Epidemiology of infections requiring hospitalization during long-term follow-up of pancreas transplantation. Transplantation. 2010;89:1126-1133. [PMID: 20164817 DOI: 10.1097/tp.0b013e3181d54bb9]

Long-term outcomes of pancreatic islet transplantation alone in type 1 diabetes: a 20-year single-centre study in Italy

BACKGROUND

Islet transplantation has the potential to cure type 1 diabetes by restoring endogenous insulin production. However, its success relies on balancing improved glycaemic control with the risks of immunosuppressive therapy. This study aimed to evaluate long-term outcomes of islet transplantation alone for type 1 diabetes, focusing on the effects of islet mass and immunosuppressive regimens on graft survival and insulin independence, and weighing glycaemic control benefits against the risks of immunosuppressive therapy.

METHODS

This cohort study retrospectively analysed individuals aged 18-67 years with type 1 diabetes who received intraportal islet transplantation alone at IRCCS Ospedale San Raffaele, Milan, Italy. Inclusion criteria comprised adults with type 1 diabetes diagnosed before the age of 55 years with severe recurrent hypoglycaemia or glycaemic instability. Major exclusion criteria included a HbA1c of more than 12·5%, a BMI of more than 30 kg/m2, and insulin requirements exceeding 1·2 IU/kg per day, along with contraindications to immunosuppressive therapy. Participants were recruited from the hospital's islet transplant registry. Follow-up was conducted through regular clinical visits, with data collected retrospectively. Outcomes assessed included patient survival, graft survival, insulin independence, glycaemic control, and adverse events. Data were analysed using an intention-to-treat method, mixed-effects models, Kaplan-Meier estimates, and Cox and logistic regression to identify factors linked to metabolic success and reduced risks.

FINDINGS

79 patients underwent intrahepatic or intraportal islet transplantation alone between Feb 16, 2001, and June 1, 2023, and received a total of 159 islet infusions, with a median total islet mass of 9637 islet equivalents (IEQ) per kg. Complications were infrequent and mostly involved minor bleeding, with only 3% (two of 79) of patients requiring surgical intervention. Glycaemic control improved significantly after infusion, with a reduction of HbA1c by -10·04 mmol/mol (-13·63 to -6·46), and a decrease in daily insulin requirements by -13·35 units per day (-17·04 to -9·65). The intention-to-treat analysis showed a median graft survival (fasting C peptide ≥0·3 ng/mL) of 3·9 years (95% CI 1·6 to 6·2) and 44% (35/79) insulin independence for a median of 6 years (95% CI 2·88 to 9·08). Patients receiving more than 10 000 IEQ/kg with BAS, FK506, and Rapa therapy had a median graft survival of 9·7 years (3·1-16·0) and 73% (16 of 22) insulin independence. Kaplan-Meier estimates indicated graft survival rates of 86% at 1 year, 65% at 5 years, 47% at 10 years, 47% at 15 years, and 40% at 20 years. Overall survival was 92% (73 of 79) over a median follow-up of 13·1 years, with a 20-year survival probability of 84%. Adverse events related to immunosuppressive therapy were reported in 44% (35 of 79) of patients, with allosensitisation rates increasing from 6% at baseline to 42% after therapy discontinuation.

INTERPRETATION

This analysis of a large islet transplantation alone cohort provides valuable insights into factors influencing outcomes and highlights potential risks, supporting informed clinical decision making and the optimisation of future β-cell replacement strategies.

FUNDING

None.

Infection-Related Hospitalizations After Simultaneous Pancreas-Kidney Transplantation Compared to Kidney Transplantation Alone

The total burden of infections after transplantation has not been compared in detail between recipients of simultaneous pancreas-kidney transplantation (SPK) and kidney transplantation alone (KTA). We compared infection-related hospitalizations and bacteremias after transplantation during 1- and 5-year follow-up among 162 patients undergoing SPK. The control group consisted of 153 type 1 diabetics undergoing KTA with the inclusion criteria of donor and recipient age < 60, and BMI < 30. During the first year, SPK patients had more infection-related hospitalizations (0.54 vs. 0.31 PPY, IRR 1.76, p = <0.001) and bacteremias (0.11 vs. 0.01 PPY, IRR 17.12, p = <0.001) compared to KTA patients. The first infection-related hospitalizations and bacteremias occurred later during follow-up in KTA patients. SPK was an independent risk factor for infection-related hospitalization and bacteremia during the first year after transplantation, but not during the 5-year follow-up. Patient survival did not differ between groups, however, KTA patients had inferior kidney graft survival. SPK patients are at greater risk for infection-related hospitalizations and bacteremias during the first year after transplantation compared to KTA patients, however, at the end of the follow-up the risk of infection was similar between groups.

