1
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Martinez EJ, Pham PH, Wang JF, Stalter LN, Welch BM, Leverson G, Marka N, Al-Qaoud T, Mandelbrot D, Parajuli S, Sollinger HW, Kaufman DB, Redfield RR, Odorico JS. Analysis of Rejection, Infection and Surgical Outcomes in Type I Versus Type II Diabetic Recipients After Simultaneous Pancreas-Kidney Transplantation. Transpl Int 2024; 37:13087. [PMID: 39364120 PMCID: PMC11446817 DOI: 10.3389/ti.2024.13087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 09/10/2024] [Indexed: 10/05/2024]
Abstract
Given the increasing frequency of simultaneous pancreas-kidney transplants performed in recipients with Type II diabetes and CKD, we sought to evaluate possible differences in the rates of allograft rejection, infection, and surgical complications in 298 Type I (T1D) versus 47 Type II (T2D) diabetic recipients of simultaneous pancreas-kidney transplants between 2006-2017. There were no significant differences in patient or graft survival. The risk of biopsy-proven rejection of both grafts was not significantly different between T2D and T1D recipients (HRpancreas = 1.04, p = 0.93; HRkidney = 0.96; p = 0.93). Rejection-free survival in both grafts were also not different between the two diabetes types (ppancreas = 0.57; pkidney = 0.41). T2D had a significantly lower incidence of de novo DSA at 1 year (21% vs. 39%, p = 0.02). There was no difference in T2D vs. T1D recipients regarding readmissions (HR = 0.77, p = 0.25), infections (HR = 0.77, p = 0.18), major surgical complications (HR = 0.89, p = 0.79) and thrombosis (HR = 0.92, p = 0.90). In conclusion, rejection, infections, and surgical complications after simultaneous pancreas-kidney transplant are not statistically significantly different in T2D compared to T1D recipients.
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Affiliation(s)
- Eric J. Martinez
- Anette C and Harold C Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Phuoc H. Pham
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, School of Medicine, Creighton University, Omaha, NE, United States
| | - Jesse F. Wang
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Lily N. Stalter
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Bridget M. Welch
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Glen Leverson
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Nicholas Marka
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Talal Al-Qaoud
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Hans W. Sollinger
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Dixon B. Kaufman
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Robert R. Redfield
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Jon Scott Odorico
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
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2
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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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3
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Pofi R, Caratti G, Ray DW, Tomlinson JW. Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad? Endocr Rev 2023; 44:975-1011. [PMID: 37253115 PMCID: PMC10638606 DOI: 10.1210/endrev/bnad016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/25/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.
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Affiliation(s)
- Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Giorgio Caratti
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - David W Ray
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Oxford Kavli Centre for Nanoscience Discovery, University of Oxford, Oxford OX37LE, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
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4
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Pham PH, Stalter LN, Martinez EJ, Wang JF, Welch BM, Leverson G, Marka N, Al-Qaoud T, Mandelbrot D, Parajuli S, Sollinger HW, Kaufman D, Redfield RR, Odorico JS. Single center results of simultaneous pancreas-kidney transplantation in patients with type 2 diabetes. Am J Transplant 2021; 21:2810-2823. [PMID: 33350048 PMCID: PMC8217396 DOI: 10.1111/ajt.16462] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/25/2020] [Accepted: 12/15/2020] [Indexed: 01/25/2023]
Abstract
Studies have found similar outcomes of Simultaneous Pancreas-Kidney transplantation (SPKT) in patients with Type 2 (T2D) and Type 1 diabetes (T1D). However, there are scarce data evaluating the association of recipient factors such as age, BMI, or pretransplant insulin requirements with outcomes, thus the criteria for the optimal recipient selection remains unclear. In this study, 284 T1D and 39 T2D patients, who underwent SPKT between 2006 and 2017 with 1 year of follow-up at minimum, were assessed for potential relationship of pretransplant BMI and insulin requirements with posttransplant diabetes and pancreatic graft failure. Kaplan-Meier analysis showed similar rates of freedom from posttransplant diabetes (94.7% T2D vs. 92.3% T1D at 1 yr, and 88.1% T2D vs. 81.1% T1D at 5 yrs) and graft survival (89.7% T2D vs. 90.4% T1D at 1 yr, and 89.7% T2D vs. 81.2% T1D at 5 yrs). There was no significant association between BMI or pretransplant insulin requirements with posttransplant diabetes occurrence in either T1D (p = .10, .43, respectively) or T2D (p = .12, .63) patients in the cohort; or with graft failure (T1D: p = .40, .09; T2D: p = .71, .28). These observations suggest a less restricted approach to selective use of SPKT in patients with T2D.
