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Mervak BM, Roseland ME, Wasnik AP. Pancreatic Transplantation: Surgical Anatomy and Complications. Radiol Clin North Am 2023; 61:821-831. [PMID: 37495290 DOI: 10.1016/j.rcl.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Pancreatic transplantation is a complex surgical procedure performed for patients with chronic severe diabetes, often performed in combination with renal transplantation. Vascular and exocrine drainage anatomy varies depending on the surgical technique. Radiology plays a critical role in the diagnosis of postoperative complications, requiring an understanding of grayscale/Doppler ultrasound as well as computed tomography and MR imaging. In this review, we detail usual surgical methods and normal postoperative imaging appearances. We then review the most common complications following pancreatic transplants, emphasizing diagnostic features of vascular (arterial/venous), surgical, and diffuse parenchymal pathologic conditions on multiple imaging modalities.
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Affiliation(s)
- Benjamin M Mervak
- Division of Abdominal Radiology, Department of Radiology, University of Michigan-Michigan Medicine, University Hospital, B1D502, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Molly E Roseland
- Division of Abdominal Radiology, Department of Radiology, University of Michigan-Michigan Medicine, University Hospital, B1D502, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Division of Nuclear Medicine, Department of Radiology, University of Michigan-Michigan Medicine, University Hospital, B1D502, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ashish P Wasnik
- Division of Abdominal Radiology, Department of Radiology, University of Michigan-Michigan Medicine, University Hospital, B1D502, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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2
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Coffman D, Jay CL, Sharda B, Garner M, Farney AC, Orlando G, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta R, Stratta RJ. Influence of donor and recipient sex on outcomes following simultaneous pancreas-kidney transplantation in the new millennium: Single-center experience and review of the literature. Clin Transplant 2023; 37:e14864. [PMID: 36399473 PMCID: PMC10078322 DOI: 10.1111/ctr.14864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The influence of sex on outcomes following simultaneous pancreas-kidney transplantation (SPKT) in the modern era is uncertain. METHODS We retrospectively studied 255 patients undergoing SPKT from 11/2001 to 8/2020. Cases were stratified according to donor (D) sex, recipient (R) sex, 4 D/R sex categories, and D/R sex-matched versus mismatched. RESULTS D-male was associated with slightly higher patient (p = .08) and kidney (p = .002) but not pancreas (p = .23) graft survival rates (GSR) compared to D-female. There were no differences in recipient outcomes other than slightly higher pancreas thrombosis (8% R-female vs. 4.2% R-male, p = .28) and early relaparotomy rates in female recipients (38% R-female vs. 29% R-male, p = .14). When analyzing the 4 D/R sex categories, the two D-male groups had higher kidney GSRs compared to the two D-female groups (p = .01) whereas early relaparotomy and pancreas thrombosis rates were numerically higher in the D-female/R-female group compared to the other three groups. Finally, there were no significant differences in outcomes between sex-matched and sex-mismatched groups although overall survival outcomes were lower with female donors irrespective of recipient sex. CONCLUSIONS The influence of D/R sex following SPKT is subject to multiple confounding issues but survival rates appear to be higher in D-male/R-male and lower in D-female/R-male categories.
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Affiliation(s)
- David Coffman
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Matthew Garner
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Robert Stratta
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
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Sharda B, Jay CL, Gurung K, Harriman D, Gurram V, Farney AC, Orlando G, Rogers J, Garner M, Stratta RJ. Improved surgical outcomes following simultaneous pancreas-kidney transplantation in the contemporary era. Clin Transplant 2022; 36:e14792. [PMID: 36029250 PMCID: PMC10078434 DOI: 10.1111/ctr.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/20/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Complications leading to early technical failure have been the Achilles' heel of simultaneous pancreas-kidney transplantation (SPKT). The study purpose was to analyze longitudinally our experience with early surgical complications following SPKT with an emphasis on changes in practice that improved outcomes in the most recent era. STUDY DESIGN Single center retrospective review of all SPKTs from 11/1/01 to 8/12/20 with enteric drainage. Early relaparotomy was defined as occurring within 3 months of SPKT. Patients were stratified into two sequential eras: Era 1 (E1): 11/1/01-5/30/13; Era 2 (E2) 6/1/13-8/12/20 based on changes in practice that occurred pursuant to donor age and pancreas cold ischemia time (CIT). RESULTS 255 consecutive SPKTs were analyzed (E1, n = 165; E2, n = 90). E1 patients received organs from older donors (mean E1 27.3 vs. E2 23.1 years) with longer pancreas cold CITs) (mean E1 16.1 vs. E2 13.3 h, both p < .05). E1 patients had a higher early relaparotomy rate (E1 43.0% vs. E2 14.4%) and were more likely to require allograft pancreatectomy (E1 9.1% vs. E2 2.2%, both p < .05). E2 patients underwent systemic venous drainage more frequently (E1 8% vs. E2 29%) but pancreas venous drainage did not influence either relaparotomy or allograft pancreatectomy rates. The most common indications for early relaparotomy in E1 were allograft thrombosis (11.5%) and peri-pancreatic phlegmon/abscess (8.5%) whereas in E2 were thrombosis, pancreatitis/infection, and bowel obstruction (each 3%). CONCLUSION Maximizing donor quality (younger donors) and minimizing pancreas CIT are paramount for reducing early surgical complications following SPKT.
