Excellent outcomes of simultaneous pancreas kidney transplantation in patients from rural and urban Australia: a national service experience

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.

Successful Islet Outcomes Using Australia-Wide Donors: A National Centre Experience

Cold ischemia and hence travel time can adversely affect outcomes of islet isolation. The aim of this study was to compare the isolation and transplant outcomes of donor pancreata according to the distance from islet isolation facility. Principally, those within a 50 km radius of the centre were compared with those from regional areas within the state and those from interstate donors within Australia. Organ donors were categorised according to distance from National Pancreas Transplant Unit Westmead (NPTU). Donor characteristics were analysed statistically against islet isolation outcomes. These were age, BMI, cause and mechanism of death, days in ICU, gender, inotrope and steroid use, cold ischemia time (CIT) and retrieval surgical team. Between March 2007 and December 2020, 297 islet isolations were performed at our centre. A total of 149 donor pancreata were local area, and 148 non-local regions. Mean distance from the isolation facility was 780.05 km. Mean pancreas CIT was 401.07 ± 137.71 min and was significantly different between local and non-local groups (297.2 vs. 487.5 min, p < 0.01). Mean age of donors was 45.22 years, mean BMI was 28.82, sex ratio was 48:52 F:M and mean time in ICU was 3.07 days. There was no significant difference between local and non-local for these characteristics. The mean CIT resulting in islet transplantation was 297.1 ± 91.5 min and longest CIT resulting in transplantation was 676 min. There was no significant difference in islet isolation outcomes between local and non-local donors for characteristics other than CIT. There was also no significant effect of distance from the isolation facility on positive islet transplant outcomes (C-peptide > 0.2 at 1 month post-transplant). Conclusions: Distance from the isolation centre did not impact on isolation or transplant outcomes supporting the ongoing nationwide use of shipping pancreata for islet isolation and transplantation.

The psychosocial experiences and supportive care preferences of organ transplant recipients and their carers who live in regional Australia

BACKGROUND

There is no evidence that being a rural or regional organ transplant recipient has adverse physical health outcomes post-surgery compared with those experienced by people living in cities, but the impact of living remotely from transplant centres on psychosocial outcomes has not been explored.

OBJECTIVE

To identify the social, emotional, psychological, spiritual, informational and practical issues associated with being a regionally based organ transplant recipient or carer and determine how support services could be improved for this group.

DESIGN/ SETTING/ PARTICIPANTS

Twenty-two purposively sampled adult Australians who lived outside metropolitan centres and had received an organ transplant (n = 15) or were the primary carer of someone who had received one (n = 7), participated in semi-structured, telephone interviews. Qualitative data were collected until data saturation was reached and were analysed using thematic analysis.

RESULTS

Five key themes (plus subthemes) were identified: (a) travelling for specialist transplant care takes a toll, (b) unique transplant-related psychological and emotional issues experienced before and after transplants, (c) caring for transplant recipients is a demanding role, (d) lay, peer and professional support, including rural general practitioners and accommodation facilities, help ease the burden, but (e) significant barriers to accessing transplant-focused psychosocial support exist.

CONCLUSION

Novel methods of delivering targeted, transplant-specific information and psychosocial care to rural transplant recipients and their carers, employers and rural health professionals require development and evaluation. Strategies might be delivered by peers or professionals via telehealth, telephone, social media or websites for example, depending on preferences and level of need.

Endovascular Management of Mycotic Pseudoaneurysm After Pancreas Transplantation: Case Report and Literature Review

INTRODUCTION

Mycotic pseudoaneurysm is a rare complication of pancreas transplantation. Successful management relies on early diagnosis and expedient treatment comprising surgery and antibiotics. While the standard of care in recipients of pancreatic transplants is open repair of pseudoaneurysm with or without excision of the allograft, endovascular management has been reported. Endovascular repair is a less invasive treatment option with advantages of expedient control of hemorrhage, avoidance of adhesions with an open repair, and greater suitability for elderly and frail patients.

MATERIAL AND METHODS

We report a case of a 40-year-old recipient of a pancreas transplant who had a mycotic pseudoaneurysm managed with endovascular repair. A systematic search of PubMed-MEDLINE, Embase, and Cochrane Library was performed of all cases of mycotic aneurysms following pancreas or kidney transplantation managed with endovascular repair.

RESULTS

There were 14 cases of mycotic aneurysms in transplant recipients managed with endovascular repair in the literature. Of those who received an endovascular stent as the only initial management strategy, 6 (54.5%) required a subsequent graft excision. Four (28.6%) patients required excision of their stent due to continued sepsis. There was 1 death from unrelated causes.

CONCLUSIONS

Endovascular repair was a reasonable bridging technique to further definitive surgical treatment in our case. Endovascular management may be used with caution in high-risk patients. We advocate for prolonged antibiotic therapy combined with vigilant surveillance of the clinical response, and a low threshold for allograft excision in the event of clinical deterioration.

The impact of distance from transplant unit on outcomes following kidney transplantation

BACKGROUND

Following transplantation, many patients travel long distances for follow-up care. Many studies have examined the influence of distance from transplant centre on access to transplantation, but few have examined post-transplant outcomes.

MATERIALS AND METHODS

Distance from transplant centre was calculated for all kidney transplant recipients transplanted over a 5-year period. Outcomes measured were rates of acute rejection, graft and patient survival.

RESULTS

Complete follow up data was available for 571 of the 585 kidney transplants performed over the study period. Distance from home to transplant centre ranged from 1.3 to 257.4 km (median 33.7 km). Patients were divided into quartiles according to their distance from the transplant centre. Distance from the transplant centre did not influence rates of acute rejection (p = 0.102). One-year graft survival for 'nearest' and 'farthest' quartiles was 99% and 97% respectively and five-year graft survival was 78% and 89% respectively (log rank p-value of 0.212). There were no differences in patient survival at 1 and 5 years between the 'nearest' and 'farthest' groups.

