Optimizing outcomes in pancreas transplantation: Impact of organ preservation time

Four Decades of Research Productivity and Hot Spots in Pancreas Transplantation

Background: The field of pancreas transplantation has undergone transformative phases, progressing from its promising inception in 1966 to becoming a standard treatment for patients with insulin-dependent diabetes. This bibliometric analysis explores the progression of pancreas transplantation research over a period of four decades, mapping milestones, contributors, and emerging trends. Methods: Our bibliometric analysis utilizes the comprehensive Scopus database, which includes publication titles, author information, affiliations, abstracts, keywords, and journal details. The search strategy was centered on research related to pancreas and pancreas-kidney transplantation. The analysis encompasses the time frame spanning from 1983 to 2023, with the data extraction taking place on October 7th, 2023. Results: The analysis of 4,897 articles uncovered unique trends in the field of pancreas transplantation research. The years 1989, 1996, and 2021 saw significant increases in the number of publications, which corresponded to the responses to clinical challenges and advancements. Contributions by authors from the United States of America were the most numerous, with 1,905 publications and 49,949 citations. The research topics were highlighted by keywords such as "graft survival," "graft rejection," and" Immunosuppressive treatment." Conclusion: The fluctuations in publication trends that have been identified indicate dynamic reactions to changing priorities and challenges. Although it has limitations, this analysis provides valuable insights for researchers, clinicians, and policymakers who are dealing with the complex field of pancreas transplantation literature. Further bibliometric research may advance our knowledge and direct future initiatives in this developing field.

The impact of time to death in donors after circulatory death on recipient outcome in simultaneous pancreas-kidney transplantation

The time to arrest donors after circulatory death is unpredictable and can vary. This leads to variable periods of warm ischemic damage prior to pancreas transplantation. There is little evidence supporting procurement team stand-down times based on donor time to death (TTD). We examined what impact TTD had on pancreas graft outcomes following donors after circulatory death (DCD) simultaneous pancreas-kidney transplantation. Data were extracted from the UK transplant registry from 2014 to 2022. Predictors of graft loss were evaluated using a Cox proportional hazards model. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. Three-hundred-and-seventy-five DCD simultaneous kidney-pancreas transplant recipients were included. Increasing TTD was not associated with graft survival (adjusted hazard ratio HR 0.98, 95% confidence interval 0.68-1.41, P = .901). Increasing asystolic time worsened graft survival (adjusted hazard ratio 2.51, 95% confidence interval 1.16-5.43, P = .020). Restricted cubic spline modeling revealed a nonlinear relationship between asystolic time and graft survival and no relationship between TTD and graft survival. We found no evidence that TTD impacts pancreas graft survival after DCD simultaneous pancreas-kidney transplantation; however, increasing asystolic time was a significant predictor of graft loss. Procurement teams should attempt to minimize asystolic time to optimize pancreas graft survival rather than focus on the duration of TTD.

Does Timepoint of Surgical Procedure Affect the Outcome in Simultaneous Pancreas-Kidney Transplantation? A Retrospective Single-Center Analysis over 20 Years

Background: Sleep deprivation and disturbances in circadian rhythms may hinder surgical performance and decision-making capabilities. Solid organ transplantations, which are technically demanding and often begin at uncertain times, frequently during nighttime hours, are particularly susceptible to these effects. This study aimed to assess how transplant operations conducted during daytime versus nighttime influence both patient and graft outcomes and function. Methods: simultaneous pancreas-kidney transplants (SPKTs) conducted at the University Hospital of Leipzig from 1998 to 2018 were reviewed retrospectively. The transplants were categorized based on whether they began during daytime hours (8 a.m. to 6 p.m.) or nighttime hours (6 p.m. to 8 a.m.). We analyzed the demographics of both donors and recipients, as well as primary outcomes, which included surgical complications, patient survival, and graft longevity. Results: In this research involving 105 patients, 43 SPKTs, accounting for 41%, took place in the daytime, while 62 transplants (59%) occurred at night. The characteristics of both donors and recipients were similar across the two groups. Further, the rate of (surgical) pancreas graft-related complications and reoperations (daytime 39.5% versus nighttime 33.9%; p = 0.552) were also not statistically significant between both groups. In this study, the five-year survival rate for patients was comparable for both daytime and nighttime surgeries, with 85.2% for daytime and 86% for nighttime procedures (p = 0.816). Similarly, the survival rates for pancreas grafts were 75% for daytime and 77% for nighttime operations (p = 0.912), and for kidney grafts, 76% during the day compared to 80% at night (p = 0.740), indicating no significant statistical difference between the two time periods. In a multivariable model, recipient BMI > 30 kg/m2, donor age, donor BMI, and cold ischemia time > 15 h were independent predictors for increased risk of (surgical) pancreas graft-related complications, whereas the timepoint of SPKT (daytime versus nighttime) did not have an impact. Conclusions: The findings from our retrospective analysis at a big single German transplant center indicate that SPKT is a reliable procedure, regardless of the start time. Additionally, our data revealed that patients undergoing nighttime transplants have no greater risk of surgical complications or inferior results concerning long-term survival of the patient and graft. However, due to the small number of cases evaluated, further studies are required to confirm these results.