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Affiliation(s)
- Phuoc H. Pham
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Lily N. Stalter
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Eric J. Martinez
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,Anette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Jesse F. Wang
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bridget M. Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Glen Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nicholas Marka
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Talal Al-Qaoud
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Hans W. Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dixon Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert R. Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jon S. Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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5
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Dong Y, Zhou J, Li Z, Xiang J, Mei S, Gu Y, Zheng H, Chen Z, Huang Z, Xu F, Hu Z. Influence of dialysis duration on outcomes of simultaneous pancreas-kidney transplant. Clin Transplant 2021; 35:e14238. [PMID: 33527545 DOI: 10.1111/ctr.14238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 01/06/2021] [Accepted: 01/22/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study was to assess how pre-transplant dialysis duration affects transplant outcomes after simultaneous pancreas-kidney transplant (SPK) in patients with type 1 diabetes mellitus (T1DM). METHODS Data of 6887 T1DM patients who underwent SPK transplantation between 2008 and 2018 were obtained from the Scientific Registry of Transplant Recipients database. According to pre-transplant dialysis duration, the patients were divided into the preemptive SPK, 0-2 years, 2-5 years, and >5 years dialysis groups. Kaplan-Meier survival analysis was performed to compare patient and graft survival among the groups. Univariate and multivariate Cox regression analyses were used to identify predictors of transplant outcomes. RESULTS The mean follow-up period was 56.7 ± 34.7 months. Compared with no dialysis or preemptive SPK, dialysis for 0-2 years was not significantly associated with patient or kidney graft survival, while long-term dialysis of 2-5 years and >5 years was significantly associated with increased risk of death and kidney graft failure. However, the duration of dialysis was not associated with pancreas graft survival. CONCLUSION Long-term dialysis duration before SPK transplant is an independent predictor of patient death and kidney graft failure in T1DM patients.
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Affiliation(s)
- Yinlei Dong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jie Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhiwei Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jie Xiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Shengmin Mei
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yangjun Gu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Huilin Zheng
- Zhejiang Provincial Collaborative Innovation Center of Agricultural Biological Resource Biochemical Manufacturing, School of Biological and Chemical Engineering, Zhejiang University of Science and Technology, Hangzhou, China
| | - Zheng Chen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhichao Huang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Fangshen Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, Fourth Affiliated Hospital, Zhejiang University, Yiwu, China
| | - Zhenhua Hu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, Fourth Affiliated Hospital, Zhejiang University, Yiwu, China
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6
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Pham PH, Stalter LN, Martinez EJ, Wang JF, Welch BM, Leverson G, Marka N, Al-Qaoud T, Mandelbrot D, Parajuli S, Sollinger HW, Kaufman D, Redfield RR, Odorico JS. Single center results of simultaneous pancreas-kidney transplantation in patients with type 2 diabetes. Am J Transplant 2020. [PMID: 33350048 DOI: 10.1111/ajt.16462.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Studies have found similar outcomes of Simultaneous Pancreas-Kidney transplantation (SPKT) in patients with Type 2 (T2D) and Type 1 diabetes (T1D). However, there are scarce data evaluating the association of recipient factors such as age, BMI, or pretransplant insulin requirements with outcomes, thus the criteria for the optimal recipient selection remains unclear. In this study, 284 T1D and 39 T2D patients, who underwent SPKT between 2006 and 2017 with 1 year of follow-up at minimum, were assessed for potential relationship of pretransplant BMI and insulin requirements with posttransplant diabetes and pancreatic graft failure. Kaplan-Meier analysis showed similar rates of freedom from posttransplant diabetes (94.7% T2D vs. 92.3% T1D at 1 yr, and 88.1% T2D vs. 81.1% T1D at 5 yrs) and graft survival (89.7% T2D vs. 90.4% T1D at 1 yr, and 89.7% T2D vs. 81.2% T1D at 5 yrs). There was no significant association between BMI or pretransplant insulin requirements with posttransplant diabetes occurrence in either T1D (p = .10, .43, respectively) or T2D (p = .12, .63) patients in the cohort; or with graft failure (T1D: p = .40, .09; T2D: p = .71, .28). These observations suggest a less restricted approach to selective use of SPKT in patients with T2D.
