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Wisel SA, Posselt AM, Szot GL, Nunez M, Santos-Parker K, Gardner JM, Worner G, Roll GR, Syed S, Kelly Y, Ward C, Tavakol M, Johnson K, Masharani U, Stock PG. A Multi-Modal Approach to Islet and Pancreas Transplantation With Calcineurin-Sparing Immunosuppression Maintains Long-Term Insulin Independence in Patients With Type I Diabetes. Transpl Int 2023; 36:11367. [PMID: 37359825 PMCID: PMC10285771 DOI: 10.3389/ti.2023.11367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
Long-term success in beta-cell replacement remains limited by the toxic effects of calcineurin inhibitors (CNI) on beta-cells and renal function. We report a multi-modal approach including islet and pancreas-after-islet (PAI) transplant utilizing calcineurin-sparing immunosuppression. Ten consecutive non-uremic patients with Type 1 diabetes underwent islet transplant with immunosuppression based on belatacept (BELA; n = 5) or efalizumab (EFA; n = 5). Following islet failure, patients were considered for repeat islet infusion and/or PAI transplant. 70% of patients (four EFA, three BELA) maintained insulin independence at 10 years post-islet transplant, including four patients receiving a single islet infusion and three patients undergoing PAI transplant. 60% remain insulin independent at mean follow-up of 13.3 ± 1.1 years, including one patient 9 years after discontinuing all immunosuppression for adverse events, suggesting operational tolerance. All patients who underwent repeat islet transplant experienced graft failure. Overall, patients demonstrated preserved renal function, with a mild decrease in GFR from 76.5 ± 23.1 mL/min to 50.2 ± 27.1 mL/min (p = 0.192). Patients undergoing PAI showed the greatest degree of renal impairment following initiation of CNI (56% ± 18.7% decrease in GFR). In our series, repeat islet transplant is ineffective at maintaining long-term insulin independence. PAI results in durable insulin independence but is associated with impaired renal function secondary to CNI dependence.
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Affiliation(s)
- Steven A. Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Andrew M. Posselt
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Gregory L. Szot
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Miguel Nunez
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Keli Santos-Parker
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - James M. Gardner
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Giulia Worner
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Shareef Syed
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Yvonne Kelly
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Casey Ward
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Medhi Tavakol
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Kristina Johnson
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Umesh Masharani
- Division of Endocrinology, University of California, San Francisco, San Francisco, CA, United States
| | - Peter G. Stock
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
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Fridell JA, Stratta RJ, Gruessner AC. Pancreas Transplantation: Current Challenges, Considerations, and Controversies. J Clin Endocrinol Metab 2023; 108:614-623. [PMID: 36377963 DOI: 10.1210/clinem/dgac644] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022]
Abstract
Pancreas transplantation (PTx) reestablishes an autoregulating source of endogenous insulin responsive to normal feedback controls. In addition to achieving complete β-cell replacement that frees the patient with diabetes from the need to monitor serum glucose and administer exogenous insulin, successful PTx provides counterregulatory hormone secretion and exocrine function. A functioning PTx mitigates glycemic variability, eliminates the daily stigma and burden of diabetes, restores normal glucose homeostasis in patients with complicated diabetes, and improves quality of life and life expectancy. The tradeoff is that it entails a major surgical procedure and requisite long-term immunosuppression. Despite the high likelihood of rendering patients euglycemic independent of exogenous insulin, PTx is considered a treatment rather than a cure. In spite of steadily improving outcomes in each successive era coupled with expansion of recipient selection criteria to include patients with a type 2 diabetes phenotype, a decline in PTx activity has occurred in the new millennium related to a number of factors including: (1) lack of a primary referral source and general acceptance by the diabetes care community; (2) absence of consensus criteria; and (3) access, education, and resource issues within the transplant community. In the author's experience, patients who present as potential candidates for PTx have felt as though they needed to circumvent the conventional diabetes care model to gain access to transplant options. PTx should be featured more prominently in the management algorithms for patients with insulin requiring diabetes who are failing exogenous insulin therapy or experiencing progressive diabetic complications regardless of diabetes type. Furthermore, all patients with diabetes and chronic kidney disease should undergo consideration for simultaneous pancreas-kidney transplantation independent of geography or location.