Efficacy and Safety Evaluation of Energy Devices in Bench Surgery for Pancreas Transplantation

INTRODUCTION

Bench surgery for the preparation of deceased donor pancreatic grafts is labor-intensive and time-consuming. We hypothesized that energy devices could be used during bench surgery to decrease the bench surgery time. However, because bench surgery has two unique characteristics, wet conditions and no blood flow in the vessels, it is necessary to verify the safety and efficacy under such conditions.

METHODS

In an animal tissue model, we validated both ultrasonic and bipolar energy devices: Harmonic Shears and the LigaSure (LS) vessel-sealing device by evaluating heat spread and pressure resistance under bench surgery conditions. In a clinical evaluation of the LS, we compared the outcomes of 22 patients in two different bench surgery groups: with and without the use of the LS.

RESULTS

Clinically, the bench surgery time was significantly shorter in the LS group than that in the conventional group (P < 0.001). In the animal tissue experiments, the highest temperature in bench surgery conditions was 60.4°C after 1 s at a 5-mm distance in the LS group. Pressure resistance of ≥ 750 mmHg was achieved in almost all trials in both veins and arteries, with no difference between Harmonic Shears and LS. There was more surgical smoke visually in bench conditions versus in dry conditions and under half bite versus full bite conditions.

CONCLUSIONS

The encouraging results of our exploratory clinical and animal studies of the energy devices suggest that they may be useful in the setting of bench surgery.

Reanimating Pancreatic Grafts Subjected to Prolonged Cold Ischemic Injury Using Normothermic Ex Vivo Perfusion

Background

Pancreas transplant volumes are limited because of poor utilization of "extended criteria grafts." Prolonged cold ischemia is a risk factor associated with poor allograft survival. We aimed to establish the feasibility of transplantation using grafts subjected to prolonged cold ischemia and determine whether these grafts could be optimized using normothermic ex vivo perfusion (NEVP) in a porcine model.

Methods

The study population consisted of 35 to 40 kg male Yorkshire pigs in an allotransplantation model with a 3-d survival plan for recipients. Control grafts were subjected to cold storage (CS) in a University of Wisconsin solution for 21 to 24 h (n = 6), whereas the test group received an additional 3 h NEVP after CS of 21 h (n = 5).

Results

The 3-d survival was 60% in the NEVP arm versus 0% in the control arm (P = 0.008; log rank). Graft parenchyma was 60% to 70% preserved in the NEVP arm at necropsy on gross appearance. In addition, the islet function was well preserved, and both the pancreas (including the islets) and the duodenal morphology were maintained histologically. The intravenous glucose tolerance test on the day of euthanasia was in the normoglycemic range for 80% of cases in the NEVP arm.

Conclusions

Optimization of pancreas grafts exposed to extended CS with NEVP seems promising at rescuing and reanimating these grafts for transplantation, resulting in significantly improved survival in a porcine pancreas transplant model.

Pancreas Transplant Alone in the USA, Where Do We Stand?

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.

Pasireotide Versus Octreotide in Preventing Complications After Simultaneous Pancreas-Kidney Transplantation

In elective pancreatic surgery, somatostatin-analogues pasireotide and octreotide are variably used to reduce postoperative complications, but knowledge on their role in pancreas transplantation is limited. This study compared pasireotide and octreotide for their association with complications after simultaneous pancreas-kidney transplantation (SPK). This retrospective study included consecutive patients undergoing SPK's from July 2013 to July 2022. Between July 2013 and April 2020, octreotide was administered 0.1 mg s.c. once daily and between May 2020 and July 2022 pasireotide was administered 0.9 mg twice daily, both until third postoperative day. Complications within 90 days postoperatively were collected, and reoperation rate and Comprehensive Complication index (CCI) ≥ 33.7 (morbidity equal to one reoperation) were used as primary outcomes. Of the 213 patients undergoing SPK, 150 patients received octreotide and 63 pasireotide. Baseline characteristics were comparable. Reoperation rate was 25.3% (n = 38) and 17.5% (n = 11) (p = 0.213) and rate of CCI ≥ 33.7 was 40.7% (n = 61) and 30.2% (n = 19) (p = 0.148) in octreotide and pasireotide groups, respectively. When adjusted with donor BMI, pancreas donor risk index, and donor sex, receiving pasireotide translated into OR 0.49 (95% CI: 0.25-0.96 p = 0.037) for CCI ≥ 33.7. Pasireotide was independently associated with lower postoperative morbidity within 90 days of SPK compared to octreotide.

Clinical Impact of Ischemic Time of the Pancreas or Kidney Graft on Simultaneous Pancreas-Kidney Transplantation: A Single-Institution Study in Japan

BACKGROUND

Total ischemic time (TIT) potentially affects graft survival in organ transplantation. However, in simultaneous pancreas-kidney (SPK) transplantation, the impact of TIT of the pancreas (P-TIT) and kidney graft (K-TIT) on posttransplant outcomes remains unclear. This study investigated the impact of P-TIT and K-TIT on postoperative outcomes in patients after SPK at our institution in Japan.

