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Hau HM, Jahn N, Vlachos C, Eichler T, Lederer A, Geisler A, Scheuermann U, Seehofer D, Köppen S, Laudi S, Sucher R, Rademacher S. Does Timepoint of Surgical Procedure Affect the Outcome in Simultaneous Pancreas-Kidney Transplantation? A Retrospective Single-Center Analysis over 20 Years. J Clin Med 2024; 13:3688. [PMID: 38999254 PMCID: PMC11242423 DOI: 10.3390/jcm13133688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/13/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
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.
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Affiliation(s)
- Hans Michael Hau
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Nora Jahn
- Department for Anesthesiology and Intensive Care Medicine, Medical University of Graz, 8010 Graz, Austria
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Christos Vlachos
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Tim Eichler
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
| | - Andri Lederer
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Antonia Geisler
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Uwe Scheuermann
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Sylvia Köppen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Sven Laudi
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Robert Sucher
- Department of General-, Visceral- and Transplant Surgery, Medical University of Graz, 8010 Graz, Austria
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
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D'Aragon F, Selzner M, Breau R, Masse MH, Lamontagne F, Masse M, Chassé M, Carrier FM, Cardinal H, Chaudhury P, Weiss M, Lauzier F, Turgeon AF, Frenette AJ, Bolduc B, Ducharme A, Lamarche C, Couture E, Holdsworth S, Bertholz L, Talbot H, Slessarev M, Luke P, Boyd JG, Shamseddin MK, Burns KEA, Zaltzman J, English S, Knoll G, Dhanani S, Healey A, Hanna S, Rochwerg B, Oczkowski SJW, Treleaven D, Meade M. Calcineurin Inhibitor in NEuRoloGically deceased donors to decrease kidney delayed graft function study: study protocol of the CINERGY Pilot randomised controlled trial. BMJ Open 2024; 14:e086777. [PMID: 38871657 PMCID: PMC11177676 DOI: 10.1136/bmjopen-2024-086777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/17/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Most solid organ transplants originate from donors meeting criteria for death by neurological criteria (DNC). Within the organ donor, physiological responses to brain death increase the risk of ischaemia reperfusion injury and delayed graft function. Donor preconditioning with calcineurin inhibition may reduce this risk. METHODS AND ANALYSIS We designed a multicentre placebo-controlled pilot randomised trial involving nine organ donation hospitals and all 28 transplant programmes in the Canadian provinces of Ontario and Québec. We planned to enrol 90 DNC donors and their approximately 324 organ recipients, totalling 414 participants. Donors receive an intravenous infusion of either tacrolimus 0.02 mg/kg over 4 hours prior to organ retrieval, or a matching placebo, while monitored in an intensive care unit for any haemodynamic changes during the infusion. Among all study organ recipients, we record measures of graft function for the first 7 days in hospital and we will record graft survival after 1 year. We examine the feasibility of this trial with respect to the proportion of all eligible donors enrolled and the proportion of all eligible transplant recipients consenting to receive a CINERGY organ transplant and to allow the use of their health data for study purposes. We will report these feasibility outcomes as proportions with 95% CIs. We also record any barriers encountered in the launch and in the implementation of this trial with detailed source documentation. ETHICS AND DISSEMINATION We will disseminate trial results through publications and presentations at participating sites and conferences. This study has been approved by Health Canada (HC6-24-c241083) and by the Research Ethics Boards of all participating sites and in Québec (MP-31-2020-3348) and Clinical Trials Ontario (Project #3309). TRIAL REGISTRATION NUMBER NCT05148715.
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Affiliation(s)
- Frederick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Markus Selzner
- Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Quebec, Canada
- Department of General Surgery, University of Toronto and Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ruth Breau
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marie-Hélène Masse
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Francois Lamontagne
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mélanie Masse
- Department of Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael Chassé
- Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - François-Martin Carrier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Héloïse Cardinal
- Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Prosanto Chaudhury
- Department of Surgery and Oncology, McGill University, Montreal, Québec, Canada
- Transplant Québec, Montréal, Québec, Canada
| | - Matthew Weiss
- Transplant Québec, Montreal, Québec, Canada
- Population Health and Optimal Health Practives Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval, Quebec, Quebec, Canada
| | - Francois Lauzier
- Population Health and Optimal Health Practives Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval, Quebec, Quebec, Canada
- Department of Medicine, Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practives Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval, Quebec, Quebec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | | | - Brigitte Bolduc
- Department of Pharmacy, Centre integre universitaire de sante et de services sociaux de l'Estrie Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Anique Ducharme
- Department of Medicine, Université de Montréal, Montreal, Québec, Canada
- Montreal Heart Institute, Montreal, Québec, Canada
| | - Caroline Lamarche
- Department of Medicine, Université de Montréal, Montreal, Québec, Canada
- Hôpital Maisonneuve-Rosemont Research Institute, Montréal, Québec, Canada
| | - Etienne Couture
- Department of Anesthesiology and Critical Care, Quebec Heart & Lung Institute, Université Laval, Quebec, Quebec, Canada
| | - Sandra Holdsworth
- Canadian Donation and Transplant Research Program, Edmonton, Alberta, Canada
| | - Liz Bertholz
- Canadian Donation and Transplant Research Program, Edmonton, Alberta, Canada
| | - Heather Talbot
- Canadian Donation and Transplant Research Program, Edmonton, Alberta, Canada
| | - Marat Slessarev
- Department of Medicine, Division of Critical Care, Western University, London, Ontario, Canada
| | - Patrick Luke
- Department of Surgery, Division of Urology, Western University, London, Ontario, Canada
| | - John Gordon Boyd
- Department of Medicine, Division of Neurology, Queen's University, Kingston, Ontario, Canada
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - M Khaled Shamseddin
- Department of Medicine, Division of Nephrology, Queen's University, Kingston, Ontario, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, University Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jeffrey Zaltzman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shane English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Greg Knoll
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sonny Dhanani
- Department of Pediatrics, Division of Critical Care, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew Healey
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Steven Hanna
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Darin Treleaven
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Maureen Meade