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Affiliation(s)
- Berjesh Sharda
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Komal Gurung
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - David Harriman
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Venkat Gurram
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Matthew Garner
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
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Rogers J, Jay CL, Farney AC, Orlando G, Jacobs ML, Harriman D, Gurram V, Sharda B, Gurung K, Reeves‐Daniel A, Doares W, Kaczmorski S, Mena‐Gutierrez A, Sakhovskaya N, Gautreaux MD, Stratta RJ. Simultaneous pancreas‐kidney transplantation in Caucasian versus African American patients: Does recipient race influence outcomes? Clin Transplant 2022; 36:e14599. [PMID: 35044001 PMCID: PMC9285604 DOI: 10.1111/ctr.14599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 11/30/2022]
Abstract
The influence of African American (AA) recipient race on outcomes following simultaneous pancreas‐kidney transplantation (SPKT) is uncertain.
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Affiliation(s)
- Jeffrey Rogers
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Colleen L. Jay
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Alan C. Farney
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Giuseppe Orlando
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Marie L. Jacobs
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - David Harriman
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Venkat Gurram
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Berjesh Sharda
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Komal Gurung
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Amber Reeves‐Daniel
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - William Doares
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Scott Kaczmorski
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Alejandra Mena‐Gutierrez
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Natalia Sakhovskaya
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Michael D. Gautreaux
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
| | - Robert J. Stratta
- Department of Surgery Section of Transplantation Atrium Health Wake Forest Baptist Winston‐Salem NC United States
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5
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Gurram V, Gurung K, Rogers J, Farney AC, Orlando G, Jay C, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Doares W, Kaczmorski S, Sharda B, Gautreaux MD, Stratta RJ. Do pretransplant C-peptide levels predict outcomes following simultaneous pancreas-kidney transplantation? A matched case-control study. Clin Transplant 2021; 36:e14498. [PMID: 34599533 DOI: 10.1111/ctr.14498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/17/2021] [Accepted: 09/27/2021] [Indexed: 11/27/2022]
Abstract
Following simultaneous pancreas-kidney transplantation (SPKT), survival outcomes are reported as equivalent in patients with detectable pretransplant C-peptide levels (Cp+) and a "type 2″ diabetes mellitus (DM) phenotype compared to type 1 (Cp negative [Cp-]) DM. We retrospectively compared 46 Cp+ patients pretransplant (≥2.0 ng/mL, mean 5.4 ng/mL) to 46 Cp- (level < 0.5 ng/mL) case controls matched for recipient age, gender, race, and transplant date. Early outcomes were comparable. Actual 5-year patient survival (91% versus 94%), kidney graft survival (69% versus 86%, p = .15), and pancreas graft survival (60% versus 86%, p = .03) rates were lower in Cp+ versus Cp- patients, respectively. The Cp+ group had more pancreas graft failures due to insulin resistance (13% Cp+ versus 0% Cp-, p = .026) or rejection (17% Cp+ versus 6.5% Cp-, p = .2). Post-transplant weight gain > 5 kg occurred in 72% of Cp+ versus 26% of Cp- patients (p = .0001). In patients with functioning grafts, mean one-year post-transplant HbA1c levels (5.0 Cp+ versus 5.2% Cp-) were comparable, whereas Cp levels were higher in Cp+ patients (5.0 Cp+ versus 2.6 ng/mL Cp-). In this matched case-control study, outcomes were inferior in Cp+ compared to Cp- patients following SPKT, with post-transplant weight gain, insulin resistance, and rejection as potential mitigating factors.
