2011; 8:259-67. [PMID: 22189549 DOI: 10.1900/rds.2011.8.259] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We report on our single-center experience with pancreas transplantation alone (PTA) in 71 patients with type 1 diabetes, and a 4-year follow-up. Portal insulin delivery was used in 73.2% of cases and enteric drainage of exocrine secretion in 100%. Immunosuppression consisted of basiliximab (76%), or thymoglobulin (24%), followed by mycophenolate mofetil, tacrolimus, and low-dose steroids. Actuarial patient and pancreas survival at 4 years were 98.4% and 76.7%, respectively. Relaparatomy was needed in 18.3% of patients. Restored endogenous insulin secretion resulted in sustained normalization of fasting plasma glucose levels and HbA1c concentration in all technically successful transplantations. Protenuria (24-hour) improved significantly after PTA. Renal function declined only in recipients with pretransplant glomerular filtration rate (GFR) greater than 90 ml/min, possibly as a result of correction of hyperfiltration following normalization of glucose metabolism. Further improvements were recorded in several cardiovascular risk factors, retinopathy, and neuropathy. We conclude that PTA was an effective and reasonably safe procedure in this single-center experience.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery in Uremic and Diabetic Patients, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
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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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Guerra G, Indahyung R, Bucci CM, Schold JD, Magliocca JF, Meier-Kriesche HU. Elevated incidence of posttransplant erythrocytosis after simultaneous pancreas kidney transplantation. Am J Transplant 2010; 10:938-942. [PMID: 20148815 DOI: 10.1111/j.1600-6143.2010.03012.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Posttransplant erythrocytosis (PTE) poses a potential risk of thrombosis in kidney transplantation. Clinical observation of our systemically drained simultaneous kidney pancreas transplant (S-SPK) patients showed a higher incidence of PTE and need for phlebotomies. To evaluate the incidence of PTE we analyzed hematocrit (Hct) levels and frequency of phlebotomies in 94 SPK as compared to 174 living donor (LD) recipients and 53 type-I diabetic with kidney transplant only. For study purposes we defined PTE as Hct >50% or the necessity for phlebotomies. Kaplan-Meier plots and Cox proportional hazard models were used to examine the association between the transplant type and PTE. We found an increased incidence of PTE in SPK compared to LD (p < 0.001). In the multivariate model, SPK had a 5-fold risk for the development of PTE (AHR 5.3, 95% CI 1.8, 15.9). The incidence of therapeutic phlebotomy was 13% among SPK patients and 4% in LD kidney recipients; 19 patients altogether. A total of 64 units were phlebotomized (48-SPK and 16-LD). Type I diabetic patients with a kidney transplant showed a 0% incidence of PTE. We observed a greater incidence of PTE and phlebotomies in S-SPK compared to LD with kidney only transplant recipients.
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Affiliation(s)
- G Guerra
- Division of Nephrology, University of Miami, Coral Gables, FL
| | - R Indahyung
- Division of Nephrology, University of Florida, Gainesville, FL
| | - C M Bucci
- Division of Nephrology, University of Florida, Gainesville, FL
| | - J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - J F Magliocca
- Division of Nephrology, University of Florida, Gainesville, FL
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Abstract
PURPOSE OF REVIEW Pancreas transplantation reproducibly induces insulin independence in beta-cell penic diabetic patients. The difference between full insulin independence, partial graft function, and graft loss, mostly results from technical failure, graft rejection, and patient death with function graft. The purpose of this review is to examine recent surgical advances and discuss their contribution to improved graft function. RECENT FINDINGS Few actual surgical innovations were described in the period reviewed. Duodenoduodenostomy is an interesting option for drainage of digestive secretions, when the pancreas is placed behind the right colon and is oriented cephalad. The main advantage of this technique is easy endoscopic assessment of donor duodenum but, when allograft pancreatectomy is necessary, repair of native duodenum may be troublesome. Selective revascularization of the gastroduodenal artery, at the back-table, possibly improves blood supply to the head of the pancreas graft and duodenal segment. There is no proof that this additional maneuver is always beneficial, although it can be graft saving in case of poor segmental graft perfusion. SUMMARY Transplant surgeons should be familiar with all techniques for pancreas transplantation. Long-term graft function is possible only after technically successful pancreas transplantation. There is clearly a need for more objective assessment and standardization of surgical techniques for pancreas transplantation.