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Drachenberg CB, Buettner-Herold M, Aguiar PV, Horsfield C, Mikhailov AV, Papadimitriou JC, Seshan SV, Perosa M, Boggi U, Uva P, Rickels M, Grzyb K, Arend L, Cuatrecasas M, Toniolo MF, Farris AB, Renaudin K, Zhang L, Roufousse C, Gruessner A, Gruessner R, Kandaswamy R, White S, Burke G, Cantarovich D, Parsons RF, Cooper M, Kudva YC, Kukla A, Haririan A, Parajuli S, Merino-Torres JF, Argente-Pla M, Meier R, Dunn T, Ugarte R, Rao JS, Vistoli F, Stratta R, Odorico J. Banff 2022 pancreas transplantation multidisciplinary report: Refinement of guidelines for T cell-mediated rejection, antibody-mediated rejection and islet pathology. Assessment of duodenal cuff biopsies and noninvasive diagnostic methods. Am J Transplant 2024; 24:362-379. [PMID: 37871799 DOI: 10.1016/j.ajt.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/02/2023] [Accepted: 10/11/2023] [Indexed: 10/25/2023]
Abstract
The Banff pancreas working schema for diagnosis and grading of rejection is widely used for treatment guidance and risk stratification in centers that perform pancreas allograft biopsies. Since the last update, various studies have provided additional insight regarding the application of the schema and enhanced our understanding of additional clinicopathologic entities. This update aims to clarify terminology and lesion description for T cell-mediated and antibody-mediated allograft rejections, in both active and chronic forms. In addition, morphologic and immunohistochemical tools are described to help distinguish rejection from nonrejection pathologies. For the first time, a clinicopathologic approach to islet pathology in the early and late posttransplant periods is discussed. This update also includes a discussion and recommendations on the utilization of endoscopic duodenal donor cuff biopsies as surrogates for pancreas biopsies in various clinical settings. Finally, an analysis and recommendations on the use of donor-derived cell-free DNA for monitoring pancreas graft recipients are provided. This multidisciplinary effort assesses the current role of pancreas allograft biopsies and offers practical guidelines that can be helpful to pancreas transplant practitioners as well as experienced pathologists and pathologists in training.
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Affiliation(s)
| | - Maike Buettner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg (FAU) and University Hospital, Erlangen, Germany
| | | | - Catherine Horsfield
- Department of Histopathology/Cytology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Alexei V Mikhailov
- Department of Pathology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - John C Papadimitriou
- Department of Pathology, University of Maryland School of Medicine, Maryland, USA
| | - Surya V Seshan
- Division of Renal Pathology, Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Marcelo Perosa
- Beneficência Portuguesa and Bandeirantes Hospital of São Paulo, São Paulo, Brazil
| | - Ugo Boggi
- Department of Surgery, University of Pisa, Pisa, The province of Pisa, Italy
| | - Pablo Uva
- Kidney/Pancreas Transplant Program, Instituto de Trasplantes y Alta Complejidad (ITAC - Nephrology), Buenos Aires, Argentina
| | - Michael Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Philadelphia, USA
| | - Krzyztof Grzyb
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lois Arend
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | | | - Alton B Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Lizhi Zhang
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Candice Roufousse
- Department of Immunology and Inflammation, Imperial College of London, London, United Kingdom
| | - Angelika Gruessner
- Department of Nephrology/Medicine, State University of New York, New York, USA
| | - Rainer Gruessner
- Department of Surgery, State University of New York, New York, USA
| | - Raja Kandaswamy
- Division of Solid Organ Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Steven White
- Department of Surgery, Newcastle Upon Tyne NHS Foundation Trust, Newcastle upon Tyne, England, United Kingdom
| | - George Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Ronald F Parsons
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew Cooper
- Division of Transplant Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Yogish C Kudva
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aleksandra Kukla
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, Minnesota, USA
| | - Abdolreza Haririan
- Department of Medicine, University of Maryland School of Medicine, Maryland, USA
| | - Sandesh Parajuli
- Department of Medicine, UWHealth Transplant Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Juan Francisco Merino-Torres
- Department of Endocrinology and Nutrition, University Hospital La Fe, La Fe Health Research Institute, University of Valencia, Valencia, Spain
| | - Maria Argente-Pla
- University Hospital La Fe, Health Research Institute La Fe, Valencia, Spain
| | - Raphael Meier
- Department of Surgery, University of Maryland School of Medicine, Maryland, USA
| | - Ty Dunn
- Division of Transplantation, Department of Surgery, Penn Transplant Institute, University of Pennsylvania, Pennsylvania, Philadelphia, USA
| | - Richard Ugarte
- Department of Medicine, University of Maryland School of Medicine, Maryland, USA
| | - Joseph Sushil Rao
- Division of Solid Organ Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA; Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Fabio Vistoli
- Department of Surgery, University of Pisa, Pisa, The province of Pisa, Italy
| | - Robert Stratta
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Jon Odorico
- Division of Transplantation, Department of Surgery, UWHealth Transplant Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Shapey IM, Tan ZL, Gioco R, Khambalia H, Fullwood C, Yiannoullou P, Summers A, Hanley NA, Augustine T, Rutter MK, van Dellen D. Peri-transplant glycaemic control as a predictor of pancreas transplant survival. Diabetes Obes Metab 2021; 23:49-57. [PMID: 32893472 DOI: 10.1111/dom.14181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/04/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022]
Abstract
AIMS The relationship between peri-transplant glycaemic control and outcomes following pancreas transplantation is unknown. We aimed to relate peri-transplant glycaemic control to pancreas graft survival and to develop a framework for defining early graft dysfunction. METHODS Peri-transplant glycaemic control profiles over the first 5 days postoperatively were determined by an area under the curve [AUC; average daily glucose level (mmol/L) × time (days)] and the coefficient of variation of mean daily glucose levels. Peri-transplant hyperglycaemia was defined as an AUC ≥35 mmol/day/L (daily mean blood glucose ≥7 mmol/L). Risks of graft failure associated with glycaemic control and variability and peri-transplant hyperglycaemia were determined using covariate-adjusted Cox regression. RESULTS We collected 7606 glucose readings over 5 days postoperatively from 123 pancreas transplant recipients. Glucose AUC was a significant predictor of graft failure during 3.6 years of follow-up (unadjusted HR [95% confidence interval] 1.17 [1.06-1.30], P = .002). Death censored non-technical graft failure occurred in eight (10%) recipients with peri-transplant normoglycaemia, and eight (25%) recipients with peri-transplant hyperglycaemia such that hyperglycaemia predicted a 3-fold higher risk of graft failure [HR (95% confidence interval): 3.0 (1.1-8.0); P = .028]. CONCLUSION Peri-transplant hyperglycaemia is strongly associated with graft loss and could be a valuable tool guiding individualized graft monitoring and treatment. The 5-day peri-transplant glucose AUC provides a robust and responsive framework for comparing graft function.
