An evidence-based analysis of simultaneous pancreas-kidney and pancreas transplantation alone

Donor audits in deceased organ donation: a scoping review

PURPOSE

We sought to collate and summarize existing literature on donor audits (DA) and how they have been used to guide deceased organ donation and transplantation system performance and quality assurance.

SOURCE

We searched MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and Web of Science supplemented by Google to identify grey literature on 6 May 2022, to locate studies in English, French, and Spanish. The data were screened, extracted, and analyzed independently by two reviewers. We grouped the results into five categories: 1) motivation for DA, 2) DA methodology, 3) potential and actual donors, 4) missed donation opportunities, and 5) quality improvement.

PRINCIPAL FINDINGS

The search yielded 2,416 unique publications and 52 were included in this review. Most studies were from the UK (n = 13) and published between 2001 and 2006 (n = 15). The methodologies described for DA were diverse. Our findings showed that the primary motivation for conducting DA was to identify potential donors and the number of potential deceased organ donors is significantly higher than the number of actual donors. Among retrieved studies, the proportion of donation opportunities following neurologic determination of death was 95/222 (43%) compared with 25/181 (14%) for donation after cardiocirculatory death (DCD), suggesting that the missed donation rate is higher for DCD.

CONCLUSION

Donor audits help identify missed donation opportunities along the deceased donation pathway and can help support the evaluation of quality improvement initiatives.

Simultaneous pancreas-kidney transplantation for end-stage renal failure in type 1 diabetes mellitus: Current perspectives

Type 1 diabetes mellitus (T1DM) is one of the important causes of chronic kidney disease (CKD) and end-stage renal failure (ESRF). Even with the best available treatment options, management of T1DM poses significant challenges for cli nicians across the world, especially when associated with CKD and ESRF. Substantial increases in morbidity and mortality along with marked rise in treatment costs and marked reduction of quality of life are the usual consequences of onset of CKD and progression to ESRF in patients with T1DM. Simultaneous pancreas-kidney transplant (SPK) is an attractive and promising treatment option for patients with advanced CKD/ESRF and T1DM for potential cure of these diseases and possibly several complications. However, limited availability of the organs for transplantation, the need for long-term immunosuppression to prevent rejection, peri- and post-operative complications of SPK, lack of resources and the expertise for the procedure in many centers, and the cost implications related to the surgery and postoperative care of these patients are major issues faced by clinicians across the globe. This clinical update review compiles the latest evidence and current recommendations of SPK for patients with T1DM and advanced CKD/ESRF to enable clinicians to care for these diseases.

Pancreas Transplantation: Current Challenges, Considerations, and Controversies

Pancreas transplantation (PTx) reestablishes an autoregulating source of endogenous insulin responsive to normal feedback controls. In addition to achieving complete β-cell replacement that frees the patient with diabetes from the need to monitor serum glucose and administer exogenous insulin, successful PTx provides counterregulatory hormone secretion and exocrine function. A functioning PTx mitigates glycemic variability, eliminates the daily stigma and burden of diabetes, restores normal glucose homeostasis in patients with complicated diabetes, and improves quality of life and life expectancy. The tradeoff is that it entails a major surgical procedure and requisite long-term immunosuppression. Despite the high likelihood of rendering patients euglycemic independent of exogenous insulin, PTx is considered a treatment rather than a cure. In spite of steadily improving outcomes in each successive era coupled with expansion of recipient selection criteria to include patients with a type 2 diabetes phenotype, a decline in PTx activity has occurred in the new millennium related to a number of factors including: (1) lack of a primary referral source and general acceptance by the diabetes care community; (2) absence of consensus criteria; and (3) access, education, and resource issues within the transplant community. In the author's experience, patients who present as potential candidates for PTx have felt as though they needed to circumvent the conventional diabetes care model to gain access to transplant options. PTx should be featured more prominently in the management algorithms for patients with insulin requiring diabetes who are failing exogenous insulin therapy or experiencing progressive diabetic complications regardless of diabetes type. Furthermore, all patients with diabetes and chronic kidney disease should undergo consideration for simultaneous pancreas-kidney transplantation independent of geography or location.

Modern indications for referral for kidney and pancreas transplantation

PURPOSE OF REVIEW

Pancreas transplantation (PTx) is currently the only therapy that can predictably achieve sustained euglycemia independent of exogenous insulin administration in patients with insulin-dependent diabetes mellitus. This procedure involves a complex abdominal operation and lifetime dependence on immunosuppressive medications. Therefore, PTx is most frequently performed in combination with other organs, usually a kidney transplant for end stage diabetic nephropathy. Less frequently, solitary PTx may be indicated in patients with potentially life-threatening complications of diabetes mellitus. There remains confusion and misperceptions regarding indications and timing of patient referral for PTx.

RECENT FINDINGS

In this review, the referral, evaluation, and listing process for PTx is described, including a detailed discussion of candidate assessment, indications, contraindications, and outcomes.