PATIENTS AND METHODS

This study included 52 patients who underwent SPK at our hospital from April 2000 to March 2022. Of this patient group, the 52 patients were divided into a short P-TIT group (n = 25), long P-TIT group (n = 27), short K-TIT group (n = 42), and long K-TIT group (n = 10). Short- and long-term postoperative outcomes were compared between the groups.

RESULTS

The long K-TIT group had a significantly higher rate of patients who did not urinate intraoperatively (50% vs 7%; P = .0007) and those requiring postoperative hemodialysis (80% vs 38%; P = .0169), as well as a significant longer duration of postoperative hemodialysis (97 ± 147 days vs 6 ± 9 days; P = .0016). These were not significantly different between the short and long P-TIT groups. Kidney or pancreas graft survival was not significantly different between the short and long P-TIT or K-TIT groups.

CONCLUSIONS

Patients with prolonged K-TIT during SPK exhibited poor short-term outcomes, but no significant influence of K-TIT was identified on long-term outcomes. The P-TIT did not affect any significant outcomes. These results indicate that shortening K-TIT may improve short-term outcomes after SPK.

Sterile Pancreas Inflammation during Preservation and after Transplantation

The pancreas is very susceptible to ischemia-reperfusion injury. Early graft losses due to pancreatitis and thrombosis represent a major issue after pancreas transplantation. Sterile inflammation during organ procurement (during brain death and ischemia-reperfusion) and after transplantation affects organ outcomes. Sterile inflammation of the pancreas linked to ischemia-reperfusion injury involves the activation of innate immune cell subsets such as macrophages and neutrophils, following tissue damage and release of damage-associated molecular patterns and pro-inflammatory cytokines. Macrophages and neutrophils favor tissue invasion by other immune cells, have deleterious effects or functions, and promote tissue fibrosis. However, some innate cell subsets may promote tissue repair. This outburst of sterile inflammation promotes adaptive immunity activation via antigen exposure and activation of antigen-presenting cells. Better controlling sterile inflammation during pancreas preservation and after transplantation is of utmost interest in order to decrease early allograft loss (in particular thrombosis) and increase long-term allograft survival. In this regard, perfusion techniques that are currently being implemented represent a promising tool to decrease global inflammation and modulate the immune response.

Effect of donor pancreas extraction time on pancreas transplantation-a Swiss tertiary center experience

We aimed to assess the effect of donor pancreas extraction time (ET) on postoperative complications and graft function after pancreas transplantation (PT). We analyzed all consecutive donor pancreas procurements for the simultaneous pancreas and kidney transplantation (SPK) and the associated PT in a Swiss transplant center over a 20-year period. Pancreas ET was defined as the time from cold flush to static storage of the pancreas on ice. The primary endpoint was the effect of extraction time on surgical complications. Secondary endpoints comprised the effect of ET on graft function (insulin-free survival) and graft pancreatitis. Of 115 procured pancreas grafts the median donor pancreas ET was 65 min (IQR: 48-78 min). In multivariable analysis, ET did not negatively affect major complications (OR 1.41 [95% CI: .59-3.36]; p = .438) and insulin-free survival (HR 1.42 [95% CI: .55-3.63]; p = .459). The median CIT was 522 (441-608) min. CIT was associated with major complications (OR 2.51 [95% CI: 1.11-5.68]; p = .027), but without impact on insulin-free survival (HR 1.94 [95% CI: .84-4.48]; p = .119). Patients with and without graft pancreatitis had no statistically significant differences in ET and CIT (p = .164 and p = .47, respectively). In multivariable analysis, Amylase levels > 270 U/L on postoperative day 1 were significantly associated with major complications (OR 3.61 [95% CI: 1.06-12.32]; p = .040). Our results suggest that although no effect of ET on complications and graft function after PT was found, shorter CIT and less graft pancreatitis can have a positive impact on surgical complications. Results could possibly be influenced by the exceptional quality of the pancreas donors, with short travel distances and preservation times in Switzerland.

Improved surgical outcomes following simultaneous pancreas-kidney transplantation in the contemporary era

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.

Towards a Rational Balanced Pancreatic and Islet Allocation Schema

Allocation of donated organs for transplantation is a complex process that considers numerous factors such as donor, organ and candidate characteristics and practical issues such as geography. Whole pancreas and isolated islet transplantation are lifesaving for certain individuals with diabetes. Herein, we suggest a revised allocation schema that matches donor characteristics with candidate medical condition while allowing for geographic considerations. It is hoped that adoption of this schema will shorten allocation time, decrease organ waste and optimize the parity between organ donor characteristics and candidate state of health.

Outcomes after simultaneous pancreas-kidney transplantation from donation after circulatory death donors: A UK registry analysis

There are concerns that simultaneous pancreas-kidney (SPK) transplants from donation after circulatory death (DCD) donors have a higher risk of graft failure than those from donation after brain death (DBD) donors. A UK registry analysis of SPK transplants between 2005 and 2018 was performed. Pancreas survivals of those receiving organs from DCD or DBD donors were compared. Multivariable analyses were used to adjust for baseline differences between the two groups and to identify factors associated with pancreas graft loss. A total of 2228 SPK transplants were implanted; 403 (18.1%) were from DCD donors. DCD donors were generally younger, slimmer, less likely to have stroke as a cause of death, with lower terminal creatinines and shorter pancreas cold ischemic times than DBD donors. Median (IQR) follow-up was 4.2 (1.6-8.1) years. On univariable analysis, there were no statistically significant differences in 5-year death-censored pancreas graft survival between the two donor types (79.5% versus 80.4%; p = .86). Multivariable analysis showed no statistically significant differences in 5-year pancreas graft loss between transplants from DCD (n = 343) and DBD (n = 1492) donors (hazard ratio 1.26, 95% CI 0.76-1.23; p = .12). The findings from this study support the increased use of SPK transplants from DCD donors.