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Affiliation(s)
- Venkat Gurram
- Departments of General Surgery, (Section of Transplantation)
| | - Komal Gurung
- Departments of General Surgery, (Section of Transplantation)
| | - Jeffrey Rogers
- Departments of General Surgery, (Section of Transplantation)
| | - Alan C Farney
- Departments of General Surgery, (Section of Transplantation)
| | | | - Colleen Jay
- Departments of General Surgery, (Section of Transplantation)
| | | | | | | | | | | | - Berjesh Sharda
- Departments of General Surgery, (Section of Transplantation)
| | - Michael D Gautreaux
- Department of Pathology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
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Gurung K, Alejo J, Rogers J, Farney AC, Orlando G, Jay C, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Doares W, Kaczmorski S, Gautreaux MD, Stratta RJ. Recipient age and outcomes following simultaneous pancreas-kidney transplantation in the new millennium: Single-center experience and review of the literature. Clin Transplant 2021; 35:e14302. [PMID: 33783874 DOI: 10.1111/ctr.14302] [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: 02/11/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/30/2022]
Abstract
The influence of recipient age on outcomes following simultaneous pancreas-kidney transplantation (SPKT) in the modern era is uncertain. METHODS We retrospectively studied 255 patients undergoing SPKT from 11/01 to 8/20. Recipients were stratified according to age group: age <30 years (n = 16); age 30-39 years (n = 91); age 40-49 years (n = 86) and age ≥50 years (n = 62 [24.3%], including 9 patients ≥60 years of age). RESULTS Three-month and one-year outcomes were comparable. The eight-year patient survival rate was lowest in the oldest age group (47.6% vs 78% in the 3 younger groups combined, p < .001). However, eight-year kidney and pancreas graft survival rates were comparable in the youngest and oldest age groups combined (36.5% and 32.7%, respectively), but inferior to those in the middle 2 groups combined (62% and 50%, respectively, both p < .05). Death-censored kidney and pancreas graft survival rates increased from youngest to oldest recipient age category because of a higher incidence of death with functioning grafts (22.6% in oldest group compared to 8.3% in the 3 younger groups combined, p = .005). CONCLUSIONS Recipient age did not appear to significantly influence early outcomes following SPKT. Late outcomes are similar in younger and older recipients, but inferior to the middle 2 age groups.
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Affiliation(s)
- Komal Gurung
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Jennifer Alejo
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Colleen Jay
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Amber Reeves-Daniel
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Alejandra Mena-Gutierrez
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Natalia Sakhovskaya
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - William Doares
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Scott Kaczmorski
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Michael D Gautreaux
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest Baptist Health, Winston-Salem, NC, USA
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7
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Fehrenbach U, Thiel R, Bady PD, Auer TA, Kahl A, Geisel D, Lopez Hänninen E, Öllinger R, Pratschke J, Gebauer B, Denecke T. CT fluoroscopy-guided pancreas transplant biopsies: a retrospective evaluation of predictors of complications and success rates. Transpl Int 2021; 34:855-864. [PMID: 33604958 DOI: 10.1111/tri.13849] [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: 11/14/2020] [Revised: 12/09/2020] [Accepted: 02/17/2021] [Indexed: 01/03/2023]
Abstract
To identify predictors of biopsy success and complications in CT-guided pancreas transplant (PTX) core biopsy. We retrospectively identified all CT fluoroscopy-guided PTX biopsies performed at our institution (2000-2017) and included 187 biopsies in 99 patients. Potential predictors related to patient characteristics (age, gender, body mass index (BMI), PTX age, PTX volume) and procedure characteristics (biopsy depth, needle size, access path, number of samples, interventionalist's experience) were correlated with biopsy success (sufficient tissue for histologic diagnosis) and the occurrence of complications. Biopsy success (72.2%) was more likely to be obtained in men [+25.3% (10.9, 39.7)] and when the intervention was performed by an experienced interventionalist [+27.2% (8.1, 46.2)]. Complications (5.9%) occurred more frequently in patients with higher PTX age [OR: 1.014 (1.002, 1.026)] and when many (3-4) tissue samples were obtained [+8.7% (-2.3, 19.7)]. Multivariable regression analysis confirmed male gender [OR: 3.741 (1.736, 8.059)] and high experience [OR: 2.923 (1.255, 6.808)] (biopsy success) as well as older PTX age [OR: 1.019 (1.002, 1.035)] and obtaining many samples [OR: 4.880 (1.240, 19.203)] (complications) as independent predictors. Our results suggest that CT-guided PTX biopsy should be performed by an experienced interventionalist to achieve higher success rates, and not more than two tissue samples should be obtained to reduce complications. Caution is in order in patients with older transplants because of higher complication rates.