SUMMARY

Because the progression of diabetic kidney disease may be less predictable than other forms of kidney failure, early referral for planning of renal and/or pancreas transplantation is paramount to optimize patient care and allow for possible preemptive transplantation.

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.

Cystoscopically Placed Pancreatic Duct Stent for Management of Bladder-Drained Pancreas Transplant with Pancreatic Duct Leak

Background: Historically, exocrine pancreas secretions during pancreas transplant were commonly managed by bladder drainage. Although this technique has fallen out of favor because of significant rates of urologic complications, urologists must still be prepared to assist when they arise. We describe the first reported case of a cystoscopically placed pancreatic duct stent for management of a pancreas transplant duodenocystostomy leak in the setting of normal bladder function. Case Presentation: A 63-year-old male with a history of type 1 diabetes mellitus complicated by end-stage renal disease underwent a simultaneous bladder-drained pancreas and kidney transplant 25 years ago. He developed hematuria and acute rejection of his pancreas, with CT showing large volume ascites concerning for pancreatic leak. Cystoscopy revealed an intact and patent duodenal-cystostomy anastomosis; however, intraperitoneal extravasation on intraoperative cystogram raised concern for pancreatic head necrosis. The patient underwent intraperitoneal drain placement and Foley catheter bladder decompression, but drain output and drain amylase and lipase remained markedly elevated. He was taken back to the operating room for attempted cystoscopic stenting of the pancreatic duct, which was effective using a 5F × 4 cm Zimmon^® pancreatic stent. His drain output normalized in the following days and the pancreatic stent and intraperitoneal drain were removed 4 and 5 weeks after discharge, respectively. Outpatient urodynamics revealed no signs of obstruction and his catheter was removed with minimal postvoid residuals on follow-up. Conclusion: Anastomotic leak after duodenocystostomy during pancreas transplant is a complication typically related to elevated intravesical pressures, managed with bladder decompression and subsequent bladder outlet procedure. We present a novel technique for cystoscopic pancreatic duct stenting in the setting of intact anastomosis and normal bladder function with delayed leak secondary to necrotic pancreatic head. Endoscopic stent placement, intraperitoneal drainage, and bladder decompression with Foley catheter are an effective technique to avoid unnecessary reconstructive surgery.

Cutting-edge biotechnological advancement in islet delivery using pancreatic and cellular approaches

There are approximately 1 billion prediabetic people worldwide, and the global cost for diabetes mellitus (DM) is estimated to be $825 billion. In regard to Type 1 DM, transplanting a whole pancreas or its islets has gained the attention of researchers in the last few decades. Recent studies showed that islet transplantation (ILT) containing insulin-producing β cells is the most notable advancement cure for Type 1 DM. However, this procedure has been hindered by shortage and lack of sufficient islet donors and the need for long-term immunosuppression of any potential graft rejection. The strategy of encapsulation may avoid the rejection of stem-cell-derived allogeneic islets or xenogeneic islets. This review article describes various biotechnology features in encapsulation-of-islet-cell therapy for humans, including the use of bile acids.

Superior Long-term Survival for Simultaneous Pancreas-Kidney Transplantation as Renal Replacement Therapy: 30-Year Follow-up of a Nationwide Cohort

OBJECTIVE

In patients with type 1 diabetes and end-stage renal disease, it is controversial whether a simultaneous pancreas-kidney (SPK) transplantation improves survival compared with kidney transplantation alone. We compared long-term survival in SPK and living- or deceased-donor kidney transplant recipients.

RESEARCH DESIGN AND METHODS

We included all 2,796 patients with type 1 diabetes in the Netherlands who started renal replacement therapy between 1986 and 2016. We used multivariable Cox regression analyses adjusted for recipient age and sex, dialysis modality and vintage, transplantation era, and donor age to compare all-cause mortality between deceased- or living-donor kidney and SPK transplant recipients. Separately, we analyzed mortality between regions where SPK transplant was the preferred intervention (80% SPK) versus regions where a kidney transplant alone was favored (30% SPK).

RESULTS

Of 996 transplanted patients, 42%, 16%, and 42% received a deceased- or living-donor kidney or SPK transplant, respectively. Mean (SD) age at transplantation was 50 (11), 48 (11), and 42 (8) years, respectively. Median (95% CI) survival time was 7.3 (6.2; 8.3), 10.5 (7.2; 13.7), and 16.5 (15.1; 17.9) years, respectively. SPK recipients with a functioning pancreas graft at 1 year (91%) had the highest survival (median 17.4 years). Compared with deceased-donor kidney transplant recipients, adjusted hazard ratios (95% CI) for 10- and 20-year all-cause mortality were 0.79 (0.49; 1.29) and 0.98 (0.69; 1.39) for living-donor kidney and 0.67 (0.46; 0.98) and 0.79 (0.60; 1.05) for SPK recipients, respectively. A treatment strategy favoring SPK over kidney transplantation alone showed 10- and 20-year mortality hazard ratios of 0.56 (0.40; 0.78) and 0.69 (0.52; 0.90), respectively.