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Affiliation(s)
- Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Robert J Stratta
- Department of Surgery, Atrium Health Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Angelika C Gruessner
- Department of Medicine/Nephrology, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA
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Ward C, Odorico JS, Rickels MR, Berney T, Burke GW, Kay TW, Thaunat O, Uva PD, de Koning EJP, Arbogast H, Scholz H, Cattral MS, Stratta RJ, Stock PG. International Survey of Clinical Monitoring Practices in Pancreas and Islet Transplantation. Transplantation 2022; 106:1647-1655. [PMID: 35019897 PMCID: PMC9271126 DOI: 10.1097/tp.0000000000004058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The long-term outcomes of both pancreas and islet allotransplantation have been compromised by difficulties in the detection of early graft dysfunction at a time when a clinical intervention can prevent further deterioration and preserve allograft function. The lack of standardized strategies for monitoring pancreas and islet allograft function prompted an international survey established by an International Pancreas and Islet Transplant Association/European Pancreas and Islet Transplant Association working group. METHODS A global survey was administered to 24 pancreas and 18 islet programs using Redcap. The survey addressed protocolized and for-cause immunologic and metabolic monitoring strategies following pancreas and islet allotransplantation. All invited programs completed the survey. RESULTS The survey identified that in both pancreas and islet allograft programs, protocolized clinical monitoring practices included assessing body weight, fasting glucose/C-peptide, hemoglobin A1c, and donor-specific antibody. Protocolized monitoring in islet transplant programs relied on the addition of mixed meal tolerance test, continuous glucose monitoring, and autoantibody titers. In the setting of either suspicion for rejection or serially increasing hemoglobin A1c/fasting glucose levels postpancreas transplant, Doppler ultrasound, computed tomography, autoantibody titers, and pancreas graft biopsy were identified as adjunctive strategies to protocolized monitoring studies. No additional assays were identified in the setting of serially increasing hemoglobin A1c levels postislet transplantation. CONCLUSIONS This international survey identifies common immunologic and metabolic monitoring strategies utilized for protocol and for cause following pancreas and islet transplantation. In the absence of any formal studies to assess the efficacy of immunologic and metabolic testing to detect early allograft dysfunction, it can serve as a guidance document for developing monitoring algorithms following beta-cell replacement.
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Affiliation(s)
- Casey Ward
- Division of Transplantation, Department of Surgery, University of California at San Francisco, San Francisco, CA, United States
- Department of Surgery, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - Jon S. Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Michael R. Rickels
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, and Institute for Diabetes, Obesity & Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Thierry Berney
- Division of Transplantation and Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - George W. Burke
- Division of Transplantation, Department of Surgery, and Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Thomas W.H. Kay
- Department of Medicine, St. Vincent’s Hospital, and St. Vincent’s Institute of Medical Research, University of Melbourne, Melbourne, Victoria, Australia
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pablo D. Uva
- Department of Kidney Pancreas Transplantation, Instituto de Trasplantes y Alta Complejidad (ITAC – Nephrology), Buenos Aires, Argentina
| | | | - Helmut Arbogast
- Department of General, Visceral and Transplant Surgery, University Hospital Grosshadern, Ludwig Maximilian's University, Munich, Germany
| | - Hanne Scholz
- Department of Transplant Medicine and Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
| | - Mark S Cattral
- Department of Surgery, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - Robert J. Stratta
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Peter G. Stock
- Division of Transplantation, Department of Surgery, University of California at San Francisco, San Francisco, CA, United States
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Sabet A, Azarpira N, Kohan L, Ghavami S. Evaluation of Autophagy Process in Differentiation of Human Induced Pluripotent Stem Cells toward Insulin Producing Cells. Int J Organ Transplant Med 2022; 13:4-13. [PMID: 37641731 PMCID: PMC10460531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Background Autophagy is an intracellular self-degradative homeostasis process which eliminates undesirable and harmful macromolecules and organelles. Autophagy is also involved in self-renewal and differentiation of induced pluripotent stem cell (iPSCs). Objective In this study, we investigated the expression profile of autophagy marker genes in human iPSCs during their differentiation induction toward insulin producing β-like cells. Methods Human iPSC line, R1-hiPSC1, was used for differentiation induction toward β-like cells. The mRNA expression of Nanog, OCT4 (pluripotency markers), SOX17, FOXA2 (endodermic markers), PTF1A, NKX6.1 (exocrine/endocrine determinants), and PDX1 were measured during differentiation stages. Autophagy was monitored by genes expression study of four autophagy markers, MAP1LC3B, BECN1, SQSTM1/P62 and ATG5, along with protein expression profile of LC3b-II during differentiation stages. Results The mRNA expression measurement of pluripotency, endoderm and exocrine/endocrine marker genes confirmed that hiPSCs skipped pluripotency, differentiated into endoderm, passed through the pancreatic lineage commitment stage and successfully generated insulin producing β-like cells. Expression profile of autophagy genes during differentiation stages indicated the decreased expression levels at the early stages (EB and MEI) and then increased at the definitive endoderm stages (DEI 1, DEI 2 and DE) followed by a subtractive pattern toward the end of differentiation. The results of protein expression of LC3b-II were consistent with gene expression data. Conclusion This study demonstrated the high contribution of key autophagy genes/proteins during the differentiation of hiPSC toward β-like cells. The enhanced autophagy levels were a prominent feature of early stages of differentiation and DE rather than the later stages.
