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Grasberger J, Ortiz F, Ekstrand A, Sallinen V, Ahopelto K, Finne P, Gissler M, Lempinen M, Helanterä I. Infection-Related Hospitalizations After Simultaneous Pancreas-Kidney Transplantation Compared to Kidney Transplantation Alone. Transpl Int 2024; 37:12235. [PMID: 38444997 PMCID: PMC10912468 DOI: 10.3389/ti.2024.12235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024]
Abstract
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.
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Affiliation(s)
- Juulia Grasberger
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Fernanda Ortiz
- Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Agneta Ekstrand
- Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kaisa Ahopelto
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Patrik Finne
- Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Marko Lempinen
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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2
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Ahopelto K, Bonsdorff A, Grasberger J, Lempinen M, Nordin A, Helanterä I, Sallinen V. Pasireotide Versus Octreotide in Preventing Complications After Simultaneous Pancreas-Kidney Transplantation. Transpl Int 2023; 36:11255. [PMID: 37388858 PMCID: PMC10300274 DOI: 10.3389/ti.2023.11255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
In elective pancreatic surgery, somatostatin-analogues pasireotide and octreotide are variably used to reduce postoperative complications, but knowledge on their role in pancreas transplantation is limited. This study compared pasireotide and octreotide for their association with complications after simultaneous pancreas-kidney transplantation (SPK). This retrospective study included consecutive patients undergoing SPK's from July 2013 to July 2022. Between July 2013 and April 2020, octreotide was administered 0.1 mg s.c. once daily and between May 2020 and July 2022 pasireotide was administered 0.9 mg twice daily, both until third postoperative day. Complications within 90 days postoperatively were collected, and reoperation rate and Comprehensive Complication index (CCI) ≥ 33.7 (morbidity equal to one reoperation) were used as primary outcomes. Of the 213 patients undergoing SPK, 150 patients received octreotide and 63 pasireotide. Baseline characteristics were comparable. Reoperation rate was 25.3% (n = 38) and 17.5% (n = 11) (p = 0.213) and rate of CCI ≥ 33.7 was 40.7% (n = 61) and 30.2% (n = 19) (p = 0.148) in octreotide and pasireotide groups, respectively. When adjusted with donor BMI, pancreas donor risk index, and donor sex, receiving pasireotide translated into OR 0.49 (95% CI: 0.25-0.96 p = 0.037) for CCI ≥ 33.7. Pasireotide was independently associated with lower postoperative morbidity within 90 days of SPK compared to octreotide.
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Affiliation(s)
- Kaisa Ahopelto
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Akseli Bonsdorff
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juulia Grasberger
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marko Lempinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Giuliani T, Ibáñez JM, Montalvá-Orón E, Robledo AB, Chicote CM, Sanz AH, Ibañez CB, Mizrahi DC, Castelló IB, Torres JFM, Andújar RL. Simultaneous pancreas-kidney transplantation: which graft warns the most? Langenbecks Arch Surg 2023; 408:196. [PMID: 37191721 DOI: 10.1007/s00423-023-02876-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/31/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Simultaneous pancreas-kidney transplantation (SPK) is still characterized by high rates of postoperative complications. This study aims to offer an in-depth characterization of early, medium-term, and late complications following SPK to derive insights for postoperative management and follow-up. METHODS Consecutive SPK transplantations were analysed. Pancreatic graft (P-graft)- and kidney graft (K-graft)-related complications were analysed separately. The global postoperative course was assessed in three timeframes (early, medium-term, and late) using the comprehensive complication index (CCI). Predictors of complications and early graft loss were explored. RESULTS Complications occurred in 61.2% of patients, and the 90-day mortality was 3.9%. The overall burden of complications was significantly high during admission (CCI 22.4 ± 21.1) and decreased gradually afterwards. P-graft-related complications burdened the most in the early postoperative course (CCI 11.6 ± 13.8); postoperative ileus and perigraft fluid collection were the most frequent complications, and pseudoaneurysms, haemorrhages, and bowel leaks were the major concerns. K-related complications were milder but represented the largest proportion of the CCI in the late postoperative timeframe (CCI 7.6 ± 13.6). No predictors of P-graft- or K-graft-related complications were found. CONCLUSION Pancreas graft-related complications represent the largest part of the clinical burden in the early postoperative timeframe but are negligible after 3 months. Kidney grafts have a relevant impact in the long term. The multidisciplinary approach to SPK recipients should be driven based on all graft-specific complications and tailored on a time-dependent basis.
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Affiliation(s)
- Tommaso Giuliani
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Verona, Italy
| | - Javier Maupoey Ibáñez
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
| | - Eva Montalvá-Orón
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
- IIS La Fe, CIBERehd, Instituto de Salud San Carlos III, Madrid, Spain
| | - Andrea Boscà Robledo
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
| | - Cristina Martínez Chicote
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
| | - Ana Hernando Sanz
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
| | - Cristina Ballester Ibañez
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
| | - David Calatayud Mizrahi
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
| | - Isabel Beneyto Castelló
- Department of Nephrology and Kidney Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain
| | | | - Rafael López Andújar
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Valencia, Spain.
- IIS La Fe, CIBERehd, Instituto de Salud San Carlos III, Madrid, Spain.