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Affiliation(s)
- Phuoc H Pham
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Lily N Stalter
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Eric J Martinez
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Anette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Jesse F Wang
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bridget M Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Glen Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nicholas Marka
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Talal Al-Qaoud
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Hans W Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dixon Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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7
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Pancreatic Islet Changes in Human Whole Organ Pancreas Explants: What Can Be Learned From Explanted Samples? Transplant Direct 2020; 6:e613. [PMID: 33134489 PMCID: PMC7575169 DOI: 10.1097/txd.0000000000001059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/24/2020] [Accepted: 07/14/2020] [Indexed: 01/09/2023] Open
Abstract
Background. Whole pancreas transplantation (Tx) is a successful treatment for type 1 diabetes resulting in independence from antidiabetic therapies. Transplant-related factors contributing to pancreatic islet failure are largely unknown; both recurring insulitis and pancreatitis have been implicated. The aim was to determine if cellular changes in islets and exocrine tissue are evident early in Tx, which could contribute to eventual graft failure using well-preserved tissue of grafts explanted from largely normoglycemic recipients. Methods. Histological specimens of explants (n = 31), Tx duration 1 day–8 years (median 29 d), cold ischemia time 7.2–17.3 hours (median 11.1 h), donor age 13–54 years (median 38 y) were examined; sections were labeled for inflammation, islet amyloidosis, and tissue fibrosis, and morphometry performed on immunolabeled insulin and glucagon positive islet cells. Data were related to clinical details of donor, recipient, and features of Tx. Results. Islet inflammation consistent with recurrent insulitis was not seen in any sample. Insulin-labeled islet cell proportion decreased with donor age (P < 0.05) and cold ischemia (P < 0.01) in explants from 26 normoglycemic patients; glucagon-labeled area proportion increased with cold ischemia (P < 0.05). Clinical pancreatitis was the explant reason in 12 of 28 normoglycemic cases. Exocrine fibrotic area/pancreas was variable (0.7%–55%) and unrelated to clinical/pathological features. Islet amyloid was present in 3 normoglycemic cases (donor ages 58, 42, and 31 y; Tx duration 8 y, 31 and 33 d, respectively). In 1 patient receiving antidiabetic therapy, the insulin-labeled area was reduced but with no evidence of islet inflammation. Conclusions. Explant histological changes after short-term Tx are similar to those seen in type 2 diabetes and occur in the absence of immunologic rejection without causing hyperglycemia. This suggests that factors associated with Tx affect islet stability; persistent deterioration of islet integrity and exocrine tissue fibrosis could impact on sustainability of islet function.