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Affiliation(s)
- Uli Fehrenbach
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Regina Thiel
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Timo A Auer
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Kahl
- Klinik für Nephrologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Geisel
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Enrique Lopez Hänninen
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Radiologie, Martin-Luther-Krankenhaus, Berlin, Germany
| | - Robert Öllinger
- Chirurgische Klinik, Campus Charité Mitte, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Chirurgische Klinik, Campus Charité Mitte, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bernhard Gebauer
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Timm Denecke
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Radiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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8
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Ferrer-Fàbrega J, Fernández-Cruz L. Exocrine drainage in pancreas transplantation: Complications and management. World J Transplant 2020; 10:392-403. [PMID: 33437672 PMCID: PMC7769732 DOI: 10.5500/wjt.v10.i12.392] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/23/2020] [Accepted: 12/08/2020] [Indexed: 02/06/2023] Open
Abstract
The aim of this minireview is to compare various pancreas transplantation exocrine drainage techniques i.e., bladder vs enteric. Both techniques have different difficulties and complications. Numerous comparisons have been made in the literature between exocrine drainage techniques throughout the history of pancreas transplantation, detailing complications and their impact on graft and patient survival. Specific emphasis has been made on the early postoperative management of these complications and the related surgical infections and their consequences. In light of the results, a number of bladder-drained pancreas grafts required conversion to enteric drainage. As a result of technical improvements, outcomes of the varied enteric exocrine drainage techniques (duodenojejunostomy, duodenoduodenostomy or gastric drainage) have also been discussed i.e., assessing specific risks vs benefits. Pancreatic exocrine secretions can be drained to the urinary or intestinal tracts. Until the late 1990s the bladder drainage technique was used in the majority of transplant centers due to ease of monitoring urine amylase and lipase levels for evaluation of possible rejection. Moreover, bladder drainage was associated at that time with fewer surgical complications, which in contrast to enteric drainage, could be managed with conservative therapies. Nowadays, the most commonly used technique for proper driving of exocrine pancreatic secretions is enteric drainage due to the high rate of urological and metabolic complications associated with bladder drainage. Of note, 10% to 40% of bladder-drained pancreata eventually required enteric conversion at no detriment to overall graft survival. Various surgical techniques were originally described using the small bowel for enteric anastomosis with Roux-en-Y loop or a direct side-to-side anastomosis. Despite the improvements in surgery, enteric drainage complication rates ranging from 2%-20% have been reported. Treatment depends on the presence of any associated complications and the condition of the patient. Intra-abdominal infection represents a potentially very serious problem. Up to 30% of deep wound infections are associated with an anastomotic leak. They can lead not only to high rates of graft loss, but also to substantial mortality. New modifications of established techniques are being developed, such as gastric or duodenal exocrine drainage. Duodenoduodenostomy is an interesting option, in which the pancreas is placed behind the right colon and is oriented cephalad. The main concern of this technique is the challenge of repairing the native duodenum when allograft pancreatectomy is necessary. Identification and prevention of technical failure remains the main objective for pancreas transplantation surgeons. In conclusion, despite numerous techniques to minimize exocrine pancreatic drainage complications e.g., leakage and infection, no universal technique has been standardized. A prospective study/registry analysis may resolve this.