First World Consensus Conference on pancreas transplantation: Part II - recommendations

The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246.

Donor Predictors of Donor Pancreas Retrieval and Subsequent Solid Pancreas Transplantation in Australia and New Zealand from 2007 to 2016

BACKGROUND

Donor characteristics help guide donor pancreas acceptance for solid pancreas-kidney transplantation; however, these criteria vary worldwide. Such variation could result in nonuse of potentially transplantable organs. Using a registry cohort, we identified donor characteristics associated with donor pancreas retrieval and subsequent solid pancreas transplantation in Australia and New Zealand.

METHODS

Australia and New Zealand Organ Donor registry donor data from 2007 to 2016 were used to define cohort 1 (all donors authorized for pancreas retrieval) and cohort 2 (all retrieved donor pancreata considered for solid pancreas transplantation). Donor factors significantly associated with donor pancreas retrieval (cohort 1) and solid pancreas transplantation of retrieved donor pancreata (cohort 2) were determined via multivariable logistic regression.

RESULTS

Nonretrieval and nonuse of solid organ donor pancreas increased throughout the study period, and nonauthorization for pancreas donation remained stable. Donor body mass index, sex, and viral serology were associated with donor pancreas retrieval but not transplantation. Donor age, cause of death, donation after brain death status, terminal serum creatinine, and donor region were associated with both donor pancreas retrieval and acceptance for solid pancreas transplantation with donation after brain death status being the strongest predictor for both outcomes.

CONCLUSIONS

Donor age, cause of death, donation after brain death status, terminal serum creatinine, and donor region were associated with both donor pancreas retrieval and subsequent transplantation in Australia and New Zealand. Subsequent correlation of these factors with post-pancreas transplant outcomes would help guide pancreas transplant decisions and minimize nonuse of potentially usable donor pancreata.

Impact of Histidine-Tryptophan-Ketoglutarate Versus University of Wisconsin Solution on the Outcome of Pancreas Transplant With Cold Ischemic Time ≥12 Hours: A Retrospective Study

OBJECTIVES

Histidine-tryptophan-ketoglutarate and University of Wisconsin solutions are currently used for pancreas graft preservation. Our hypothesis was whether the use of histidine-tryptophan-ketoglutarate solution is associated with worse pancreas graft survival than University of Wisconsin solution, in general and after prolonged cold ischemic time of ≥12 hours.

MATERIALS AND METHODS

This retrospective study investigated the impact of static cold storage in histidine-tryptophan-ketoglutarate (n = 133) versus University of Wisconsin (n = 107) solution on outcomes of 240 pancreas transplant procedures. Patient and graft survival rates were compared after 1, 3, and 5 years in both groups. Serum lipase, amylase, and C-reactive protein levels and incidence of surgical complications were evaluated at postoperative week 1. A subgroup analysis of 96 grafts (52 with histidine-tryptophanketoglutarate/44 with University of Wisconsin) with pancreas graft cold ischemic time ≥12 hours was also performed.

RESULTS

At mean follow-up of 75.2 ± 9.9 months, both groups demonstrated comparable short- and long-term patient survival. Overall, pancreas graft survival was slightly better in the histidine-tryptophan-ketoglutarate group (Kaplan-Meier analysis, log-rank P = .013). However, the subgroup analysis of grafts with cold ischemic time ≥12 hours showed slightly better pancreatic graft survival in the University of Wisconsin group, although not significantly (log-rank P = .95). Serum lipase and C-reactive protein levels at postoperative week 1 were higher in the histidinetryptophan-ketoglutarate group. Surgical complications were comparable. Multivariable Cox regression analysis identified neither solution as a risk factor affecting patient and graft survival.

CONCLUSIONS

Although a direct comparison between histidine-tryptophan-ketoglutarate and University of Wisconsin showed better pancreas graft survival with histidine-tryptophan-ketoglutarate, the multivariable analysis showed that the perfusion solution does not significantly influence patient and graft survival. However, in the analysis of transplants with cold ischemic time ≥12 hours, pancreas graft survival was slightly better in the University of Wisconsin group, although not significantly.

Pancreas preservation time as a predictor of prolonged hospital stay after pancreas transplantation

Objective

Length of hospital stay is a sensitive indicator of short-term prognosis. In this retrospective study, we investigated how pancreas preservation time affects length of hospital stay after pancreas transplantation.

Methods

Patients receiving pancreas transplantation (1998.7–2018.6) were identified from the Scientific Registry of Transplant Recipients database and grouped according to pancreas preservation time. We analyzed the relationship of pancreas preservation time with graft and patient survival and prolonged length of stay (PLOS; i.e., hospital stay ≥20 days).