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Affiliation(s)
- Iestyn M Shapey
- Department of Renal and Pancreas Transplantation, Manchester University NHSFT, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Zheng L Tan
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Rossella Gioco
- Department of Renal and Pancreas Transplantation, Manchester University NHSFT, Manchester, UK
| | - Hussein Khambalia
- Department of Renal and Pancreas Transplantation, Manchester University NHSFT, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Catherine Fullwood
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
- Department of Research and Innovation (Medical Statistics), Manchester University NHSFT, Manchester, UK
| | - Petros Yiannoullou
- Department of Renal and Pancreas Transplantation, Manchester University NHSFT, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Angela Summers
- Department of Renal and Pancreas Transplantation, Manchester University NHSFT, Manchester, UK
| | - Neil A Hanley
- Department of Renal and Pancreas Transplantation, Manchester University NHSFT, Manchester, UK
| | - Titus Augustine
- Department of Renal and Pancreas Transplantation, Manchester University NHSFT, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, MAHSC, Manchester, UK
| | - David van Dellen
- Department of Renal and Pancreas Transplantation, Manchester University NHSFT, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
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5
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Bellini MI, Yiu J, Nozdrin M, Papalois V. The Effect of Preservation Temperature on Liver, Kidney, and Pancreas Tissue ATP in Animal and Preclinical Human Models. J Clin Med 2019; 8:jcm8091421. [PMID: 31505880 PMCID: PMC6780500 DOI: 10.3390/jcm8091421] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 02/06/2023] Open
Abstract
The recent advances in machine perfusion (MP) technology involve settings ranging between hypothermic, subnormothermic, and normothermic temperatures. Tissue level adenosine triphosphate (ATP) is a long-established marker of viability and functionality and is universal for all organs. In the midst of a growing number of complex clinical parameters for the quality assessment of graft prior to transplantation, a revisit of ATP may shed light on the underlying reconditioning mechanisms of different perfusion temperatures in the form of restoration of metabolic and energy status. This article aims to review and critically analyse animal and preclinical human studies (discarded grafts) during MP of three abdominal organs (liver, kidney, and pancreas) in which ATP was a primary endpoint. A selective review of recent novel reconditioning approaches relevant to mitigation of graft ischaemia-reperfusion injury via MP and for different perfusion temperatures was also conducted. With a current reiterated interest for oxygenation during MP, a re-introduction of tissue ATP levels may be valuable for graft viability assessment prior to transplantation. Further studies may help delineate the benefits of selective perfusion temperatures on organs viability.
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Affiliation(s)
| | - Janice Yiu
- School of Medicine, University College London, London WC1E 6BT, UK
| | - Mikhail Nozdrin
- School of Medicine, Imperial College London, London SW72AZ, UK
| | - Vassilios Papalois
- Renal and Transplant Directorate, Imperial College Healthcare NHS Trust, London W120HS, UK
- Department of Surgery and Cancer, Imperial College London, London SW72AZ, UK
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6
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Shapey IM, Summers A, Yiannoullou P, Bannard-Smith J, Augustine T, Rutter MK, van Dellen D. Insulin therapy in organ donation and transplantation. Diabetes Obes Metab 2019; 21:1521-1528. [PMID: 30924574 DOI: 10.1111/dom.13728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/12/2019] [Accepted: 03/26/2019] [Indexed: 12/27/2022]
Abstract
Hyperglycaemia is common in hospitalized individuals, and is often caused by physiological stress associated with critical illness or major surgery. Insulin therapy is an established treatment for hyperglycaemia and acute hyperkalaemia, and has also been used for myocardial dysfunction resistant to inotropic support. Insulin is commonly used in both organ donors and transplant recipients for hyperglycaemia, but the underlying knowledge base supporting its use remains limited. Insulin therapy plays an important yet poorly understood role in both organ donation and transplantation. Tight glycaemic control has been extensively studied in critical care over the past 15 years; however, this has not yet translated into the field of transplantation, where patients are more unwell and where improved outcomes remain an ongoing challenge. Insulin therapy and optimization of glycaemic control represent important areas for future hypothesis-driven research into organ donation and transplantation, such as amelioration of ischaemia-reperfusion injury, rejection and infection.
