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Rössler F, Kalliola F, de Rougemont O, Hübel K, Hügli S, Viggiani d’Avalos L, Schachtner T, Oberholzer J. Simultaneous Pancreas and Kidney Transplantation from Donors after Circulatory Death in Switzerland. J Clin Med 2024; 13:3525. [PMID: 38930054 PMCID: PMC11204996 DOI: 10.3390/jcm13123525] [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: 05/20/2024] [Revised: 06/08/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Simultaneous pancreas and kidney transplantation (SPK) remains the only curative treatment for type I diabetics with end-stage kidney disease. SPK using donors after circulatory death (DCD) is one important measure to expand the organ pool for pancreas transplantation (PT). After initial doubts due to higher complications, DCD SPK is now considered safe and equivalent to donation after brain death in terms of survival and graft function. Materials and Methods: We assessed pancreas and kidney graft function, as well as complications of the first three patients who underwent a DCD SPK in Switzerland. Two transplantations were after rapid procurement, one following normothermic regional perfusion (NRP). Results: Intra- and postoperative courses were uneventful and without major complications in all patients. In the two SPK after rapid procurement, pancreas graft function was excellent, with 100% insulin-free survival, and hemoglobin A1C dropped from 7.9 and 7.5 before SPK and to 5.1 and 4.3 after three years, respectively. Kidney graft function was excellent in the first year, followed by a gradual decline due to recurrent infections. The patient, after NRP SPK, experienced short-term delayed pancreatic graft function requiring low-dose insulin treatment for 5 days post-transplant, most likely due to increased peripheral insulin resistance in obesity. During follow-up, there was persistent euglycemia and excellent kidney function. Conclusions: We report on the first series of DCD SPK ever performed in Switzerland. Results were promising, with low complication rates and sustained graft survival. With almost half of all donors in Switzerland currently being DCD, we see great potential for the expansion of DCD PT.
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Affiliation(s)
- Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Fiona Kalliola
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Kerstin Hübel
- Department of Nephrology, University Hospital Zurich, 8091 Zurich, Switzerland; (K.H.); (T.S.)
| | - Sandro Hügli
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Lorenzo Viggiani d’Avalos
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Thomas Schachtner
- Department of Nephrology, University Hospital Zurich, 8091 Zurich, Switzerland; (K.H.); (T.S.)
| | - Jose Oberholzer
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
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Moein M, Papa S, Bahreini A, Saidi R. Pancreas Transplant Alone in the USA, Where Do We Stand? World J Surg 2023; 47:2250-2258. [PMID: 37258778 DOI: 10.1007/s00268-023-07062-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Currently, over 63,000 pancreas transplant procedures have been performed worldwide, with only approximately 8% of all pancreas transplants having been a pancreas transplant alone. Our study aimed to quantify outcomes following pancreas transplant alone in the United States from 2001 to 2020, with an emphasis on graft and patient survival. METHODS AND MATERIALS We performed a retrospective registry analysis utilizing the OPTN/UNOS database for pancreas transplants alone performed in the United States from January 2001 to May 2020 to assess transplant outcomes. The study population was divided into two subgroups: patients receiving a pancreas transplant between 2000 and 2009 and those receiving a pancreas transplant between 2010 and 2020. RESULTS 3008 allograft recipients were included in the study. 1679 (54.87%) transplants were done from January 2000 to the end of 2009. 1381 (45.13%) transplants were done from 2010 to May 2020. Although the BMI and recipient sex comparison indicate a statistically significant difference, the differences are not clinically significant. The overall 5-year allograft survival rate was 52.17% in the 2000-2009 group, which increased to 58.82% in pancreas transplants alone from 2010 to 2020 (P = 0.02). The overall 5-year patient survival rate was 74.52% in the 2000-2009 group, which increased to 74.92% in pancreas transplants alone from 2010 to 2020 (P = 0.81). CONCLUSION With all the progress in terms of surgical techniques, organ allocation and preservation, and immunosuppressive regimens, the pancreas transplant alone allograft survival has been improving over the years, although it has been still being underutilized around the US.
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Affiliation(s)
- Mahmoudreza Moein
- Division of Transplant Services, Department of Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA
| | - Sarah Papa
- Division of Transplant Services, Department of Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA
| | - Amin Bahreini
- Division of Transplant Services, Department of Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA
| | - Reza Saidi
- Division of Transplant Services, Department of Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA.
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Pancreas Transplantation in Minorities including Patients with a Type 2 Diabetes Phenotype. URO 2022. [DOI: 10.3390/uro2040026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: Prior to year 2000, the majority of pancreas transplants (PTx) were performed as simultaneous pancreas-kidney transplants (SPKTs) in Caucasian adults with end stage renal failure secondary to type 1 diabetes mellitus (T1DM) who were middle-aged. In the new millennium, improving outcomes have led to expanded recipient selection that includes patients with a type 2 diabetes mellitus (T2DM) phenotype, which excessively affects minority populations. Methods: Using PubMed® to identify appropriate citations, we performed a literature review of PTx in minorities and in patients with a T2DM phenotype. Results: Mid-term outcomes with SPKT in patients with uremia and circulating C-peptide levels (T2DMphenotype) are comparable to those patients with T1DM although there may exist a selection bias in the former group. Excellent outcomes with SPKT suggests that the pathophysiology of T2DM is heterogeneous with elements consisting of both insulin deficiency and resistance related to beta-cell failure. As a result, increasing endogenous insulin (Cp) production following PTx may lead to freedom checking blood sugars or taking insulin, better metabolic counter-regulation, and improvements in quality of life and life expectancy compared to other available treatment options. Experience with solitary PTx for T2DM or in minorities is limited but largely mirrors the trends reported in SPKT. Conclusions: PTx is a viable treatment option in patients with pancreas endocrine failure who are selected appropriately regardless of diabetes type or recipient race. This review will summarize data that unconventional patient populations with insulin-requiring diabetes may gain value from PTx with an emphasis on contemporary experiences and appropriate selection in minorities in the new millennium.
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Anti-Oxidative Therapy in Islet Cell Transplantation. Antioxidants (Basel) 2022; 11:antiox11061038. [PMID: 35739935 PMCID: PMC9219662 DOI: 10.3390/antiox11061038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 01/27/2023] Open
Abstract
Islet cell transplantation has become a favorable therapeutic approach in the treatment of Type 1 Diabetes due to the lower surgical risks and potential complications compared to conventional pancreas transplantation. Despite significant improvements in islet cell transplantation outcomes, several limitations hamper long-term graft survival due to tremendous damage and loss of islet cells during the islet cell transplantation process. Oxidative stress has been identified as an omnipresent stressor that negatively affects both the viability and function of isolated islets. Furthermore, it has been established that at baseline, pancreatic β cells exhibit reduced antioxidative capacity, rendering them even more susceptible to oxidative stress during metabolic stress. Thus, identifying antioxidants capable of conferring protection against oxidative stressors present throughout the islet transplantation process is a valuable approach to improving the overall outcomes of islet cell transplantation. In this review we discuss the potential application of antioxidative therapy during each step of islet cell transplantation.
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Pham PH, Stalter LN, Martinez EJ, Wang JF, Welch BM, Leverson G, Marka N, Al-Qaoud T, Mandelbrot D, Parajuli S, Sollinger HW, Kaufman D, Redfield RR, Odorico JS. Single center results of simultaneous pancreas-kidney transplantation in patients with type 2 diabetes. Am J Transplant 2021; 21:2810-2823. [PMID: 33350048 PMCID: PMC8217396 DOI: 10.1111/ajt.16462] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/25/2020] [Accepted: 12/15/2020] [Indexed: 01/25/2023]
Abstract
Studies have found similar outcomes of Simultaneous Pancreas-Kidney transplantation (SPKT) in patients with Type 2 (T2D) and Type 1 diabetes (T1D). However, there are scarce data evaluating the association of recipient factors such as age, BMI, or pretransplant insulin requirements with outcomes, thus the criteria for the optimal recipient selection remains unclear. In this study, 284 T1D and 39 T2D patients, who underwent SPKT between 2006 and 2017 with 1 year of follow-up at minimum, were assessed for potential relationship of pretransplant BMI and insulin requirements with posttransplant diabetes and pancreatic graft failure. Kaplan-Meier analysis showed similar rates of freedom from posttransplant diabetes (94.7% T2D vs. 92.3% T1D at 1 yr, and 88.1% T2D vs. 81.1% T1D at 5 yrs) and graft survival (89.7% T2D vs. 90.4% T1D at 1 yr, and 89.7% T2D vs. 81.2% T1D at 5 yrs). There was no significant association between BMI or pretransplant insulin requirements with posttransplant diabetes occurrence in either T1D (p = .10, .43, respectively) or T2D (p = .12, .63) patients in the cohort; or with graft failure (T1D: p = .40, .09; T2D: p = .71, .28). These observations suggest a less restricted approach to selective use of SPKT in patients with T2D.