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Stadler M, Anderwald C, Pacini G, Zbýň Š, Promintzer-Schifferl M, Mandl M, Bischof M, Gruber S, Nowotny P, Luger A, Prager R, Krebs M. Chronic peripheral hyperinsulinemia in type 1 diabetic patients after successful combined pancreas-kidney transplantation does not affect ectopic lipid accumulation in skeletal muscle and liver. Diabetes 2010; 59:215-8. [PMID: 19833878 PMCID: PMC2797924 DOI: 10.2337/db09-0354] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE So far it is unclear whether chronic peripheral hyperinsulinemia per se might contribute to ectopic lipid accumulation and consequently insulin resistance. We investigated the effects of systemic instead of portal insulin release in type 1 diabetic patients after successful pancreas-kidney transplantation (PKT) with systemic venous drainage on the intracellular lipid content in liver and soleus muscle, endogenous glucose production (EGP), and insulin sensitivity. RESEARCH DESIGN AND METHODS In nine PKT patients and nine matching nondiabetic control subjects, intrahepatocellular lipids (IHCLs) and intramyocellular lipids (IMCLs) were measured using (1)H nuclear magnetic resonance spectroscopy. Fasting EGP was measured using d-[6,6-(2)H(2)]glucose tracer dilution. A 3-h 75-g oral glucose tolerance test (OGTT) allowed us to assess kinetics of glucose, free fatty acids, insulin, and C-peptide concentrations in plasma and to calculate the clamp-like index (CLIX) for insulin sensitivity and the hepatic insulin resistance (HIR) index. RESULTS The PKT patients displayed approximately twofold increased fasting insulin (20 +/- 6 vs. 9 +/- 3 microU/ml; P < 0.0002) compared with that in nondiabetic control subjects and approximately 10% increased fasting glucose (P < 0.02) concentrations, but during the OGTT areas under the concentration curves of C-peptide and insulin were similar. IHCL (PKT, 2.9 +/- 2.5%; nondiabetic control subjects, 4.4 +/- 6.6%), IMCL (PKT, 1.0 +/- 0.4%; nondiabetic control subjects, 1.0 +/- 0.5%), CLIX (PKT, 8 +/- 2; nondiabetic control subjects, 7 +/- 3), HIR (PKT, 25.6 +/- 13.2; nondiabetic control subjects, 35.6 +/- 20 [mg * min(-1) * kg(-1)] x [microU/ml]), and EGP (PKT, 1.6 +/- 0.2; nondiabetic control subjects, 1.7 +/- 0.2 mg * min(-1) * kg(-1)) were comparable between PKT patients and nondiabetic control subjects. IHCL was negatively correlated with CLIX in all participants (r = -0.55; P < 0.04). CONCLUSIONS Despite fasting peripheral hyperinsulinemia because of systemic venous drainage, type 1 diabetic patients after PKT show similar IHCL, IMCL, insulin sensitivity, and fasting EGP in comparison with nondiabetic control subjects. These results suggest that systemic hyperinsulinemia per se does not cause ectopic lipid accumulation in liver and skeletal muscle.