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8
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Sally MB, Ellis MK, Hutchens M, Groat T, Swanson E, Patel MS, Niemann CU, Malinoski DJ. Deceased organ donor factors influencing pancreatic graft transplantation and survival. Clin Transplant 2020; 33:e13571. [PMID: 31001850 DOI: 10.1111/ctr.13571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 12/15/2022]
Abstract
Criteria for organ acceptance in brain-dead organ donors remain inconsistent, especially when concerning pancreatic transplants. We sought to examine donor-specific predictors of pancreatic graft use and survival to better guide the selection and management of potential donors. A prospective observational study of all donors from ten organ procurement organizations was conducted from March 2012 to January 2015. Critical care endpoints were collected at 4 standardized time points. Data associated with pancreatic transplantation and graft survival rates were first determined using univariate analyses, and then logistic regression was used to identify independent predictors of these two outcomes. From 1819 donors, 238 (13.1%) pancreata were transplanted, and at a mean follow-up of 192 days, 218 (91.6%) grafts had survived. After regression analysis, donor age (OR = 0.89), HgbA1C (OR = 0.07), and achieving the donor management goal (DMG) for ejection fraction at allocation of ≥50% (OR = 3.29) remained as independent predictors of pancreatic utilization. On regression analysis, graft survival was independently predicted by lower donor age (OR = 0.93) and achieving the DMGs for mean arterial pressure (60-110 mm Hg) and glucose (≤180 mg/dL) at separate time points. These results may help guide the management and selection of potential pancreatic donors after brain death.
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Affiliation(s)
- Mitchell B Sally
- Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon.,Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - Margaret Katherine Ellis
- Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon
| | - Michael Hutchens
- Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon
| | - Tahnee Groat
- Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon
| | - Elizabeth Swanson
- Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon
| | - Madhukar S Patel
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Claus U Niemann
- Department of Anesthesiology and Surgery, University of California San Francisco, San Francisco, California
| | - Darren J Malinoski
- Operative Care Division, Section of Surgical Critical Care, VA Portland Health Care System, Portland, Oregon.,Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
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9
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Zhou J, Dong Y, Mei S, Gu Y, Li Z, Xiang J, Zheng H, Chen Z, Huang Z, Hu Z. Influence of duration of type 1 diabetes on long‐term pancreatic transplant outcomes. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:583-592. [PMID: 31566900 DOI: 10.1002/jhbp.677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Jie Zhou
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Yinlei Dong
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Shengmin Mei
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Yangjun Gu
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Zhiwei Li
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Jie Xiang
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Huilin Zheng
- Zhejiang Provincial Collaborative Innovation Center of Agricultural Biological Resource Biochemical Manufacturing School of Biological and Chemical Engineering Zhejiang University of Science and Technology Hangzhou Zhejiang China
| | - Zheng Chen
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Zhichao Huang
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Zhenhua Hu
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery Fourth Affiliated Hospital School of Medicine Zhejiang University Yiwu Zhejiang China
- Division of Hepatobiliary and Pancreatic Surgery Yiwu Central Hospital Yiwu Zhejiang China
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10
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Niederhaus SV, Carrico RJ, Prentice MA, Fox AC, Mujtaba MA, Dunn TB, Olaitan OK, Fisher JS, Stratta RJ, Farney AC, Odorico JS, Fridell JA. C-peptide levels do not correlate with pancreas allograft failure: Multicenter retrospective analysis and discussion of the new OPT definition of pancreas allograft failure. Am J Transplant 2019; 19:1178-1186. [PMID: 30230218 DOI: 10.1111/ajt.15118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/24/2018] [Accepted: 09/08/2018] [Indexed: 01/25/2023]
Abstract
The OPTN Pancreas Transplantation Committee performed a multicenter retrospective study to determine if undetectable serum C-peptide levels correspond to center-reported pancreas graft failures. C-peptide data from seven participating centers (n = 415 graft failures for transplants performed from 2002 to 2012) were analyzed pretransplant, at graft failure, and at return to insulin. One hundred forty-nine C-peptide values were submitted at pretransplant, 94 at return to insulin, and 233 at graft failure. There were 77 transplants with two available values (at pretransplant and at graft failure). For recipients in the study with pretransplant C-peptide <0.75 ng/mL who had a posttransplant C-peptide value available (n = 61), graft failure was declared at varying levels of C-peptide. High C-peptide values at graft failure were not explained by nonfasting testing or by individual center bias. Transplant centers declare pancreas graft failure at varying levels of C-peptide and do not consistently report C-peptide data. Until February 28, 2018, OPTN did not require reporting of posttransplant C-peptide levels and it appears that C-peptide levels are not consistently used for evaluating graft function. C-peptide levels should not be used as the sole criterion for the definition of pancreas graft failure.