CONCLUSIONS

Compared with living- or deceased-donor kidney transplantation, SPK transplant was associated with improved patient survival, especially in recipients with a long-term functioning pancreatic graft, and resulted in an almost twofold lower 10-year mortality rate.

Is simultaneous pancreas kidney transplant the most cost-effective strategy for type 1 diabetes patients with renal failure?

Introduction:

Simultaneous pancreas kidney transplant (SPK) has shown beneficial outcomes in type 1 diabetes patients with renal failure (IDDM-RF). The objective of this study was to assess its cost-effectiveness compared with other treatment strategies for IDDM-RF.

Methods:

A decision analytic model was developed for IDDM-RF treatment with four possible strategies: deceased donor kidney transplant (DDKT), living donor kidney transplant (LDKT), SPK and dialysis. A cost-utility analysis from the healthcare provider perspective was conducted based on a five-year model. Local data were used whenever possible except for SPK survival variables, wherein data from United Network for Organ Sharing and Scientific Registry of Transplant Recipients were used. Sensitivity analyses were performed to evaluate the impact of uncertainties around key variables.

Results:

In the baseline analysis, LDKT was the most cost-effective strategy with the lowest cost per quality-adjusted life year gained, i.e. SGD77,068, followed by SPK (SGD82,991), DDKT (SGD92,432) and dialysis (SGD181,192). The DDKT was extended dominated by dialysis and LDKT strategies. Incremental cost-effectiveness ratios with dialysis as a reference for LDKT and SPK strategies were SGD43,094 and SGD56,201, respectively. Both strategies are considered highly cost-effective under World Health Organization (WHO) guidelines. In the sensitivity analysis, a 6% increase in both SPK kidney graft survival and patient survival would make SPK the most cost-effective strategy.

Conclusions:

Both LDKT and SPK are highly cost-effective strategies in the treatment of IDDM-RF. SPK is potentially the most cost-effective strategy if a 6% increase in both SPK kidney graft survival and patient survival is achieved.

A comparison of long-term outcomes of portal versus systemic venous drainage in pancreatic transplantation: a systematic review and meta-analysis

Pancreas transplantation venous effluent can be drained via the portal vein or the systemic circulation; however, no recommendation exists for the ideal technique. A systematic review of the literature from 1989 through 2014 using PubMed, CINHAL, and Cochrane Library for portal versus systemic venous drainage was undertaken. Only studies on humans and published in English were considered. Measures of glycemic control and total cholesterol were synthesized for meta-analysis utilizing random-effects models. Of 166 articles retrieved, 15 articles were included for meta-analysis. Patient and graft survival were comparable in a large database study as well as in the only randomized control study. No differences in complications were seen when exocrine drainage was enteric for the systemic venous group. Fasting insulin (-34.13 pmol/mL, p < 0.001) was significantly lower within the portal drained group; however, fasting blood glucose levels (-3.4 mg/dL, p = 0.32) and hemoglobin A1C levels (mean difference 0.124%, p = 0.25) were comparable. Total cholesterol levels (-3.62 mg/dL, p = 0.447), as well as other measures of lipids, showed no difference. Based on this systematic review and meta-analysis, there is no evidence of differences in outcomes or metabolic control in patients undergoing pancreatic transplant with portal venous drainage compared to the systemic venous drainage.

Charcot neuroarthropathy after simultaneous pancreas-kidney transplantation: risk factors, prevalence, and outcome

We retrospectively analyzed outcome and risk factors of developing Charcot foot (CF) in 100 patients with type 1 diabetes mellitus who underwent a simultaneous pancreas-kidney (SPK) transplantation. Patients who developed CF after SPK transplantation had significantly higher mortality (56% vs. 18%) and more frequently graft failure (44% vs. 13%). Recipients with CF also experienced acute rejections more frequently (78% vs. 41%). They furthermore had higher pre-transplant values of HbA1c , received cyclosporine and azathioprine more often, and had significantly higher cumulative corticosteroid use. Patients transplanted in an earlier era (1992-1998) received cyclosporine and azathioprine more often and had a significantly higher cumulative corticosteroid use with the higher prevalence of CF. Conversely, patients with diabetes transplanted more recently (1999-2012) received lower doses of corticosteroids as part of their tacrolimus-based immunosuppressive therapy, resulting in fewer CF attacks. In conclusion, development of CF after SPK is associated with poor patient and graft outcome. Poor pre-transplant diabetic control and the use of high-dose corticosteroids are risk factors for the development of CF. We recommend reduction in or even total avoidance of corticosteroids after SPK transplantation. Given the importance of the diagnosis of CF on outcome, a systematic examination of SPK patients' feet is recommended.