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Affiliation(s)
- Marietta Stadler
- Hietzing Hospital, 3rd Medical Department of Metabolic Diseases and Nephrology, Vienna, Austria
- Karl Landsteiner Institute of Metabolic Diseases and Nephrology, Vienna, Austria
| | - Christian Anderwald
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
- Corresponding author: Christian Anderwald,
| | - Giovanni Pacini
- Metabolic Unit, Institute of Biomedical Engineering, National Research Council, Padova, Italy
| | - Štefan Zbýň
- Medical University of Vienna, Department of Radiology, MR Center–High Field MR, Vienna, Austria
| | - Miriam Promintzer-Schifferl
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Martina Mandl
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Martin Bischof
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Stephan Gruber
- Medical University of Vienna, Department of Radiology, MR Center–High Field MR, Vienna, Austria
| | - Peter Nowotny
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Anton Luger
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
| | - Rudolf Prager
- Hietzing Hospital, 3rd Medical Department of Metabolic Diseases and Nephrology, Vienna, Austria
- Karl Landsteiner Institute of Metabolic Diseases and Nephrology, Vienna, Austria
| | - Michael Krebs
- Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, Vienna, Austria
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Are there still roles for exocrine bladder drainage and portal venous drainage for pancreatic allografts? Curr Opin Organ Transplant 2009; 14:90-4. [PMID: 19337153 DOI: 10.1097/mot.0b013e328320a8d9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Controversy remains regarding the best methodology of handling exocrine pancreatic fluid and pancreatic venous effluent. Bladder drainage has given way to enteric drainage. However, is there an instance in which bladder drainage is preferable? Also, hyperinsulinemia, as a result of systemic venous drainage (SVD), is claimed to be proatherosclerotic, whereas portal venous drainage (PVD) is more physiologic and less atherosclerotic. RECENT FINDINGS Bladder drainage remains a viable method of exocrine pancreas drainage, but evidence is sparse that measuring urinary amylase has a substantial benefit in the early detection of acute rejection in all types of pancreas transplants. Currently, there is no incontrovertible evidence that systemic hyperinsulinemia is proatherosclerotic, whereas recent metabolic studies on SVD and PVD showed that there was no benefit to PVD. SUMMARY Given the advent of newer immunosuppressive agents and overall lower acute rejection rates, the perceived benefit of bladder drainage as a means to measure urinary amylase as an early marker of rejection has not been substantiated. However, there may be a selective role for bladder drainage in 'high risk' pancreases. Also, without a clear-cut metabolic benefit to PVD over SVD, it remains the surgeon's choice as to which method to use.
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Abstract
Simultaneous pancreas-kidney (SPK) transplantation is a promising treatment option for patients with type 1 diabetes and end-stage renal disease. Most of these patients can achieve normalization of glucose and hemoglobin A(1c) levels. Patient and graft survival continues to improve; however, defects in beta-cell function and insulin resistance can be seen over time after transplant. Various methods can be used to assess the SPK recipient for the development of hyperglycemia and graft dysfunction, with treatment aimed at minimizing diabetogenic immunosuppression, using agents that may preserve beta-cell function, and improving insulin resistance.
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Affiliation(s)
- Elizabeth Diakoff
- The Ohio State University, Division of Endocrinology, Diabetes, and Metabolism, 1581 Dodd Drive, 491C McCampbell Hall, Columbus, OH 43210, USA.