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Affiliation(s)
- Silke V Niederhaus
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | | | - Abigail C Fox
- United Network for Organ Sharing, Richmond, Virginia
| | - Muhammad A Mujtaba
- Division of Nephrology and Transplant, Department of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Ty B Dunn
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnsota
| | - Oyedolamu K Olaitan
- Section of Abdominal Transplantation, Department of General Surgery, Rush Medical College, Chicago, Illinois
| | - Jonathan S Fisher
- Scripps Center for Organ Transplantation, Scripps Health, La Jolla, California
| | - Robert J Stratta
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Alan C Farney
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Jon S Odorico
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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11
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Yeh CC, Spaggiari M, Tzvetanov I, Oberholzer J. Robotic pancreas transplantation in a type 1 diabetic patient with morbid obesity: A case report. Medicine (Baltimore) 2017; 96:e5847. [PMID: 28178127 PMCID: PMC5312984 DOI: 10.1097/md.0000000000005847] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Obesity is considered a relative contraindication to pancreas transplantation due to increased risks of wound-related complications. Robotic surgeries have never been applied for pancreas transplantation in obese recipients though robotic kidney transplantation did and already proved its value in reducing wound-related complications in obese recipients. PATIENT CONCERNS & DIAGNOSES We performed the first robotic pancreas after kidney transplantation for a 34-year-old Hispanic type 1 diabetic male with class III obesity (BMI = 41 kg/m). INTERVENTIONS The pancreas graft was procured and benched in the standard fashion. Methylene blue was used to detect any vascular leaks. The operation was completed via two 12-mm ports (camera, laparoscopic bed-side assistance), two 8-mm ports for robotic arms, and a 7-cm epigastric incision for hand port. The portal vein and arterial Y-graft of the pancreas were anastomosed to the recipient's left external iliac vein and artery, respectively. Duodenum-bladder drainage was performed with a circular stapler. OUTCOMES Duration of warm and cold ischemia was: 45 minutes and 7 hours, respectively. The patient was discharged uneventfully without wound-related complications. Excellent metabolic control was achieved with hemoglobin A1c lowering from 9% before transplantation to 4.4% on day 120. The patient remained in nondiabetic status in 1-year follow-up. LESSONS In conclusion, robotic pancreas transplantation is feasible in patients with morbid obesity.
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Affiliation(s)
- Chun Chieh Yeh
- Division of Transplantation, University of Illinois at Chicago, IL
- Department of Surgery, China Medical University Hospital
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Mario Spaggiari
- Division of Transplantation, University of Illinois at Chicago, IL
| | - Ivo Tzvetanov
- Division of Transplantation, University of Illinois at Chicago, IL
| | - José Oberholzer
- Division of Transplantation, University of Illinois at Chicago, IL
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12
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Lauria MW, Ribeiro-Oliveira A. Diabetes and other endocrine-metabolic abnormalities in the long-term follow-up of pancreas transplantation. Clin Diabetes Endocrinol 2016; 2:14. [PMID: 28702248 PMCID: PMC5471933 DOI: 10.1186/s40842-016-0032-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 07/03/2016] [Indexed: 12/12/2022] Open
Abstract
Pancreas transplantation (PTX) has been demonstrated to restore long-term glucose homeostasis beyond what can be achieved by intensive insulin therapy or islet transplants. Moreover, PTX has been shown to decrease the progression of the chronic complications of diabetes. However, PTX patients require chronic use of immunosuppressive drugs with potential side effects. The long-term follow-up of PTX patients demands special care regarding metabolic deviations, infectious complications, and chronic rejection. Diabetes and other endocrine metabolic abnormalities following transplantation are common and can increase morbidity and mortality. Previous recipient-related and donor-related factors, as well as other aspects inherent to the transplant, act together in the pathogenesis of those abnormalities. Early recognition of these disturbances is the key to timely treatment; however, adequate tools to achieve this goal are often lacking. In a way, the type of PTX procedure, whether simultaneous pancreas kidney or not, seems to differentially influence the evolution of endocrine and metabolic abnormalities. Further studies are needed to define the best approach for PTX patients. This review will focus on the most common endocrine metabolic disorders seen in the long-term management of PTX: diabetes mellitus, hyperlipidemia, and bone loss. The authors here cover each one of these endocrine topics by showing the evaluation as well as proper management in the follow-up after PTX.