A Simplified Technique of Pancreas Transplantation in a Porcine Model

Background: The incidence of diabetes has been steadily increasing. The only curative option for diabetes is pancreas transplantation (PTx). Porcine models are valuable because of their anatomical and physiological similarities to human beings. Our aim is to introduce a simplified technique of PTx in a porcine model. Methods: In Landrace pigs (n = 32), after median laparotomy, the pancreas was mobilized, and the portal and splenic veins were divided. The proper hepatic and splenic arteries and the bile duct were also prepared, and the duodenal bulb was prepared and stapled. The third portion of the duodenum was freed up to the ligament of Treitz and stapled, and the renal arteries were ligated. After systemic heparinization, the pancreas was perfused through the abdominal aorta with histidine-tryptophan-ketoglutarate solution. The portal and splenic veins were cut for evaluating the sufficiency of perfusion. Whole pancreaticoduodenal graft was procured along with an aortic jump graft containing mesenteric and celiac trunks. In recipients, after total pancreatectomy, the suprarenal inferior vena cava and infrarenal aorta were prepared for vascular anastomosis in an end-to-side manner. After pancreas reperfusion, duodenoduodenostomy was performed in an end-to-side manner. Results: Median cold and warm ischemia times were 10 h (range, 9-14 h) and 50 min (range, 35-80 min), respectively. The hemodynamic status was stable throughout the operation. The median follow-up period was 7 days (range, 4-10). There were no major intra- and postoperative complications. Conclusion: By using an aortic jump graft, there was no need to perform additional arterial reconstruction resulting in a short warm ischemic and operation time. End-to-side portocaval and duodenoduodenal anastomoses make this model of PTx a very feasible method for experimental evaluations.

Transplantation of Encapsulated Pancreatic Islets as a Treatment for Patients with Type 1 Diabetes Mellitus

Encapsulation of pancreatic islets has been proposed and investigated for over three decades to improve islet transplantation outcomes and to eliminate the side effects of immunosuppressive medications. Of the numerous encapsulation systems developed in the past, microencapsulation have been studied most extensively so far. A wide variety of materials has been tested for microencapsulation in various animal models (including nonhuman primates or NHPs) and some materials were shown to induce immunoprotection to islet grafts without the need for chronic immunosuppression. Despite the initial success of microcapsules in NHP models, the combined use of islet transplantation (allograft) and microencapsulation has not yet been successful in clinical trials. This review consists of three sections: introduction to islet transplantation, transplantation of encapsulated pancreatic islets as a treatment for patients with type 1 diabetes mellitus (T1DM), and present challenges and future perspectives.

Epidemiology, risk factors and impact on long-term pancreatic function of infection following pancreas-kidney transplantation

Limited information exists about epidemiology and risk factors of infection following pancreas-kidney transplantation and its impact on long-term pancreatic graft function. A retrospective chart review of episodes of severe infection in consecutive pancreas-kidney transplantations in a single institution was performed to assess the epidemiology, risk factors for infection and their impact on the development of pancreatic graft dysfunction. Ninety-four (81%) of 116 recipients (median follow-up of 1492 days; mean 1594) developed 248 episodes of severe infection. Bacterial infections were present in 208 episodes, with 12% of the isolates resistant to antibiotics used in prophylaxis. There were 40 episodes of fungal infection in 32 patients (28%) (mostly Candida spp), and CMV disease appeared in 20 patients (17%), of which 50% appeared after the third month following surgery. The multivariate analysis identified that surgical re-intervention and the use of steroid pulses were independently associated with the development of any infection. Additionally, pre-transplant evidence of peripheral artery disease, a longer cold ischaemia time and high transfusional requirements were associated with fungal infections. Cytomegalovirus (CMV) mismatch was independently related to CMV disease and female sex, and bladder drainage of the exocrine pancreas was associated with urinary tract infection. At the end of follow-up, 29 patients (25%) had developed severe pancreatic graft dysfunction, and fungal infection was independently associated with it. Our study identifies a subset of pancreas-kidney transplant recipients at a higher risk of developing severe infection. Fungal infection is an independent risk factor for the development of severe pancreatic graft dysfunction.

Corneal confocal microscopy detects early nerve regeneration in diabetic neuropathy after simultaneous pancreas and kidney transplantation

Diabetic neuropathy is associated with increased morbidity and mortality. To date, limited data in subjects with impaired glucose tolerance and diabetes demonstrate nerve fiber repair after intervention. This may reflect a lack of efficacy of the interventions but may also reflect difficulty of the tests currently deployed to adequately assess nerve fiber repair, particularly in short-term studies. Corneal confocal microscopy (CCM) represents a novel noninvasive means to quantify nerve fiber damage and repair. Fifteen type 1 diabetic patients undergoing simultaneous pancreas-kidney transplantation (SPK) underwent detailed assessment of neurologic deficits, quantitative sensory testing (QST), electrophysiology, skin biopsy, corneal sensitivity, and CCM at baseline and at 6 and 12 months after successful SPK. At baseline, diabetic patients had a significant neuropathy compared with control subjects. After successful SPK there was no significant change in neurologic impairment, neurophysiology, QST, corneal sensitivity, and intraepidermal nerve fiber density (IENFD). However, CCM demonstrated significant improvements in corneal nerve fiber density, branch density, and length at 12 months. Normalization of glycemia after SPK shows no significant improvement in neuropathy assessed by the neurologic deficits, QST, electrophysiology, and IENFD. However, CCM shows a significant improvement in nerve morphology, providing a novel noninvasive means to establish early nerve repair that is missed by currently advocated assessment techniques.