Results

We included 18,099 pancreas transplants in the survival analysis. Pancreas preservation time >20 hours had a significantly higher risk of graft failure than 8 to 12 hours. Pancreas preservation time was not significantly associated with patient survival. We included 17,567 pancreas transplants in the analysis for PLOS. Compared with 8 to 12 hours, pancreas preservation time >12 hours had a significantly higher PLOS risk, which increased with increased pancreas preservation time. In simultaneous pancreas–kidney transplantation, we also found that pancreas preservation time was positively associated with PLOS risk with pancreas preservation time >12 hours.

Conclusion

Pancreas preservation time is a sensitive predictor of PLOS. Transplant centers should minimize pancreas preservation time to optimize patient outcomes.

The impact of donor pancreas extraction time on graft survival and postoperative complications in pancreas transplant recipients

BACKGROUND

Simultaneous pancreas kidney transplantation (SPK) is the best therapeutic option for patients with diabetes mellitus type 1 and end-stage renal disease. Recently, donor organ extraction time has been shown to affect kidney and liver graft survival. This study aimed to assess the effect of pancreas donor extraction time on graft survival and postoperative complications.

METHODS

We retrospectively analyzed all pancreas transplants performed in two Eurotransplant centers. The association of pancreas extraction time with pancreas graft survival was analyzed by a Cox proportional hazards regression analysis after 3 months, 1 and 5 year. Besides, the effect of pancreas extraction time on the incidence of severe postoperative complications was analyzed.

RESULTS

A total of 317 pancreas transplants were included in this study. Death-censored pancreas graft survival was 85.7% after one year and 76.7% after five years. Median pancreas donor extraction time was 64 min [IQR: 52-79 min]. After adjustment for potential confounders, death censored graft survival after 30 days (HR 1.01, 95% CI 0.9-1.03 (p = 0.23), 1 year (HR 1.01, 95% CI 0.99-1.03 (p = 0.22) and 5 years (HR 1.00, 95% CI 0.99-1.02 (p = 0.57) was not associated with pancreas donor extraction time. However, extraction time was significantly associated with a higher incidence of Clavien-Dindo ≥3 complications compared to Clavien-Dindo 1 + 2 complications: OR 1.012, 95% CI 1.00-1.02 (p = 0.039).

CONCLUSIONS

Our findings suggest that although no effect on graft survival was found, limiting pancreas extraction time can have a significant impact on lowering postoperative complications.

The Value of Graft Implantation Sequence in Simultaneous Pancreas-Kidney Transplantation on the Outcome and Graft Survival

BACKGROUND/OBJECTIVES

The sequence of graft implantation in simultaneous pancreas-kidney transplantation (SPKT) warrants additional study and more targeted focus, since little is known about the short- and long-term effects on the outcome and graft survival after transplantation.

MATERIAL AND METHODS

103 patients receiving SPKT in our department between 1999 and 2015 were included in the study. Patients were divided according to the sequence of graft implantation into pancreas-first (PF, n = 61) and kidney-first (KF, n = 42) groups. Clinicopathological characteristics, outcome and survival were reviewed retrospectively.

RESULTS

Donor and recipient characteristics were similar. Rates of post-operative complications and graft dysfunction were significantly higher in the PF group compared with the KF group (episodes of acute rejection within the first year after SPKT: 11 (18%) versus 2 (4.8%); graft pancreatitis: 18 (18%) versus 2 (4.8%), p = 0.04; vascular thrombosis of the pancreas: 9 (14.8%) versus 1 (2.4%), p = 0.03; and delayed graft function of the kidney: 12 (19.6%) versus 2 (4.8%), p = 0.019). The three-month pancreas graft survival was significantly higher in the KF group (PF: 77% versus KF: 92.1%; p = 0.037). No significant difference was observed in pancreas graft survival five years after transplantation (PF: 71.6% versus KF: 84.8%; p = 0.104). Kidney graft survival was similar between the two groups. Multivariate analysis revealed order of graft implantation as an independent prognostic factor for graft survival three months after SPKT (HR 2.6, 1.3-17.1, p = 0.026) and five years (HR 3.7, 2.1-23.4, p = 0.040).

CONCLUSION

Our data indicates that implantation of the pancreas prior to the kidney during SPKT has an influence especially on the early-post-operative outcome and survival rate of pancreas grafts.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

Anaesthetic considerations for fertility-sparing surgery and uterine transplantation

A number of benign and malignant gynaecological conditions can cause infertility. Advancements in assisted reproductive technologies have facilitated the rapidly evolving subspecialty of fertility preservation. Regardless of clinical indication, women now have the reproductive autonomy to make fully informed decisions regarding their future fertility. In particular, there has been an increasing interest and demand among patients and healthcare professionals for fertility-sparing surgery. Gynaecologists find themselves continually adapting surgical techniques and introducing novel procedures to facilitate this rapidly emerging field and anaesthetists need to manage the consequent physiological demands intra-operatively. Not only is it important to understand the surgical procedures now undertaken, but also the intra-operative management in an ever evolving field. This article reviews the methods of fertility-sparing surgery and also describes important anaesthetic challenges including peri-operative care for women undergoing complex fertility-sparing surgeries such as uterus transplantation.