Medical and Surgical Management of the Failed Pancreas Transplant

Despite the continued improvements in pancreas transplant outcomes in recent decades, a subset of recipients experience graft failure and can experience substantial morbidity and mortality. Here, we summarize what is known about the failed pancreas allograft and what factors are important for consideration of retransplantation. The current definition of pancreas allograft failure and its challenges for the transplant community are explored. The impacts of a failed pancreas allograft are presented, including patient survival and resultant morbidities. The signs, symptoms, and medical and surgical management of a failed pancreas allograft are described, whereas the options and consequences of immunosuppression withdrawal are reviewed. Medical and surgical factors necessary for successful retransplant candidacy are detailed with emphasis on how well-selected patients may achieve excellent retransplant outcomes. To achieve substantial medical mitigation and even pancreas retransplantation, patients with a failed pancreas allograft warrant special attention to their residual renal, cardiovascular, and pulmonary function. Future studies of the failed pancreas allograft will require improved reporting of graft failure from transplant centers and continued investigation from experienced centers.

Epidemiology and Risk Factors for Invasive Fungal Infections in Pancreas Transplant in the Absence of Postoperative Antifungal Prophylaxis

Background

Invasive fungal infections (IFIs) remain a rare yet dreaded complication following pancreas transplantation. Current guidelines recommend antifungal prophylaxis in patients with 1 or more risk factors. At our center, single-dose antifungal prophylaxis is administered in the operating room but none subsequently, regardless of risk factors. Here we evaluate the 1-year incidence, outcome, and risk factors associated with IFI following pancreas transplantation.

Methods

A retrospective, single-center cohort study was conducted in patients who underwent pancreas transplantation between 1 January 2009 and 31 December 2019. Records were manually reviewed, and cases were adjudicated using consensus definitions. The 1-year cumulative incidence, mortality, and risk factors were analyzed by Kaplan-Meier method and differences between populations were assessed with Fisher test and Mann-Whitney U test.

Results

Three hundred sixty-nine recipients were included. Twelve IFIs were identified: candidiasis (8), aspergillosis (2), histoplasmosis (1), and cryptococcosis (1). Intra-abdominal infections were the most common presentation (5), followed by bloodstream infections (3), disseminated disease (2), pulmonary disease (1), and invasive fungal sinusitis (1). Median time to IFI was 64 days (interquartile range, 30-234 days). One-year cumulative incidence was 3.25% (95% confidence interval, 1.86%-5.65%). There were no significant differences between patients with or without IFI regarding type of transplant (P = .17), posttransplant dialysis (P = .3), rejection (P = .5), cytomegalovirus serostatus (P = .45), or reoperation (P = .19). For patients with IFI, the 1-year graft and patient survival rates were 58% versus 95% (P < .0001) and 75% versus 98.6% (P < .001), respectively.

Conclusions

Our study suggests that the use of a single-dose antifungal prophylaxis administered in the operating room but none subsequently does not result in an increased incidence of IFI following pancreas transplantation.

Ultrasound of pancreatic transplant complications: a primer for radiologists

Pancreatic transplantation is an established treatment for patients with type 1 diabetes patients and select type 2 diabetes patients, with excellent survival rates as graft health is evaluated through regular imaging and early detection of complications. Amongst the various imaging methods that may aid in diagnosis of pancreatic transplant complications, ultrasound is a widely available, quick, portable, and cost-effective technique, often used as the sole method to assess for pancreatic transplant complications. When assessing a patient with a pancreatic transplant, the radiologist should be methodical in assessing the vasculature, the pancreatic parenchyma, and the peripancreatic regions. Complications can be categorised based on time from transplant and type of complications, and include vascular, parenchymal, and enteric/anastomotic complications. Doppler has a major role in the diagnosis of vascular complications including arterial and venous thrombosis, arterial stenosis, pseudoaneurysms, and haematomas. Pancreatic complications include rejections and pancreatitis, and are often diagnosed through a combination of clinical, laboratory, and imaging findings, such as pancreatic heterogeneity or the presence of pancreatic pseudocysts. Enteric/anastomotic complications include leaks and bowel obstructions, and may require cross-sectional imaging in addition to ultrasound. This review covers the most common and high-impact vascular, parenchymal, and enteric/anastomotic complications that should be considered in every radiologist's search pattern when assessing a pancreatic graft, as well as their respective postoperative timeframes.