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Affiliation(s)
- Phuoc H. Pham
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Lily N. Stalter
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Eric J. Martinez
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,Anette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Jesse F. Wang
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bridget M. Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Glen Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nicholas Marka
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Talal Al-Qaoud
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Hans W. Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dixon Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert R. Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jon S. Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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6
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Matsushima H, Ito T, Aida N, Kurihara K, Tomimaru Y, Ito T, Kenmochi T. Outcomes of pancreas transplantation in older versus younger recipients: a comparative analysis. Surg Today 2021; 51:1655-1664. [PMID: 33844061 DOI: 10.1007/s00595-021-02284-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/31/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The feasibility of pancreas transplantation (PT) in older recipients remains a matter of debate. We examined the influence of recipient age on PT outcomes and identified the prognostic factors for older recipients. METHODS We compared the outcomes of PT in recipients aged < 50 years (younger group; n = 285) with those in recipients aged ≥ 50 years (older group; n = 94). Prognostic factors in the older group were analyzed by a logistic regression model and the influence of recipient age on survival outcomes were analyzed using propensity score matching. RESULTS The patient survival rate was significantly worse in the older group (P < 0.001). Patient death from infection or/and multiple organ failure or cardiac/cerebrovascular events was also more frequent in the older group than in the younger group (P = 0.012 and P = 0.045, respectively). A longer duration of diabetes was an independent risk factor of 1-year mortality in the older group. In a propensity score-matched comparison, the older recipients (n = 77) had significantly poorer survival than the younger recipients (n = 77) (P = 0.026). CONCLUSIONS PT should be considered with appropriate caution, especially for older recipients with a long duration of diabetes.
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Affiliation(s)
- Hajime Matsushima
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukakecho, Toyoake-shi, Aichi, 470-1192, Japan.
| | - Taihei Ito
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukakecho, Toyoake-shi, Aichi, 470-1192, Japan
| | - Naohiro Aida
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukakecho, Toyoake-shi, Aichi, 470-1192, Japan
| | - Kei Kurihara
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukakecho, Toyoake-shi, Aichi, 470-1192, Japan
| | - Yoshito Tomimaru
- Japan Society for Pancreas and Islet Transplantation, The Japan Pancreas Transplant Registry, Osaka, Japan
| | - Toshinori Ito
- Japan Society for Pancreas and Islet Transplantation, The Japan Pancreas Transplant Registry, Osaka, Japan
| | - Takashi Kenmochi
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukakecho, Toyoake-shi, Aichi, 470-1192, Japan
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7
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Pham PH, Stalter LN, Martinez EJ, Wang JF, Welch BM, Leverson G, Marka N, Al-Qaoud T, Mandelbrot D, Parajuli S, Sollinger HW, Kaufman D, Redfield RR, Odorico JS. Single center results of simultaneous pancreas-kidney transplantation in patients with type 2 diabetes. Am J Transplant 2020. [PMID: 33350048 DOI: 10.1111/ajt.16462.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Studies have found similar outcomes of Simultaneous Pancreas-Kidney transplantation (SPKT) in patients with Type 2 (T2D) and Type 1 diabetes (T1D). However, there are scarce data evaluating the association of recipient factors such as age, BMI, or pretransplant insulin requirements with outcomes, thus the criteria for the optimal recipient selection remains unclear. In this study, 284 T1D and 39 T2D patients, who underwent SPKT between 2006 and 2017 with 1 year of follow-up at minimum, were assessed for potential relationship of pretransplant BMI and insulin requirements with posttransplant diabetes and pancreatic graft failure. Kaplan-Meier analysis showed similar rates of freedom from posttransplant diabetes (94.7% T2D vs. 92.3% T1D at 1 yr, and 88.1% T2D vs. 81.1% T1D at 5 yrs) and graft survival (89.7% T2D vs. 90.4% T1D at 1 yr, and 89.7% T2D vs. 81.2% T1D at 5 yrs). There was no significant association between BMI or pretransplant insulin requirements with posttransplant diabetes occurrence in either T1D (p = .10, .43, respectively) or T2D (p = .12, .63) patients in the cohort; or with graft failure (T1D: p = .40, .09; T2D: p = .71, .28). These observations suggest a less restricted approach to selective use of SPKT in patients with T2D.
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Affiliation(s)
- Phuoc H Pham
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Lily N Stalter
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Eric J Martinez
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Anette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Jesse F Wang
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bridget M Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Glen Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nicholas Marka
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Talal Al-Qaoud
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Hans W Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dixon Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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8
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Goussous N, St Michel DP, Mcdade H, Gaines S, Borth A, Dawany N, Al-Qaoud T, Bromberg JS, Barth RN, Scalea JR. Is Prophylactic Drainage After Pancreas Transplant Associated With Reduced Reoperation Rate? EXP CLIN TRANSPLANT 2020; 19:64-71. [PMID: 33272163 DOI: 10.6002/ect.2020.0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Advances in surgery and perioperative care have contributed to improved outcomes after pancreas transplant. However, the development of peripancreatic infections carries a poor prognosis. It is not clear whether abdominal drainage is helpful in collection prevention. MATERIALS AND METHODS A retrospective review of adult consecutive pancreas transplants at a single institution between January 2017 and December 2018 was undertaken. Postoperative outcomes were compared between patients in whom prophylactic intraoperative drains were placed and patients with no drains. RESULTS We identified 83 patients who underwent pancreas transplant with a median age of 45 years; 54.2% were males, and median body mass index was 25.8. Thirty patients had 1 or 2 drains placed (36.1%). There was no difference in the readmission rate (70.0% vs 60.4%; P = .48), reoperation (20.0% vs 30.2%; P = .44), or percutaneous drainage of peripancreatic infections (20.0% vs 15.1%; P = .56) between patients with drains and no drains, respectively. However, prophylactic drainage was associated with a lower rate of reoperation for peripancreatic infections compared with those who were not drained (0.0% vs 13.2%; P < .05). No graft loss occurred in the drain group. CONCLUSIONS Prophylactic drainage after pancreas transplant may be helpful for reduction in the infection rate after reoperation. The risks of drain placement should be weighed against those of drain avoidance.
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Affiliation(s)
- Naeem Goussous
- From the Division of Transplantation, Department of Surgery, University of Maryland School of Medicine Baltimore, Maryland, USA
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9
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Abstract
PURPOSE OF REVIEW Despite significant improvement in pancreas allograft survival, rejection continues to be a major clinical problem. This review will focus on emerging literature related to the impact of pretransplant and de-novo DSA (dnDSA) in pancreas transplant recipients, and the diagnosis and treatment of T-cell-medicated rejection (TCMR) and antibody-mediated rejection (ABMR) in this complex group of patients. RECENT FINDINGS Recent data suggest that pretransplant DSA and the emergence of dnDSA in pancreas transplant recipients are both associated with increased risk of ABMR. The pancreas allograft biopsy is essential for the specific diagnosis of TCMR and/or ABMR, distinguish rejection from other causes of graft dysfunction, and to guide-targeted therapy. This distinction is important especially in the setting of solitary pancreas transplants but also in simultaneous pancreas-kidney transplants where solid evidence has now emerged demonstrating discordant biopsy findings. Treatment of rejection in a functioning pancreas can prolong allograft survival. SUMMARY The accurate and timely diagnosis of active alloimmune destruction in pancreas transplant recipients is paramount to preserving graft function in the long term. This review will discuss new, rapidly evolving information that is valuable for the physician caring for these patients to achieve optimal immunological outcomes.