Early detection of complications in pancreas transplants by microdialysis catheters, an observational feasibility study

Background

Despite advances in immunosuppression and surgical technique, pancreas transplantation is encumbered with a high rate of complication and graft losses. Particularly, venous graft thrombi occur relatively frequently and are rarely detected before the transplant is irreversibly damaged.

Methods

To detect complications early, when the grafts are potentially salvageable, we placed microdialysis catheters anteriorly and posteriorly to the graft in a cohort of 34 consecutive patients. Glucose, lactate, pyruvate, and glycerol were measured at the bedside every 1–2 hours.

Results

Nine patients with graft venous thrombosis had significant lactate and lactate–to-pyruvate-ratio increases without concomitant rise in blood glucose or clinical symptoms. The median lactate in these patients was significantly higher in both catheters compared to non-events (n = 15). Out of the nine thrombi, four grafts underwent successful angiographic extraction, one did not require intervention and four grafts were irreversibly damaged and explanted. Four patients with enteric anastomosis leakages had significantly higher glycerol measurements compared to non-events. As with the venous thrombi, lactate and lactate-to-pyruvate ratio were also increased in six patients with graft surrounding hematomas.

Conclusions

Bedside monitoring with microdialysis catheters is a promising surveillance modality of pancreatic grafts, but differentiating between the various pathologies proves challenging.

First-day plasma amylase detects patients at risk of complications after simultaneous pancreas-kidney transplantation

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPK) carries a high risk of major postoperative complications, but knowledge on early warning signs and surrogate markers for postoperative complications is scarce.

AIMS

Our aim was to analyze the complication-predictive value of different laboratory tests in pancreas transplantation.

MATERIALS & METHODS

All SPKs in Finland between January 2010 and February 2020 were retrospectively analyzed. Levels of first three-day plasma amylase, drain fluid amylase, C-reactive protein, C-peptide, plasma trypsinogen, and white blood cell count were assessed for their performance predicting cumulative postoperative complications (assessed using the Comprehensive Complication Index) within 90 days from transplantation by using ROC analyses.

RESULTS

Of the 164 SPK patients included, 39 suffered at least one complication requiring laparotomy. First-day plasma amylase had the best value in predicting complications based on its high AUC value and easy clinical applicability, with an optimum cutoff of six times the upper normal limit. Negative predictive values (NPVs) and positive predictive values of this cutoff were 0.81 and 0.71 for any relaparotomy, and 0.91 and 0.71 for the Comprehensive Complication Index >47.7 (which equals the morbidity of two relaparotomies), respectively.

CONCLUSION

In conclusion, first-day plasma amylase could be able to detect patients at risk of complications after SPK.

Donor risk factors in pancreas transplantation

The aim of the work was to analyze and expose the donor and recipient risk factors in pancreas transplantation. In the following paper, we exposed the 2018 Spanish Consensus Document on Donor and Recipient Selection Criteria for Pancreas Transplantation. An assessment of the previous Selection Criteria for Donors and Recipients of Pancreas Transplantation, published in 2005 by the Spanish Pancreas Transplant Group (GETP) and the National Transplant Organization (ONT) was performed. A literature review was performed using Cochrane Library, PubMed and Google Scholar databases. Some of the following terms were used for the literature search: “Diabetes Mellitus,” “Pancreas Transplantation,” “Insulin-Secreting Cells,” “Pancreas Allograft Thrombosis,” “Allograft Pancreatitis,” “Donors’ Risk Factors,” “Recipients’ Risk Factors,” “Pancreas Allograft Rejection” and “Pancreas Allograft Survival.” After an extended search, different inclusion criteria were established. Articles and documents with abstracts of full text and in English or Spanish language were selected. Subsequently, different scientific meetings took place during 2015 and 2016 by the GETP. Finally, the updated criteria were published by the GETP and ONT in 2018. Several risk factors have been described in pancreas transplantation that can be divided into donor risk factors: Advanced age (> 50 years); high body mass index (BMI) (> 30 kg/m²); cause of death (e.g., stroke); previous hyperglycemia; hyperamylasemia; cold ischemia time (greater than 8 or 12 h, depending on the type of donation); the use of vasopressors in the intensive care unit or cardiac arrest; and the macroscopic aspect of the pancreas allograft. The following are recipient risk factors: Advanced age (> 50 years); active smoking; high BMI (> 30 kg/m²); and peripheral artery disease or sensorimotor polyneuropathy. Based on the aforementioned parameters, different selection criteria have been established for the recipients depending on the type of pancreas transplantation. Knowledge of the risk factors for pancreas transplantation allows the establishment of reliable selection criteria for choosing donors and recipients.

Early protocol computer tomography and endovascular interventions in pancreas transplantation

BACKGROUND

Early vascular complications following pancreatic transplantation are not uncommon (3%-8%). Typically, cross-sectional imaging is requested in response to clinical change. We instituted a change in protocol to request imaging pre-emptively to identify patients with thrombotic complications.

METHODS

In 2013, protocol computer tomography angiography (CTA) at days 3-5 and day 10 following pancreas transplantation was introduced. A retrospective analysis of all pancreas transplants performed at our institution from January 2001 to May 2019 was undertaken.