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Affiliation(s)
- Marcio W Lauria
- Department of Internal Medicine (Endocrinology section and Transplantation unit), Federal University of Minas Gerais, Rua Alfredo Balena, 190, 30130-100 Belo Horizonte, MG Brazil
| | - Antonio Ribeiro-Oliveira
- Department of Internal Medicine (Endocrinology section and Transplantation unit), Federal University of Minas Gerais, Rua Alfredo Balena, 190, 30130-100 Belo Horizonte, MG Brazil
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13
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Vendrame F, Hopfner Y, Diamantopoulos S, Virdi SK, Allende G, Snowhite IV, Reijonen HK, Chen L, Ruiz P, Ciancio G, Hutton JC, Messinger S, Burke GW, Pugliese A. Risk Factors for Type 1 Diabetes Recurrence in Immunosuppressed Recipients of Simultaneous Pancreas-Kidney Transplants. Am J Transplant 2016; 16:235-45. [PMID: 26317167 PMCID: PMC5053280 DOI: 10.1111/ajt.13426] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 05/29/2015] [Accepted: 06/15/2015] [Indexed: 01/25/2023]
Abstract
Patients with type 1 diabetes (T1D) who are recipients of pancreas transplants are believed to rarely develop T1D recurrence in the allograft if effectively immunosuppressed. We evaluated a cohort of 223 recipients of simultaneous pancreas-kidney allografts for T1D recurrence and its risk factors. With long-term follow-up, recurrence was observed in approximately 7% of patients. Comparing the therapeutic regimens employed in this cohort over time, lack of induction therapy was associated with recurrence, but this occurs even with the current regimen, which includes induction; there was no influence of maintenance regimens. Longitudinal testing for T1D-associated autoantibodies identified autoantibody positivity, number of autoantibodies, and autoantibody conversion after transplantation as critical risk factors. Autoantibodies to the zinc transporter 8 had the strongest and closest temporal association with recurrence, which was not explained by genetically encoded amino acid sequence donor-recipient mismatches for this autoantigen. Genetic risk factors included the presence of the T1D-predisposing HLA-DR3/DR4 genotype in the recipient and donor-recipient sharing of HLA-DR alleles, especially HLA-DR3. Thus, T1D recurrence is not uncommon and is developing in patients treated with current immunosuppression. The risk factors identified in this study can be assessed in the transplant clinic to identify recurrent T1D and may lead to therapeutic advances.
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Affiliation(s)
- F. Vendrame
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - Y‐Y. Hopfner
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - S. Diamantopoulos
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Pediatrics, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - S. K. Virdi
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. Allende
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - I. V. Snowhite
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | | | - L. Chen
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - P. Ruiz
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. Ciancio
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - J. C. Hutton
- Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverAuroraCO
| | - S. Messinger
- Department of Epidemiology and Public Health Sciences, Division of Biostatistics, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. W. Burke
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - A. Pugliese
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Medicine, Division of Endocrinology and Metabolism, Leonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Microbiology and ImmunologyLeonard Miller School of MedicineUniversity of MiamiMiamiFL
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14
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Abstract
Transplantation of the whole vascularized pancreas can provide insulin secretion in patients with insulin-dependent, type 1 diabetes mellitus (T1D). It restores euglycemia in most patients, with the potential to impact the chronic diabetic complications and quality of life. Pancreas transplantation (PT) is presently controversial for type 2 diabetes mellitus (T2D). For those patients with severe glycemic dysregulation, T2D can be associated with the same life-threatening sequelae as T1D such as severe hypoglycemia and kidney failure that could be corrected by pancreas (and kidney) transplantation. Thus, clinical indications and patient selection criteria are very important. This chapter will review the current status of PT for T2D and discuss the options and evolution of transplant perspectives.