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Shingde R, Calisa V, Craig JC, Chapman JR, Webster AC, Pleass H, O’Connell PJ, Allen R, Robertson P, Yuen L, Kable K, Nankivell B, Rogers NM, Wong G. Relative survival and quality of life benefits of pancreas–kidney transplantation, deceased kidney transplantation and dialysis in type 1 diabetes mellitus—a probabilistic simulation model. Transpl Int 2020; 33:1393-1404. [DOI: 10.1111/tri.13679] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/27/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Rashmi Shingde
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
| | - Vaishnavi Calisa
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health Flinders University Adelaide SA Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Angela C. Webster
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
- Sydney School of Public Health University of Sydney Sydney NSW Australia
| | - Henry Pleass
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Philip J. O’Connell
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Richard Allen
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Paul Robertson
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Lawrence Yuen
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Kathy Kable
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Brian Nankivell
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Natasha M. Rogers
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Germaine Wong
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
- College of Medicine and Public Health Flinders University Adelaide SA Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Sydney School of Public Health University of Sydney Sydney NSW Australia
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11
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Rohan VS, McGillicuddy JW, Taber DJ, Nadig SN, Baliga PK, Bratton CF. Long‐standing diabetes mellitus and pancreas transplantation: An avenue to increase utilization of an ideal treatment modality. Clin Transplant 2019; 33:e13695. [DOI: 10.1111/ctr.13695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/03/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Vinayak S. Rohan
- Division of Transplant Surgery Department of Surgery Medical University of South Carolina Charleston SC USA
| | - John W. McGillicuddy
- Division of Transplant Surgery Department of Surgery Medical University of South Carolina Charleston SC USA
| | - David J. Taber
- Division of Transplant Surgery Department of Surgery Medical University of South Carolina Charleston SC USA
| | - Satish N. Nadig
- Division of Transplant Surgery Department of Surgery Medical University of South Carolina Charleston SC USA
| | - Prabhakar K. Baliga
- Division of Transplant Surgery Department of Surgery Medical University of South Carolina Charleston SC USA
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12
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Li J, Koch M, Kramer K, Kloth K, Abu Ganim AR, Scheidat S, Rinninger F, Thaiss F, Gulati A, Herden U, Achilles E, Fischer L, Nashan B. Dual antibody induction and de novo use of everolimus enable low-dose tacrolimus with early corticosteroid withdrawal in simultaneous pancreas-kidney transplantation. Transpl Immunol 2018; 50:26-33. [DOI: 10.1016/j.trim.2018.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 05/27/2018] [Accepted: 06/01/2018] [Indexed: 12/28/2022]
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13
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Black CK, Termanini KM, Aguirre O, Hawksworth JS, Sosin M. Solid organ transplantation in the 21 st century. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:409. [PMID: 30498736 PMCID: PMC6230860 DOI: 10.21037/atm.2018.09.68] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/29/2018] [Indexed: 12/20/2022]
Abstract
Solid organ transplantation (SOT) has emerged from an experimental approach in the 20th century to now being an established and practical definitive treatment option for patients with end-organ dysfunction. The evolution of SOT has seen the field progress rapidly over the past few decades with incorporation of a variety of solid organs-liver, kidney, pancreas, heart, and lung-into the donor pool. New advancements in surgical technique have allowed for more efficient and refined multi-organ procurements with minimal complications and decreased ischemic injury events. Additionally, immunosuppression therapy has also seen advancements with the expansion of immunosuppressive protocols to dampen the host immune response and improve short and long-term graft survival. However, the field of SOT faces new barriers, most importantly the expanding demand for SOT that is outpacing the current supply. Allocation protocols have been developed in an attempt to address these concerns. Other avenues for SOT are also being explored to increase the donor pool, including split-liver donor transplants, islet cell implantation for pancreas transplants, and xenotransplantation. The future of SOT is bright with exciting new research being explored to overcome current obstacles.
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Affiliation(s)
- Cara K. Black
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Oswaldo Aguirre
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC, USA
| | - Jason S. Hawksworth
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC, USA
| | - Michael Sosin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
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14
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Bladder Versus Enteric Drainage of Exocrine Secretions in Pancreas Transplantation: A Retrospective Analysis of the United Network for Organ Sharing Database. Pancreas 2018; 47:625-630. [PMID: 29683972 DOI: 10.1097/mpa.0000000000001043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The method for drainage of exocrine secretions in pancreas transplantation remains a matter of debate. Different methods have evolved over time. Most data on these methods are from single-center studies with small sample sizes. Larger studies have yielded conflicting results. METHODS Data from the United Network for Organ Sharing database on all adult subjects who received pancreas and kidney-pancreas transplants between 1996 and 2012 were analyzed (n = 19,934). Subjects were divided into 3 groups: enteric drainage with Roux-en-Y (n = 4308), enteric drainage without Roux-en-Y (n = 11,145), and bladder drainage (n = 4481). Primary end points were patient and graft survival at 1, 3, 5, 10, and 15 years. RESULTS There was a patient and graft survival advantage with enteric drainage without Roux-en-Y reconstruction compared with the other methods. This was consistent at 1, 3, 5, 10, and 15 years. CONCLUSIONS Our study demonstrated increased graft and patient survival when comparing enteric drainage of the transplanted pancreas without Roux-en-Y reconstruction to enteric drainage with Roux-en-Y and bladder drainage at 1, 3, 5, 10, and 15 years. Based on this study, we recommend enteric drainage without Roux-en-Y reconstruction as the method of choice in pancreas transplantation.
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Burrack AL, Landry LG, Siebert J, Coulombe M, Gill RG, Nakayama M. Simultaneous Recognition of Allogeneic MHC and Cognate Autoantigen by Autoreactive T Cells in Transplant Rejection. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2018; 200:1504-1512. [PMID: 29311365 PMCID: PMC5809255 DOI: 10.4049/jimmunol.1700856] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 12/10/2017] [Indexed: 12/15/2022]
Abstract
The autoimmune condition is a primary obstacle to inducing tolerance in type 1 diabetes patients receiving allogeneic pancreas transplants. It is unknown how autoreactive T cells that recognize self-MHC molecules contribute to MHC-disparate allograft rejection. In this report, we show the presence and accumulation of dual-reactive, that is autoreactive and alloreactive, T cells in C3H islet allografts that were transplanted into autoimmune diabetic NOD mice. Using high-throughput sequencing, we discovered that T cells prevalent in allografts share identical TCRs with autoreactive T cells present in pancreatic islets. T cells expressing TCRs that are enriched in allograft lesions recognized C3H MHC molecules, and five of six cell lines expressing these TCRs were also reactive to NOD islet cells. These results reveal the presence of autoreactive T cells that mediate cross-reactive alloreactivity, and indicate a requirement for regulating such dual-reactive T cells in tissue replacement therapies given to autoimmune individuals.
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Affiliation(s)
- Adam L Burrack
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO 80045
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045
| | - Laurie G Landry
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO 80045; and
| | | | - Marilyne Coulombe
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO 80045
| | - Ronald G Gill
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO 80045
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045
| | - Maki Nakayama
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045;
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO 80045; and
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16
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Nacif LS, Rocha-Santos V, Claro LC, Vintimilla A, Ferreira LA, Arantes RM, Pinheiro RS, Andraus W, Alves VA, D’Albuquerque LC. Liver biopsy may facilitate pancreatic graft evaluation: Positive association between liver steatosis and pancreatic graft adipose infiltration. Clinics (Sao Paulo) 2018; 73:e49. [PMID: 29846412 PMCID: PMC5960076 DOI: 10.6061/clinics/2018/e49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 12/11/2017] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES The number of pancreatic transplants has decreased in recent years. Pancreatic grafts have been underutilized compared to other solid grafts. One cause of discard is the macroscopic appearance of the pancreas, especially the presence of fatty infiltration. The current research is aimed at understanding any graft-related association between fatty tissue infiltration of the pancreas and liver steatosis. METHODS From August 2013 to August 2014, a prospective cross-sectional clinical study using data from 54 multiple deceased donor organs was performed. RESULTS Micro- and macroscopic liver steatosis were significantly correlated with the donor body mass index ([BMI]; p=0.029 and p=0.006, respectively). Positive gamma associations between pancreatic and liver macroscopic and microscopic findings (0.98; confidence interval [CI]: 0.95-1 and 0.52; CI 0.04-1, respectively) were observed. Furthermore, comparisons of liver microscopy findings showed significant differences between severe versus absent (p<0.001), severe versus mild (p<0.001), and severe versus moderate classifications (p<0.001). The area under the receiver operating curve was 0.94 for the diagnosis of steatosis by BMI evaluation using a cut-off BMI of 27.5 kg/m2, which yielded 100% sensitivity, 87% specificity, and 100% negative predictive value. CONCLUSIONS We observed a positive association of macroscopic and microscopic histopathological findings in steatotic livers with adipose infiltration of pancreatic grafts.
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Affiliation(s)
- Lucas S. Nacif
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Vinicius Rocha-Santos
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Laura C.L. Claro
- Departamento de Patologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Agustin Vintimilla
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Leandro A. Ferreira
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rubens M. Arantes
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rafael S. Pinheiro
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Wellington Andraus
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Venancio A.F. Alves
- Departamento de Patologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Carneiro D’Albuquerque
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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17
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Incidence and Indications for Late Allograft Pancreatectomy While on Continued Immunosuppression. Transplantation 2017; 101:2228-2234. [PMID: 27798517 DOI: 10.1097/tp.0000000000001556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are limited data about the incidence and indications for late allograft pancreatectomy while on continued immunosuppression for functional kidney allografts. METHODS We analyzed recipients of simultaneous pancreas and kidney and pancreas after kidney transplants between January 1994 and July 2013. Patients with functional kidney but failed pancreas allografts after 90 days were included. RESULTS Out of 1022 simultaneous pancreas and kidney or pancreas after kidney recipients, 246 satisfied these criteria. Of these, 50 underwent allograft pancreatectomy (Px) and 196 did not (no-Px). Eleven of these pancreatectomies were performed at the time of repeat transplant and were analyzed separately. None of the basic recipient or donor characteristics differed significantly between the Px (n = 39) and no-Px groups, except for a higher proportion of females in the Px group. The most common presentation in the Px group was abdominal pain. Histopathology of the pancreas varied widely with graft thrombosis as the most common finding. In univariate and multivariate Cox regression analyses, only female recipient was associated with higher risk for allograft pancreatectomy. Px was not associated with kidney allograft survival (P = 0.16). CONCLUSIONS Despite the ongoing presence of full immunosuppression for a functioning kidney allograft, the need for Px for symptoms and radiological findings is not rare (39/246, 15.8%).