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Petruzzo P, Lefrancois N, Berthillot C, Danjou F, Contu P, Codas R, Morelon E, Dubernard JM, Martin X, Badet L. Impact of pancreatic venous drainage site on long-term patient and graft outcome in simultaneous pancreas-kidney transplantation. Clin Transplant 2008; 22:107-12. [PMID: 18217911 DOI: 10.1111/j.1399-0012.2007.00773.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The impact of portal or systemic venous pancreas graft drainage on patient and graft outcome remains controversial. In the present study, the impact of venous drainage type on long-term patient and graft survival is assessed. From July 1996 to December 2002 80 simultaneous pancreas-kidney transplants were enrolled into a prospective study: 44 received a pancreas allograft with portal (P-SPK group) and 36 with systemic venous drainage (S-SPK group). Enteric exocrine drainage was performed in all recipients receiving the same immunosuppressive treatment. At one yr, the patient survival rates were 91.7% and 95.5% both for S-SPK and P-SPK groups, respectively; no significant difference in survival was shown at any time point of the follow-up. The one-, three-, five-, and eight-yr pancreas survival rates were 75%, 60.6%, 56.7%, and 44%, respectively in the S-SPK group compared to 88.6%, 84.1%, 78.4%, and 31.3% in the P-SPK group. The one-, three-, five-, and eight-yr kidney survival rates were 91.7%, 78.15%, 74.1%, and 57.9%, respectively in the S-SPK group compared to 93.2%, 88.6%, 78.4%, and 38.9% in the P-SPK group. Comparing the two groups, no significant difference was shown in the total number of surgical complications as well as in the number of each complication. No significant difference in long-term outcomes between the two groups was shown, even if in S-SPK group a higher incidence of pancreas graft loss has been reported and it was in part correlated to a higher number of graft thromboses.
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Affiliation(s)
- Palmina Petruzzo
- Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Lyon, France.
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Dieterle C, Brendel MD, Seissler J, Eckhard M, Bretzel RG, Landgraf R. [Therapy of diabetes mellitus. Pancreas transplantation, islet transplantation, stem cell and gene therapy]. Internist (Berl) 2007; 47:489-96, 498-501. [PMID: 16575611 DOI: 10.1007/s00108-006-1607-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The long-term normalization of glucose metabolism - a prerequisite for the prevention of secondary complications in patients with diabetes mellitus - is only possible by transplantation of a whole pancreas or a reasonable number of islets. An absolute indication for pancreas grafting is given in type 1 diabetic patients with end-stage renal disease. The 1-year survival after simultaneous kidney/pancreas transplantation is, according to the international registry, 94-100% for patients, 89-92% for kidneys and 85-87% for the pancreas. The high success rate with long lasting normalization of glucose metabolism leads to a stabilization and/or amelioration of secondary complications, to an increase in quality of life and, most importantly, to a significant reduction in mortality when compared to diabetic kidney recipients. The indications for islet transplantation are similar to those for pancreatic grafting. Islet grafting is only a minor surgical procedure, but islet isolation is difficult. The 1-year survival for the recipients is 98%, for the islets 82% and for insulin-independency 42%. There is a significant decline of islet function to 10% 5 years after transplantation. Stem cell therapy would provide a definitive treatment solution not only for patients with type 1 diabetes. So far, this therapeutic option is still at an early stage of development.
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Affiliation(s)
- C Dieterle
- Diabeteszentrum, Medizinische Klinik Innenstadt, Universität München
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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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Petruzzo P, Badet L, Lefrançois N, Berthillot C, Dorel SB, Martin X, Laville M. Metabolic consequences of pancreatic systemic or portal venous drainage in simultaneous pancreas-kidney transplant recipients. Diabet Med 2006; 23:654-9. [PMID: 16759308 DOI: 10.1111/j.1464-5491.2006.01891.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIMS The aim was to investigate pancreatic B-cell function and insulin sensitivity in simultaneous pancreas-kidney (SPK) recipients with systemic or portal venous drained pancreas allograft using simple and easy tests. METHODS The study included 44 patients with Type 1 diabetes and end-stage renal disease who had undergone SPK transplantation: 20 recipients received a pancreas allograft with systemic venous drainage (S-SPK) and 24 with portal venous drainage (P-SPK). We studied only recipients with functioning grafts, with normal serum glucose, HbA(1c) and serum creatinine values, on a stable drug regimen. The subjects were studied at 6, 12, 24, 36, 48 and 60 months after transplantation. Insulin sensitivity and B-cell function indices were derived from blood samples and oral glucose tolerance tests. RESULTS All patients from both groups had normal fasting glucose, body mass index and HbA(1c) values by selection. The homeostatic model (HOMA) beta-cell index was significantly lower in P-SPK recipients at several points of the follow-up. HOMA-IR was significantly higher in S-SPK recipients at 6 and 24 months after transplantation and was positively correlated with fasting insulin values, but never exceeded 3.2. There was no significant difference in QUICKI index values between the two groups. Although all patients from both groups always had normal glucose tolerance, the area under the insulin curve was higher in the S-SPK group. Cholesterol, low-density lipoprotein-cholesterol and triglycerides were higher in the P-SPK group. CONCLUSIONS The results suggest sustained long-term endocrine function in both groups and show that portal venous drainage does not offer major metabolic advantages.