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Affiliation(s)
- Iestyn M Shapey
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Angela Summers
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Petros Yiannoullou
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jonathan Bannard-Smith
- Department of Critical Care, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Titus Augustine
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - David van Dellen
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Gniewkiewicz MS, Czerwińska M, Gozdowska J, Wyzgał J, Grochowiecki T, Nazarewski S, Kosieradzki M, Durlik M. Long-term Outcomes in Simultaneous Pancreas-Kidney Transplant Recipients: Single-center Experience From Poland. Transplant Proc 2018; 50:2128-2131. [PMID: 30177123 DOI: 10.1016/j.transproceed.2018.02.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Simultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal disease (ESRD) due to type 1 diabetes mellitus (DM1). Since the 1980s, pancreas transplantation has become the most effective strategy to restore normoglycemia in patients with DM1. The aim of this study was to present long-term outcomes data for SPKT. METHODS We performed a retrospective analysis of 73 SPKT recipients followed in our outpatient center who underwent transplantation between 1988 and 2015. RESULTS A total of 50.7% of the patients were male. At the time of surgery, patients' mean age was 37.38 ± 7.44 years. Patients were diagnosed with DM1 at an average of 25 ± 6.08 years before SPKT. For 21.9% of patients, the transplant was done preemptively. Most (91.8%) had enteric drainage. All patients received induction of immunosuppression (either polyclonal immunoglobulins anti-thymocyte globulin or thymoglobulin [64.4%] or monoclonal globulins daclizumab or basiliximab [35.6%]). Patient survival at 1, 5, 10, 15 years was 99%, 97%, 89%, and 75%; kidney survival was 99%, 96%, 84%, and 67%; and pancreas survival was 95%, 92%, 84%, and 64%, respectively. There was a notable tendency toward increased creatinine level (from 1.18 at 1 year to 1.78 at 15 years) and decreased hemoglobin level (from 13.84 at 1 year to 12.65 at 15 years). CONCLUSION Diabetic patients with ESRD have a poor prognosis without transplantation. SPKT provides marked prolongation of the patient's life and freedom from insulin injections. Enteric drainage is currently the surgical technique of choice. SPKT should remain as the treatment of choice in this patient population.
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Affiliation(s)
- M S Gniewkiewicz
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - M Czerwińska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - J Gozdowska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - J Wyzgał
- Department of Nephrology Nursing, Medical University of Warsaw, Warsaw, Poland
| | - T Grochowiecki
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - S Nazarewski
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Kosieradzki
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Durlik
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Long-term Effects of Delayed Graft Function on Pancreas Graft Survival After Pancreas Transplantation. Transplantation 2015; 98:1316-22. [PMID: 24839896 DOI: 10.1097/tp.0000000000000214] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Compared with the impact of delayed graft function (DGF) after renal transplantation, DGF after pancreas transplantation has not been fully evaluated. METHODS We retrospectively verified the impact of DGF on long-term pancreas graft survival in surgically successful cases. Pancreas graft failure was defined by the recipient's return to exogenous insulin administration. RESULTS Between May 2004 and April 2013, we performed 135 technically successful primary pancreas transplantations. Delayed graft function was defined as a total cumulative insulin requirement of 19 UI or greater within postoperative 7 days. Of the 135 recipients in our study cohort, 47 (34.8%) developed DGF after the pancreas transplantation. By multivariate analysis, DGF was found to be associated with a donor age of 30 years or older (odds ratio, 3.4; 95% confidence interval, 1.50-7.69; P=0.003) and the increased ratio of body mass index in a recipient to a donor (odds ratio, 26.1; 95% confidence interval, 2.53-270.0; P=0.006). There was a trend toward higher acute rejection (P=0.622) and mortality (P=0.49) rates in recipients with versus without DGF, although this did not reach statistical significance. Delayed graft function was found to be associated with a greater risk of overall pancreas graft failure (P=0.016) and death-censored graft failure (P=0.037). CONCLUSION Delayed graft function after pancreas transplantation was found to be associated with a greater risk of overall pancreas graft failure and death-censored graft failure.
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Kim SM, Youn WY, Kim DJ, Kim JS, Lee S. Simultaneous pancreas-kidney transplantation: lessons learned from the initial experience of a single center in Korea. Ann Surg Treat Res 2015; 88:41-7. [PMID: 25553324 PMCID: PMC4279990 DOI: 10.4174/astr.2015.88.1.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/04/2014] [Accepted: 08/07/2014] [Indexed: 01/26/2023] Open
Abstract
Purpose The purpose of this study is to report the results of simultaneous pancreas-kidney (SPK) transplantations and describe the lessons learned from the early experiences of a single center. Methods Between January 2002 and June 2013, a total of 8 patients underwent SPK transplantation. Clinical and radiologic data were reviewed retrospectively. Results Seven patients were diagnosed with type I diabetes mellitus and one patient became insulin-dependent after undergoing a total pancreatectomy because of trauma. Pancreas exocrine drainage was performed by enteric drainage in 4 patients and bladder drainage in 4 patients. Three patients required conversion from initial bladder drainage to enteric drainage due to urinary symptoms and duodenal leakage. Four patients required a relaparotomy due to hemorrhage, ureteral stricture, duodenal leakage, and venous thrombosis. There was no kidney graft loss, and 2 patients had pancreas graft loss because of venous thrombosis and new onset of type II diabetes mellitus. With a median follow-up of 76 months (range, 2-147 months), the death-censored graft survival rates for the pancreas were 85.7% at 1, 3, and 5 years and 42.9% at 10 years. The patient survival rate was 87.5% at 1, 3, 5, and 10 years. Conclusion The long-term grafts and patient survival in the current series are comparable to previous studies. A successful pancreas transplant program can be established in a single small-volume institute. A meticulous surgical technique and early anticoagulation therapy are required for further improvement in the outcomes.