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18
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Moinuddin I, Yaqub MS, Taber T, Powelson J, Fridell J, Sharfuddin A. Isolated pancreas rejections do not have an adverse impact on kidney graft survival whereas kidney rejections are associated with adverse pancreas graft survival in simultaneous pancreas kidney transplantation. J Nephrol 2017; 31:307-315. [DOI: 10.1007/s40620-017-0438-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/06/2017] [Indexed: 12/17/2022]
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19
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Selected Mildly Obese Donors Can Be Used Safely in Simultaneous Pancreas and Kidney Transplantation. Transplantation 2017; 101:1159-1166. [PMID: 27428713 DOI: 10.1097/tp.0000000000001303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Donor obesity, defined as donor body mass index (D-BMI) of 30 kg/m or greater, has been associated with increased risk of technical failure and poor pancreas allograft outcomes. Many transplant centers establish a threshold of D-BMI of 30 kg/m to decline donor offers for pancreas transplantation. However, no previous studies differentiate the impact of mild (D-BMI, 30-35 kg/m) versus severe obesity (D-BMI, ≥35 kg/m) on pancreas allograft outcomes. METHODS We examined Organ Procurement Transplant Network database records for 9916 simultaneous pancreas-kidney transplants (SPKT) performed between 2000 and 2013. We categorized donor body mass index (D-BMI) into 4 groups: 20 to 25 (n = 5724), 25 to 30 (n = 3303), 30 to 35 (n = 751), and 35 to 50 kg/m (n= 138). Associations of D-BMI with pancreas and kidney allograft failure were assessed by multivariate Cox regression adjusted for recipient, donor, and transplant factors. RESULTS Compared with D-BMI 20 to 25 kg/m, only D-BMI 35 to 50 kg/m was associated with significantly higher pancreas allograft [adjusted hazard ratio [aHR], 1.37; 95% confidence interval (CI], 1.04-1.79] and kidney allograft (aHR, 1.36; CI, 1.02-1.82) failure over the study period (13 years). Donor BMI 30 to 35 kg/m did not impact pancreas allograft (aHR, 0.99; CI, 0.86-1.37) or kidney allograft (aHR, 0.98; CI, 0.84-1.15) failure. Similar patterns were noted at 3 months, and 1, 5, and 10 years posttransplant. CONCLUSIONS These data support that pancreata from mildly obese donors (BMI, 30-35 kg/m) can be safely used for transplantation, with comparable short-term and long-term outcomes as organs from lean donors. Consideration of pancreata from obese donors may decrease the pancreas discard rate.
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20
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Scalea JR, Redfield RR, Arpali E, Leverson G, Sollinger HW, Kaufman DB, Odorico JS. Pancreas transplantation in older patients is safe, but patient selection is paramount. Transpl Int 2017; 29:810-8. [PMID: 26859581 DOI: 10.1111/tri.12754] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/03/2015] [Accepted: 01/29/2016] [Indexed: 12/13/2022]
Abstract
Pancreas transplant outcomes have progressively improved. Despite this, some centers have continued to employ historical age limits for pancreas transplant candidates. We sought to determine the importance of chronological age in determining patient and graft survival rates after pancreas transplantation. A single-center, retrospective study of adult, deceased donor simultaneous pancreas and kidney (SPK) and solitary pancreas transplants (SP, including pancreas transplant alone and pancreas after kidney transplants) in recipients ≥ 55 years (55 + ), occurring between July 1, 1999, and June 30, 2012, was performed. Seven-hundred and forty patients underwent pancreas transplantation, of which 28 patients were 55 + . Patient survival was comparable for younger and older pancreas transplant recipients. Both non-death-censored and death-censored pancreatic graft survival rates were similar in younger and in older patients. Patients aged 45-54 and those aged 55 + had more frequent cardiovascular events than younger pancreas transplant recipients. There was no difference in renal graft survival for SPK patients when compared with diabetic kidney transplant alone recipients aged 55 years and older. Older pancreas transplant recipients had acceptable long-term patient and graft survival rates, although complications may occur. Chronological age alone should not exclude a patient for pancreas transplant candidacy.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Emre Arpali
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Glen Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Hans W Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
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21
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Al-Adra D, McGilvray I, Goldaracena N, Spetzler V, Laurence J, Norgate A, Marquez M, Greig P, Sapisochin G, Schiff J, Singh S, Selzner M, Cattral M. Preserving the Pancreas Graft: Outcomes of Surgical Repair of Duodenal Leaks in Enterically Drained Pancreas Allografts. Transplant Direct 2017; 3:e179. [PMID: 28706982 PMCID: PMC5498020 DOI: 10.1097/txd.0000000000000698] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/16/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Duodenal leak remains a major cause of morbidity and graft loss in pancreas transplant recipients. The role and efficacy of surgical and image-guided interventions to salvage enterically drained grafts with a duodenal leak has yet to be defined. METHODS We investigated the incidence, treatment, and outcome of duodenal leak in 426 pancreas transplantation recipients from 2000 to 2015. RESULTS Duodenal leak developed in 33 (7.8%) recipients after a median follow-up of 5.3 (range, 0.5-15.2) years. Most leaks occurred during the first year (n = 22; 67%), and most were located near the proximal and distal duodenal staple line. Graft pancreatectomy was performed in 8 patients as primary therapy because of unfavorable local and/or systemic conditions. Salvage was attempted in 25 patients using percutaneous drainage (n = 4), surgical drainage (n = 4), or surgical repair (n = 17). Percutaneous or surgical drainage failed to control the leak in 7 of these 8 patients, and all 7 ultimately required graft pancreatectomy for persistent leak and sepsis. Surgical repair salvaged 14 grafts, and 13 grafts continue to function after a median follow-up of 2.9 (range, 1.1-6.3) years after repair. CONCLUSIONS Our study shows that in selected patients a duodenal leak can be repaired successfully and safely in enterically drained grafts.
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Affiliation(s)
- David Al-Adra
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian McGilvray
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nicolas Goldaracena
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vinzent Spetzler
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jerome Laurence
- Royal Prince Alfred Institute of Academic Surgery, University of Sydney, Sydney, Australia
| | - Andrea Norgate
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Max Marquez
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Greig
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Department of Medicine, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sunita Singh
- Department of Medicine, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Markus Selzner
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark Cattral
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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22
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Virtual HLA Crossmatching as a Means to Safely Expedite Transplantation of Imported Pancreata. Transplantation 2017; 100:1103-10. [PMID: 26950720 DOI: 10.1097/tp.0000000000001125] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Imported pancreata accumulate cold ischemia time (CIT), limiting utilization and worsening outcomes. Flow cytometric crossmatching (FXM) is a standard method to assess recipient and donor compatibility, but can prolong CIT. Single-antigen bead assays allow for detection of recipient donor-specific HLA antibodies, enabling prediction of compatibility through a "virtual crossmatch" (VXM). This study investigates the utility and outcomes of VXM after transplantation of imported pancreata. METHODS We retrospectively compared outcomes of 153 patients undergoing pancreas transplantation at our institution over a 3.5-year period. RESULTS Three patient groups were analyzed based on geographic source of the pancreas graft and the type of prospective crossmatch performed: (1) imported VXM-only, n = 39; (2) imported VXM + FXM, n = 12; and (3) local VXM + FXM, n = 102. There were no episodes of hyperacute rejection and 1 episode of early antibody-mediated rejection (<90 days) in the imported VXM group. Death-censored graft survival, patient survival, and rejection rates were comparable among the recipient groups. For pancreata imported from United Network of Organ Sharing regions 3 and 4, proceeding to surgery without an FXM reduced CIT by 5.1 hours (P < 0.001). The time from organ arrival at the hospital to operation start was significantly shorter in the VXM-only group compared with the VXM + FXM group (P < 0.001). CONCLUSIONS Virtual crossmatch helps minimize CIT without increasing rejection or adversely affecting graft survival, making it a viable method to increase pancreas graft utilization across distant organ sharing regions.
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23
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Alemtuzumab Induction and Delayed Acute Rejection in Steroid-Free Simultaneous Pancreas-Kidney Transplant Recipients. Transplant Direct 2016; 3:e124. [PMID: 28349124 PMCID: PMC5361562 DOI: 10.1097/txd.0000000000000634] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/13/2016] [Indexed: 01/07/2023] Open
Abstract
Supplemental digital content is available in the text. Background The optimal immunosuppressive regimen in simultaneous pancreas-kidney transplant (SPKT) recipients that prevents acute rejection episodes (AREs) and allows optimal outcome remains elusive. Methods This cohort study assessed incidence and time to AREs in 73 consecutive SPKT recipients receiving alemtuzumab induction and steroid-free maintenance with tacrolimus and mycophenolate mofetil. A cohort with single high-dose antithymocyte globulin (ATG; n = 85) and triple therapy served as controls. In addition, we provided mechanistic insights in AREs after alemtuzumab depletion, including composition and alloreactivity of lymphocytes (flow cytometry and mixed lymphocyte reaction) plasma alemtuzumab levels (enzyme-linked immunosorbent assay), and maintenance drug exposure. Results Overall number of AREs at 3 years was significantly lower with alemtuzumab versus ATG induction (26.0% vs 43.5%; adjusted hazard ratio, 0.38; P = 0.029). Most AREs (94.6%) with ATG occurred within the first month, whereas 84.2% of AREs with alemtuzumab occurred beyond 3 months. Patients with and without an ARE in the steroid-free alemtuzumab group showed no differences in composition of lymphocytes, or in alemtuzumab levels. Of note, more than two thirds of these AREs were preceded by empiric tacrolimus and/or mycophenolate mofetil dose adjustments due to viral infections, leukopenia, or gastrointestinal symptoms. Conclusions Alemtuzumab induction resulted in a significant lower incidence of AREs. Empiric dose adjustments beyond 3 months in the absence of steroids carry a significant risk for subsequent rejection in SPKT recipients.