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Affiliation(s)
- Gaetano Ciancio
- The DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA,
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15
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Burke GW, Vendrame F, Pileggi A, Ciancio G, Reijonen H, Pugliese A. Recurrence of autoimmunity following pancreas transplantation. Curr Diab Rep 2011; 11:413-9. [PMID: 21660419 PMCID: PMC4018301 DOI: 10.1007/s11892-011-0206-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pancreas transplantation is a therapeutic option for patients with type 1 diabetes. Advances in immunosuppression have reduced immunologic failures, and these are usually categorized as chronic rejection. Yet studies in our cohort of pancreas transplant recipients identified several patients in whom chronic islet autoimmunity led to recurrent diabetes, despite immunosuppression that prevented rejection. Recurrent diabetes in our cohort is as frequent as chronic rejection, and thus is a significant cause of immunologic graft failure. Our studies demonstrated islet autoimmunity by the presence of autoantibodies and autoreactive T cells, which mediated ß-cell destruction in a transplantation model. Biopsy of the transplanted pancreas revealed variable degrees of ß-cell loss, with or without insulitis, in the absence of pancreas and kidney transplant rejection. Additional research is needed to better understand recurrent disease and to identify new treatment regimens that can suppress autoimmunity, as in our experience this is not effectively inhibited by conventional immunosuppression.
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Affiliation(s)
- George W. Burke
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, 1801 NW 9th Avenue, Miami FL 33136, Tel. 305-355-5000 Fax 305-355-5134
| | - Francesco Vendrame
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-5353 Fax 305-243-4404
| | - Antonello Pileggi
- Diabetes Research Institute and Department of Surgery, Leonard Miller School of Medicine, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-2924 Fax 305-243-4404
| | - Gaetano Ciancio
- Departments of Urology and Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, 1801 NW 9th Avenue, Miami FL 33136, Tel. 305-355-5000 Fax 305-355-5134
| | - Helena Reijonen
- Benaroya Research Institute, 1201 Ninth Avenue, Seattle, WA 98101, Tel. 206-223-8813 Fax 206-223-7638
| | - Alberto Pugliese
- Diabetes Research Institute, Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, and Department of Microbiology and Immunology, Leonard Miller School of Medicine, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-5348 Fax 305-243-4404
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16
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Chakkera HA, Bodner JK, Heilman RL, Mulligan DC, Moss AA, Mekeel KL, Mazur MJ, Hamawi K, Ray RM, Beck GL, Reddy KS. Outcomes after simultaneous pancreas and kidney transplantation and the discriminative ability of the C-peptide measurement pretransplant among type 1 and type 2 diabetes mellitus. Transplant Proc 2011; 42:2650-2. [PMID: 20832562 DOI: 10.1016/j.transproceed.2010.04.065] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 04/20/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Earlier studies reporting outcomes after pancreas transplantation have included a combination of C-peptide cutoffs and clinical criteria to classify type 2 diabetes mellitus (T2DM). However, because the kidney is the major site for C-peptide catabolism, C-peptide is unreliable to discriminate the type of diabetes in patients with kidney disease. METHODS To improve the discriminative power and better classify the type of diabetes, we used a composite definition to identify T2DM: presence of C-peptide, negative glutamic acid decarboxylase antibody, absence of diabetic ketoacidosis, and use of oral hypoglycemics. Additionally among T2DM patients with end-stage renal disease (ESRD), body mass index of <30 kg/m(2) and use of <1 u/kg of insulin per day were selection criteria for suitablity for simultaneous pancreas and kidney transplantation (SPKT). We compared graft and patient survival between T1DM and T2DM after SPKT. RESULTS Our study cohort consisted of 80 patients, 10 of whom were assigned as T2DM based on our study criteria. Approximately 15% of patients with T1DM had detectable C-peptide. Cox regression survival analyses found no significant differences in allograft (pancreas and kidney) or patient survival between the 2 groups. The mean creatinine clearance at 1 year estimated by the modification of Diet in Renal Disease (MDRD) equation was not significantly different between the 2 groups. Among those with 1 year of follow-up, all patients with T2DM had glycosylate hemoglobin of <6.0 at 1 year versus 92% of those with T1DM. CONCLUSION SPKT should be considered in the therapeutic armamentarium for renal replacement in selected patients with T2DM and ESRD. Use of C-peptide measurements for ESRD patients can be misleading as the sole criterion to determine the type of diabetes.