Clinical Outcomes and Risk Factors for Death following Carbapenem-Resistant Klebsiella pneumoniae Infection in Solid Organ Transplant Recipients

Infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) are associated with significant morbidity and mortality. Among solid organ transplant recipients (SOTRs), clinical outcomes and risk factors for death following such infections remain not well documented. A single-center retrospective study was performed. All SOTRs with a CRKP infection at the First Affiliated Hospital of Zhengzhou University between 1 January 2018 and 31 December 2021 were included. Multivariable Cox regression was performed to determine risk factors for death following CRKP infection. We identified 94 SOTRs with CRKP infection, with a median age of 50 years old. CRKP infections resulted in 38.3% of overall 30-day mortality. On multivariable analysis, independent risk factors for death following CRKP infection included older age (hazard ratio [HR], 1.044; 95% confidence interval [CI], 1.007 to 1.083; P = 0.02), allograft failure (HR, 3.962; 95% CI, 1.628 to 9.644; P = 0.002), and septic shock (HR, 8.512; 95% CI, 3.294 to 21.998; P < 0.001). Receiving appropriate targeted therapy was associated with a reduced hazard of death (HR, 0.245; 95% CI, 0.111 to 0.543; P = 0.001). Our study characterized the clinical features and mortality in SOTRs with CRKP infection. The protective effects of appropriate targeted therapy highlight the importance of assessing how antibiotic choices affect the clinical outcomes among SOTRs. IMPORTANCE Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections are increasingly identified in solid organ transplant recipients (SOTRs), but data on the clinical outcomes and risk factors for death following such infections remain limited. Here, we reported CRKP infection was associated with 38.3% of overall 30-day mortality in SOTRs. Independent risk factors for death after CRKP infection included older age, allograft failure, and septic shock. Appropriate targeted therapy was important for alleviating the impact of CRKP infections on these SOTRs.

Incidence rate of active tuberculosis in solid organ transplant recipients: Data from a nationwide population cohort in a high-endemic country

BACKGROUND

The management of active tuberculosis (TB) in solid organ transplantation (SOT) recipients is challenging given the pharmacological interaction and the potential delays in diagnosis due to atypical presentation. The incidence rates (IRs) of post-SOT TB from the whole recipients' cohort in a high-endemic country have not been evaluated.

METHODS

We established a SOT cohort (n = 15 598) and confirmed cases of TB between 2011 and 2015 from the Korean National Health Insurance Database using ICD-10 codes. After excluding 1302 and 180 SOT-recipients due to age (<18 years) and presence of pre-SOT TB and/or treatment for latent TB during wash-out period between 2006 and cohort entry, we analyzed 14 116 SOT recipients and 70 580 individuals with no history of SOT matched by age and sex. The hazard ratios (HRs) of IRs were adjusted for age, sex, low-income status, diabetes mellitus, chronic co-morbidities, and anti-TNF-α therapy.

RESULTS

The IR of TB was significantly higher (adjusted HR [aHR]: 6.1, 95% confidence interval [CI]: 4.5-7.6) in SOT recipients (4.9/1000 person-years) than in non-SOT individuals (0.8/1000 person-years). Of the transplanted organs, the pancreas (pancreas alone and simultaneous pancreas-kidney) and lung had the highest IR (aHR: 16.3 [6.1-42.2] and 16.1 [5.9-43.8], respectively). The use of anti-thymocyte globulin and azathioprine was associated with a higher IR (aHR: 1.53 [1.01-2.43] and 3.92 [1.21-12.47], respectively), but basiliximab was associated with a lower IR (aHR: 0.67 [0.48-0.98]).