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Affiliation(s)
- Joana Ferrer-Fàbrega
- HepatoBiliaryPancreatic Surgery and Liver and Pancreas Transplantation Department, ICMDM, Hospital Clinic Barcelona, University of Barcelona, Barcelona Clinic Liver Cancer Group, August Pi i Sunyer Biomedical Research Institute, Barcelona 08036, Barcelona, Spain
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9
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Wasnik AP, Aslam AA, Millet JD, Pandya A, Bude RO. Multimodality imaging of pancreas-kidney transplants. Clin Imaging 2020; 69:185-195. [PMID: 32866771 DOI: 10.1016/j.clinimag.2020.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
Simultaneous pancreas-kidney transplant remains a treatment option for patients with insulin-dependent diabetes mellitus type 1, aimed at restoring normoglycemia, alleviating insulin dependency, avoiding diabetic nephropathy, and thereby improving the quality of life. Imaging remains critical in the assessment of these transplant grafts. Ultrasound with Doppler remains the primary imaging modality for establishing baseline assessment of the graft as well as for evaluating vascular, parenchymal, and perigraft complications. Noncontrast MR imaging is preferred over non-contrast CT for evaluation of parenchymal or perigraft complications in patients with decreased renal function, although contrast-enhanced CT/MR imaging may be obtained following multidisciplinary consultation in cases with high clinical and laboratory suspicion for graft dysfunction. Catheter angiography is reserved primarily for therapeutic intervention in suspected or confirmed vascular complications. An understanding of the surgical techniques and imaging appearance of a normal graft is crucial to identify potential complications and direct timely management. This article provides an overview of surgical techniques, normal imaging appearance, as well as the spectrum of imaging findings and potential complications in pancreas-kidney transplants.
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Affiliation(s)
- Ashish P Wasnik
- Department of Radiology, University of Michigan-Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States.
| | - Anum A Aslam
- Department of Radiology, University of Michigan-Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States.
| | - John D Millet
- Department of Radiology, University of Michigan-Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States.
| | - Amit Pandya
- Department of Radiology, University of Michigan-Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States.
| | - Ronald O Bude
- Department of Radiology, University of Michigan-Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States.
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10
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Shampain KL, Liles AL, Chong ST. Imaging of Transplant Emergencies. Semin Roentgenol 2020; 55:115-131. [PMID: 32438975 DOI: 10.1053/j.ro.2019.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Amber L Liles
- Department of Radiology, Michigan Medicine, Ann Arbor, MI
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11
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David A, Frampas E, Douane F, Perret C, Leaute F, Cantarovich D, Karam G, Branchereau J. Management of vascular and nonvascular complications following pancreas transplantation with interventional radiology. Diagn Interv Imaging 2020; 101:629-638. [PMID: 32089482 DOI: 10.1016/j.diii.2020.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/29/2020] [Accepted: 02/02/2020] [Indexed: 12/23/2022]
Abstract
Pancreas transplantation exposes to high rates of complications, either vascular (thrombosis, stenosis, pseudoaneurysm, arteriovenous fistula) or nonvascular (fluid collection, graft rejection). With advances in percutaneous and endovascular techniques, interventional radiologists are increasingly involved in the management of these complications. In this article, we review the anatomical considerations relevant to pancreas transplantation, the techniques used for image-guided interventions for vascular and nonvascular complications, and the expected outcomes of these interventions.
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Affiliation(s)
- A David
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France.
| | - E Frampas
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - F Douane
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - C Perret
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - F Leaute
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - D Cantarovich
- Department of Nephrology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - G Karam
- Department of Urology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - J Branchereau
- Department of Urology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
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Cahalane AM, Mojtahed A, Sahani DV, Elias N, Kambadakone AR. Pre-hepatic and pre-pancreatic transplant donor evaluation. Cardiovasc Diagn Ther 2019; 9:S97-S115. [PMID: 31559157 DOI: 10.21037/cdt.2018.09.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Innovations in surgical techniques coupled with advances in medical and pharmacological management in the past few decades have enabled organ transplantation to become integral to the management of end stage organ failure. In this review article, we will review the role of the radiologist in the work up of liver and pancreas donors during evaluation of their donor candidacy. The critical role of imaging in assessing the parenchymal, biliary and vascular anatomy in liver donor candidates will be reviewed, as well as highlighting the anatomical findings that may pose a contraindication to transplantation. The limited role of imaging in pancreas donor evaluation is also covered, as well as a brief overview of the surgical techniques available and how the radiologist's findings influence operative technique selection.