Transplantation of the pancreas

Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.

Pancreatic islet transplantation

Pancreatic islet transplantation is a minimally invasive treatment that has the potential to prevent diabetes after total pancreatectomy for benign disease (islet autotransplantation) and to reverse diabetes in those with type 1 diabetes (islet allotransplantation). In both scenarios, the treatment involves extracting sufficient numbers of pancreatic islets from the resected or donor pancreas and infusing these through the portal vein into the patient's liver. The results for both forms of this treatment have been encouraging over recent years, with up to 85% of adult patients remaining insulin independent for at least 1 year after transplantation. However, there are a number of challenges that need to be overcome before these treatments can be used routinely in children. The aim of this review is to outline the rationale, methodology, and current results of islet allotransplantation, and to discuss the potential new developments that could enable this important treatment to be widely applicable to children. Although islet autotransplantation is not discussed in detail, the overall rationale and methods are similar. However, as the procedure involves the transplantation of the patient's own islets, and the indication for the procedure is not for autoimmune disease, there are none of the difficult immune challenges of allotransplantation.

Human fibrinogen patches application reduces intra-abdominal infectious complications in pancreas transplant with enteric drainage

PURPOSE

The purpose of the study was to analyze the incidence of intra-abdominal infectious complications after the application of a fibrinogen sealant to the duodenojejunal anastomosis in simultaneous pancreas-kidney transplants (SPK) with enteric drainage.

METHODS

Results of 68 SPKs with enteric drainage were prospectively assessed. A fibrinogen and thrombin sheet was applied to the duodenojejunal anastomosis in 34 patients, who were compared to a control group of 34 patients. The incidence and severity of intra-abdominal infectious complications and the 1-year patient and grafts survival were analyzed.

RESULTS

Eighteen patients experienced intra-abdominal infectious complications. Grade 1a complications occurred in the study group, whereas surgery was required only in patients from the control group: complications grade 3a (15%) and complications grade 3b (18%) (p = 0.003 vs. study group, respectively). The overall rate of anastomotic leakage (complications grade 2b and 3b) was 10%, all of which occurred in the control group. The length of hospital stay was higher in the control group was 34.6 ± 11.3 days vs. 22.8 ± 11.1 days (p = 0.03). There were no significant differences in 1-year patient and graft survival between groups.

CONCLUSIONS

In our study, the application of fibrinogen and thrombin sheets was associated to a decrease in the number and severity of intra-abdominal infectious complications.

Consolidation of enteric drainage for exocrine secretions in simultaneous pancreas-kidney transplant

INTRODUCTION

Management of the exocrine drainage of the pancreatic graft in simultaneous pancreas kidney (SPK) transplantation has been a matter of debate for years. There is currently a trend toward a more physiological enteric drainage (ED). This study compared short- and long-term complications and graft survival in patients with enteric versus bladder exocrine secretion drainage.

PATIENTS AND METHODS

Between January 1995 and November 2005, we performed 75 SPK transplants: 55 with ED and 20 with bladder drainage (BD). The rates of complications and graft survival were monitored over at least 36 months after transplantation.

RESULTS

Mean posttransplant follow-up was 119.5 +/- 6.6 months. Urinary infection, hematuria, reflux pancreatitis, and repeat surgery rates were all significantly higher among the BD area. There was no intergroup difference in rejection rates or in the incidence of graft thrombosis, transplantectomy, anastomotic dehiscence, or intra-abdominal abscesses. Pancreas and kidney graft survival rates were similar in the two groups.

CONCLUSIONS

In our experience, ED was more physiological than BD, and was associated with fewer complications.

Epidemiology of infections requiring hospitalization during long-term follow-up of pancreas transplantation