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Affiliation(s)
- Suh Min Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Woo Young Youn
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Doo Jin Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joo Seop Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Samuel Lee
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Rangel EB. Tacrolimus in pancreas transplant: a focus on toxicity, diabetogenic effect and drug–drug interactions. Expert Opin Drug Metab Toxicol 2014; 10:1585-605. [DOI: 10.1517/17425255.2014.964205] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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12
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Short- and Long-Term Outcomes of Every Graft Recovered During a Multi-Organ Procurement Procedure Including the Intestine. Transplant Proc 2014; 46:2090-5. [DOI: 10.1016/j.transproceed.2014.06.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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Evaluation of Institut Georges Lopez-1 Preservation Solution in Pig Pancreas Transplantation. Transplantation 2014; 97:901-7. [PMID: 24646772 DOI: 10.1097/tp.0000000000000050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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14
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Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft. Case Rep Transplant 2013; 2013:171807. [PMID: 24455393 PMCID: PMC3886212 DOI: 10.1155/2013/171807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/05/2013] [Indexed: 12/13/2022] Open
Abstract
We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population.
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Dong M, Parsaik AK, Kremers W, Sun A, Dean P, Prieto M, Cosio FG, Gandhi MJ, Zhang L, Smyrk TC, Stegall MD, Kudva YC. Acute pancreas allograft rejection is associated with increased risk of graft failure in pancreas transplantation. Am J Transplant 2013; 13:1019-1025. [PMID: 23432918 DOI: 10.1111/ajt.12167] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 12/18/2012] [Accepted: 12/26/2012] [Indexed: 01/25/2023]
Abstract
The effect of acute allograft rejection (AR) on long-term pancreas allograft function is unclear. We retrospectively studied 227 consecutive pancreas transplants performed at our institution between January 1, 998 and December 31, 2009 including: 56 simultaneous pancreas and kidney (SPK), 69 pancreas transplantation alone (PTA); and 102 pancreas after kidney (PAK) transplants. With a median follow-up of 6.1 (IQR 3-9) years, 57 patients developed 79 episodes of AR, and 19 experienced more than one episode. The cumulative incidence for AR was 14.7%, 19.7%, 26.6% and 29.1% at 1, 2, 5 and 10 years. PTA transplant (hazards ratio [HR]=2.28, p=0.001) and donor age (per 10 years) (HR=1.34, p=0.006) were associated with higher risk for AR. The first AR episode after 3 months post PT was associated with increased risk for complete loss (CL) (HR 3.79, p<0.001), and the first AR episode occurring during 3- to 12-month and 12- to 24-month periods after PT were associated with significantly increased risk for at least partial loss (PL) (HR 2.84, p=0.014; and HR 6.25, p<0.001, respectively). We conclude that AR is associated with increased risk for CL and at least PL. The time that the first AR is observed may influence subsequent graft failure.
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Affiliation(s)
- M Dong
- Division of Endocrinology, Diabetes, Nutrition, and Metabolism, Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Department of Endocrinology and Metabolism, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - A K Parsaik
- Division of Endocrinology, Diabetes, Nutrition, and Metabolism, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - W Kremers
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - A Sun
- Division of Endocrinology, Diabetes, Nutrition, and Metabolism, Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Department of Endocrinology and Metabolism, Zibo First People's Hospital, Zibo, Shandong, P. R. China
| | - P Dean
- Division of Transplantation Surgery, Department of Surgery
| | - M Prieto
- Division of Transplantation Surgery, Department of Surgery
| | - F G Cosio
- Division of Nephrology and Hypertension, Department of Internal Medicine
| | - M J Gandhi
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology
| | - L Zhang
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - T C Smyrk
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - M D Stegall
- Division of Transplantation Surgery, Department of Surgery
| | - Y C Kudva
- Division of Endocrinology, Diabetes, Nutrition, and Metabolism, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Abstract
Long-standing type 1 diabetes (T1D) is associated with an absolute loss of endogenous insulin secretion (circulating C-peptide is undetectable) and a related defect in glucose counter-regulation that is often complicated by hypoglycemia unawareness, markedly increasing the risk for severe hypoglycemia. Both the transplantation of isolated islets and a whole pancreas can restore β-cell secretory capacity, improve glucose counter-regulation, and return hypoglycemia awareness, thus alleviating severe hypoglycemia. The transplantation of islets may require more than one donor pancreas, and the recovery of endocrine function for now appears more durable with a whole pancreas; however, islet transplantation outcomes are steadily improving. Because not all patients with T1D experiencing severe hypoglycemia are candidates to receive a whole pancreas, and since not all pancreata are technically suitable for whole organ transplantation, islet and pancreas transplantation are evolving as complementary approaches for the recovery of endocrine function in patients with the most problematic T1D.
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Affiliation(s)
- Michael R Rickels
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine at the University of Pennsylvania, Institute for Diabetes, Obesity, and Metabolism, 12-134 Translational Research Center, Philadelphia, PA 19104, USA.