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Affiliation(s)
- A. Sabet
- Department of Genetics, Fars Science and Research Branch, Islamic Azad University, Marvdasht, Iran
- Department of Genetics, Marvdasht Branch, Islamic Azad University, Marvdasht, Iran
| | - N. Azarpira
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - L. Kohan
- Department of Biology, Arsanjan Branch, Islamic Azad University, Arsanjan, Iran
| | - S. Ghavami
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Rios P, Baidal D, Lemos J, Camhi SS, Infante M, Padilla N, Gil AMA, Fuenmayor V, Ambut J, Qasmi FA, Mantero AM, Cayetano SM, Ruiz P, Ricordi C, Alejandro R. Long-term Persistence of Allosensitization After Islet Allograft Failure. Transplantation 2021; 105:2490-2498. [PMID: 33481552 PMCID: PMC8289921 DOI: 10.1097/tp.0000000000003635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Allosensitization has been reported after discontinuation of immunosuppression following graft failure in islet transplantation (ITx) recipients, though duration of its persistence is unknown. METHODS We evaluated 35 patients with type 1 diabetes who received ITx, including 17 who developed graft failure (ITx alone, n = 13; ITx plus bone marrow-derived hematopoietic stem cells, n = 4) and 18 with persistent graft function. Panel-reactive antibody (PRA) was measured yearly for the duration of graft function within 1 y after graft failure at enrollment and yearly thereafter. RESULTS In ITx alone graft failure patients, 61% (8/13) were PRA-positive at 6 y postgraft failure, and 46% (6/13) developed donor-specific anti-HLA antibodies (DSA to 2 ± 1 donors) during follow-up. The degree of sensitization was variable (cPRA ranging between 22% and 100% after graft failure). Allosensitization persisted for 7-15 y. Three subjects (3/13) were not allosensitized. In ITx plus bone marrow-derived hematopoietic stem cell recipients, cPRA-positivity (88%-98%) and DSA positivity persisted for 15 y in 75% (3/4) of subjects. CONCLUSIONS Allosensitization was minimal while subjects remained on immunosuppression, but after discontinuation of immunosuppressive therapy, the majority of subjects (77%) became allosensitized with persistence of PRA positivity for up to 15 y. Persistence of allosensitization in this patient population is of clinical importance as it may result in longer transplant waiting list times for identification of a suitable donor in the case of requiring a subsequent transplant.