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Rössler F, Kümmerli C, Hügli S, Jonas JP, Hübel K, Oberkofler CE, Müller PC, de Rougemont O. Effect of donor pancreas extraction time on pancreas transplantation-a Swiss tertiary center experience. Clin Transplant 2023; 37:e14846. [PMID: 36322914 DOI: 10.1111/ctr.14846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
We aimed to assess the effect of donor pancreas extraction time (ET) on postoperative complications and graft function after pancreas transplantation (PT). We analyzed all consecutive donor pancreas procurements for the simultaneous pancreas and kidney transplantation (SPK) and the associated PT in a Swiss transplant center over a 20-year period. Pancreas ET was defined as the time from cold flush to static storage of the pancreas on ice. The primary endpoint was the effect of extraction time on surgical complications. Secondary endpoints comprised the effect of ET on graft function (insulin-free survival) and graft pancreatitis. Of 115 procured pancreas grafts the median donor pancreas ET was 65 min (IQR: 48-78 min). In multivariable analysis, ET did not negatively affect major complications (OR 1.41 [95% CI: .59-3.36]; p = .438) and insulin-free survival (HR 1.42 [95% CI: .55-3.63]; p = .459). The median CIT was 522 (441-608) min. CIT was associated with major complications (OR 2.51 [95% CI: 1.11-5.68]; p = .027), but without impact on insulin-free survival (HR 1.94 [95% CI: .84-4.48]; p = .119). Patients with and without graft pancreatitis had no statistically significant differences in ET and CIT (p = .164 and p = .47, respectively). In multivariable analysis, Amylase levels > 270 U/L on postoperative day 1 were significantly associated with major complications (OR 3.61 [95% CI: 1.06-12.32]; p = .040). Our results suggest that although no effect of ET on complications and graft function after PT was found, shorter CIT and less graft pancreatitis can have a positive impact on surgical complications. Results could possibly be influenced by the exceptional quality of the pancreas donors, with short travel distances and preservation times in Switzerland.
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Affiliation(s)
- Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Kümmerli
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, University Hospital Basel, Basel, Switzerland
| | - Sandro Hügli
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jan P Jonas
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Kerstin Hübel
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.,Vivèvis AG - Visceral, Tumor And Robotic Surgery Clinic Hirslanden Zürich, Zürich, Switzerland
| | - Philip C Müller
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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5
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Sharda B, Jay CL, Gurung K, Harriman D, Gurram V, Farney AC, Orlando G, Rogers J, Garner M, Stratta RJ. Improved surgical outcomes following simultaneous pancreas-kidney transplantation in the contemporary era. Clin Transplant 2022; 36:e14792. [PMID: 36029250 PMCID: PMC10078434 DOI: 10.1111/ctr.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/20/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Complications leading to early technical failure have been the Achilles' heel of simultaneous pancreas-kidney transplantation (SPKT). The study purpose was to analyze longitudinally our experience with early surgical complications following SPKT with an emphasis on changes in practice that improved outcomes in the most recent era. STUDY DESIGN Single center retrospective review of all SPKTs from 11/1/01 to 8/12/20 with enteric drainage. Early relaparotomy was defined as occurring within 3 months of SPKT. Patients were stratified into two sequential eras: Era 1 (E1): 11/1/01-5/30/13; Era 2 (E2) 6/1/13-8/12/20 based on changes in practice that occurred pursuant to donor age and pancreas cold ischemia time (CIT). RESULTS 255 consecutive SPKTs were analyzed (E1, n = 165; E2, n = 90). E1 patients received organs from older donors (mean E1 27.3 vs. E2 23.1 years) with longer pancreas cold CITs) (mean E1 16.1 vs. E2 13.3 h, both p < .05). E1 patients had a higher early relaparotomy rate (E1 43.0% vs. E2 14.4%) and were more likely to require allograft pancreatectomy (E1 9.1% vs. E2 2.2%, both p < .05). E2 patients underwent systemic venous drainage more frequently (E1 8% vs. E2 29%) but pancreas venous drainage did not influence either relaparotomy or allograft pancreatectomy rates. The most common indications for early relaparotomy in E1 were allograft thrombosis (11.5%) and peri-pancreatic phlegmon/abscess (8.5%) whereas in E2 were thrombosis, pancreatitis/infection, and bowel obstruction (each 3%). CONCLUSION Maximizing donor quality (younger donors) and minimizing pancreas CIT are paramount for reducing early surgical complications following SPKT.
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Affiliation(s)
- Berjesh Sharda
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Komal Gurung
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - David Harriman
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Venkat Gurram
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Matthew Garner
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
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6
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Lehner LJ, Öllinger R, Globke B, Naik MG, Budde K, Pratschke J, Eckardt KU, Kahl A, Zhang K, Halleck F. Impact of Early Pancreatic Graft Loss on Outcome after Simultaneous Pancreas-Kidney Transplantation (SPKT)-A Landmark Analysis. J Clin Med 2021; 10:jcm10153237. [PMID: 34362019 PMCID: PMC8347953 DOI: 10.3390/jcm10153237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 01/06/2023] Open
Abstract
(1) Background: Simultaneous pancreas-kidney transplantation (SPKT) is a standard therapeutic option for patients with diabetes mellitus type I and kidney failure. Early pancreas allograft failure is a complication potentially associated with worse outcomes. (2) Methods: We performed a landmark analysis to assess the impact of early pancreas graft loss within 3 months on mortality and kidney graft survival over 10 years. This retrospective single-center study included 114 adult patients who underwent an SPKT between 2005 and 2018. (3) Results: Pancreas graft survival rate was 85.1% at 3 months. The main causes of early pancreas graft loss were thrombosis (6.1%), necrosis (2.6%), and pancreatitis (2.6%). Early pancreas graft loss was not associated with reduced patient survival (p = 0.168) or major adverse cerebral or cardiovascular events over 10 years (p = 0.741) compared to patients with functioning pancreas, after 3 months. Moreover, kidney graft function (p = 0.494) and survival (p = 0.461) were not significantly influenced by early pancreas graft loss. (4) Conclusion: In this study, using the landmark analysis technique, early pancreas graft loss within 3 months did not significantly impact patient or kidney graft survival over 10 years.