CONCLUSION

The IR of TB in SOT recipients, especially in the pancreas and lung, was significantly higher than that in the non-SOT population.

Late complications of pancreas transplant

To summarize the long-term complications after pancreas transplantation that affect graft function, a literature search was carried out on the long-term complications of pancreatic transplantation, namely, complications from postoperative 3^rd mo onwards, in terms of loss of graft function, late infection and vascular complications as pseudoaneurysms. The most relevant reviews and studies were selected to obtain the current evidence on these topics. The definition of graft failure varies among different studies, so it is difficult to evaluate, a standardized definition is of utmost importance to know the magnitude of the problem in all worldwide series. Chronic rejection is the main cause of long-term graft failure, occurring in 10% of patients. From the 3rd mo of transplantation onwards, the main risk factor for late infections is immunosuppression, and patients have opportunistic infections like: Cytomegalovirus, hepatitis B and C viruses, Epstein-Barr virus and varicella-zoster virus; opportunistic bacteria, reactivation of latent infections as tuberculosis or fungal infections. Complete preoperative studies and serological tests should be made in all recipients to avoid these infections, adding perioperative prophylactic treatments when indicated. Pseudoaneurysm are uncommon, but one of the main causes of late bleeding, which can be fatal. The treatment should be performed with radiological endovascular approaches or open surgery in case of failure. Despite all therapeutic options for the complications mentioned above, transplantectomy is a necessary option in approximately 50% of relaparotomies, especially in life-threatening complications. Late complications in pancreatic transplantation threatens long-term graft function. An exhaustive follow-up as well as a correct immunosuppression protocol are necessary for prevention.

Exocrine drainage in pancreas transplantation: Complications and management

The aim of this minireview is to compare various pancreas transplantation exocrine drainage techniques i.e., bladder vs enteric. Both techniques have different difficulties and complications. Numerous comparisons have been made in the literature between exocrine drainage techniques throughout the history of pancreas transplantation, detailing complications and their impact on graft and patient survival. Specific emphasis has been made on the early postoperative management of these complications and the related surgical infections and their consequences. In light of the results, a number of bladder-drained pancreas grafts required conversion to enteric drainage. As a result of technical improvements, outcomes of the varied enteric exocrine drainage techniques (duodenojejunostomy, duodenoduodenostomy or gastric drainage) have also been discussed i.e., assessing specific risks vs benefits. Pancreatic exocrine secretions can be drained to the urinary or intestinal tracts. Until the late 1990s the bladder drainage technique was used in the majority of transplant centers due to ease of monitoring urine amylase and lipase levels for evaluation of possible rejection. Moreover, bladder drainage was associated at that time with fewer surgical complications, which in contrast to enteric drainage, could be managed with conservative therapies. Nowadays, the most commonly used technique for proper driving of exocrine pancreatic secretions is enteric drainage due to the high rate of urological and metabolic complications associated with bladder drainage. Of note, 10% to 40% of bladder-drained pancreata eventually required enteric conversion at no detriment to overall graft survival. Various surgical techniques were originally described using the small bowel for enteric anastomosis with Roux-en-Y loop or a direct side-to-side anastomosis. Despite the improvements in surgery, enteric drainage complication rates ranging from 2%-20% have been reported. Treatment depends on the presence of any associated complications and the condition of the patient. Intra-abdominal infection represents a potentially very serious problem. Up to 30% of deep wound infections are associated with an anastomotic leak. They can lead not only to high rates of graft loss, but also to substantial mortality. New modifications of established techniques are being developed, such as gastric or duodenal exocrine drainage. Duodenoduodenostomy is an interesting option, in which the pancreas is placed behind the right colon and is oriented cephalad. The main concern of this technique is the challenge of repairing the native duodenum when allograft pancreatectomy is necessary. Identification and prevention of technical failure remains the main objective for pancreas transplantation surgeons. In conclusion, despite numerous techniques to minimize exocrine pancreatic drainage complications e.g., leakage and infection, no universal technique has been standardized. A prospective study/registry analysis may resolve this.

Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.