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Affiliation(s)
- Paola Rios
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - David Baidal
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Joana Lemos
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - Stephanie S. Camhi
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - Marco Infante
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - Nathalia Padilla
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - Ana M. Alvarez Gil
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - Virginia Fuenmayor
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - Jonathan Ambut
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - Fatima A. Qasmi
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
| | - Alejandro M. Mantero
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Shari Messinger Cayetano
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Phillip Ruiz
- Department of Surgery and Pathology, University of Miami Miller School of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Camillo Ricordi
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
- Division of Cellular Transplantation, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Rodolfo Alejandro
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, FL
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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6
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Landstra CP, Andres A, Chetboun M, Conte C, Kelly Y, Berney T, de Koning EJP, Piemonti L, Stock PG, Pattou F, Vantyghem MC, Bellin MD, Rickels MR. Examination of the Igls Criteria for Defining Functional Outcomes of β-cell Replacement Therapy: IPITA Symposium Report. J Clin Endocrinol Metab 2021; 106:3049-3059. [PMID: 34061967 PMCID: PMC8571711 DOI: 10.1210/clinem/dgab386] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT The Igls criteria were developed to provide a consensus definition for outcomes of β-cell replacement therapy in the treatment of diabetes during a January 2017 workshop sponsored by the International Pancreas & Islet Transplant Association (IPITA) and the European Pancreas & Islet Transplant Association. In July 2019, a symposium at the 17th IPITA World Congress was held to examine the Igls criteria after 2 years in clinical practice, including validation against continuous glucose monitoring (CGM)-derived glucose targets, and to propose future refinements that would allow for comparison of outcomes with artificial pancreas system approaches. EVIDENCE ACQUISITION Utilization of the criteria in various clinical and research settings was illustrated by population as well as individual outcome data of 4 islet and/or pancreas transplant centers. Validation against CGM metrics was conducted in 55 islet transplant recipients followed-up to 10 years from a fifth center. EVIDENCE SYNTHESIS The Igls criteria provided meaningful clinical assessment on an individual patient and treatment group level, allowing for comparison both within and between different β-cell replacement modalities. Important limitations include the need to account for changes in insulin requirements and C-peptide levels relative to baseline. In islet transplant recipients, CGM glucose time in range improved with each category of increasing β-cell graft function. CONCLUSIONS Future Igls 2.0 criteria should consider absolute rather than relative levels of insulin use and C-peptide as qualifiers with treatment success based on glucose assessment using CGM metrics on par with assessment of glycated hemoglobin and severe hypoglycemia events.
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Affiliation(s)
- Cyril P Landstra
- Division of Endocrinology & Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Axel Andres
- Divison of Transplantation and Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Mikael Chetboun
- Department of General and Endocrine Surgery, Centre Hospitalier Universitaire de Lille, and Inserm, Translational Research for Diabetes, Université de Lille, Lille, France
| | - Caterina Conte
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, and Vita-Salute San Raffaele University, Milan, Italy
| | - Yvonne Kelly
- Division of Transplantation, Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Thierry Berney
- Divison of Transplantation and Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Eelco J P de Koning
- Division of Endocrinology & Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, and Vita-Salute San Raffaele University, Milan, Italy
| | - Peter G Stock
- Division of Transplantation, Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - François Pattou
- Department of General and Endocrine Surgery, Centre Hospitalier Universitaire de Lille, and Inserm, Translational Research for Diabetes, Université de Lille, Lille, France
| | - Marie-Christine Vantyghem
- Department of Endocrinology, Diabetology and Metabolism, Centre Hospitalier Universitaire de Lille, and Inserm, Translational Research for Diabetes, Université de Lille, Lille, France
| | - Melena D Bellin
- Division of Endocrinology, Department of Pediatrics, and the Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, and Institute for Diabetes, Obesity & Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Correspondence: Michael R. Rickels, MD, MS, Institute for Diabetes, Obesity & Metabolism, University of Pennsylvania Perelman School of Medicine, 12-134 Smilow Center for Translational Research, 3400 Civic Center Boulevard, Philadelphia, PA, USA 19104-5160.
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Response to Treatment for Chronic-active T Cell-mediated Rejection in Kidney Transplantation: A Report of 3 Cases. Transplant Direct 2020; 6:e628. [PMID: 33204826 PMCID: PMC7665267 DOI: 10.1097/txd.0000000000001079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/27/2022] Open
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Ryu JH, Ko HJ, Shim JR, Lee TB, Yang KH, Lee JH, Lee HJ, Kim T, Choi BH. Eosinophil-to-monocyte ratio is an excellent predictor of acute cellular rejection in pancreas transplant alone recipients. Clin Transplant 2020; 34:e13785. [PMID: 31957063 DOI: 10.1111/ctr.13785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/20/2019] [Accepted: 01/07/2020] [Indexed: 01/23/2023]
Abstract
Serum pancreatic enzymes (serum amylase and lipase) are sensitive markers for monitoring acute rejection in pancreatic transplant recipients. However, those enzymes are not specific, as their levels are elevated in other conditions. We evaluated the eosinophil-to-monocyte ratio (EMR) in peripheral blood as a biomarker of acute rejection in the clinical setting in recipients of pancreatic transplant alone. We performed 32 cases of pancreatic transplantation alone since 2015. Nine patients were diagnosed with rejection. Serum amylase and lipase levels and eosinophil and monocytes counts were analyzed and compared retrospectively between the non-rejection and rejection groups. The serum eosinophil count, eosinophil fraction of the complete blood count, and serum amylase and lipase levels were significant predictors of rejection according to the receiver operation characteristic (ROC) curve. However, the EMR was the best indicator of rejection based on the ROC curve (area under the curve 0.918, sensitivity 100%, specificity 76.2% at the cutoff value 0.80, P < .001). The combination of EMR and the lipase level had 100% sensitivity and 90.5% specificity. The EMR is a simple and excellent predictor of acute rejection in recipients of pancreatic transplant alone.