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Motallebzadeh R, Aly M, El-Khairi M, Drage M, Olsburgh J, Callaghan CJ. High alcohol intake in deceased donors has no effect on pancreas graft survival: a registry analysis. Transpl Int 2016; 30:170-177. [PMID: 27864893 DOI: 10.1111/tri.12890] [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: 07/25/2016] [Revised: 09/04/2016] [Accepted: 11/12/2016] [Indexed: 01/18/2023]
Abstract
Outcomes of pancreas transplantation from donors with high alcohol consumption are poorly described. The UK Transplant Registry was used to determine whether donor alcohol intake influenced pancreas survival in simultaneous pancreas-kidney (SPK) transplants performed between 2006 and 2012 (n = 770). Recipients were stratified by donor alcohol intake: group I (n = 122)-high recent alcohol intake (>21 or >14 units of alcohol/week in males or females, respectively) or previous alcohol abuse and group II (n = 648)-low/unknown current intake and no previous alcohol abuse. Median current alcohol intake was higher in group I than group II: 36.3 vs. 10 units/week; P < 0.001. One- and five-year pancreas graft survivals were 88.5% and 73.6% in group I, and 87% and 74.9% in group II. There was no difference in unadjusted graft survival between groups I and II (P = 0.76), and no difference between group II and a subgroup of group I with a donor history of alcohol abuse and high current intake (P = 0.26), or from donors with current alcohol consumption of >50 units/week (P = 0.41). Pancreas donors with past alcohol abuse or current high intake are common, and graft outcomes appear to be acceptable. This analysis suggests that high donor alcohol intake, by itself, should not exclude consideration of pancreas transplantation.
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Affiliation(s)
- Reza Motallebzadeh
- Department of Surgery, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Mohamed Aly
- Department of Surgery, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Muna El-Khairi
- Department of Statistical Science, University College London, London, UK
| | - Martin Drage
- Department of Nephrology and Transplantation, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan Olsburgh
- Department of Nephrology and Transplantation, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Christopher J Callaghan
- Department of Nephrology and Transplantation, Guy's & St Thomas' NHS Foundation Trust, London, UK
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25
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Kim HJ, Byun N, Kwon O, Park CG. Cross-sensitization between xeno- and allo-antigens on subsequent allogeneic and xenogeneic pancreatic islet transplantation in a murine model. Biochem Biophys Res Commun 2016; 480:474-478. [PMID: 27773813 DOI: 10.1016/j.bbrc.2016.10.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 10/20/2016] [Indexed: 11/30/2022]
Abstract
The number of patients in need of organ transplantation is continuously on the rise. However, because of organ donor shortage, xenotransplantation has been highlighted as an alternative. Among the various porcine organs and tissues, porcine islets are considered to be the best-matching implantable candidates for clinical application based on recent progress in nonhuman primate pre-clinical studies. Nevertheless, before initiation of clinical trials, it should be confirmed whether the requisite xeno-antigen sensitization would have a deleterious effect on subsequent allo-transplantation or vice versa. Therefore, in the present study, the survival rate of islets grafted in naïve recipients was compared with that in cross-sensitized recipients. Enzyme-linked immunosorbent spot, fluorescence-activated cell sorting, and immunohistochemistry were conducted to assess the cellular and humoral immune responses. The survival days of Balb/c mouse islets transplanted into B6 mice that had been previously sensitized with porcine cells (i.e., xeno-sensitized) showed no significant difference from that of naïve B6 mice. Moreover, the survival days of porcine islets transplanted into allo-antigen (Balb/c)-sensitized B6 recipients was not significantly different from that in naïve B6 mice. Furthermore, our data provide the first demonstration that the cellular xenogeneic immune response (against porcine antigen) measured by an enzyme-linked immunosorbent spot assay is not cross-reactive to the allogeneic immune responses in a murine islet transplantation model. These results suggest that clinical application of islet xenotransplantation is not likely to have a deleterious effect on subsequent allogeneic islet transplantation.
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Affiliation(s)
- Hyun-Je Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, 110-799, South Korea; Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, 110-799, South Korea; Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, 110-799, South Korea.
| | - Nari Byun
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, 110-799, South Korea; Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, 110-799, South Korea; Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, 110-799, South Korea.
| | - Ohsang Kwon
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, 110-799, South Korea.
| | - Chung-Gyu Park
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, 110-799, South Korea; Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, 110-799, South Korea; Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, 110-799, South Korea.
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26
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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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Fernandes-Silva G, Ivani de Paula M, Rangel ÉB. mTOR inhibitors in pancreas transplant: adverse effects and drug-drug interactions. Expert Opin Drug Metab Toxicol 2016; 13:367-385. [DOI: 10.1080/17425255.2017.1239708] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Gabriel Fernandes-Silva
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
| | - Mayara Ivani de Paula
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
| | - Érika B. Rangel
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
- Hospital Israelita Albert Einstein, Instituto Israelita de Ensino e Pesquisa, São Paulo, SP, Brazil
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Kuan KG, Wee MN, Chung WY, Kumar R, Mees ST, Dennison A, Maddern G, Trochsler M. A Study of Normothermic Hemoperfusion of the Porcine Pancreas and Kidney. Artif Organs 2016; 41:490-495. [PMID: 27654319 DOI: 10.1111/aor.12770] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/14/2016] [Accepted: 03/21/2016] [Indexed: 01/19/2023]
Abstract
Normothermic machine perfusion has enormous potential to improve organ preservation and expand the organ donor pool. It is well established in other organs but not the pancreas, which has especially strict organ acceptance criteria. We established a model of normothermic hemoperfusion of the porcine pancreas with and without addition of the kidney as a dialysis organ. Four pancreases were harvested and perfused for 120 min with autologous whole blood at body temperature, two with parallel perfusion of the kidney and two without. The organs and perfusion circuit were evaluated for gross appearance, pH, histology and perfusion parameters. The organs maintained steadily increasing flow rate and perfusion pressure. Gross appearance of the organs was stable but appeared grossly ischemic toward the end of the perfusion period. Histology demonstrated necrosis centered in acinar tissue but islet cells were preserved. pH was significantly alkalotic toward the end of the perfusion, likely due to pancreatic tissue damage. Addition of the kidney did not result in significant improvement of the acid-base environment in this small series. In conclusion, normothermic perfusion of the pancreas is still in the experimental stages but holds great potential. Further studies to optimize perfusion parameters will significantly improve results. Parallel perfusion of the kidney may facilitate improvement in the acid-base environment.
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Affiliation(s)
- Kean Guan Kuan
- Department of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Woodville, SA, Australia
| | - Mau Nam Wee
- Department of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Woodville, SA, Australia
| | - Wen Yuan Chung
- Department of Hepatobiliary Surgery, Leicester General Hospital, Leicester, UK
| | - Rohan Kumar
- Department of Hepatobiliary Surgery, Leicester General Hospital, Leicester, UK
| | - Soeren Torge Mees
- Department of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Woodville, SA, Australia
| | - Ashley Dennison
- Department of Hepatobiliary Surgery, Leicester General Hospital, Leicester, UK
| | - Guy Maddern
- Department of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Woodville, SA, Australia
| | - Markus Trochsler
- Department of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Woodville, SA, Australia
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Usatin DJ, Perito ER, Posselt AM, Rosenthal P. Under Utilization of Pancreas Transplants in Cystic Fibrosis Recipients in the United Network Organ Sharing (UNOS) Data 1987-2014. Am J Transplant 2016; 16:1620-5. [PMID: 26603034 PMCID: PMC5436302 DOI: 10.1111/ajt.13630] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 10/22/2015] [Accepted: 11/12/2015] [Indexed: 01/25/2023]
Abstract
Despite a high prevalence of pancreatic endocrine and exocrine insufficiency in cystic fibrosis (CF), pancreas transplantation is rarely reported. United Network for Organ Sharing (UNOS) data were used to examine utilization of pancreas transplant and posttransplant outcomes in CF patients. Between 1987-2014, CF patients (N = 4600) underwent 17 liver-pancreas, three lung-pancreas, one liver-lung pancreas, four kidney-pancreas, and three pancreas-only transplants. Of the 303 CF patients who received liver transplantation, 20% had CF-related diabetes (CFRD) before transplantation, and nine of those received a liver-pancreas transplant. Of 4241 CF patients who underwent lung transplantation, 33% had CFRD before transplantation, and three of those received a pancreas transplant. Of 49 CF patients who received a liver-lung transplant, 57% had CFRD before transplantation and one received a pancreas transplant. Posttransplantation diabetes developed in 7% of CF pancreas transplant recipients versus 24% of CF liver and 29% of CF lung recipients. UNOS has no data on pancreas exocrine insufficiency. Two-year posttransplantation survival was 88% after liver-pancreas transplant, 33% after lung-pancreas transplant, and 100% after pancreas-kidney and pancreas-only transplants. Diabetes is common pretransplantation and posttransplantation in CF solid organ transplant recipients, but pancreas transplantation remains rare. Further consideration of pancreas transplant in CF patients undergoing other solid organ transplant may be warranted.