RESULTS

A total of 115 patients received pancreas transplants during this time period. A total of 78 received pancreas transplant without routine CTA and 37 patients with the new protocol. Following the change in protocol, we detected a high number of subclinical thromboses (41.7%). There was a significant decrease in invasive intervention for thrombosis (78.6% before vs 30.8% after, p = .02), and graft survival was significantly higher (61.5% before vs 86.1% after, p = .04). There was also a significant reduction in the number of graft failures (all-cause) where thrombosis was present (23.4% before vs 5.6% after, p = .02). Patient survival was unaffected (p = .48).

CONCLUSIONS

Implementation of early protocol CTA identifies a large number of patients with subclinical graft thromboses that are more amenable to conservative management and significantly reduces the requirement for invasive intervention.

Development and validation of a quantitative electron microscopy score to assess acute cellular stress in the human exocrine pancreas

The pancreas is particularly sensitive to acute cellular stress, but this has been difficult to evaluate using light microscopy. Pancreatic ischaemia associated with deceased organ donation negatively impacts whole‐organ and isolated‐islet transplantation outcomes. Post‐mortem changes have also hampered accurate interpretation of ante‐mortem pancreatic pathology. A rigorous histological scoring system accurately quantifying ischaemia is required to experimentally evaluate innovations in organ preservation and to increase rigour in clinical/research evaluation of underlying pancreatic pathology. We developed and validated an unbiased electron microscopy (EM) score of acute pancreatic exocrine cellular stress in deceased organ donor cohorts (development [n = 28] and validation [n = 16]). Standardised assessment led to clearly described numerical scores (0–3) for nuclear, mitochondrial and endoplasmic reticulum (ER) morphology and intracellular vacuolisation; with a maximum (worst) aggregate total score of 12. In the Validation cohort, a trend towards higher scores was observed for tail versus head regions (nucleus score following donation after brainstem death [DBD]: head 0.67 ± 0.19; tail 0.86 ± 0.11; p = 0.027) and donation after circulatory death (DCD) versus DBD (mitochondrial score: DCD (head + tail) 2.59 ± 0.16; DBD (head + tail) 2.38 ± 0.21; p = 0.004). Significant mitochondrial changes were seen ubiquitously even with short cold ischaemia, whereas nuclear and vacuolisation changes remained mild even after prolonged ischaemia. ER score correlated with cold ischaemia time (CIT) following DBD (pancreatic tail region: r = 0.796; p = 0.018). No relationships between CIT and EM scores were observed following DCD. In conclusion, we have developed and validated a novel EM score providing standardised quantitative assessment of subcellular ultrastructural morphology in pancreatic acinar cells. This provides a robust novel tool for gold standard measurement of acute cellular stress in studies evaluating surrogate measures of peri‐transplant ischaemia, organ preservation technologies and in samples obtained for detailed pathological examination of underlying pancreatic pathology.

Risk factors for intra-abdominal fungal infection after simultaneous pancreas-kidney transplantation: A single-center retrospective experience

BACKGROUND

Data on the risk factors and outcome of intra-abdominal fungal infections (IAFI) following simultaneous pancreas-kidney transplantation (PKT) are scarce.

MATERIALS/METHODS

A retrospective monocentric study was conducted on all patients who underwent simultaneous PKT from January 2007 to December 2016. Deep sites positive cultures for fungi during the first post-transplantation year were collected. Clinical, radiological, and microbiological data of proven and probable invasive fungal infections were analysed.

RESULTS

Among sixteen PKT patients, 15 were included. Seven patients (47%) developed an invasive fungal infection, exclusively IAFI (six proven, one probable). The proven IAFI included four peritonitis, one pancreatic necrosis with infected hematoma, and one patient with positive preservation fluid only (PF). Candida albicans (n = 4) was the most prevalent species (associated with Galactomyces candidus in one case), C glabrata, C dubliniensis, and C krusei were found in one case each. Three patients had either a positive direct examination and/or culture for renal or pancreatic PF and the culture of PF was positive for the same species that caused IAFI. IAFIs were significantly associated with pancreatic graft arterial thrombosis (5/7 vs 0/8, P = .007) and fungal contamination of PF (3/7 vs 0/8, P = .008). Among patients with IAFI, all required an early surgical revision post-transplantation [1-18 days] and six had early or delayed pancreatic graft removal. One patient died in the first post-transplant year.

CONCLUSION

IAFI is a common complication in PKT, associated with pancreatic graft thrombosis or fungal contamination of the graft PF, and can sometimes lead to pancreatic detransplantation.

Challenges of pancreas transplantation in developing countries, exploring the Turkey example

Pancreas transplantation significantly improves the quality of life for people with type 1 diabetes, primarily by eliminating the need for insulin and frequent blood glucose measurements. Despite the growing numbers of solid organ transplantations worldwide, number of pancreas transplantations in the developing countries` remain significantly low. This difference of pancreas transplantation practices was striking among the participating countries at the 1st International Transplant Network Meeting which was held in Turkey on 2018. In this meeting more than 40 countries were represented. Most of these counties were developing countries located in Africa, Middle East or Asia. The aim of this article is to identify the challenges and limiting factors for pancreas transplantations in these developing countries, by exploring the Turkish example. The challenges faced by the developing countries are broadly classified in four categories; wait-listing, donor pool, team work and follow up. Under these categorical titles, issues are further discussed in detail, giving examples from Turkish practice of pancreas transplantation. Additionally, several solutions to these challenges have been proposed- some of which have already been undertaken by the Turkish Ministry of Health. With the insight and methods presented in this article, pancreas transplantation should be made possible for the potential recipients in the developing countries.