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Bratton CF, Hamid A, Selby JB, Baliga PK. Case report: gastrointestinal hemorrhage caused by a pancreas transplant arteriovenous fistula with large psuedoanuerysm 9 years after transplantation. Transplant Proc 2012; 43:4039-43. [PMID: 22172898 DOI: 10.1016/j.transproceed.2011.09.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 09/16/2011] [Indexed: 02/07/2023]
Abstract
Reported cases of arteriovenous fistulae in transplant recipients are uncommon. We present a case of an arteriovenous fistula associated with a large pseudoaneurysm in the root of the small bowel mesentery of a pancreas transplant. Uniquely, in our case, the arteriovenous fistula presented with an episode of gastrointestinal (GI) hemorrhage 9 years postoperatively. Radiographic imaging including coronal computed tomography angiogram and conventional angiogram demonstrated an arteriovenous fistula in the patient's pancreas transplant between the distal superior mesenteric artery (SMA) and superior mesenteric vein (SMV) with 6 cm aneurysmal dilatation. The tremendous flow in the fistula in the root of the graft small intestine mesentery led to graft duodenal mucosal congestion and lower GI hemorrhage. After successful embolization of the SMA-SMV fistula and pseudoaneurysm using interventional radiographic techniques, the arteriovenous fistula remained thrombosed. The patient had no further episodes of GI bleeding and her endoscopic evaluation was otherwise negative. The presence of arteriovenous fistulae and pseudoaneurysms in pancreas transplant recipients is uncommon, but has been previously documented. This case is further distinguished from previous reports by the notable 9-year interval between transplantation and the onset of hemorrhage. Historically, symptomatic vascular malformations have been associated with significant patient morbidity and mortality. Successful patient management involves timely and accurate diagnosis and intervention.
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Affiliation(s)
- C F Bratton
- Department of Surgery, Division of Transplant, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Sanchez EQ, Melton LB, Chinnakotla S, Levy MF, Fischbach BV, Goldstein R, Klintmalm GB. Whole-organ pancreas transplantation at Baylor Regional Transplant Institute: a chance to cure diabetes. Proc (Bayl Univ Med Cent) 2011; 23:3-6. [PMID: 20157494 DOI: 10.1080/08998280.2010.11928569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The success of pancreas transplantation has improved over the past several decades with advancements in surgical technique, immunosuppressive medicines, and immunologic testing. We retrospectively reviewed our experience with pancreas transplantation from 1995 to 2008. At the Baylor Regional Transplant Program, 151 pancreas transplants were performed in 147 patients: 135 were simultaneous pancreas-kidney transplants, 10 were pancreas transplants after kidney transplants, and 6 were pancreas transplants alone. Follow-up information was available for 138 patients. The 1-year acute cellular rejection rate was 31.6%; the 30-day surgical reexploration rate was 10%; and the technical failure rate was 5.3%. Five-year pancreas graft survival rates were 67% for simultaneous pancreas and kidney transplants and 50% for pancreas transplants after kidney transplants. These outcomes exceed expected results as calculated by the Scientific Registry of Transplant Recipients. In addition, the median time to transplant was 3.8 months, compared with a US median of 14.1 months. Pancreas transplantation is currently the closest thing to a cure for diabetes and should be given as an option for diabetic patients with or without end-stage renal disease.
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Affiliation(s)
- Edmund Q Sanchez
- Baylor Regional Transplant Institute (Sanchez, Chinnakotla, Levy, Goldstein, Klintmalm), Dallas and Fort Worth, Texas; the Division of Nephrology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas (Melton); and the Division of Nephrology, Department of Internal Medicine, Baylor All Saints Medical Center, Fort Worth, Texas (Fischbach)
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Cytomegalovirus Mismatch as Major Risk Factor for Delayed Graft Function After Pancreas Transplantation. Transplantation 2010; 90:666-71. [DOI: 10.1097/tp.0b013e3181ea67a1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Abstract
PURPOSE OF REVIEW The history of transplantation of the pancreas, unlike that of transplantation of other abdominal organs, has largely been shaped by the associated surgical complications. After more than three decades of progress, surgical-technical pancreas graft failure rates have decreased to approximately 8%. The most recent developments in this area are systematically reviewed in this article. RECENT FINDINGS Vascular graft thrombosis remains, by far, the most common cause of technical graft failure. Recent reports suggested that pancreas preservation with histidine-tryptophan-ketoglutarate solution (HTK) might be a risk factor for reperfusion pancreatitis, graft thrombosis and decreased short- and long-term graft survival. It remains unclear whether these results are, at least in part, related to HTK flush volumes and extended preservation (e.g.,>12 h). For selected thrombosed pancreas grafts, there has been renewed interest in pharmacological, interventional, and surgical salvage. For selected recipients with early pancreas graft thrombosis not amenable to a salvage intervention, transplant pancreatectomy in conjunction with immediate retransplantation has emerged as a viable option. For graft thrombosis prevention, the enhanced backtable pancreas vascular reconstruction techniques (e.g., gastroduodenal artery revascularization) proposed by some authors await more formal study. For prevention of native vascular complications in high-risk recipients, several technical modifications have been reported. Developments with respect to other surgical complications (wound infection, pancreatitis, leak, and bleeding) have been more incremental. CONCLUSION Recent evidence underscores the importance of judicious donor and recipient selection and of optimization of preservation and surgical factors for excellent short- and long-term pancreas transplant outcomes.
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Abstract
PURPOSE OF REVIEW Pancreas transplantation is considered the optimal therapy for patients with insulin-dependent diabetes. Successful pancreas transplantation achieves euglycemia and allows freedom from insulin therapy. Long-term allograft success may be limited by the development of impaired glucose metabolism. The objectives of the present review are to summarize the possible reasons for endocrine pancreatic dysfunction and to focus on its prevention and management and emphasize the role of immunosuppression. RECENT FINDINGS The diabetogenic effects of current immunosuppressive agents have been well established. Regimens without corticosteroids and calcineurin-inhibitor minimization or avoidance have been promoted. Recent studies have revisited the pathogenesis of type I and type II diabetes and demonstrated common pathways, including apoptosis induction, for the exhaustion and destruction of the pancreatic islets. SUMMARY The immunosuppressive regimens in pancreatic transplantation should be designed and appropriately modified according to the graft immunological and metabolic conditions. New molecules that are able to preserve islet function and maintain optimal insulin secretion should be considered for pancreas transplant recipients.