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Affiliation(s)
- D. J. Usatin
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, San Francisco, CA,Corresponding author: Danielle Usatin,
| | - E. R. Perito
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, San Francisco, CA
| | - A. M. Posselt
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - P. Rosenthal
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, San Francisco, CA,Department of Surgery, University of California, San Francisco, San Francisco, CA
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30
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Song S, Roy S. Progress and challenges in macroencapsulation approaches for type 1 diabetes (T1D) treatment: Cells, biomaterials, and devices. Biotechnol Bioeng 2016; 113:1381-402. [PMID: 26615050 DOI: 10.1002/bit.25895] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 10/30/2015] [Accepted: 11/24/2015] [Indexed: 12/15/2022]
Abstract
Macroencapsulation technology has been an attractive topic in the field of treatment for Type 1 diabetes due to mechanical stability, versatility, and retrievability of the macro-capsule design. Macro-capsules can be categorized into extravascular and intravascular devices, in which solute transport relies either on diffusion or convection, respectively. Failure of macroencapsulation strategies can be due to limited regenerative capacity of the encased insulin-producing cells, sub-optimal performance of encapsulation biomaterials, insufficient immunoisolation, excessive blood thrombosis for vascular perfusion devices, and inadequate modes of mass transfer to support cell viability and function. However, significant technical advancements have been achieved in macroencapsulation technology, namely reducing diffusion distance for oxygen and nutrients, using pro-angiogenic factors to increase vascularization for islet engraftment, and optimizing membrane permeability and selectivity to prevent immune attacks from host's body. This review presents an overview of existing macroencapsulation devices and discusses the advances based on tissue-engineering approaches that will stimulate future research and development of macroencapsulation technology. Biotechnol. Bioeng. 2016;113: 1381-1402. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Shang Song
- Department of Bioengineering and Therapeutic Sciences, University of California-San Francisco, San Francisco, California 94158
| | - Shuvo Roy
- Department of Bioengineering and Therapeutic Sciences, University of California-San Francisco, San Francisco, California 94158.
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31
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Kuan KG, Wee MN, Chung WY, Kumar R, Mees ST, Dennison A, Maddern G, Trochsler M. Extracorporeal machine perfusion of the pancreas: technical aspects and its clinical implications – a systematic review of experimental models. Transplant Rev (Orlando) 2016; 30:31-47. [DOI: 10.1016/j.trre.2015.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/11/2015] [Accepted: 06/14/2015] [Indexed: 12/25/2022]
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32
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Laurence JM, Barbas AS, Sapisochin G, Marquez MA, Bazerbachi F, Selzner M, Norgate A, McGilvray ID, Schiff J, Ross H, Cattral MS. The significance of pre-operative coronary interventions on outcome after pancreas transplantation. Clin Transplant 2015; 30:233-40. [PMID: 26700761 DOI: 10.1111/ctr.12681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 11/28/2022]
Abstract
Pancreas transplant candidates are at very high risk of coronary vascular disease. We hypothesized that the requirement for pre-operative coronary intervention (PCI) may be associated with an adverse impact on short- and long-term outcomes. Retrospective analysis of 366 consecutive primary pancreas transplants was undertaken. Outcomes were compared between recipients who had undergone PCI (n = 48) and those who had not (n = 318). In 48% (23/48) of instances, the PCI was initiated by the transplant cardiology evaluation. The recipients undergoing PCI were older than those not undergoing PCI (47.6 yr vs. 41.9 yr, respectively, p < 0.0001). Although not statistically significant, there was a higher rate of post-operative major cardiovascular events (MCVE) in the PCI group (10.4%) compared with those not undergoing PCI (4.7%) (RR [95% CI]: 2.0 [0.90-4.5]; p = 0.17). In the long term, there were no differences in the rate of death with graft function (p = 0.77) or rejection (p = 0.17). There were no statistically significant differences between the groups with respect to patient (p = 0.54), kidney (p = 0.76), or pancreas (p = 0.63) graft survival. PCI is not a risk factor for short-term perioperative events, and long-term transplant outcomes are equivalent to patients not requiring PCI. PCI, by itself, should not be considered a contraindication for pancreas transplantation, but should raise awareness of perioperative risk.
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Affiliation(s)
- Jerome M Laurence
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, University of Sydney, NSW, Australia
| | - Andrew S Barbas
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Max A Marquez
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Fateh Bazerbachi
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Andrea Norgate
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Ian D McGilvray
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Schiff
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Heather Ross
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, University of Sydney, NSW, Australia
| | - Mark S Cattral
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Echenique IA, Stosor V, Gallon L, Kaufman D, Qi C, Zembower TR. Prolonged norovirus infection after pancreas transplantation: a case report and review of chronic norovirus. Transpl Infect Dis 2015; 18:98-104. [PMID: 26460906 DOI: 10.1111/tid.12472] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 08/27/2015] [Accepted: 09/12/2015] [Indexed: 02/04/2023]
Abstract
Norovirus is a major cause of self-limited gastroenteritis worldwide. Prevention and treatment are thwarted by rapid viral evolution, and thus supportive care remains the mainstay of therapy. Chronic infection in immunocompromised hosts is increasingly described. We report a case of norovirus infection lasting 2543 days in a pancreas transplant recipient. Serial fecal specimens were obtained, from which a map of genetic relatedness was derived. The clinical course was complicated by renal failure that progressed to end-stage renal disease. Minimization of immunosuppression was associated with resolution of the infection. Subsequently, the patient experienced a suspected allograft rejection that did not compromise pancreas function. The patient later underwent living-related renal transplantation without recurrence of enteritis.
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Affiliation(s)
- I A Echenique
- Division of Infectious Disease, Cleveland Clinic Florida, Weston, Florida, USA
| | - V Stosor
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - L Gallon
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - D Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - C Qi
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Clinical Microbiology Laboratory, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - T R Zembower
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Ausania F, Drage M, Manas D, Callaghan CJ. A registry analysis of damage to the deceased donor pancreas during procurement. Am J Transplant 2015; 15:2955-62. [PMID: 26484838 DOI: 10.1111/ajt.13419] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/18/2015] [Accepted: 06/02/2015] [Indexed: 01/25/2023]
Abstract
Surgical injury to the pancreas is thought to occur commonly during procurement. The UK Transplant Registry was analyzed to determine the frequency of pancreatic injuries, identify factors associated with damage, and assess the impact of injuries on graft survival. Twelve hundred ninety-six pancreata were procured from donation after brain death donors, with 314 (19.5%) from donation after circulatory death donors. More than 50% of recovered pancreata had at least one injury, most commonly a short portal vein (21.5%). Liver donation, procurement team origin, hepatic artery (HA) arising from the superior mesenteric artery (SMA), and increasing donor BMI were associated with increased rates of pancreas damage on univariate analyses; on multivariate analysis only the presence of an HA from the SMA remained significant (p = 0.02). Six hundred forty solid organ pancreas transplants were performed; 238 had some form of damage. Overall, there was no difference in graft survival between damaged and undamaged organs (p = 0.28); however, graft loss was significantly more frequent in pancreata with arterial damage (p = 0.04) and in those with parenchymal damage (p = 0.05). Damage to the pancreas during organ recovery is more common than other organs, and meticulous surgical technique and awareness of damage risk factors are essential to reduce rates of procurement-related injuries.
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Affiliation(s)
- F Ausania
- HPB Surgery, Hospital Xeral, Vigo, Spain
| | - M Drage
- Department of Nephrology and Transplantation, Guy's Hospital, London, UK
| | - D Manas
- HPB and Transplant Surgery, Freeman Hospital, Newcastle, UK
| | - C J Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, London, UK
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Meirelles Júnior RF, Salvalaggio P, Pacheco-Silva A. Pancreas transplantation: review. EINSTEIN-SAO PAULO 2015; 13:305-9. [PMID: 26154551 PMCID: PMC4943828 DOI: 10.1590/s1679-45082015rw3163] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 02/08/2015] [Indexed: 12/20/2022] Open
Abstract
Vascularized pancreas transplantation is the only treatment that establishes normal glucose levels and normalizes glycosylated hemoglobin levels in type 1 diabetic patients. The first vascularized pancreas transplant was performed by William Kelly and Richard Lillehei, to treat a type 1 diabetes patient, in December 1966. In Brazil, Edison Teixeira performed the first isolated segmental pancreas transplant in 1968. Until the 1980s, pancreas transplants were restricted to a few centers of the United States and Europe. The introduction of tacrolimus and mycophenolate mofetil in 1994, led to a significant outcome improvement and consequently, an increase in pancreas transplants in several countries. According to the International Pancreas Transplant Registry, until December 31st, 2010, more than 35 thousand pancreas transplants had been performed. The one-year survival of patients and pancreatic grafts exceeds 95 and 83%, respectively. The better survival of pancreatic (86%) and renal (93%) grafts in the first year after transplantation is in the simultaneous pancreas-kidney transplant group of patients. Immunological loss in the first year after transplant for simultaneous pancreas-kidney, pancreas after kidney, and pancreas alone are 1.8, 3.7, and 6%, respectively. Pancreas transplant has 10 to 20% surgical complications requiring laparotomy. Besides enhancing quality of life, pancreatic transplant increases survival of uremic diabetic patient as compared to uremic diabetic patients on dialysis or with kidney transplantation alone.