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Affiliation(s)
- Alexis M Cahalane
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Amirkasra Mojtahed
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Dushyant V Sahani
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nahel Elias
- Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Avinash R Kambadakone
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
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13
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Choi BH, Park YM, Yang KH, Chu CW, Ryu JH. Inferior Vena Cava-Duodenal Drainage in Pancreas Alone Transplantation for Chronic Pancreatitis: A Case Report. Transplant Proc 2016; 48:3217-3221. [PMID: 27932185 DOI: 10.1016/j.transproceed.2016.02.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 02/02/2016] [Indexed: 11/25/2022]
Abstract
Enteric drainage has been the main trend in solitary pancreas transplantation. Compared with bladder drainage, it does not cause metabolic or urologic complications, but there is no way to perform immunologic monitoring, except by graft pancreas biopsy. Additionally, although portal drainage of the graft vein is considered physiological drainage, it has more of a risk for surgical complications. To overcome these disadvantages, we successfully performed inferior vena cava (IVC)-duodenal drainage in pancreas alone transplantation. A 44-year-old man underwent pancreas alone transplantation. He had insulin-dependent diabetes because of chronic pancreatitis, thus he had taken a pancreatic enzyme. After right-sided medial visceral rotation, the IVC was dissected for anastomosis with a graft portal vein. The right common iliac artery was anastomosed with a Y-graft in the pancreas graft. The graft duodenum was anastomosed with recipient duodenum using the side-to-side manner. Postoperatively, he underwent protocol biopsies of the graft duodenum through endoscopy two times. There was no evidence of graft thrombosis or rejection. He had a normal glucose level without any diabetic drugs, and he required no pancreatic enzyme for digestion. The IVC-duodenum drainage procedure was a feasible method for preventing thrombosis and providing an opportunity for direct graft monitoring through endoscopy.
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Affiliation(s)
- B H Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Y M Park
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - K H Yang
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - C W Chu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - J H Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
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O'Malley RB, Moshiri M, Osman S, Menias CO, Katz DS. Imaging of Pancreas Transplantation and Its Complications. Radiol Clin North Am 2016; 54:251-66. [PMID: 26896223 DOI: 10.1016/j.rcl.2015.09.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Whole pancreas transplantation is an effective treatment for obtaining euglycemic status in patients with insulin-dependent diabetes mellitus, and is usually performed concurrent with renal transplantation in the affected patient. This article discusses complex surgical anatomical details of pancreas transplantation including surgical options for endocrine and exocrine drainage pathways. It then describes several possible complications related to surgical factors in the immediate post operative period followed by other complications related to systemic issues, vasculature, and the pancreatic parenchyma.
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Affiliation(s)
- Ryan B O'Malley
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | - Mariam Moshiri
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA.
| | - Sherif Osman
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | | | - Douglas S Katz
- Department of Radiology, Winthrop-University Hospital, Mineola, NY, USA
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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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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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Stratta RJ, Rogers J, Farney AC, Orlando G, El-Hennawy H, Gautreaux MD, Reeves-Daniel A, Palanisamy A, Iskandar SS, Bodner JK. Pancreas transplantation in C-peptide positive patients: does "type" of diabetes really matter? J Am Coll Surg 2014; 220:716-27. [PMID: 25667140 DOI: 10.1016/j.jamcollsurg.2014.12.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 12/15/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND In the past, type 2 (C-peptide positive) diabetes mellitus (DM) was a contraindication for simultaneous pancreas-kidney transplantation (SPKT). STUDY DESIGN We retrospectively analyzed outcomes in SPKT recipients according to pretransplantation C-peptide levels ≥ 2.0 ng/mL or < 2.0 ng/mL. RESULTS From November 2001 to March 2013, we performed 162 SPKTs including 30 (18.5%) in patients with C-peptide levels ≥ 2.0 ng/mL pretransplantation (C-peptide positive group, range 2.1 to 12.4 ng/mL) and 132 in patients with absent or low C-peptide levels (<2.0 ng/mL, C-peptide "negative"). C-peptide positive patients were older at SPKT, had a later age of onset and shorter duration of pretransplantation DM, and more were African-American (all p < 0.05) compared with C-peptide negative patients. With a mean follow-up of 5.6 years, patient (80% vs 82.6%), kidney graft (63.3% vs 68.9%), and pancreas graft survivals (50% vs 62.1%, all p = NS) rates were comparable in C-peptide positive and negative patients, respectively. At latest follow-up, there were no differences in acute rejection episodes, surgical complications, major infections, readmissions, hemoglobin A1c levels, serum creatinine, and estimated glomerular filtration rate levels between the 2 groups. C-peptide levels were higher (mean 5.0 vs 2.6 ng/mL, p < 0.05) and post-transplant weight gain (≥ 5 kg) was more common (57% vs 33%, p = 0.004) in the C-peptide positive group. Survival outcomes in C-peptide positive (n = 14) vs C-peptide negative (n = 22) African-American patients were similar, as were outcomes in C-peptide positive patients with a body mass index < or ≥ 28 kg/m(2). CONCLUSIONS Patients with higher pretransplantion C-peptide levels appear to have a type 2 DM phenotype compared to insulinopenic patients undergoing SPKT. However, survival and functional outcomes were similar, suggesting that pretransplantation C-peptide levels should not be used exclusively to determine candidacy for SPKT.