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Affiliation(s)
- Lukas Johannes Lehner
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
- Correspondence: ; Tel.: +49-30-45-051-4002
| | - Robert Öllinger
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.Ö.); (B.G.); (J.P.)
| | - Brigitta Globke
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.Ö.); (B.G.); (J.P.)
| | - Marcel G. Naik
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
- Berlin Institute of Health (BIH), 10117 Berlin, Germany;
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.Ö.); (B.G.); (J.P.)
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
| | - Andreas Kahl
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
| | - Kun Zhang
- Berlin Institute of Health (BIH), 10117 Berlin, Germany;
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (M.G.N.); (K.B.); (K.-U.E.); (A.K.); (F.H.)
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7
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Blundell J, Shahrestani S, Lendzion R, Pleass HJ, Hawthorne WJ. Risk Factors for Early Pancreatic Allograft Thrombosis Following Simultaneous Pancreas-Kidney Transplantation: A Systematic Review. Clin Appl Thromb Hemost 2021; 26:1076029620942589. [PMID: 33052066 PMCID: PMC7573738 DOI: 10.1177/1076029620942589] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Simultaneous pancreas-kidney (SPK) transplantation remains the most effective treatment for providing consistent and long-term euglycemia in patients having type 1 diabetes with renal failure. Thrombosis of the pancreatic vasculature continues to contribute significantly to early graft failure and loss. We compared the rate of thrombosis to graft loss and systematically reviewed risk factors impacting early thrombosis of the pancreas allograft following SPK transplantation. We searched the MEDLINE, EMBASE, The Cochrane Library, and PREMEDLINE databases for studies reporting thrombosis following pancreas transplantation. Identified publications were screened for inclusion and synthesized into a data extraction sheet. Sixty-three studies satisfied eligibility criteria: 39 cohort studies, 22 conference abstracts, and 2 meta-analyses. Newcastle-Ottawa Scale appraisal of included studies demonstrated cohort studies of low bias risk; 1127 thrombi were identified in 15 936 deceased donor, whole pancreas transplants, conferring a 7.07% overall thrombosis rate. Thrombosis resulted in pancreatic allograft loss in 83.3% of reported cases. This review has established significant associations between donor and recipient characteristics, procurement and preservation methodology, transplantation technique, postoperative management, and increased risk of early thrombosis in the pancreas allograft. Further studies examining the type of organ preservation fluid, prophylactic heparin protocol, and exocrine drainage method and early thrombosis should also be performed.
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Affiliation(s)
- Jian Blundell
- Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Sara Shahrestani
- Sydney Medical School, University of Sydney, New South Wales, Australia.,Department of Surgery, University of Sydney at Westmead Hospital, New South Wales, Australia
| | - Rebecca Lendzion
- Department of Surgery, University of Sydney at Westmead Hospital, New South Wales, Australia
| | - Henry J Pleass
- Sydney Medical School, University of Sydney, New South Wales, Australia.,Department of Surgery, University of Sydney at Westmead Hospital, New South Wales, Australia
| | - Wayne J Hawthorne
- Sydney Medical School, University of Sydney, New South Wales, Australia.,Department of Surgery, University of Sydney at Westmead Hospital, New South Wales, Australia.,The Centre for Transplant & Renal Research, Westmead Institute for Medical Research, New South Wales, Australia
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8
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Bonsdorff A, Sallinen V, Räihä J, Ekstrand A, Nordin A, Lempinen M, Helanterä I. First-day plasma amylase detects patients at risk of complications after simultaneous pancreas-kidney transplantation. Clin Transplant 2021; 35:e14233. [PMID: 33506535 DOI: 10.1111/ctr.14233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/28/2020] [Accepted: 01/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Simultaneous pancreas-kidney transplantation (SPK) carries a high risk of major postoperative complications, but knowledge on early warning signs and surrogate markers for postoperative complications is scarce. AIMS Our aim was to analyze the complication-predictive value of different laboratory tests in pancreas transplantation. MATERIALS & METHODS All SPKs in Finland between January 2010 and February 2020 were retrospectively analyzed. Levels of first three-day plasma amylase, drain fluid amylase, C-reactive protein, C-peptide, plasma trypsinogen, and white blood cell count were assessed for their performance predicting cumulative postoperative complications (assessed using the Comprehensive Complication Index) within 90 days from transplantation by using ROC analyses. RESULTS Of the 164 SPK patients included, 39 suffered at least one complication requiring laparotomy. First-day plasma amylase had the best value in predicting complications based on its high AUC value and easy clinical applicability, with an optimum cutoff of six times the upper normal limit. Negative predictive values (NPVs) and positive predictive values of this cutoff were 0.81 and 0.71 for any relaparotomy, and 0.91 and 0.71 for the Comprehensive Complication Index >47.7 (which equals the morbidity of two relaparotomies), respectively. CONCLUSION In conclusion, first-day plasma amylase could be able to detect patients at risk of complications after SPK.