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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: 40] [Impact Index Per Article: 4.4] [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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37
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The current challenges for pancreas transplantation for diabetes mellitus. Pharmacol Res 2015; 98:45-51. [DOI: 10.1016/j.phrs.2015.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 01/26/2015] [Accepted: 01/27/2015] [Indexed: 12/27/2022]
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Abstract
Purpose of review Important trends are being observed in pancreas transplantation in the USA. We will describe recent trends in simultaneous pancreas kidney (SPK) transplantation related to immunosuppression, treatment of rejection, and transplantation for patients of advanced age and C-peptide positive diabetes. Recent findings Rates of pancreas transplantation have declined, despite improved pancreatic graft outcomes. Regarding immunosuppression, trends in SPK transplantation include T-cell depletion induction therapy, waning mammalian target of rapamycin inhibitor use and steroid use in greater than 50% of pancreas transplant recipients with few patients undergoing late steroid weaning. Rejection of the pancreas may be discordant with the kidney after SPK and there is a greater appreciation of antibody-mediated rejection of the pancreas allograft. De-novo donor-specific antibody without graft dysfunction remains an active area of study, and the treatment for this condition is unclear. SPKs are being performed with greater frequency in type 2 diabetes mellitus patients and in patients of advanced age, with exemplary results. Summary The current state of the art in SPK transplantation is yielding superb and improving results.
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Abstract
Despite significant improvement in pancreas allograft survival, rejection of the pancreas remains a major clinical problem. In addition to cellular rejection of the pancreas, antibody-mediated rejection of the pancreas is now a well-described entity. The 2011 Banff update established comprehensive guidelines for the diagnosis of acute and chronic AMR. The pancreas biopsy is critical in order to accurately diagnose and treat pancreas rejection. Other modes of monitoring pancreas rejection we feel are neither sensitive nor specific enough. In this review, we examine recent advances in the diagnosis and treatment of pancreas rejection as well as describe practical diagnostic and treatment algorithms.
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Affiliation(s)
- R R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Clinical Science Cntr-H4/756, Madison, WI 53792 USA
| | - D B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Clinical Science Cntr-H4/756, Madison, WI 53792 USA
| | - J S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Clinical Science Cntr-H4/756, Madison, WI 53792 USA
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41
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Fridell JA, Mangus RS, Chen JM, Goble ML, Mujtaba MA, Taber TE, Powelson JA. Late pancreas retransplantation. Clin Transplant 2014; 29:1-8. [DOI: 10.1111/ctr.12468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2014] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Jeanne M. Chen
- Department of Pharmacy; Indiana University Health - University Hospital; Indianapolis IN USA
| | | | | | - Tim E. Taber
- Medicine; Indiana University School of Medicine; Indianapolis IN USA
| | - John A. Powelson
- Surgery; Indiana University School of Medicine; Indianapolis IN USA
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42
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Fridell JA, Powelson JA, Kubal CA, Burke GW, Sageshima J, Rogers J, Stratta RJ. Retrieval of the pancreas allograft for whole-organ transplantation. Clin Transplant 2014; 28:1313-30. [PMID: 25203627 DOI: 10.1111/ctr.12459] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2014] [Indexed: 01/15/2023]
Abstract
Proper pancreas retrieval during multi-organ recovery is one of the cornerstones of technically successful whole-organ pancreas transplantation. With evolving surgical approaches for organ retrieval and implantation, it has become standard to procure the pancreas in conjunction with other abdominal organs without compromising either vasculature, graft quality, or transplant outcomes. This review summarizes the major steps required for proper whole-organ retrieval of the pancreas allograft with suggestions and tips whenever alternative approaches are available.
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Affiliation(s)
- Jonathan A Fridell
- The Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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43
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Stratta RJ, Farney AC, Rogers J, Orlando G. Immunosuppression for pancreas transplantation with an emphasis on antibody induction strategies: review and perspective. Expert Rev Clin Immunol 2014; 10:117-32. [PMID: 24236648 DOI: 10.1586/1744666x.2014.853616] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A review of recent literature was performed to identify trends and evaluate outcomes with respect to immunosuppression in pancreas transplantation (PTX). In the past decade, the majority of PTXs were performed with depleting antibody induction, particularly in the setting of either calcineurin inhibitor minimization, corticosteroid withdrawal or both. Maintenance immunosuppression consisted of predominantly tacrolimus (TAC)/mycophenolatemofetil, TAC/mycophenolic acid or TAC/sirolimus with or without corticosteroids. Depending on PTX category, donor and recipient risk factors, case mix and immunosuppressive regimen, the 1-year incidence of acute rejection has decreased to 5-20%. Current 1-year rates of immunological pancreas graft loss range between 1.8 and 6%. Depleting antibody induction and either TAC/mycophenolatemofetil or TAC/sirolimus maintenance therapy with early steroid withdrawal have become the mainstay of immunosuppression in PTX. However, the development of non-nephrotoxic, nondiabetogenic, and nongastrointestinal toxic regimens is highly desirable to improve quality of life in all solid organ transplant recipients.
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Affiliation(s)
- Robert J Stratta
- Department of General Surgery, Section of Transplantation, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC27157, USA
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Montero N, Webster AC, Royuela A, Zamora J, Crespo Barrio M, Pascual J. Steroid avoidance or withdrawal for pancreas and pancreas with kidney transplant recipients. Cochrane Database Syst Rev 2014; 2014:CD007669. [PMID: 25220222 PMCID: PMC11129845 DOI: 10.1002/14651858.cd007669.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreas or kidney-pancreas transplantation improves survival and quality of life for people with type 1 diabetes mellitus and kidney failure. Immunosuppression after transplantation is associated with complications. Steroids have adverse effects on cardiovascular risk factors such as hypertension, hyperglycaemia or hyperlipidaemia, increase risk of infection, obesity, cataracts, myopathy, bone metabolism alterations, dermatologic problems and cushingoid appearance. Whether avoiding steroids changes outcomes is unclear. OBJECTIVES We aimed to assess the safety and efficacy of steroid early withdrawal (treatment for less than 14 days after transplantation), late withdrawal (after 14 days after transplantation) or steroid avoidance in patients receiving a pancreas (including a vascularized organ) alone (PTA), simultaneous with a kidney (SPK) or after kidney transplantation (PAK). SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register (to 18 June 2014) through contact with the Trials' Search Co-ordinator. We handsearched: reference lists of nephrology textbooks, relevant studies, recent publications and clinical practice guidelines; abstracts from international transplantation society scientific meetings; and sent emails and letters seeking information about unpublished or incomplete studies to known investigators. SELECTION CRITERIA We included randomised controlled trials (RCTs) or cohort studies of steroid avoidance (including early withdrawal) versus steroid maintenance or versus late withdrawal in pancreas or pancreas with kidney transplant recipients. We defined steroid avoidance as complete avoidance of steroid immunosuppression, early steroid withdrawal as steroid treatment for less than 14 days after transplantation and late withdrawal as steroid withdrawal after 14 days after transplantation. DATA COLLECTION AND ANALYSIS Two authors independently assessed the retrieved titles and abstracts, and where necessary the full text reports to determine which studies satisfied the inclusion criteria. Authors of included studies were contacted to obtain missing information. Statistical analyses were performed using random effects models and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Cohort studies were not meta-analysed, but their findings summarised descriptively. MAIN RESULTS Three RCTs enrolling 144 participants met our inclusion criteria. Two compared steroid avoidance versus late steroid withdrawal and one compared late steroid withdrawal versus steroid maintenance. All studies included SPK and only one also included PTA. All studies had an overall moderate risk of bias and presented only short-term results (six to 12 months). Two studies (89 participants) compared steroid avoidance or early steroid withdrawal versus late steroid withdrawal. There was no clear evidence of an impact on mortality (2 studies, 89 participants: RR 1.64, 95% CI 0.21 to 12.75), risk of kidney loss censored for death (2 studies, 89 participants: RR 0.35, 95% CI 0.04 to 3.09), risk of pancreas loss censored for death (2 studies, 89 participants: RR 1.05, 95% CI 0.36 to 3.04), or acute kidney rejection (1 study, 49 participants: RR 2.08, 95% CI 0.20 to 21.50), however results were uncertain and consistent with no difference or important benefit or harm of steroid avoidance/early steroid withdrawal. The study that compared late steroid withdrawal versus steroid maintenance observed no deaths, no graft loss or acute kidney rejection at six months in either group and reported uncertain effects on acute pancreas rejection (RR 0.88, 95% CI 0.06 to 13.35). Of the possible adverse effects only infection was reported by one study. There were significantly more UTIs reported in the late withdrawal group compared to the steroid avoidance group (1 study, 25 patients: RR 0.41, 95% CI 0.26 to 0.66).We also identified 13 cohort studies and one RCT which randomised tacrolimus versus cyclosporin. These studies in general showed that steroid-sparing and withdrawal strategies had benefits in lowering HbAc1 and risk of infections (BK virus and CMV disease) and improved blood pressure control without increasing the risk of rejection. However, two studies found an increased incidence of acute pancreas rejection (HR 2.8, 95% CI 0.89 to 8.81, P = 0.066 in one study and 43.3% in the steroid withdrawal group versus 9.3% in the steroid maintenance, P < 0.05 at three years in the other) and one study found an increased incidence of acute kidney rejection (18.7% in the steroid withdrawal group versus 2.8% in the steroid maintenance, P < 0.05) at three years. AUTHORS' CONCLUSIONS There is currently insufficient evidence for the benefits and harms of steroid withdrawal in pancreas transplantation in the three RCTs (144 patients) identified. The results showed uncertain results for short-term risk of rejection, mortality, or graft survival in steroid-sparing strategies in a very small number of patients over a short period of follow-up. Overall the data was sparse, so no firm conclusions are possible. Moreover, the 13 observational studies findings generally concur with the evidence found in the RCTs.