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Affiliation(s)
- Robert J Stratta
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC.
| | - Jeffrey Rogers
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
| | - Alan C Farney
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
| | - Giuseppe Orlando
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
| | - Hany El-Hennawy
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael D Gautreaux
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amber Reeves-Daniel
- Department of Internal Medicine (Section of Nephrology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Amudha Palanisamy
- Department of Internal Medicine (Section of Nephrology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Samy S Iskandar
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jason K Bodner
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
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Rogers J, Farney AC, Orlando G, Iskandar SS, Doares W, Gautreaux MD, Kaczmorski S, Reeves-Daniel A, Palanisamy A, Stratta RJ. Pancreas transplantation: The Wake Forest experience in the new millennium. World J Diabetes 2014; 5:951-961. [PMID: 25512802 PMCID: PMC4265886 DOI: 10.4239/wjd.v5.i6.951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/09/2014] [Accepted: 11/10/2014] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate the Wake Forest experience with pancreas transplantation in the new millennium with attention to surgical techniques and immunosuppression.
METHODS: A monocentric, retrospective review of outcomes in simultaneous kidney-pancreas transplant (SKPT) and solitary pancreas transplant (SPT) recipients was performed. All patients underwent pancreas transplantation as intent-to-treat with portal venous and enteric exocrine drainage and received depleting antibody induction; maintenance therapy included tapered steroids or early steroid elimination with mycophenolate and tacrolimus. Recipient selection was based on clinical judgment whether or not the patient exhibited measureable levels of C-peptide.
RESULTS: Over an 11.25 year period, 202 pancreas transplants were performed in 192 patients including 162 SKPTs and 40 SPTs. A total of 186 (92%) were primary and 16 (8%) pancreas retransplants; portal-enteric drainage was performed in 179 cases. A total of 39 pancreas transplants were performed in African American (AA) patients; of the 162 SKPTs, 30 were performed in patients with pretransplant C-peptide levels > 2.0 ng/mL. In addition, from 2005-2008, 46 SKPT patients were enrolled in a prospective study of single dose alemtuzumab vs 3-5 doses of rabbit anti-thymocyte globulin induction therapy. With a mean follow-up of 5.7 in SKPT vs 7.7 years in SPT recipients, overall patient (86% SKPT vs 87% SPT) and kidney (74% SKPT vs 80% SPT) graft survival rates as well as insulin-free rates (both 65%) were similar (P = NS). Although mortality rates were nearly identical in SKPT compared to SPT recipients, patterns and timing of death were different as no early mortality occurred in SPT recipients whereas the rates of mortality following SKPT were 4%, 9% and 12%, at 1-, 3- and 5-years follow-up, respectively (P < 0.05). The primary cause of graft loss in SKPT recipients was death with a functioning graft whereas the major cause of graft loss following SPT was acute and chronic rejection. The overall incidence of acute rejection was 29% in SKPT and 27.5% in SPT recipients (P = NS). Lower rates of acute rejection and major infection were evidenced in SKPT patients receiving alemtuzumab induction therapy. Comparable kidney and pancreas graft survival rates were observed in AA and non-AA recipients despite a higher prevalence of a “type 2 diabetes” phenotype in AA. Results comparable to those achieved in insulinopenic diabetics were found in the transplantation of type 2 diabetics with detectable C-peptide levels.
CONCLUSION: In the new millennium, acceptable medium-term outcomes can be achieved in SKPT and SPTs as nearly 2/3rds of patients are insulin independent following pancreas transplantation.
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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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