BACKGROUND.: Pancreas transplantation (PT) provides the best glycemic control option for diabetes mellitus but is associated with significant morbidities related to infectious disease. METHODS.: We performed a retrospective study of a cohort of consecutive PT recipients in whom PT was performed from 1998 to 2006 (n=216) and followed up them until July 2008. Data regarding infections, rejection, infection chemoprophylaxis, graft failure, absolute lymphocyte counts (ALCs), and mortalities were collected. RESULTS.: Simultaneous pancreas and kidney, pancreas transplantation alone, and pancreas after kidney (PAK) transplantations were performed in 42, 67, and 107 patients, with a mean (standard deviation) age at transplantation of 46.8 (8.03), 40.6 (10.1), and 43.7 (8.19) years. Of the simultaneous pancreas and kidney, pancreas transplantation alone, and PAK transplant recipients, 54.7%, 37.3%, and 58.8% were men. Overall, 63% developed a serious infection during the median follow-up of 6.4 years. Mean (range) number of infectious episodes was 2.3 (1-12), with mostly bacterial infections both within (68%) and after 1 year (78%). Incidence of bacterial and viral infections was greatest in the first 3 months after transplantation. Fungal infections were more constant. Bladder exocrine drainage was associated with higher risk of infection (hazard ratio=2.5, P<0.001). Infection within the first 3 months after transplantation was related to higher mortality after the first 3 months (hazard ratio=3.19). ALC was associated with the risk of first infections (P=0.005) and bacterial infections (P<0.001). CONCLUSIONS.: Incidence of infections after PT was 63% and mostly bacterial. Bladder drainage increases infection risk and low ALC partially predicts episodes. Limitations include retrospective design, unequal composition of PT groups, and lack of data between kidney and PT for PAK.

Urological complications after simultaneous pancreas-kidney transplantation

OBJECTIVE

We evaluated the incidence of urological complications after simultaneous renal and pancreatic transplantation.

PATIENTS AND METHODS

We retrospectively reviewed urological complications following 107 simultaneous kidney-pancreas transplantations performed at our institution between March 1995 and June 2008. The 46 women and 61 men were of mean age 37.8 years (range, 25-66). The mean duration of diabetes mellitus was 23.0 years (range, 9-48) and the mean duration of dialysis was 19.9 months (range, 0-70). The exocrine pancreatic secretions were drained to bladder in 58 cases, or enterically in 49 patients. The mean length of follow-up was 51.7 months.

RESULTS

The most frequent urological complication was urinary tract infection, reported in 63.8% of patients: 42 bladder-drained and 25 enteric-drained (P = .011). Hematuria occurred in 13 patients (12.5%): 12 bladder-drained and 1 enteric-drained (P = .002). Five bladder-drained patients developed bladder calculi. Among 58 bladder-drained patients, reflux pancreatitis occurred in 28 patients and urine leaks related to the pancreatic graft occurred in 7 patients. Conversion of exocrine secretions from bladder to enteric diversion was required in 6 patients. One- and 3-year patient survival rates were 92.7% and 89.1%, respectively. Moreover, 1 and 3-year kidney graft survival rates were 90.6% and 84.4%, and pancreas graft survival rates were 78.1 and 70.3%, respectively.

CONCLUSION

Simultaneous kidney-pancreas transplantation with bladder drainage is associated with a high frequency of urological complications. Appropriate treatment can resolve most complications. In our opinion, both enteric and bladder drainage seemed to be safe and effective alternatives to manage pancreatic exocrine secretions.

The current state of pancreas-kidney transplantation in China: the indications, surgical techniques and outcome

It is currently estimated that 50 million Chinese have diabetic mellitus (DM) with more than 90% of these being afflicted with type 2 DM. Concomitantly, the socio-economic improvements in China are supporting the adoption of pancreas-kidney transplantations as a treatment option for these patients. Recipient candidate pool has yet to be expanded and the final effect to be improved in clinical practice. To date, more than 250 pancreas-kidney transplants have been performed on patients with type 1 and type 2 DM. To improve the outcome, a new surgical technique that involves anastomosis of the graft duodenum to recipient jejunum side-to-side but not Roux-en-Y, has been devised for enteric drainage. Furthermore, the systemic venous drainage (SVD) has been used as the method of choice for endocrine secretions. Graft and recipient long-term survival in China was similar to that in America and Europe. Three-year survival rate of pancreas and kidney grafts was 92.2% and 90.2%, respectively, in our center. No difference in survival and graft function between type 1 and type 2 DM recipients was noted. It is concluded that pancreas-kidney transplantation is an effective way for the treatment of type 1 DM and some type 2 DM complicated with uremia.

Conversion to sirolimus in kidney-pancreas and pancreas transplantation

Reports on the use of sirolimus (SRL) in pancreas transplantation are still limited. The aim of this study was to evaluate the outcome of SRL conversion in pancreas transplant patients. Among 247 patients undergoing simultaneous kidney-pancreas or solitary pancreas transplantation, 33 (13%) were converted to SRL. The reasons for conversion were calcineurin inhibitors (CNI) nephrotoxicity (n = 24; 73%), severe neurotoxicity owing to CNI (n = 1; 3%), severe and/or recurrent acute rejection episodes (n = 7; 21%), gastrointestinal (GI) side effects of mycophenolate mofetil (MMF; n = 5; 15%), and hyperglycemia (n = 4; 12%). Before conversion, all patients were maintained on a CNI, MMF, and low-dose steroids. They were gradually converted to SRL associated with either CNI or MMF withdrawal. Sixty-three percent (n = 15) of patients who were converted owing to CNI nephrotoxicity, showed stable or improved renal function. At 12 months after conversion, serum creatinine levels were significantly decreased in this group (2.2 +/- 0.5 vs 1.6 +/- 0.3 mg/dL; P = .001) and C-peptide values increased (2.9 +/- 1.1.1 vs 3.1 +/- 1.3 nmol/L; P = .018). The only patient with leucoencephalopathy showed improved neurologic status after SRL conversion. All patients converted to SRL because of GI side effects of MMF showed improvements, and none of those converted because of hyperglycemia experienced improvement. There were no episodes of acute rejection after conversion. We concluded that conversion to SRL in pancreas transplantation should be considered an important alternative strategy, particularly for CNI nephrotoxicity and neurotoxicity, and in cases of severe diarrhea due to MMF.