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Tirapelli LF, Bagnato VS, Tirapelli DPC, Kurachi C, Barione DF, Tucci S, Suaid HJ, Cologna AJ, Martins ACP. Renal ischemia in rats: mitochondria function and laser autofluorescence. Transplant Proc 2008; 40:1679-84. [PMID: 18589172 DOI: 10.1016/j.transproceed.2008.02.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Accepted: 02/26/2008] [Indexed: 10/21/2022]
Abstract
Ischemia-reperfusion injury is the major cause of organ dysfunction or even nonfunction following transplantation. It can attenuate the long-term survival of transplanted organs. To evaluate the severity of renal ischemia injury determined by histology, we applied laser- (442 nm and 532 nm) induced fluorescence (LIF), mitochondria respiration, and membrane swelling to evaluate 28 Wistar rats that underwent left kidney warm ischemia for 20, 40, 60, or 80 minutes. LIF performed before ischemia (control) was repeated at 20, 40, 60, and 80 minutes thereafter. We harvested left kidney tissue samples immediately after LIF determination for histology and mitochondrial analyses: state 3 and 4 respiration, respiration control rate (RCR), and membrane swelling. The association of optic spectroscopy with histological damage showed: LIF, 442 nm (r2 = 0.39, P < .001) and 532 nm, (r2 = 0.18, P = .003); reflecting laser/fluorescence-induced, 442 nm (r2 = 0.20, P = .002) and 532 nm (r2 = 0.004, P = .67). The associations between mitochondria function and tissue damage were: state 3 respiration (r2 = 0.43, P = .0004), state 4 respiration (r2 = 0.03, P = 0.38), RCR (r2 = 0.28, P = .007), and membrane swelling (r2 = 0.02, P = .43). The intensity of fluorescence emitted by tissue excited by laser, especially at a wave length of 442 nm, was determined in real time. Mitochondrial state 3 respiration and respiratory control ratio also exhibited good correlations with the grade of ischemic tissue damage.
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Affiliation(s)
- L F Tirapelli
- Department of Surgery and Anatomy, Medical School of Ribeirão Preto, São Paulo, Brazil.
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Lerner SM. Kidney and pancreas transplantation in type 1 diabetes mellitus. ACTA ACUST UNITED AC 2008; 75:372-84. [DOI: 10.1002/msj.20056] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Sá JRD, Gonzalez AM, Melaragno CS, Saitovich D, Franco DR, Rangel EB, Noronha IL, Pestana JOM, Bertoluci MC, Linhares M, Miranda MPD, Monteagudo P, Genzini T, Eliaschewitz FG. Transplante de pâncreas e ilhotas em portadores de diabetes melito. ACTA ACUST UNITED AC 2008; 52:355-66. [DOI: 10.1590/s0004-27302008000200024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 01/08/2008] [Indexed: 02/12/2023]
Abstract
O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.
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Ponte GM, Pileggi A, Messinger S, Alejandro A, Ichii H, Baidal DA, Khan A, Ricordi C, Goss JA, Alejandro R. Toward maximizing the success rates of human islet isolation: influence of donor and isolation factors. Cell Transplant 2007; 16:595-607. [PMID: 17912951 DOI: 10.3727/000000007783465082] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
In order to make islet transplantation a therapeutic option for patients with diabetes there is an urgent need for more efficient islet cell processing to maximize islet recovery. Improved donor management, organ recovery techniques, implementation of more stringent donor criteria, and improved islet cell processing techniques may contribute to enhance organ utilization for transplantation. We have analyzed the effects of donor and islet processing factors on the success rate of human islet cell processing for transplantation performed at a single islet cell processing center. Islet isolation outcomes improved when vasopressors, and in particular pitressin, and steroids were used for the management of multiorgan donors. Higher islet yields were obtained from adult male donors, BMI >25 kg/m2, adequate glycemic control during hospital stay, and when the pancreas was retrieved by a local surgical team. Successful isolations were obtained in 58% of the cases when > or = 4 donor criteria were met, and even higher success rates (69%) were observed when considering > or = 5 criteria. Our data suggest that a sequential, integrated approach is highly desirable to improve the success rate of islet cell processing.
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Affiliation(s)
- Gaston M Ponte
- Cell Transplant Center and Clinical Islet Transplant Center, Diabetes Research Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL 33136, USA
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Gaber LW. Pancreas allograft biopsies in the management of pancreas transplant recipients: histopathologic review and clinical correlations. Arch Pathol Lab Med 2007; 131:1192-9. [PMID: 17683181 DOI: 10.5858/2007-131-1192-pabitm] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2007] [Indexed: 11/06/2022]
Abstract
CONTEXT Pancreas transplantation has become a therapeutic option for patients with type 1 diabetes mellitus who are in end-stage renal failure. It also is indicated for a subset of nonuremic, insulin-dependent diabetics who experience extreme difficulties in maintaining proper glucose homeostasis by insulin therapy that compromises their productivity and safety. OBJECTIVE To provide a review of the literature and expert experiences for understanding the histologic findings in pancreas transplantation. DATA SOURCES The published literature between 1990 and 2005 was reviewed for this report. Additionally, personal files of the author were used, along with biopsy slides that were used for figures. CONCLUSIONS Pancreas transplantation reestablishes the physiologic state of insulin secretion, and pancreas transplant recipients are able to maintain a state of long-term euglycemia and are less likely to be exposed to hyperglycemia and its systemic complications. Key to the success of transplantation is the scrupulous management and close monitoring of the pancreas transplant recipients. To that end, histologic evaluation of pancreas allografts assumed a pivotal role in management of pancreas allograft dysfunction episodes, and in some centers surveillance biopsies are used to monitor immunologically high-risk situations.
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Affiliation(s)
- Lillian W Gaber
- Department of Pathology, University of Tennessee Health Science Center, Memphis, Tenn, USA.
