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Kizilgul M, Wilhelm JJ, Dunn TB, Beilman GJ, Pruett TL, Chinnakotla S, Amin K, Hering BJ, Bellin MD. The prognostic significance of glutamic acid decarboxylase antibodies in patients with chronic pancreatitis undergoing total pancreatectomy with islet autotransplantation. Diabetes Metab 2018; 45:301-305. [PMID: 29395812 DOI: 10.1016/j.diabet.2018.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/17/2017] [Accepted: 01/02/2018] [Indexed: 11/29/2022]
Abstract
AIM Islet autotransplantation (IAT) is considered a 'non-immune' model of islet transplant, with no risk for autoimmune-mediated beta cell loss, but we have previously observed de novo type 1 diabetes in one total pancreatectomy with islet autotransplantation (TPIAT) recipient. We aimed to investigate the clinical significance of glutamic acid decarboxylase antibodies (GADA), as a sensitive marker for autoimmune diabetes mellitus (DM), in patients with chronic pancreatitis undergoing TPIAT. METHODS We identified 9 patients undergoing TPIAT with elevated GADA pre-TPIAT (8 non-diabetic and 1 with C-peptide positive DM), otherwise demographically similar to GADA negative TPIAT recipients (n=341). Metabolic and clinical measures related to islet cell function were recorded both before and after TPIAT. RESULTS None of the 9 TPIAT patients achieved insulin independence after surgery, vs. 33% of GADA negative patients (n=318 with 1-yr follow-up). The two patients with the highest titters of GADA (>250 IU/mL) both experienced islet graft failure, despite normoglycaemia pre-TPIAT and high islet mass transplanted (5276 and 9378 IEQ per kg), with elevated HbA1c levels post-TPIAT (8.3%, 9.6%). The remaining 7 seven were insulin dependent with partial graft function and HbA1c levels <7%. CONCLUSION Insulin dependence was more frequent in 9 patients with elevated GADA prior to TPIAT than in GADA negative TPIAT recipients, with graft failure in 2 cases. We speculate that beta-cell autoimmunity may occur in a small subset of TPIAT recipients and that beta cell antibody testing prior to TPIAT may be warranted to identify individuals at higher risk for insulin dependence.
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Affiliation(s)
- M Kizilgul
- Department of Endocrinology and Metabolism, SBU Diskapi Training and Research Hospital, Ankara, Turkey; Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA.
| | - J J Wilhelm
- Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA
| | - T B Dunn
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - G J Beilman
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - T L Pruett
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - S Chinnakotla
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - K Amin
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - B J Hering
- Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA
| | - M D Bellin
- Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA; Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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2
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Axelrod D, Lentine KL, Schnitzler MA, Luo X, Xiao H, Orandi BJ, Massie A, Garonzik-Wang J, Stegall MD, Jordan SC, Oberholzer J, Dunn TB, Ratner LE, Kapur S, Pelletier RP, Roberts JP, Melcher ML, Singh P, Sudan DL, Posner MP, El-Amm JM, Shapiro R, Cooper M, Lipkowitz GS, Rees MA, Marsh CL, Sankari BR, Gerber DA, Nelson PW, Wellen J, Bozorgzadeh A, Osama Gaber A, Montgomery RA, Segev DL. The Incremental Cost of Incompatible Living Donor Kidney Transplantation: A National Cohort Analysis. Am J Transplant 2017; 17:3123-3130. [PMID: 28613436 DOI: 10.1111/ajt.14392] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 05/04/2017] [Accepted: 05/22/2017] [Indexed: 01/25/2023]
Abstract
Incompatible living donor kidney transplantation (ILDKT) has been established as an effective option for end-stage renal disease patients with willing but HLA-incompatible living donors, reducing mortality and improving quality of life. Depending on antibody titer, ILDKT can require highly resource-intensive procedures, including intravenous immunoglobulin, plasma exchange, and/or cell-depleting antibody treatment, as well as protocol biopsies and donor-specific antibody testing. This study sought to compare the cost and Medicare reimbursement, exclusive of organ acquisition payment, for ILDKT (n = 926) with varying antibody titers to matched compatible transplants (n = 2762) performed between 2002 and 2011. Data were assembled from a national cohort study of ILDKT and a unique data set linking hospital cost accounting data and Medicare claims. ILDKT was more expensive than matched compatible transplantation, ranging from 20% higher adjusted costs for positive on Luminex assay but negative flow cytometric crossmatch, 26% higher for positive flow cytometric crossmatch but negative cytotoxic crossmatch, and 39% higher for positive cytotoxic crossmatch (p < 0.0001 for all). ILDKT was associated with longer median length of stay (12.9 vs. 7.8 days), higher Medicare payments ($91 330 vs. $63 782 p < 0.0001), and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplantation.