Pancreas transplantation

The first successful pancreas transplantation in conjunction with a simultaneous kidney transplantation was performed in 1966 by Kelly, Lillehei and others from the University of Minnesota. In Taipei Veterans General Hospital, the first pancreas transplantation (simultaneously coupled with kidney transplantation) was successfully performed on September 19, 2003, and we were qualified to harvest and transplant pancreas graft by the Taiwan Department of Health on August 31, 2007. Currently, pancreas transplantation remains the most effective method of establishing physiological and durable normoglycemia for patients with diabetes mellitus. The main indication for pancreas transplantation is type 1 diabetes with diabetic complications such as nephropathy, retinopathy, neuropathy and cardiocerebral vasculopathy, or with frequent life-threatening hypoglycemia or hyperglycemia. Pancreas graft survival rate at 1 year was 85% for simultaneous pancreas-kidney transplantation, 78% for pancreas-after-kidney transplantation, and 76% for pancreas transplantation alone. At 3 years, pancreas graft survival rates were at least 62% in all categories.

Minimization and withdrawal of steroids in pancreas and islet transplantation

For reducing the corticosteroid (CS)-related side-effects, especially cardiovascular events, CS-sparing protocols have become increasingly common in pancreas transplantation (PT). Lympho-depleting induction antibodies, such as rabbit anti-thymocyte globulin (rATG) or alemtuzumab, have been widely used in successful trials. The results of various CS-sparing protocols combining calcineurin inhibitors (CNI) and mycophenolate or sirolimus, have been mixed for rejection and survival rates. Most of the studies were uncontrolled trials of low-risk patients, therefore the grade of evidence is limited. Large-scale prospective studies with long-term follow up are necessary to assess risks and benefits of CS-sparing regimens in PT before recommending such strategies as standard practice. Islet allo-transplantation for patients with brittle type 1 diabetes mellitus, less invasive and safer procedure than PT, has been attempted since late 1980s, but diabetogenic immunosuppressants at maintenance, mainly CS and high-dose CNI, prevented satisfactory results (10% insulin-independence at 1-year post-transplant). Since 2000, CS-free and CNI-reducing protocols, including more potent induction [daclizumab, OKT3gamma1(ala-ala) anti-CD3 antibody, rATG] and maintenance (sirolimus, mycophenolate) agents, have significantly improved short-term outcomes whereas long-term are still inadequate (from 80% to 20% insulin-independence from 1- to 5-year post-transplant). Main limitations are allo- and autoimmunity, immunosuppression-related islet and systemic toxicity and transplant site unsuitability, which tolerogenic protocols and biotechnological solutions may solve.

Minimization protocols in pancreas transplantation

Diagnosis of immunologic injury (acute and chronic) is much more difficult in pancreas transplants when compared with transplants of other organs. Currently, the immunosuppressive regimen for induction involves calcineurin inhibitors (CNI), antimetabolites and corticosteroids (Cs). This strong and nonspecific regimen does not take into consideration pancreas specificities (i.e. the need to avoid diabetogenic compounds). For obvious reasons, CNI might be calling for review, if permanently indicated in recipients of solitary pancreas with mild renal dysfunction. CNI as well as corticosteroids may induce hyperglycemia and contribute to differential diagnosis of a rejection process. However, in spite of the benefits accruing from withdrawal of above immunosuppressive agents, minimization or avoidance of these drugs could be dangerous and may end up with graft loss (i.e. antibody-mediated process). Long-term results of pancreas transplantation are now achieving comparable survival rates similar to the transplant of traditional organs such as kidney and liver. As a consequence, the physicians' objectives are to prolong the patient's quality of life and organ function as long as possible. Weaning strategies in regard to CNI and steroids are tested. Sirolimus, everolimus, CTLA-4 Ig, etc, are agents known to be either both nonnephrotoxic and nondiabetogenic or less so when compared with CNI. Their impact on pancreas transplantation is beginning to be evaluated. Large randomized trials in all pancreas categories, with long-term clinical and histologic results, are mandatory to establish new guidelines for immunosuppressive regimens for pancreas transplantation.