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Affiliation(s)
- Akseli Bonsdorff
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juulia Räihä
- Department of Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Agneta Ekstrand
- Department of Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arno Nordin
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marko Lempinen
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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9
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Prudhomme T, Kervella D, Le Bas-Bernardet S, Cantarovich D, Karam G, Blancho G, Branchereau J. Ex situ Perfusion of Pancreas for Whole-Organ Transplantation: Is it Safe and Feasible? A Systematic Review. J Diabetes Sci Technol 2020; 14:120-134. [PMID: 31409133 PMCID: PMC7189158 DOI: 10.1177/1932296819869312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pancreas transplantation is currently one of the best treatments proposed in highly selected patients with unstable and brittle type 1 diabetes. The objective of pancreas transplantation is to restore normoglycemia and avoid the occurrence of complications associated with diabetes. Graft pancreatitis and thrombosis, arising from ischemia reperfusion injuries, are major causes of graft loss in the postoperative period. Ex situ perfusion, in hypothermic or normothermic settings, allowed to improve ischemic reperfusion injury in other organ transplantations (kidney, liver, or lung). The development of pancreatic graft perfusion techniques would limit these ischemic reperfusion injuries. OBJECTIVE Evaluation of the safety and feasibility of ex situ perfusion of pancreas for whole-organ transplantation. METHODS English literature about pancreas perfusion was analyzed using electronic database Medline via PubMed (1950-2018). Exclusion criteria were studies that did not specify the technical aspects of machine perfusion and studies focused only on pancreas perfusion for islet isolation. RESULTS Hypothermic machine perfusion for pancreas preservation has been evaluated in nine studies and normothermic machine perfusion in ten studies. We evaluated machine perfusion model, types of experimental model, anatomy, perfusion parameters, flushing and perfusion solution, length of perfusion, and comparison between static cold storage and perfusion. CONCLUSIONS This review compared ex vivo machine perfusion of experimental pancreas for whole-organ transplantation. Pancreas perfusion is feasible and could be a helpful tool to evaluate pancreas prior to transplantation. Pancreas perfusion (in hypothermic or normothermic settings) could reduce ischemic reperfusion injuries, and maybe could avoid pancreas thrombosis and reduce morbidity of pancreas transplantation.
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Affiliation(s)
- Thomas Prudhomme
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Delphine Kervella
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Stéphanie Le Bas-Bernardet
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Diego Cantarovich
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Georges Karam
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Gilles Blancho
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Julien Branchereau
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
- Julien Branchereau, Centre de Recherche en
Transplantation et Immunologie UMR 1064, INSERM, 30 Bd Jean Monnet, Nantes
44035, France.
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10
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Papachristos S, Tavakoli A, Dhanda R, Pararajasingam R, Campbell T, Forgacs B. Comparison of Ipsilateral and Contralateral Simultaneous Pancreas and Kidney Transplantation: A Single-Center Analysis with 5-Year Outcome. Ann Transplant 2019; 24:298-303. [PMID: 31123244 PMCID: PMC6556074 DOI: 10.12659/aot.912633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background It is routine to implant the pancreas on the right and the renal graft on the left iliac fossa during a simultaneous kidney and pancreas transplant (cSPK). Ipsilateral placement of both organs on the same side raises concerns that the pancreas graft might compromise the distally placed kidney. However, ipsilateral SPK (iSPK) can be faster than the conventional contralateral graft placement and allows for preservation of the other side for future transplants. Material/Methods In a single unit, 67 SPK transplantations (cSPK n=49, iSPK n=18) were performed from 2008 to 2011. The decision for graft placement was made during the procedure. Donor and recipient demographics, surgical complications, reoperations, surgical time, and patient and graft survival with 5-year follow-up were compared between the 2 groups. Results Duration of operation was shorter in the iSPK group. Recipient and donor demographics were comparable, apart from more females receiving ipsilateral graft placement. The broader female pelvis was probably the determining factor contributing to this outcome. The iSPK group included marginally younger recipients. The ipsilateral group also demonstrated a trend to improved survival of patient, pancreas, and kidney graft, at 1- and 5-year follow-up. There was no difference in complication rates between the 2 groups. Conclusions There were no significant differences in overall outcomes. iSPK is a safe procedure, which proves similar patient and graft survival as with cSPK. Both procedures have comparable surgical complication rates. iSPK is a safe and quicker procedure that allows for preservation of the contralateral side for potential subsequent transplants.
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Affiliation(s)
- Stavros Papachristos
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Afshin Tavakoli
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Raman Dhanda
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Ravi Pararajasingam
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Tunde Campbell
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Bence Forgacs
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
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11
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Gniewkiewicz MS, Czerwińska M, Gozdowska J, Wyzgał J, Grochowiecki T, Nazarewski S, Kosieradzki M, Durlik M. Long-term Outcomes in Simultaneous Pancreas-Kidney Transplant Recipients: Single-center Experience From Poland. Transplant Proc 2018; 50:2128-2131. [PMID: 30177123 DOI: 10.1016/j.transproceed.2018.02.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Simultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal disease (ESRD) due to type 1 diabetes mellitus (DM1). Since the 1980s, pancreas transplantation has become the most effective strategy to restore normoglycemia in patients with DM1. The aim of this study was to present long-term outcomes data for SPKT. METHODS We performed a retrospective analysis of 73 SPKT recipients followed in our outpatient center who underwent transplantation between 1988 and 2015. RESULTS A total of 50.7% of the patients were male. At the time of surgery, patients' mean age was 37.38 ± 7.44 years. Patients were diagnosed with DM1 at an average of 25 ± 6.08 years before SPKT. For 21.9% of patients, the transplant was done preemptively. Most (91.8%) had enteric drainage. All patients received induction of immunosuppression (either polyclonal immunoglobulins anti-thymocyte globulin or thymoglobulin [64.4%] or monoclonal globulins daclizumab or basiliximab [35.6%]). Patient survival at 1, 5, 10, 15 years was 99%, 97%, 89%, and 75%; kidney survival was 99%, 96%, 84%, and 67%; and pancreas survival was 95%, 92%, 84%, and 64%, respectively. There was a notable tendency toward increased creatinine level (from 1.18 at 1 year to 1.78 at 15 years) and decreased hemoglobin level (from 13.84 at 1 year to 12.65 at 15 years). CONCLUSION Diabetic patients with ESRD have a poor prognosis without transplantation. SPKT provides marked prolongation of the patient's life and freedom from insulin injections. Enteric drainage is currently the surgical technique of choice. SPKT should remain as the treatment of choice in this patient population.