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Affiliation(s)
- P Petruzzo
- Department of Surgery, University of Cagliari, Cagliari, Italy.
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Bak MI, Grochowiecki T, Gałazka Z, Nazarewski S, Jakimowicz T, Pietrasik K, Wojtaszek M, Durlik M, Karnafel W, Szmidt J. Proinsulinemia in Simultaneous Pancreas and Kidney Transplant Recipients. Transplant Proc 2006; 38:280-1. [PMID: 16504725 DOI: 10.1016/j.transproceed.2005.12.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
It has been shown that lipid profiles do not differ between pancreas recipients with systemic and portal venous anastomosis. However, it is unclear whether venous drainage from the transplanted pancreas has an impact on recipient atherogenesis and if other factors should be considered. Increased concentration of proinsulin correlates with tachycardia and other risk factors for ischemic heart disease. The aim of this study was to compare proinsulin levels in different types of pancreatic graft venous drainage. Twenty-four simultaneous pancreas and kidney transplantation (SPK) recipients with systemic venous drainage (group S, n = 12) and portal venous drainage (group P, n = 12) under identical immunosuppressive treatment were prospectively observed during 24 months. Following transplantation, only recipients with normoglycemia, normal HbA1c, and normal serum creatine were evaluated. Proinsulin was assessed in fasting state; after glucagon stimulation (Delta-proinsulin), and during oral 75-g glucose tolerance test twice: between 3 and 6 months and 12 to 24 months posttransplantation. All SPK patients had higher proinsulin concentration in fasting state compared with age-matched healthy controls. After stimulation, proinsulin level did not significantly differ between groups; the type of the pancreas venous anastomosis did not change the release of proinsulin and should not have impact on cardiovascular risk factors.
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Affiliation(s)
- M I Bak
- Department of Gastroenterology and Metabolic Diseases, Warsaw Medical University, ul. Banacha 1a, 02-097 Warsaw, Poland.
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Demartines N, Schiesser M, Clavien PA. An evidence-based analysis of simultaneous pancreas-kidney and pancreas transplantation alone. Am J Transplant 2005; 5:2688-97. [PMID: 16212628 DOI: 10.1111/j.1600-6143.2005.01069.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Nicolas Demartines
- Department of Visceral and Transplant Surgery, University Hospital, Zurich, Switzerland
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Bucher P, Mathe Z, Buhler LH, Andres A, Bosco D, Berney T, Morel P. [Diabetes Type I therapy through transplantation]. ACTA ACUST UNITED AC 2005; 130:374-83. [PMID: 15992762 DOI: 10.1016/j.anchir.2005.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2004] [Accepted: 06/01/2005] [Indexed: 11/25/2022]
Abstract
Diabetes is one of the most common chronic diseases in our society. While insulin treatment for diabetes type I could delay and reduce the incidence of diabetic complications, it is associated with an increased risk of severe hypoglycemia. To restore physiologic insulin metabolism, transplantation of insulin producing cells (pancreatic Beta cells) represent the sole available therapy. It could be done either through pancreas or islet of Langerhans transplantation. In this paper, we review actual knowledge regarding these two types of transplantations.
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Affiliation(s)
- P Bucher
- Département de chirurgie, service de chirurgie viscérale et de transplantation, hôpitaux universitaires de Genève, 24 rue Micheli-Du-Crest, 1211 Geneva 14, Switzerland.
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