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27
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Ischemia-reperfusion injury in transplantation: novel mechanisms and protective strategies. Transplant Rev (Orlando) 2007. [DOI: 10.1016/j.trre.2007.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Wullstein C, Woeste G, de Vries E, Persijn GG, Bechstein WO. Acceptance criteria of pancreas grafts: how do surgeons decide in Europe? Transplant Proc 2005; 37:1259-61. [PMID: 15848688 DOI: 10.1016/j.transproceed.2004.12.146] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Some donor factors, such as age, cause of death, and obesity, affect the outcomes of pancreas transplantation. Donors with a high-risk profile are usually not declined for pancreas donation. The purpose of our study was to investigate differences between accepted and refused pancreata after being procured and offered. METHODS In a retrospective study we analyzed all offered pancreata (n = 1360) in the "Eurotransplant Area" between May 25, 2002 and September 18, 2003. Included in this study were 525 pancreata transplanted (38.6%) and 608 pancreata refused for medical reasons (44.7%). A total of 227 pancreata (16.7%) refused for other than medical reasons were excluded from this analysis. RESULTS The significant differences in the donor profiles between transplanted and refused pancreata were cause of death (P < .001), donor age (P < .001), body mass index (BMI, P < .001), serum lipase and amylase (P < .05) at the time of procurement, and a history of smoking (P = .001) or alcohol abuse (P < .001). No differences were found for serum sodium (P = .188), blood leukocytes (P = .349), serum glucose at the time of procurement (P = .155), amylase and lipase at the time of admission (P = .34; P = .758), and vasopressor use at the time of admission or at the procedure (P = .802; P = .982). CONCLUSION Even after procuring and offering potentially good pancreata, nearly half the organs are refused for medical reasons. Acceptance criteria in the Eurotransplant region reveal a conservative attitude toward pancreas acceptance.
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Affiliation(s)
- C Wullstein
- Department of General and Vascular Surgery, Goethe University, Frankfurt, Germany.
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Ridgway DM, White SA, Kimber RM, Nicholson ML. Current practices of donor pancreas allocation in the UK: future implications for pancreas and islet transplantation*. Transpl Int 2005; 18:828-34. [PMID: 15948863 DOI: 10.1111/j.1432-2277.2005.00144.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Recent refinements in technique mean islet cell transplantation offers the chance of a cure to an increasing patient cohort with diabetes. Such developments put pressure upon the scarce resource of donor organs, with potential competition between the modalities of cellular and solid organ transplantation. This questionnaire based study examines current patterns of donor pancreas procurement and use. Reasons for non procurement are studied together with the attitudes of transplant professionals to pancreas allocation. The minority of potentially useful pancreata are currently made available to either whole pancreas or islet transplant programs. Whilst professionals appreciate the role of each modality, there is a need to define criteria for pancreas allocation to avoid under use of donor organs.
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Affiliation(s)
- Dan M Ridgway
- Division of Transplantation, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, UK.
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Abstract
Pancreas transplantation is considered the optimal therapy for patients with diabetes mellitus who reach end-stage renal disease. Despite achievement of euglycaemia after this procedure, the progression to impaired pancreatic function and metabolic exhaustion still represents one of the major concerns that increase the risk of graft loss. This paper reviews the possible mechanisms that can induce post-transplant hyperglycaemia, including those related to immunosuppression and those non-related, and the new strategies available for minimising or preventing this complication. Different aetiologies can induce pancreatic dysfunction. Technical complications, acute pancreatitis and delayed graft function, mostly related to impaired insulin secretion, are considered the early causes for abnormal glucose control. In general, acute rejection does not affect the endocrine portion of the pancreas graft because islet destruction occurs later than the inflammation of the exocrine components. Hyperinsulinaemia and insulin resistance represent the main concern for the progression of blood glucose intolerance. The anastomotic techniques of the exocrine portion of the pancreas and the immunosuppressive regimens are of critical importance for the development of impaired glucose metabolism. Hyperinsulinaemia, as a result of the fact that systemic-enteric or systemic-bladder drainages reducing the hepatic clearance of insulin, has led to the introduction of more physiological techniques using portal drainage of the endocrine secretions. Experimental and clinical data have shown that many of the current immunosuppressants account, to a large degree, for the increased risk of the development of post-transplant hyperglycaemia. The most common maintenance regimen in pancreatic transplantation still consists of triple therapy with a combination of corticosteroids, calcineurin inhibitors (either ciclosporin [cyclosporine] or tacrolimus), and mycophenolate mofetil (MMF).The diabetogenic effects of corticosteroids and calcineurin inhibitors have resulted in the need for protocols able to minimise their use. Recent studies have shown the safety and efficacy of steroid-sparing or -free regimens. Sirolimus has shown powerful immunosuppressive potency in absence of nephrotoxicity and diabetogenicity. Multicentre and single-centre reports have demonstrated that both calcineurin inhibitor withdrawal and avoidance were possible when sirolimus was used in a concentration-controlled fashion, with low-dose corticosteroids and MMF. Although the experience with sirolimus in pancreatic transplantation is still limited, the results are promising. Patients affected by diabetic gastroparesis seem to better tolerate a regimen with sirolimus and low-dose tacrolimus than one with tacrolimus in combination with MMF.For successful, long-term results of pancreatic transplantation, it is crucial to combine donor selection, technical aspects, modified anastomotic techniques and new therapeutic approaches designed to minimise the metabolic and non-metabolic adverse effects of the immunosuppressive regimens.
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Affiliation(s)
- Francesca M Egidi
- Division of Nephrology, University of Tennessee Health Science Center, 951 Court Avenue, Suite # 649 D, Memphis, TN 38163, USA.
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