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Affiliation(s)
- M S Gniewkiewicz
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - M Czerwińska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - J Gozdowska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - J Wyzgał
- Department of Nephrology Nursing, Medical University of Warsaw, Warsaw, Poland
| | - T Grochowiecki
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - S Nazarewski
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Kosieradzki
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Durlik
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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12
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Messner F, Bösmüller C, Oberhuber R, Maglione M, Cardini B, Resch T, Scheidl S, Öfner D, Schneeberger S, Margreiter C. Late recurrent bleeding episodes from duodenojejunostomy after pancreas transplantation. Clin Transplant 2018; 32:e13350. [PMID: 30007083 DOI: 10.1111/ctr.13350] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/29/2018] [Accepted: 07/09/2018] [Indexed: 12/19/2022]
Abstract
In response to a number of late, repetitive bleeding episodes from the site of the enteric anastomosis, we herein analyze the clinical courses and etiologies of 379 consecutively performed pancreas transplants between January 2000 and December 2016. Duodenojejunostomies for enteric drainage were performed at the upper jejunum in a side to side, double layer fashion. Five patients (1.3%) developed recurrent late hemorrhagic episodes originating from the graft duodenal anastomosis. Bleeding from the anastomotic site was associated with hematochezia, hemodynamic instability and decrease in serum hemoglobin. Mean onset was 6.4(±2.8) years after transplantation. Bleeding was recurrent (mean 5.2 ± 2.6) and required 9(±2.5) interventions. Hypervascularization, mucosal vulnerability, and bleeding at the site of the enteric anastomosis could be identified in all cases. In four patients, the enteric pancreas anastomosis was resected and a new duodenojejunostomy was performed. No pancreas graft loss occurred due to bleeding. In two patients, hepatic cirrhosis and portal hypertension were identified, one patient had a liver fibrosis as putative cause for the repetitive bleeding episodes. Late anastomotic hemorrhage is a rare but severe complication following pancreas transplantation. The treatment is challenging and includes endoscopy, interventional radiology, and surgery. Hepatic conditions with an increased portal pressure may be the underlying cause.
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Affiliation(s)
- Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Bösmüller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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13
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[Transplantation strategy in type 1 diabetic patients]. Nephrol Ther 2018; 14 Suppl 1:S23-S30. [PMID: 29606260 DOI: 10.1016/j.nephro.2018.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/01/2018] [Indexed: 11/23/2022]
Abstract
Beta cell replacement by pancreas or Langerhans islets transplantation is the only way to restore glucose homeostasis in type 1 diabetic patients. The counterpart is the need for long-term immunosuppression. These transplantations are therefore mainly indicated for patients candidates for kidney transplantation and for patients with poor quality of life due to unstable diabetes with life-threatening hypoglycemic events. Both beta cell replacement techniques have different benefits and risks and should be adapted to each type 1 diabetic patient. The transplant strategy must be personalized according to parameters assessed in the pre-transplant period, validated by a multidisciplinary team and reassessed regularly until transplantation.
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14
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Schachtner T, Zaks M, Otto NM, Kahl A, Reinke P. Factors and outcomes in association with sepsis differ between simultaneous pancreas/kidney and single kidney transplant recipients. Transpl Infect Dis 2018; 20:e12848. [PMID: 29359836 DOI: 10.1111/tid.12848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/29/2017] [Accepted: 09/24/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND As immunosuppressive therapy has improved in simultaneous pancreas/kidney transplant recipients (SPKTRs), infection has become the major limitation of disease-free survival. METHODS We studied all SPKTRs and deceased-donor kidney transplant recipients (KTRs) between 2003 and 2015. Thirty-six of 134 SPKTRs (26.9%) were diagnosed with sepsis among which 13/36 SPKTRs (36.1%) developed severe sepsis/septic shock. A control group of 98 SPKTRs without sepsis and 61/538 KTRs (11.3%) with sepsis were used for comparison. RESULTS Among SPKTRs, female sex, low BMI, CMV seronegativity, CMV disease, and acute cellular rejection increased the risk for sepsis (P < .05). Patient and allograft survival was comparable among SPKTRs with and without sepsis (P > .05), but showed inferior kidney allograft function (P < .05). While urosepsis was less common among SPKTRs (45%), pneumonia (33%) and peritonitis (15%) as site of infections were more frequent (P < .05). Here, gram-positive and fungal sepsis were more common among SPKTRs compared to KTRs (P < .05). SPKTRs showed a higher incidence and an earlier onset of sepsis compared to KTRs (P < .001). SPKTRs with severe sepsis/septic shock were more likely to show pneumonia as site of infection with gram-positive/polymicrobial bacteremia (P < .05). Mortality from severe sepsis was 29% among SPKTRs compared to 58% among KTRs (P < .05). CONCLUSION Differences in incidence, site, causative pathogens, and onset of sepsis between SPKTRs and KTRs may be attributed to more intense immunosuppression, major surgery, and complications of diabetes among SPKTRs. Lower sepsis-related mortality may reflect younger age and more timely diagnosis, but also supports recent findings of less sepsis-related mortality among recipients of solid organ transplantation.