CONCLUSION

Distance from transplant centre does not affect early outcomes following kidney transplantation. The centralized practice which involves a low threshold for rapid assessment and readmission of patients post-transplantation appears to provide good outcomes for kidney transplant recipients.

Necessities for a Clinical Islet Program

For more than two decades we have been refining advances in islet cell transplantation as a clinical therapy for patients suffering from type 1 diabetes. A great deal of effort has gone to making this a viable therapy for a broader range of patients with type 1 diabetes. Clinical results have progressively improved, demonstrating clinical outcomes on par with other organ transplants, specifically in terms of insulin independence, graft and patient survival. We are now at the point where islet cell transplantation, in the form of allotransplantation, has become accepted as a clinical therapy in adult patients affected by type 1 diabetes, in particular those suffering from severe hypoglycaemic unawareness. This chapter provides an overview on how this has been undertaken over the years to provide outcomes on par with other organ transplantation results. In particular this chapter focuses on the processes and facilities that are required to establish a clinical islet isolation and transplantation program. It also outlines the very important underpinning processes of selection of the organ donor for islet isolation, the processes of organ donor operation and preservation of the pancreas by various means and the ideal ways to best improve outcomes for human islet cell isolation. Providing these more optimal conditions we can underpin the isolation processes to provide islets for transplantation and as such a safe, effective and feasible therapeutic option for an increasing number of patients suffering from type 1 diabetes with severe hypoglycaemic unawareness.

A let-7 microRNA-binding site polymorphism in KRAS predicts improved outcome in patients with metastatic colorectal cancer treated with salvage cetuximab/panitumumab monotherapy

PURPOSE

An inherited mutation in KRAS (LCS6-variant or rs61764370) results in altered control of the KRAS oncogene. We studied this biomarker's correlation to anti-EGFR monoclonal antibody (mAb) therapy response in patients with metastatic colorectal cancer.

EXPERIMENTAL DESIGN

LCS6-variant and KRAS/BRAF mutational status was determined in 512 patients with metastatic colorectal cancer treated with salvage anti-EGFR mAb therapy, and findings correlated with outcome. Reporters were tested in colon cancer cell lines to evaluate the differential response of the LCS6-variant allele to therapy exposure.

RESULTS

In this study, 21.2% (109 of 512) of patients with metastatic colorectal cancer had the LCS6-variant (TG/GG), which was found twice as frequently in the BRAF-mutated versus the wild-type (WT) group (P=0.03). LCS6-variant patients had significantly longer progression-free survival (PFS) with anti-EGFR mAb monotherapy treatment in the whole cohort (16.85 vs. 7.85 weeks; P=0.019) and in the double WT (KRAS and BRAF) patient population (18 vs. 10.4 weeks; P=0.039). Combination therapy (mAbs plus chemotherapy) led to improved PFS and overall survival (OS) for nonvariant patients, and brought their outcome to levels comparable with LCS6-variant patients receiving anti-EGFR mAb monotherapy. Combination therapy did not lead to improved PFS or OS for LCS6-variant patients. Cell line studies confirmed a unique response of the LCS6-variant allele to both anti-EGFR mAb monotherapy and chemotherapy.

CONCLUSIONS

LCS6-variant patients with metastatic colorectal cancer have an excellent response to anti-EGFR mAb monotherapy, without any benefit from the addition of chemotherapy. These findings further confirm the importance of this mutation as a biomarker of anti-EGFR mAb response in patients with metastatic colorectal cancer, and warrant further prospective confirmation.

Simultaneous pancreas and kidney transplantation for liver transplant recipients with diabetes and uremia

BACKGROUND AND OBJECTIVES

Chronic kidney disease (CKD) has become a critical problem due to immunosuppressant related nephrotoxicity in liver transplant (LTx) recipients, especially in patients with pre-transplant risk factors. LTx recipients with uraemia and diabetes have poor prognosis even when treated with dialysis and insulin. Simultaneous pancreas and kidney transplantation (SPK) has been proven to be an effective treatment for patients with diabetic uraemia, but rarely performed in patients after LTx. Two cases of SPK after LTx were performed in our centre and we present our experience here.

PATIENTS AND METHODS

Two patients received LTx because of HBV related liver cirrhosis; both of them had pre-transplant diabetes mellitus (DM), which worsened after the administration of immunosuppressive drugs. These two patients suffered from CKD and developed uraemia due to diabetic nephropathy and immunosuppressive drugs induced renal toxicity years after LTx. They relied on dialysis and insulin injection. SPK were performed years after LTx and the clinical data was retrospectively analyzed.

RESULTS

SPK was successfully performed in these two patients. Pancreatic fluid drainage was achieved via a side-to-side duodenojejunostomy into the proximal jejunum. No serious surgical complications, including pancreatitis or pancreatic fistula were observed postoperatively. In both cases, kidney and pancreatic grafts were functioning well as evidenced by euglycemia without the need for insulin injections and normal serum-creatinine level 7days after the operation. One of the patients presented with renal graft impairment 1week after the operation. FK506 was tapered and rapamycin was used when the renal graft biopsy indicated drug toxicity. The patient's kidney graft function recovered gradually after the adjustment. Both patients have good function of liver, kidney and pancreas grafts during a 60-month and 30-month period of follow up.

CONCLUSIONS

SPK could serve as an effective option for patients with diabetes and uremia after LTx. Perioperative management, especially the immunosuppressive strategy is crucial to improve the outcome of this procedure.