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Affiliation(s)
- D Axelrod
- Department of Transplantation, Lahey Hospital and Health System, Burlington, MA
| | - K L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - M A Schnitzler
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - X Luo
- Division of Abdominal Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - H Xiao
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - B J Orandi
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - A Massie
- Division of Abdominal Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - J Garonzik-Wang
- Division of Abdominal Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - M D Stegall
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - S C Jordan
- Department of Medicine, Cedars-Sinai Comprehensive Transplant Center, Los Angeles, CA
| | - J Oberholzer
- Department of Surgery, University of Illinois-Chicago, Chicago, IL
| | - T B Dunn
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - L E Ratner
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - S Kapur
- Department of Surgery, New York Presbyterian/Weill Cornell Medical Center, New York, NY
| | - R P Pelletier
- Department of Surgery, The Ohio State University, Columbus, OH
| | - J P Roberts
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - M L Melcher
- Department of Surgery, Stanford University, Palo Alto, CA
| | - P Singh
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA
| | - D L Sudan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - M P Posner
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - J M El-Amm
- Integris Baptist Medical Center, Transplant Division, Oklahoma City, OK
| | - R Shapiro
- Department of Surgery, Mt. Sinai Medical Center, New York, NY
| | - M Cooper
- Medstar Georgetown Transplant Institute, Washington, DC
| | - G S Lipkowitz
- Department of Surgery, Baystate Medical Center, Springfield, MA
| | - M A Rees
- Department of Urology, University of Toledo Medical Center, Toledo, OH
| | - C L Marsh
- Division of Organ Transplantation, Scripps Center for Organ Transplantation, Department of Surgery, Scripps Clinic and Green Hospital, La Jolla, CA
| | - B R Sankari
- Department of Urology, Cleveland Clinic, Cleveland, OH
| | - D A Gerber
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - P W Nelson
- Department of Surgery, University of Nevada, Las Vegas, NV
| | - J Wellen
- Department of Surgery, Barnes-Jewish Hospital, St. Louis, MO
| | - A Bozorgzadeh
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - R A Montgomery
- Department of Surgery, New York University Langone Medical Center, New York, NY
| | - D L Segev
- Division of Abdominal Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD
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3
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Rees MA, Paloyo SR, Roth AE, Krawiec KD, Ekwenna O, Marsh CL, Wenig AJ, Dunn TB. Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs. Am J Transplant 2017; 17:2743-2744. [PMID: 28758331 DOI: 10.1111/ajt.14451] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- M A Rees
- Department of Urology, University of Toledo, Toledo, OH, USA
| | - S R Paloyo
- Department of Surgery, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - A E Roth
- Department of Economics, Stanford University, Stanford, CA, USA
| | - K D Krawiec
- School of Law, Duke University, Durham, NC, USA
| | - O Ekwenna
- Department of Urology, University of Toledo, Toledo, OH, USA
| | - C L Marsh
- Scripps Clinic, Scripps Center for Organ and Cell Transplant, La Jolla, CA, USA
| | - A J Wenig
- Department of Urology, University of Toledo, Toledo, OH, USA
| | - T B Dunn
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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4
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Serrano OK, Bangdiwala AS, Vock DM, Berglund D, Dunn TB, Finger EB, Pruett TL, Matas AJ, Kandaswamy R. Defining the Tipping Point in Surgical Performance for Laparoscopic Donor Nephrectomy Among Transplant Surgery Fellows: A Risk-Adjusted Cumulative Summation Learning Curve Analysis. Am J Transplant 2017; 17:1868-1878. [PMID: 28029219 DOI: 10.1111/ajt.14187] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 12/20/2016] [Indexed: 01/25/2023]
Abstract
The United Network for Organ Sharing recommends that fellowship-trained surgeons participate in 15 laparoscopic donor nephrectomy (LDN) procedures to be considered proficient. The American Society of Transplant Surgeons (ASTS) mandates 12 LDNs during an abdominal transplant surgery fellowship. We performed a retrospective intraoperative case analysis to create a risk-adjusted cumulative summation (RACUSUM) model to assess the learning curve of novice transplant surgery fellows (TSFs). Between January 2000 and December 2014, 30 novice TSFs participated in the organ procurement rotation of our ASTS-approved abdominal transplant surgery fellowship. Measures of surgical performance included intraoperative time, estimated blood loss, and incidence of intraoperative complications. The performance of senior TSFs was used to benchmark novice TSF performance. Scores were tabulated in a learning curve model, adjusting for case complexity and prior TSF case volume. Rates of adverse surgical events were significantly higher for novice TSFs than for senior TSFs. In univariable analysis, multiple renal arteries, high BMI, prior abdominal surgery, male donor, and nephrolithiasis were correlated with higher incidence of adverse surgical events. Based on the RACUSUM model, high intraoperative time is mitigated after 28 procedures, incidence of intraoperative complications tends to diminish after 24 procedures, and improvement in estimated blood loss did not remain consistent. TSFs exhibit a tipping point in LDN performance by 24-28 cases and proficiency by 35-38 cases.