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Affiliation(s)
- Nuria Montero
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Marítim 25‐29BarcelonaSpain08003
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Ana Royuela
- Hospital Ramon y CajalCIBER Epidemiologia y Salud Publica (CIBERESP)Ctra. Colmenar km, 9.1MadridSpain28047
- Unidad de Bioestadística, Hospital Ramón y CajalMadridSpain
| | - Javier Zamora
- Ramon y Cajal Institute for Health Research (IRYCIS), CIBER Epidemiology and Public Health (CIBERESP) and Cochrane Collaborating CentreClinical Biostatistics UnitCtra. Colmenar km 9,100MadridMadridSpain28034
- CIBER Epidemiologia y Salud Publica (CIBERESP)MadridSpain
| | - Marta Crespo Barrio
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Marítim 25‐29BarcelonaSpain08003
| | - Julio Pascual
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Marítim 25‐29BarcelonaSpain08003
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Hoogwerf BJ, Kendall DM, Seaquist ER. Frederick C. Goetz, MD: a profile of the intersection among science, the fine arts, and education. Diabetes Care 2014; 37:2419-23. [PMID: 25147251 DOI: 10.2337/dc14-0283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
| | - David M Kendall
- Eli Lilly and Co., Indianapolis, IN University of Minnesota, Minneapolis, MN
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Stratta RJ, Rogers J, Orlando G, Farooq U, Al-Shraideh Y, Doares W, Kaczmorski S, Farney AC. Depleting antibody induction in simultaneous pancreas-kidney transplantation: a prospective single-center comparison of alemtuzumab versus rabbit anti-thymocyte globulin. Expert Opin Biol Ther 2014; 14:1723-30. [DOI: 10.1517/14712598.2014.953049] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Stratta RJ, Farney AC, Orlando G, Farooq U, Al-Shraideh Y, Rogers J. Similar results with solitary pancreas transplantation compared with simultaneous pancreas-kidney transplantation in the new millennium. Transplant Proc 2014; 46:1924-7. [PMID: 25131072 DOI: 10.1016/j.transproceed.2014.05.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The purpose of this study was to analyze our single-center outcomes according to pancreas transplant (PT) category in the new millennium by using standardized management protocols. PATIENTS AND METHODS We retrospectively studied 202 consecutive PTs (179 with portal-enteric drainage) in 192 patients; all received either rabbit antithymocyte globulin or alemtuzumab induction in combination with tacrolimus, mycophenolate mofetil, and tapered corticosteroids or early steroid withdrawal. Unlike simultaneous pancreas/kidney (SPK) transplant, solitary PT (SPT) recipients were managed with routine perioperative anticoagulation and surveillance pancreas biopsies. RESULTS From November 2001 to March 2013, we performed 162 SPK transplants, 35 pancreas after kidney transplants, and 5 pancreas-alone transplants (40 SPTs). Demographic characteristics were mostly comparable; however, the SPT group had younger donors, shorter waiting time, fewer HLA mismatches, and fewer African-American recipients but more retransplants (all, P < .05). With a mean follow-up of 5.5 versus 7.5 years, overall patient (86.4% SPK vs 86.8% SPT), kidney graft (74% SPK vs 80% SPT), and pancreas graft (both 65%) survival rates were comparable. Although mortality rates were similar, mortality patterns differed because no SPT recipients died early, whereas the 1-, 3-, and 5-year mortality rates after SPK transplant were 4%, 9% and 12%, respectively (P < .05). The most common causes of pancreas graft loss were death with functioning grafts in SPK recipients and acute/chronic rejection in SPT recipients. Rates of early thrombosis were 8.6% in SPK patients and 5% in SPT patients. Cumulative clinical acute rejection rates were similar between groups (SPK 29% vs SPT 27.5%; P = NS). CONCLUSIONS In the setting of depleting antibody induction and tacrolimus-based therapy, HLA matching, careful donor and recipient selection, portal-enteric drainage, selective perioperative anticoagulation, and surveillance SPT biopsy monitoring, similar medium-term outcomes can be achieved in SPK transplants and SPTs in the new millennium.
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Affiliation(s)
- R J Stratta
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - A C Farney
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - G Orlando
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - U Farooq
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Y Al-Shraideh
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - J Rogers
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Stratta R, Rogers J, Orlando G, Farooq U, Al-Shraideh Y, Farney A. 5-Year Results of a Prospective, Randomized, Single-Center Study of Alemtuzumab Compared With Rabbit Antithymocyte Globulin Induction in Simultaneous Kidney–Pancreas Transplantation. Transplant Proc 2014; 46:1928-31. [DOI: 10.1016/j.transproceed.2014.05.080] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mittal S, Page SL, Friend PJ, Sharples EJ, Fuggle SV. De novo donor-specific HLA antibodies: biomarkers of pancreas transplant failure. Am J Transplant 2014; 14:1664-71. [PMID: 24866735 DOI: 10.1111/ajt.12750] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/18/2014] [Accepted: 03/19/2014] [Indexed: 01/25/2023]
Abstract
This study assesses the role of posttransplant HLA antibody monitoring in the surveillance of pancreas transplant recipients. Four hundred thirty-three pancreas transplants were performed at the Oxford Transplant Centre 2006-2011 (317 simultaneous pancreas kidney [SPK] and 116 isolated pancreas [IP]). HLA antibody monitoring was performed at 0, 6 and 12 months and annually and during clinical events. There was no association between pancreas graft failure and recipient or donor characteristics. Posttransplant antibody status, available for 354 (81.8%) of recipients, demonstrated that 141 (39.8%) developed de novo HLA antibodies, of which 52 (36.9%) were de novo donor-specific HLA antibodies (DSA) (34 SPK, 18 IP). The development of antibodies to donor HLA, but not to nondonor HLA, was significantly associated with poorer graft outcomes, with 1- and 3-year graft survival inferior in SPK recipients (85.2% vs. 93.5%; 71.8% vs. 90.3%, respectively; log-rank p = 0.002), and particularly in IP recipients (50.0% vs. 82.9%; 16.7 vs. 79.4%, respectively; log-rank p = 0.001). In a multivariate analysis, development of de novo DSA emerged as a strong independent predictor of pancreas graft failure (hazard ratio 4.66, p < 0.001). This is the largest study to examine de novo HLA antibodies following pancreas transplantation and clearly defines a high-risk group in need of specific intervention.
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Affiliation(s)
- S Mittal
- Oxford Transplant Centre, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
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Jr CSK, Koval CE, Duin DV, Morais AGD, Gonzalez BE, Avery RK, Mawhorter SD, Brizendine KD, Cober ED, Miranda C, Shrestha RK, Teixeira L, Mossad SB. Selecting suitable solid organ transplant donors: Reducing the risk of donor-transmitted infections. World J Transplant 2014; 4:43-56. [PMID: 25032095 PMCID: PMC4094952 DOI: 10.5500/wjt.v4.i2.43] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/21/2014] [Accepted: 05/14/2014] [Indexed: 02/05/2023] Open
Abstract
Selection of the appropriate donor is essential to a successful allograft recipient outcome for solid organ transplantation. Multiple infectious diseases have been transmitted from the donor to the recipient via transplantation. Donor-transmitted infections cause increased morbidity and mortality to the recipient. In recent years, a series of high-profile transmissions of infections have occurred in organ recipients prompting increased attention on the process of improving the selection of an appropriate donor that balances the shortage of needed allografts with an approach that mitigates the risk of donor-transmitted infection to the recipient. Important advances focused on improving donor screening diagnostics, using previously excluded high-risk donors, and individualizing the selection of allografts to recipients based on their prior infection history are serving to increase the donor pool and improve outcomes after transplant. This article serves to review the relevant literature surrounding this topic and to provide a suggested approach to the selection of an appropriate solid organ transplant donor.
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