Transplantation for the treatment of type 1 diabetes

Transplantation of pancreatic tissue, as either the intact whole pancreas or isolated pancreatic islets has become a clinical option to be considered in the treatment of patients with type 1 insulin-dependant diabetes mellitus. A successful whole pancreas or islet transplant offers the advantages of attaining normal or near normal blood glucose control and normal hemoglobin A1c levels without the risks of severe hypoglycemia associate with intensive insulin therapy. Both forms of transplants are also effective at eliminating the occurrence of significant hypoglycemic events (even with only partial islet function evident). Whereas whole pancreas transplantation has also been shown to be very effective at maintaining a euglycemic state over a sustained period of time, thus providing an opportunity for a recipient to benefit from improvement of their blood glucose control, it is associated with a significant risk of surgical and post-operative complications. Islet transplantation is attractive as a less invasive alternative to whole pancreas transplant and offers the future promise of immunosuppression-free transplantation through pre-transplant culture. Islet transplantation however, may not always achieve the sustained level of tight glucose control necessary for reducing the risk of secondary diabetic complications and exposes the patient to the adverse effects of immunosuppression. Although recent advances have led to an increased rate of obtaining insulin-independence following islet transplantation, further developments are needed to improve the long-term viability and function of the graft to maintain improved glucose control over time.

Transplante de pâncreas e ilhotas em portadores de diabetes melito

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.

Transplantation for the treatment of type 1 diabetes

Transplantation of pancreatic tissue, as either the intact whole pancreas or isolated pancreatic islets has become a clinical option to be considered in the treatment of patients with type 1 insulin-dependant diabetes mellitus. A successful whole pancreas or islet transplant offers the advantages of attaining normal or near normal blood glucose control and normal hemoglobin A1c levels without the risks of severe hypoglycemia associate with intensive insulin therapy. Both forms of transplants are also effective at eliminating the occurrence of significant hypoglycemic events (even with only partial islet function evident). Whereas whole pancreas transplantation has also been shown to be very effective at maintaining a euglycemic state over a sustained period of time, thus providing an opportunity for a recipient to benefit from improvement of their blood glucose control, it is associated with a significant risk of surgical and post-operative complications. Islet transplantation is attractive as a less invasive alternative to whole pancreas transplant and offers the future promise of immunosuppression-free transplantation through pre-transplant culture. Islet transplantation however, may not always achieve the sustained level of tight glucose control necessary for reducing the risk of secondary diabetic complications and exposes the patient to the adverse effects of immunosuppression. Although recent advances have led to an increased rate of obtaining insulin-independence following islet transplantation, further developments are needed to improve the long-term viability and function of the graft to maintain improved glucose control over time.

Exocrine drainage into the duodenum: a novel technique for pancreas transplantation

Simultaneous pancreas-kidney transplantation is the treatment of choice for patients suffering from type 1 diabetes mellitus and end-stage renal failure secondary to diabetic nephropathy. Until 1995, about 90% of pancreas transplantations were performed with exocrine drainage into the bladder. Since then the proportion of pancreas transplants with enteric drainage increased steadily because of frequency of complications and long-term disadvantages of bladder drainage. However, the use of enteric drainage removes the opportunity to monitor pancreatic allograft function either by measuring urinary amylase or by carrying out biopsy via cystoscopy. We report a new technique of exocrine pancreatic drainage into the recipient duodenum. This modification places the pancreas graft including the duodenal anastomosis in a retroperitoneal location and, importantly, allows easy graft monitoring via gastroscopy.

Impact of Portal Versus Systemic Venous Drainage on Acute Rejection of Simultaneous Pancreas−Kidney Transplantation in Pig

BACKGROUND

The immunological benefits of portal venous drainage (PVD) in pancreas transplantation remain debated clinically. We established simultaneous pancreas-kidney transplantation (SPK) models with portal venous drainage and systemic venous drainage to compare the impact of venous drainage site on acute rejection in pig.

METHODS

Forty-eight nonrelated, first hybrid landrace pigs were divided into PE (portal-enteric drainage) and SE (systemic-enteric drainage) groups. Type I diabetes mellitus was induced by whole pancreatectomy, and right-side nephrectomy was also performed in the recipients. The donor portal vein was anastomosed to superior mesenteric vein of the recipients in PE group or to the inferior hepatic cava vena of the recipients in SE group. Graft tissue specimens were obtained with laparotomy on Day 3 and 7 after transplant, and the severity of acute rejection was scored according to Nakhleh and Banff criteria.

RESULTS

The cold ischemia time, fasting plasma glucose and urine creatinine of the 2 groups had no statistic difference between 2 groups at Day 1, 3, 5, and 7 after transplant (P>0.05). The occurrence of both pancreas and kidney acute rejections in PE group was significant later and slighter than SE group (P<0.05).

CONCLUSION

PVD, compared with SVD, could ameliorate and delay acute rejection in pig SPK. It might become a tolerance inducing method of pancreas transplantation, decrease the cost and improve the quality of SPK, if further confirmed by clinical trials.