Successful Implementation of Unmanned Aircraft Use for Delivery of a Human Organ for Transplantation

OBJECTIVE

To understand and overcome the challenges associated with moving life-urgent payloads using unmanned aircraft.

BACKGROUND DATA

Organ transportation has not been substantially innovated in the last 60 years. Unmanned aircraft systems (UAS; ie, drones) have the potential to reduce system inefficiencies and improve access to transplantation. We sought to determine if UASs could successfully be integrated into the current system of organ delivery.

METHODS

A multi-disciplinary team was convened to design and build an unmanned aircraft to autonomously carry a human organ. A kidney transplant recipient was enrolled to receive a drone-shipped kidney.

RESULTS

A uniquely designed organ drone was built. The aircraft was flown 44 times (total of 7.38 hours). Three experimental missions were then flown in Baltimore City over 2.8 miles. For mission #1, no payload was carried. In mission #2, a payload of ice, saline, and blood tubes (3.8 kg, 8.4 lbs) was flown. In mission #3, a human kidney for transplant (4.4 kg, 9.7 lbs) was successfully flown by a UAS. The organ was transplanted into a 44-year-old female with a history of hypertensive nephrosclerosis and anuria on dialysis for 8 years. Between postoperative days (POD) 1 and 4, urine increased from 1.0 L to 3.6 L. Creatinine decreased starting on POD 3, to an inpatient nadir of 6.9 mg/dL. The patient was discharged on POD 4.

CONCLUSIONS

Here, we completed the first successful delivery of a human organ using unmanned aircraft. This study brought together multidisciplinary resources to develop, build, and test the first organ drone system, through which we performed the first transplant of a drone transported kidney. These innovations could inform not just transplantation, but other areas of medicine requiring life-saving payload delivery as well.

Beneficial effects of the novel marine oxygen carrier M101 during cold preservation of rat and human pancreas

Ischaemia impairs organ quality during preservation in a time‐dependent manner, due to a lack of oxygen supply. Its impact on pancreas and islet transplantation outcome has been demonstrated by a correlation between cold ischaemia time and poor islet isolation efficiency. Our goal in the present study was to improve pancreas and islet quality using a novel natural oxygen carrier (M101, 2 g/L), which has been proven safe and efficient in other clinical applications, including kidney transplantation, and for several pre‐clinical transplantation models. When M101 was added to the preservation solution of rat pancreas during ischaemia, a decrease in oxidative stress (ROS), necrosis (HMGB1), and cellular stress pathway (p38 MAPK)activity was observed. Freshly isolated islets had improved function when M101 was injected in the pancreas. Additionally, human pancreases exposed to M101 for 3 hours had an increase in complex 1 mitochondrial activity, as well as activation of AKT activity, a cell survival marker. Insulin secretion was also up‐regulated for isolated islets. In summary, these results demonstrate a positive effect of the oxygen carrier M101 on rat and human pancreas during preservation, with an overall improvement in post‐isolation islet quality.

The Pancreas Can Take the Cold: Lower Waitlist Times Through Importation

BACKGROUND

Our center has used a strategy of pancreas importation owing to long regional waitlist times. Here we assess the clinical outcomes and financial considerations of this strategy.

METHODS

This was a retrospective observational cohort study of patients who received a pancreas transplant at Montefiore Medical Center (MMC) from 2014 to 2017 (n = 28). Clinical parameters, including hemoglobin A_1c and complications, were analyzed. The cohort was compared with United Network for Organ Sharing (UNOS) Region 9 with the use of the UNOS/Organ Procurement and Transplantation Network database. Cost analysis of length of stay (LOS), standard acquisition (SAC) fees, and transportation was performed with the use of internal financial data.

RESULTS

Pancreas importation resulted in significantly shorter simultaneous pancreas kidney transplant waitlist times compared with Region 9: 518 days vs 1001 days (P = .038). In addition, postoperative complications and 1-year HbA_1c did not differ between groups: local 6.30% vs import 6.17% (P = .87). Patients receiving local pancreata stayed an average of 9.2 days compared with 11 days for the import group (P = .36). As such, pancreas importation was associated with higher mean charges ($445,968) compared with local pancreas recipients ($325,470).

CONCLUSIONS

Long waitlist times in Region 9 have encouraged our center's adoption of pancreas importation to address the needs of our patient population. This practice has resulted in a reduction of waitlist times by an average of 483 days. Understandably, centers have long been wary of importation owing to perceived risk in clinical outcomes. In our single-center experience, we have demonstrated equivalent postoperative glucose control and graft survival. Importantly, there does appear to be increased costs associated with importation, which are mainly driven by LOS. Curiously, importation from regions with lower SAC fees has the potential to offset costs related to transportation expenses. Notwithstanding these findings, pancreas importation does have the potential to lessen the financial societal burden through reduction in waitlist times.