[Pancreas transplantation followed by stumpless duodenal exocrine drainage]

Pancreas transplantation followed by stumpless duodenal exocrine drainage was performed in 2 patients. Primary kidney and pancreas graft function was noted in both cases. Two procedures of pancreas transplantation followed by stumpless duodenal exocrine drainage were carried out for the first time. Perhaps, absent donor duodenal stump has several advantages for the further course of postoperative period that may be confirmed in prospective trials.

Yeast Infections in Solid Organ Transplantation

Invasive candidiasis (IC) remains the most common invasive fungal infection following solid-organ transplant (SOT), but risk factors are evolving. Current challenges include infection due to drug resistant non-albicans and emerging novel species such as Candida auris. Preventive antifungal use in SOT needs to be re-examined in light of these current challenges. Cryptococcosis is the second most common IFI following SOT. Cryptococcus gattii is an emerging pathogen that can have reduced in-vitro susceptibility to antifungal agents. Cryptococcus associated IRIS in SOT is a clinical entity that warrants heightened awareness for timely recognition and management.

Epidemiology, risk factors, and impact of bacterial infections on outcomes for pancreatic grafts

We aimed to determine the epidemiology, risk factors, and impact of bacterial infection on pancreatic function after pancreas transplantation. Data for pancreas transplant recipients were retrospectively reviewed between 2000 and 2014 for at least 1 year. We collected and analyzed post-transplant data for bacterial infection, morbidity, and mortality. During the study period, 312 pancreas transplants were performed. In total, 509 episodes of bacterial infection were diagnosed in 191 patients (61%). Multidrug-resistant (MDR) organisms were present in 173 of the 513 isolated microorganisms (33%). Risk factors independently associated with bacterial infection were acute allograft rejection (OR 1.7, 95%CI 1.1-3), the need for post-transplant hemodialysis, (OR 5.3, 95%CI 1.8-15.7) and surgical re-intervention (OR 2.8, 95%CI 1.5-5.1), which was also considered a risk factor for infections caused by MDR bacteria. Graft survival was associated with the occurrence of one or more episodes of bacterial infection (log-rank test = 0.009). Surgical re-intervention was independently associated with graft loss (OR 2.5, 95%CI 1.3-4.7). To conclude, pancreas recipients frequently experienced bacterial infections associated with the need for hemodialysis or surgical re-intervention. Infection by MDR organisms is a growing concern in these patients and was related to graft survival. Graft loss was independently associated with surgical re-intervention.

Retroperitoneal Pancreas Transplantation With the Use of Duodenal Drainage via "Button Technique": First Clinical Practice (Case Report)

The persistent relative high incidence of duodenum-associated surgical complications significantly reduces pancreas grafts' (PG) and recipients' survival rates. A 31-year-old female patient underwent retroperitoneal pancreas transplantation with the use of PG exocrine drainage into the recipient's duodenum via the "button technique" approach. An uncomplicated postoperative period with satisfactory function of both transplants (pancreas and kidney) was noted. This was the 1st time ever that the transplantation was performed with the use of retroperitoneal placement of the pancreas transplant and duodenal drainage via the "button technique" approach. It is possible that the absence of the duodenal stump in the donor's transplant has a number of benefits in the postoperative period, which can be confirmed during the follow-up observations.

Prevalence of Clostridium difficile infection among solid organ transplant recipients: a meta-analysis of published studies

Several factors including antibiotic use, immunosuppression and frequent hospitalizations make solid organ transplant (SOT) recipients vulnerable to Clostridium difficile infection (CDI). We conducted a meta-analysis of published studies from 1991-2014 to estimate the prevalence of CDI in this patient population. We searched PubMed, EMBASE and Google Scholar databases. Among the 75,940 retrieved citations, we found 30 studies coded from 35 articles that were relevant to our study. Based on these studies, we estimated the prevalence of CDI among 21,683 patients who underwent transplantation of kidney, liver, lungs, heart, pancreas, intestine or more than one organ and stratified each study based on the type of transplanted organ, place of the study conduction, and size of patient population. The overall estimated prevalence in SOT recipients was 7.4% [95%CI, (5.6-9.5%)] and it varied based on the type of organ transplant. The prevalence was 12.7% [95%CI, (6.4%-20.9%)] among patients who underwent transplantation for more than one organ. The prevalence among other SOT recipients was: lung 10.8% [95% CI, (5.5%-17.7%)], liver 9.1 % [95%CI, (5.8%-13.2%)], intestine 8% [95% CI, (2.6%-15.9%)], heart 5.2% [95%CI, (1.8%-10.2%)], kidney 4.7% [95% CI, (2.6%-7.3%)], and pancreas 3.2% [95% CI, (0.5%-7.9%)]. Among the studies that reported relevant data, the estimated prevalence of severe CDI was 5.3% [95% CI (2.3%-9.3%)] and the overall recurrence rate was 19.7% [95% CI, (13.7%-26.6%)]. In summary, CDI is a significant complication after SOT and preventive strategies are important in order to reduce the CDI related morbidity and mortality.