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17
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Abstract
A discussion of hyperglycemia during organ transplantation is a broad topic that includes patients with a known history of diabetes pretransplant, those at risk for post-transplant diabetes, those with stress-induced hyperglycemia, those with hyperglycemia related to immunosuppressive therapy, and hyperglycemia in the deceased organ donor. In contrast to the plethora of articles and studies describing perioperative and critical care management of hyperglycemia in cardiac, trauma, and medical/surgical intensive care unit patients, relatively few published articles in the field of organ transplantation can be found. This article consists of a review of available literature in the form of publications and abstracts, and a preliminary report of the authors' work with liver transplantation and deceased organ donors.
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Affiliation(s)
- Michael R Marvin
- Surgery, Division of Transplantation, University of Louisville, Louisville, Kentucky, USA.
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18
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Rangel ÉB, de Sá JR, Melaragno CS, Gonzalez AM, Linhares MM, Salzedas A, Medina-Pestana JO. Kidney transplant in diabetic patients: modalities, indications and results. Diabetol Metab Syndr 2009; 1:2. [PMID: 19825194 PMCID: PMC2758579 DOI: 10.1186/1758-5996-1-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 08/26/2009] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Diabetes is a disease of increasing worldwide prevalence and is the main cause of chronic renal failure. Type 1 diabetic patients with chronic renal failure have the following therapy options: kidney transplant from a living donor, pancreas after kidney transplant, simultaneous pancreas-kidney transplant, or awaiting a deceased donor kidney transplant. For type 2 diabetic patients, only kidney transplant from deceased or living donors are recommended. Patient survival after kidney transplant has been improving for all age ranges in comparison to the dialysis therapy. The main causes of mortality after transplant are cardiovascular and cerebrovascular events, infections and neoplasias. Five-year patient survival for type 2 diabetic patients is lower than the non-diabetics' because they are older and have higher body mass index on the occasion of the transplant and both pre- and posttransplant cardiovascular diseases prevalences. The increased postransplant cardiovascular mortality in these patients is attributed to the presence of well-known risk factors, such as insulin resistance, higher triglycerides values, lower HDL-cholesterol values, abnormalities in fibrinolysis and coagulation and endothelial dysfunction. In type 1 diabetic patients, simultaneous pancreas-kidney transplant is associated with lower prevalence of vascular diseases, including acute myocardial infarction, stroke and amputation in comparison to isolated kidney transplant and dialysis therapy. CONCLUSION Type 1 and 2 diabetic patients present higher survival rates after transplant in comparison to the dialysis therapy, although the prevalence of cardiovascular events and infectious complications remain higher than in the general population.
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Affiliation(s)
- Érika B Rangel
- Division of Nephrology, Universidade Federal de São Paulo, Brazil
| | - João R de Sá
- Division of Endocrinology, Universidade Federal de São Paulo, Brazil
| | | | | | | | - Alcides Salzedas
- Departament of Sugery, Universidade Federal de São Paulo, Brazil
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