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Affiliation(s)
- Thomas Schachtner
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.,Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany.,Berlin Institute of Health (BIH), Charité und Max-Delbrück Center, Berlin, Germany
| | - Marina Zaks
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Natalie M Otto
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Andreas Kahl
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany
| | - Petra Reinke
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.,Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
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15
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Development and results of a novel pancreas transplant program in Spain: the surgeon's point of view. Cir Esp 2018; 96:205-212. [PMID: 29501238 DOI: 10.1016/j.ciresp.2017.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 10/13/2017] [Accepted: 12/31/2017] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Simultaneous kidney-pancreas transplantation for patients with type 1 diabetes and end-stage chronic renal disease is widely performed. However, the rate of surgical morbidity from pancreatic complications remains high. The aim of this study was to describe the development and results of a new program, from the point of view of the pancreatic surgeon. METHODS We analyzed 53 simultaneous kidney-pancreas transplantations performed over a period of seven years (2009-2016), with a median follow up of 39 months (range: 1-86 months). RESULTS Out of the total of this series, two patients died: one patient because of cardiac arrest immediately after surgery; and another patient due to traffic accident, complicated by pneumonia. Among the 51 living patients, two grafts were lost: one due to chronic rejection four years after transplantation; and the other due to arterial thrombosis 20 days after transplantation (the only case requiring transplantectomy). In ten patients, one or more re-operations were necessary due to the following: graft pancreatitis (n=4), small intestinal obstruction (n=4), arterial thrombosis (n=1), fistula (n=1) and hemoperitoneum (n=1). Overall patient and graft survival rates after 1, 3 and 5 years were 98, 95 and 95% and 96, 93 and 89%, respectively. CONCLUSIONS This study has shown that the results of a new pancreas transplant program, which relies on the previous experience of other groups, do not demonstrate a learning curve. Adequate surgeon education and training, as well as the proper use of standardized techniques, should ensure optimal results.
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16
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Gerber PA, Hochuli M, Benediktsdottir BD, Zuellig RA, Tschopp O, Glenck M, de Rougemont O, Oberkofler C, Spinas GA, Lehmann R. Islet transplantation as safe and efficacious method to restore glycemic control and to avoid severe hypoglycemia after donor organ failure in pancreas transplantation. Clin Transplant 2017; 32. [DOI: 10.1111/ctr.13153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Philipp A. Gerber
- Division of Endocrinology, Diabetes and Clinical Nutrition; University Hospital Zurich; Zurich Switzerland
| | - Michel Hochuli
- Division of Endocrinology, Diabetes and Clinical Nutrition; University Hospital Zurich; Zurich Switzerland
| | - Bara D. Benediktsdottir
- Division of Endocrinology, Diabetes and Clinical Nutrition; University Hospital Zurich; Zurich Switzerland
| | - Richard A. Zuellig
- Division of Endocrinology, Diabetes and Clinical Nutrition; University Hospital Zurich; Zurich Switzerland
| | - Oliver Tschopp
- Division of Endocrinology, Diabetes and Clinical Nutrition; University Hospital Zurich; Zurich Switzerland
| | - Michael Glenck
- Division of Radiology; University Hospital Zurich; Zurich Switzerland
| | | | | | - Giatgen A. Spinas
- Division of Endocrinology, Diabetes and Clinical Nutrition; University Hospital Zurich; Zurich Switzerland
| | - Roger Lehmann
- Division of Endocrinology, Diabetes and Clinical Nutrition; University Hospital Zurich; Zurich Switzerland
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17
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Techniques of pancreas graft salvage/indications for allograft pancreatectomy. Curr Opin Organ Transplant 2017; 21:405-11. [PMID: 27058314 DOI: 10.1097/mot.0000000000000318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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18
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[Simultaneous pancreas and kidney transplantation]. Prog Urol 2016; 26:1053-1065. [PMID: 27720628 DOI: 10.1016/j.purol.2016.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/19/2016] [Accepted: 08/22/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To perform a State of The Art about the different aspects of pancreas transplantation such as indications, technical features, immunosuppressive strategies and outcomes of simultaneous pancreas-kidney transplantation. MATERIAL AND METHODS An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH) : « pancreas transplantation; kidney transplantation; simultaneous pancreas-kidney transplantation; immunosuppression ». Publications obtained were selected based on methodology, language, date of publication (last 20 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 2736 articles. After reading titles and abstracts, 23 were included in the text, based on their relevance. RESULTS These last few years, considerable progresses were done in optimizing indication for pancreas transplantation, as well as surgical improvement and a better used of immunosuppression. In the first part of this article, demographics, indication and pre-transplant evaluation will be described. The different techniques of procurement, preparation and transplantation will then be discussed. Finally, the results and outcomes of pancreas transplantation will be reported. CONCLUSIONS Despite its morbidity, pancreas transplantation is the optimal treatment of end stage renal disease in diabetic patients under 55. Long-term results and quality of life improvement after pancreas transplantation are excellent. LEVEL OF EVIDENCE NA.