Acute pancreas allograft rejection is associated with increased risk of graft failure in pancreas transplantation

The effect of acute allograft rejection (AR) on long-term pancreas allograft function is unclear. We retrospectively studied 227 consecutive pancreas transplants performed at our institution between January 1, 998 and December 31, 2009 including: 56 simultaneous pancreas and kidney (SPK), 69 pancreas transplantation alone (PTA); and 102 pancreas after kidney (PAK) transplants. With a median follow-up of 6.1 (IQR 3-9) years, 57 patients developed 79 episodes of AR, and 19 experienced more than one episode. The cumulative incidence for AR was 14.7%, 19.7%, 26.6% and 29.1% at 1, 2, 5 and 10 years. PTA transplant (hazards ratio [HR]=2.28, p=0.001) and donor age (per 10 years) (HR=1.34, p=0.006) were associated with higher risk for AR. The first AR episode after 3 months post PT was associated with increased risk for complete loss (CL) (HR 3.79, p<0.001), and the first AR episode occurring during 3- to 12-month and 12- to 24-month periods after PT were associated with significantly increased risk for at least partial loss (PL) (HR 2.84, p=0.014; and HR 6.25, p<0.001, respectively). We conclude that AR is associated with increased risk for CL and at least PL. The time that the first AR is observed may influence subsequent graft failure.

Epidemiology, risk factors and impact on long-term pancreatic function of infection following pancreas-kidney transplantation

Limited information exists about epidemiology and risk factors of infection following pancreas-kidney transplantation and its impact on long-term pancreatic graft function. A retrospective chart review of episodes of severe infection in consecutive pancreas-kidney transplantations in a single institution was performed to assess the epidemiology, risk factors for infection and their impact on the development of pancreatic graft dysfunction. Ninety-four (81%) of 116 recipients (median follow-up of 1492 days; mean 1594) developed 248 episodes of severe infection. Bacterial infections were present in 208 episodes, with 12% of the isolates resistant to antibiotics used in prophylaxis. There were 40 episodes of fungal infection in 32 patients (28%) (mostly Candida spp), and CMV disease appeared in 20 patients (17%), of which 50% appeared after the third month following surgery. The multivariate analysis identified that surgical re-intervention and the use of steroid pulses were independently associated with the development of any infection. Additionally, pre-transplant evidence of peripheral artery disease, a longer cold ischaemia time and high transfusional requirements were associated with fungal infections. Cytomegalovirus (CMV) mismatch was independently related to CMV disease and female sex, and bladder drainage of the exocrine pancreas was associated with urinary tract infection. At the end of follow-up, 29 patients (25%) had developed severe pancreatic graft dysfunction, and fungal infection was independently associated with it. Our study identifies a subset of pancreas-kidney transplant recipients at a higher risk of developing severe infection. Fungal infection is an independent risk factor for the development of severe pancreatic graft dysfunction.

Transplantation of the pancreas

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.

Laparoscopic robot-assisted pancreas transplantation: first world experience

BACKGROUND

Surgical complications are a major disincentive to pancreas transplantation, despite the undisputed benefits of restored insulin independence. The da Vinci surgical system, a computer-assisted electromechanical device, provides the unique opportunity to test whether laparoscopy can reduce the morbidity of pancreas transplantation.

METHODS

Pancreas transplantation was performed by robot-assisted laparoscopy in three patients. The first patient received a pancreas after kidney transplant, the second a simultaneous pancreas kidney transplantation, and the third a pancreas transplant alone. Operations were carried out through an 11-mm optic port, two 8-mm operative ports, and a 7-cm midline incision. The latter was used to introduce the grafts, enable vascular cross-clamping, and create exocrine drainage into the jejunum.