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Affiliation(s)
- Je Ho Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyo Jung Ko
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae Ryong Shim
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Tae Beom Lee
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kwang Ho Yang
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jung Hee Lee
- Department of Pathology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun Ji Lee
- Department of Laboratory medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Taeun Kim
- Department of Radiology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Byung Hyun Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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9
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Cerise A, Nagaraju S, Powelson JA, Lutz A, Fridell JA. Pancreas transplantation following total pancreatectomy for chronic pancreatitis. Clin Transplant 2019; 33:e13731. [PMID: 31627258 DOI: 10.1111/ctr.13731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Total pancreatectomy for chronic pancreatitis leads to brittle diabetes and challenging glycemic control with half of all patients experiencing severe hypoglycemia, many requiring medical intervention or hospitalization. Pancreas transplantation has the potential to manage both the endocrine and the exocrine insufficiency in this patient population. METHODS Between June 1, 2005, and July 1, 2016, 8 patients with brittle diabetes following total pancreatectomy underwent pancreas transplantation. All grafts had systemic venous and enteric exocrine drainage. Data included demographics, graft and patient survival, pre- and post-transplant supplementation with pancreatic enzymes, and narcotic usage. RESULTS Patient survival rate at 1 and 3 years was 88%. Pancreas graft survival rate of those alive at 1 year was 100% and 86%, respectively. About 75% of these patients remained insulin-free until their time of death, loss of follow-up, or present day. Of the patients with maintained graft function at 3 years, none required further hospitalization for glycemic control. About 75% of these patients have also maintained exocrine function without pancreatic enzyme supplementation. CONCLUSIONS Pancreas transplant can treat both exocrine and endocrine insufficiency and give long-term insulin-free survival and should be considered as a viable treatment option for patients who have undergone total pancreatectomy for chronic pancreatitis.
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Affiliation(s)
- Adam Cerise
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Santosh Nagaraju
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrew Lutz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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10
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Fridell JA, Mangus RS, Chen JM, Taber TE, Cabrales AE, Sharfuddin AA, Yaqub MS, Powelson JA. Steroid-free three-drug maintenance regimen for pancreas transplant alone: Comparison of induction with rabbit antithymocyte globulin +/- rituximab. Am J Transplant 2018; 18:3000-3006. [PMID: 29738100 DOI: 10.1111/ajt.14921] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/13/2018] [Accepted: 04/27/2018] [Indexed: 01/25/2023]
Abstract
Graft survival following pancreas transplant alone (PTA) is inferior to other pancreas transplants. Steroid elimination is appealing, but a two-drug maintenance strategy may be inadequate. Additionally, recipients tend to have diabetic nephropathy and do not tolerate nephrotoxic medications. A three-drug maintenance strategy permits immunosuppression through different mechanisms as well as an opportunity to use lower doses of the individual medications. Induction consisted of five doses of rabbit antithymocyte globulin (1 mg/kg/dose). As of October 2007, a single dose of rituximab (150 mg/m2 ) was added. Maintenance consisted of tacrolimus, sirolimus and mycophenolate mofetil. From 2004 to 2017, 166 PTA were performed. Graft loss at 7 and 90 days were 4% and 5%, and 1-year patient and graft survival were 97% and 91%. Comparing induction without and with rituximab, there was no significant difference in 7- or 90-day graft loss, 1-year patient or graft survival, or in the rate of rejection or infection. Rabbit antithymocyte globulin induction and steroid withdrawal followed by a three-drug immunosuppression regimen is an excellent strategy for PTA recipients.
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Affiliation(s)
- Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard S Mangus
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeanne M Chen
- Department of Pharmacy, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim E Taber
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Arianna E Cabrales
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Asif A Sharfuddin
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Muhammad S Yaqub
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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