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19
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Barlow AD, Hamed MO, Mallon DH, Brais RJ, Gribble FM, Scott MA, Howat WJ, Bradley JA, Bolton EM, Pettigrew GJ, Hosgood SA, Nicholson ML, Saeb-Parsy K. Use of Ex Vivo Normothermic Perfusion for Quality Assessment of Discarded Human Donor Pancreases. Am J Transplant 2015; 15:2475-82. [PMID: 25989187 PMCID: PMC7212093 DOI: 10.1111/ajt.13303] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 02/10/2015] [Accepted: 02/28/2015] [Indexed: 01/25/2023]
Abstract
A significant number of pancreases procured for transplantation are deemed unsuitable due to concerns about graft quality and the associated risk of complications. However, this decision is subjective and some declined grafts may be suitable for transplantation. Ex vivo normothermic perfusion (EVNP) prior to transplantation may allow a more objective assessment of graft quality and reduce discard rates. We report ex vivo normothermic perfusion of human pancreases procured but declined for transplantation, with ABO-compatible warm oxygenated packed red blood cells for 1-2 h. Five declined human pancreases were assessed using this technique after a median cold ischemia time of 13 h 19 min. One pancreas, with cold ischemia over 30 h, did not appear viable and was excluded. In the remaining pancreases, blood flow and pH were maintained throughout perfusion. Insulin secretion was observed in all four pancreases, but was lowest in an older donation after cardiac death pancreas. Amylase levels were highest in a gland with significant fat infiltration. This is the first study to assess the perfusion, injury, as measured by amylase, and exocrine function of human pancreases using EVNP and demonstrates the feasibility of the approach, although further refinements are required.
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Affiliation(s)
- AD Barlow
- Dept of Surgery, University of Cambridge, Cambridge, UK,NIHR Biomedical Research Campus, Cambridge, UK
| | - MO Hamed
- Dept of Surgery, University of Cambridge, Cambridge, UK,NIHR Biomedical Research Campus, Cambridge, UK
| | - DH Mallon
- Dept of Surgery, University of Cambridge, Cambridge, UK,NIHR Biomedical Research Campus, Cambridge, UK
| | - RJ Brais
- NIHR Biomedical Research Campus, Cambridge, UK,Dept of Histopathology, Addenbrooke’s Hospital, Cambridge, UK
| | - FM Gribble
- NIHR Biomedical Research Campus, Cambridge, UK,Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - MA Scott
- NIHR Biomedical Research Campus, Cambridge, UK,Dept of Haematology, Addenbrooke’s Hospital, Cambridge, UK
| | - WJ Howat
- NIHR Biomedical Research Campus, Cambridge, UK,Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - JA Bradley
- Dept of Surgery, University of Cambridge, Cambridge, UK,NIHR Biomedical Research Campus, Cambridge, UK
| | - EM Bolton
- Dept of Surgery, University of Cambridge, Cambridge, UK,NIHR Biomedical Research Campus, Cambridge, UK
| | - GJ Pettigrew
- Dept of Surgery, University of Cambridge, Cambridge, UK,NIHR Biomedical Research Campus, Cambridge, UK
| | - SA Hosgood
- Division of Transplant Surgery, University of Leicester, Leicester, UK
| | - ML Nicholson
- Division of Transplant Surgery, University of Leicester, Leicester, UK
| | - K Saeb-Parsy
- Dept of Surgery, University of Cambridge, Cambridge, UK,NIHR Biomedical Research Campus, Cambridge, UK
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20
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Lehmann R, Graziano J, Brockmann J, Pfammatter T, Kron P, de Rougemont O, Mueller T, Zuellig RA, Spinas GA, Gerber PA. Glycemic Control in Simultaneous Islet-Kidney Versus Pancreas-Kidney Transplantation in Type 1 Diabetes: A Prospective 13-Year Follow-up. Diabetes Care 2015; 38:752-9. [PMID: 25665814 DOI: 10.2337/dc14-1686] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 01/06/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In patients with type 1 diabetes and end-stage renal disease, combined transplantation of a kidney together with a pancreas or isolated pancreatic islets are options to improve glycemic control. The aim of this study was to compare their long-term outcome with regard to metabolic control and surgical complication rate, as well as function of the transplanted kidney. RESEARCH DESIGN AND METHODS We conducted a prospective cohort study in consecutive patients receiving either a pancreas or islet transplant simultaneously with or after kidney transplantation (simultaneous pancreas-kidney [SPK]/pancreas-after-kidney [PAK] or simultaneous islet-kidney [SIK]/islet-after-kidney [IAK] transplantation). RESULTS Ninety-four patients who had undergone SPK/PAK transplantation were compared with 38 patients who had undergone SIK/IAK transplantation over a period of up to 13 years. HbA1c levels declined from 7.8 ± 1.3% (62 ± 14 mmol/mol) to 5.9 ± 1.1% (41 ± 12 mmol/mol), and from 8.0 ± 1.3% (64 ± 14 mmol/mol) to 6.5 ± 1.1% (48 ± 12 mmol/mol), respectively, in the SPK/PAK and SIK/IAK groups (P < 0.001 for both) and remained stable during follow-up, despite a reduction in the rate of severe hypoglycemia by >90%. The 5-year insulin independence rate was higher in the SPK/PAK group (73.6 vs. 9.3% in the SIK/IAK group), as was the rate of relaparotomy after transplantation (41.5 vs. 10.5% in the SIK/IAK group). There was no difference in the rate of kidney function decline. CONCLUSIONS During a long-term follow-up, SPK/PAK transplantation as well as SIK/IAK transplantation resulted in a sustained improvement of glycemic control with a slightly higher glycated hemoglobin level in the SIK/IAK group. While insulin independence is more common in whole-organ pancreas recipients, islet transplantation can be conducted with a much lower surgical complication rate and no difference in kidney function decline.