RESULTS

The two solitary pancreas transplants required an operating time of 3 and 5 hr, respectively; the simultaneous pancreas kidney transplantation took 8 hr. Mean warm ischemia time of the pancreas graft was 34 min. All pancreatic transplants functioned immediately, and all recipients became insulin independent. The kidney graft, revascularized after 35 min of warm ischemia, also functioned immediately. No patient had complications during or after surgery. At the longer follow-up of 10, 8, and 6 months, respectively, all recipients are alive with normal graft function.

CONCLUSIONS

We have shown the feasibility of laparoscopic robot-assisted solitary pancreas and simultaneous pancreas and kidney transplantation. If the safety and feasibility of this procedure can be confirmed by larger series, laparoscopic robot-assisted pancreas transplantation could become a new option for diabetic patients needing beta-cell replacement.

Risks and benefits of transplantation in the cure of type 1 diabetes: whole pancreas versus islet transplantation. A single center study

BACKGROUND

Pancreas and islet transplantation are the only available options to replace beta-cell function in patients with type 1 diabetes. Great variability in terms of rate of success for both approaches is reported in the literature and it is difficult to compare the respective risks and benefits.

OBJECTIVES

The aim of this study was to analyze risks and benefits of pancreas transplantation alone (PTA) and islet transplantation alone (ITA) by making use of the long-term experience of a single center where both transplantations are performed. We focused on the risks and benefits of both procedures, with the objective of better defining indications and providing evidence to support the decision-making process. The outcomes of 33 PTA and 33 ITA were analyzed, and pancreas and islet function (i.e., insulin independence), perioperative events, and long-term adverse events were recorded.

RESULTS

We observed a higher rate of insulin independence in PTA (75%) versus ITA (59%), with the longer insulin independence among PTA patients receiving tacrolimus. The occurrence of adverse events was higher for PTA patients in terms of hospitalization length and frequency, re-intervention for surgical and immunological acute complications, CMV reactivation, and other infections.

CONCLUSIONS

In conclusion, these results support the practice of listing patients for PTA when the metabolic control and the progression of chronic complications require a rapid normalization of glucose levels, with the exception of patients with cardiovascular disease, because of the high surgical risks. ITA is indicated when replacement of beta-cell mass is needed in patients with a high surgical risk.

Current perspectives on laparoscopic robot-assisted pancreas and pancreas-kidney transplantation

Pancreas transplant recipients continue to suffer high surgical morbidity. Current robotic technology provides a unique opportunity to test whether laparoscopy can improve the post-operative course of pancreas transplantation (PT). Current knowledge on robotic pancreas and renal transplantation was reviewed to determine feasibility and safety of robotic PT. Information available from literature was included in this review, together with personal experience including three PT, and two renal allotransplants. As of April 2011, the relevant literature provides two case reports on robotic renal transplantation. The author's experience consists of one further renal allotransplantation, two solitary PT, and one simultaneous pancreas-kidney transplantation. Information obtained at international conferences include several other renal allotransplants, but no additional PT. Preliminary data show that PT is feasible laparoscopically under robotic assistance, but raises concerns regarding the effects of increased warm ischemia time on graft viability. Indeed, during construction of vascular anastomoses, graft temperature progressively increases, since maintenance of a stable graft temperature is difficult to achieve laparoscopically. There is no proof that progressive graft warming produces actual damage to transplanted organs, unless exceedingly long. However, this important question is likely to elicit a vibrant discussion in the transplant community.

Pancreatic transplantation

A pancreas transplant is a surgical procedure to place a healthy pancreas from a donor into a patient whose pancreas no longer functions properly. Exocrine pancreas transplantation remains the standard treatment of choice for patients with diabetes mellitus complicated by end-stage renal disease. The use of pancreas transplantation for type 2 diabetes mellitus is an emerging concept. A pancreas transplant is often done in conjunction with a kidney transplant. Even if pancreas transplantation provides the best glycemic control option for diabetes mellitus, it is associated with significant morbidities related to infectious disease. The present article provides with a review of pancreatic transplantation.