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Affiliation(s)
- Roger Lehmann
- Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Jessica Graziano
- Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Jens Brockmann
- Division of Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Pfammatter
- Division of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Kron
- Division of Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olivier de Rougemont
- Division of Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Mueller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Richard A Zuellig
- Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Giatgen A Spinas
- Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Philipp A Gerber
- Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
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21
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Abstract
Both pancreas and islet transplantations are therapeutic options for complicated type 1 diabetes. Until recent years, outcomes of islet transplantation have been significantly inferior to those of whole pancreas. Islet transplantation is primarily performed alone in patients with severe hypoglycemia, and recent registry reports have suggested that results of islet transplantation alone in this indication may be about to match those of pancreas transplant alone in insulin independence. Figures of 50% insulin independence at 5 years for either procedure have been cited. In this article, we address the question whether islet transplantation has indeed bridged the gap with whole pancreas. Looking at the evidence to answer this question, we propose that although pancreas may still be more efficient in taking recipients off insulin than islets, there are in fact numerous "gaps" separating both procedures that must be taken into the equation. These "gaps" relate to organ utilization, organ allocation, indication for transplantation, and morbidity. In-depth analysis reveals that islet transplantation, in fact, has an edge on whole pancreas in some of these aspects. Accordingly, attempts should be made to bridge these gaps from both sides to achieve the same level of success with either procedure. More realistically, it is likely that some of these gaps will remain and that both procedures will coexist and complement each other, to ensure that β cell replacement can be successfully implemented in the greatest possible number of patients with type 1 diabetes.
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22
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Kim SM, Youn WY, Kim DJ, Kim JS, Lee S. Simultaneous pancreas-kidney transplantation: lessons learned from the initial experience of a single center in Korea. Ann Surg Treat Res 2015; 88:41-7. [PMID: 25553324 PMCID: PMC4279990 DOI: 10.4174/astr.2015.88.1.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/04/2014] [Accepted: 08/07/2014] [Indexed: 01/26/2023] Open
Abstract
Purpose The purpose of this study is to report the results of simultaneous pancreas-kidney (SPK) transplantations and describe the lessons learned from the early experiences of a single center. Methods Between January 2002 and June 2013, a total of 8 patients underwent SPK transplantation. Clinical and radiologic data were reviewed retrospectively. Results Seven patients were diagnosed with type I diabetes mellitus and one patient became insulin-dependent after undergoing a total pancreatectomy because of trauma. Pancreas exocrine drainage was performed by enteric drainage in 4 patients and bladder drainage in 4 patients. Three patients required conversion from initial bladder drainage to enteric drainage due to urinary symptoms and duodenal leakage. Four patients required a relaparotomy due to hemorrhage, ureteral stricture, duodenal leakage, and venous thrombosis. There was no kidney graft loss, and 2 patients had pancreas graft loss because of venous thrombosis and new onset of type II diabetes mellitus. With a median follow-up of 76 months (range, 2-147 months), the death-censored graft survival rates for the pancreas were 85.7% at 1, 3, and 5 years and 42.9% at 10 years. The patient survival rate was 87.5% at 1, 3, 5, and 10 years. Conclusion The long-term grafts and patient survival in the current series are comparable to previous studies. A successful pancreas transplant program can be established in a single small-volume institute. A meticulous surgical technique and early anticoagulation therapy are required for further improvement in the outcomes.
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Affiliation(s)
- Suh Min Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Woo Young Youn
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Doo Jin Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joo Seop Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Samuel Lee
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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23
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Influence of Surgical Complications on Kidney Graft Survival in Recipients of Simultaneous Pancreas Kidney Transplantation. Transplant Proc 2015; 47:112-6. [DOI: 10.1016/j.transproceed.2014.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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24
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Donor risk factors, retrieval technique, preservation and ischemia/reperfusion injury in pancreas transplantation. Curr Opin Organ Transplant 2013; 18:83-8. [PMID: 23254698 DOI: 10.1097/mot.0b013e32835c29ef] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Pancreas transplantation is still hampered by a high incidence of early graft loss, and organ quality concerns result in high nonrecovery/discard rates. Demographic donor characteristics, surgical retrieval strategy, preservation fluid and ischemia time are crucial factors in the process of organ selection and are discussed in this review. RECENT FINDINGS The donor shortage is driving an increasing utilization of nonideal organs which would previously have been identified as unsuitable. Recent literature suggests that organs from extended criteria donors - older (>45 years), BMI >30 kg/m(2), and donation after cardiac death (DCD) - can achieve the same graft and patient survival as those from standard criteria donors, with the proviso that the accumulation of risk factors and long ischemic times should be avoided. Visual assessment of the pancreas is advisable before declining/accepting a pancreas. University of Wisconsin represents the gold standard solution; however, histidine-tryptophan-ketoglutarate and Celsior result in equal outcomes if cold ischemia time (CIT) is less than 12 h. Currently in pancreas transplantation, there is no proven effective ischemia/reperfusion injury prophylaxis than trying to keep CIT as short as possible. SUMMARY Demographic risk factors, inspection of the pancreas by an experienced surgeon and predicted CIT are crucial factors in deciding whether to accept a pancreas for transplantation. However, there is a need for an improved evidence base to determine where to set the 'cut-off' for unsuitable pancreatic grafts.
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