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Affiliation(s)
- O K Serrano
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - A S Bangdiwala
- Biostatistics and Bioinformatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - D M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - D Berglund
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T B Dunn
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - E B Finger
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T L Pruett
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - A J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - R Kandaswamy
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
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5
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Rees MA, Dunn TB, Kuhr CS, Marsh CL, Rogers J, Rees SE, Cicero A, Reece LJ, Roth AE, Ekwenna O, Fumo DE, Krawiec KD, Kopke JE, Jain S, Tan M, Paloyo SR. Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation. Am J Transplant 2017; 17:782-790. [PMID: 27992110 DOI: 10.1111/ajt.14106] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 01/25/2023]
Abstract
Organ shortage is the major limitation to kidney transplantation in the developed world. Conversely, millions of patients in the developing world with end-stage renal disease die because they cannot afford renal replacement therapy-even when willing living kidney donors exist. This juxtaposition between countries with funds but no available kidneys and those with available kidneys but no funds prompts us to propose an exchange program using each nation's unique assets. Our proposal leverages the cost savings achieved through earlier transplantation over dialysis to fund the cost of kidney exchange between developed-world patient-donor pairs with immunological barriers and developing-world patient-donor pairs with financial barriers. By making developed-world health care available to impoverished patients in the developing world, we replace unethical transplant tourism with global kidney exchange-a modality equally benefitting rich and poor. We report the 1-year experience of an initial Filipino pair, whose recipient was transplanted in the United states with an American donor's kidney at no cost to him. The Filipino donor donated to an American in the United States through a kidney exchange chain. Follow-up care and medications in the Philippines were supported by funds from the United States. We show that the logistical obstacles in this approach, although considerable, are surmountable.
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Affiliation(s)
- M A Rees
- University of Toledo Medical Center, Toledo, OH.,Alliance for Paired Donation, Perrysburg, OH
| | - T B Dunn
- University of Minnesota, Minneapolis, MN
| | - C S Kuhr
- Virginia Mason Medical Center, Seattle, WA
| | - C L Marsh
- Scripps Green Hospital, La Jolla, CA
| | - J Rogers
- Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - S E Rees
- University of Toledo Medical Center, Toledo, OH.,Alliance for Paired Donation, Perrysburg, OH
| | - A Cicero
- ABC Medical Center, Mexico City, Mexico
| | - L J Reece
- Alliance for Paired Donation, Perrysburg, OH
| | - A E Roth
- Stanford University, Stanford, CA
| | - O Ekwenna
- University of Toledo Medical Center, Toledo, OH.,Alliance for Paired Donation, Perrysburg, OH
| | - D E Fumo
- University of Toledo Medical Center, Toledo, OH.,Alliance for Paired Donation, Perrysburg, OH
| | | | - J E Kopke
- Alliance for Paired Donation, Perrysburg, OH
| | - S Jain
- University of Toledo Medical Center, Toledo, OH
| | - M Tan
- Piedmont Hospital, Atlanta, GA
| | - S R Paloyo
- University of the Philippines-Philippine General Hospital, Manila, Philippines.,St. Luke's Medical Center-Global City, Manila, Philippines
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6
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Bellin MD, Beilman GJ, Dunn TB, Pruett TL, Sutherland DER, Chinnakotla S, Hodges JS, Lane A, Ptacek P, Berry KL, Hering BJ, Moran A. Sitagliptin Treatment After Total Pancreatectomy With Islet Autotransplantation: A Randomized, Placebo-Controlled Study. Am J Transplant 2017; 17:443-450. [PMID: 27459721 PMCID: PMC5266635 DOI: 10.1111/ajt.13979] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/19/2016] [Accepted: 07/12/2016] [Indexed: 01/25/2023]
Abstract
Insulin independence after total pancreatectomy and islet autotransplant (TPIAT) for chronic pancreatitis is limited by a high rate of postprocedure beta cell apoptosis. Endogenous glucagon-like peptide-1 and glucose-dependent insulinotropic peptide, which are increased by dipeptidyl peptidase 4 inhibitor therapy (sitagliptin) may protect against beta cell apoptosis. To determine the effect of sitagliptin after TPIAT, 83 adult TPIAT recipients were randomized to receive sitagliptin (n = 54) or placebo (n = 29) for 12 months after TPIAT. At 12 and 18 months after TPIAT, participants were assessed for insulin independence; metabolic testing was performed with mixed meal tolerance testing and frequent sample intravenous glucose tolerance testing. Insulin independence did not differ between the sitagliptin and placebo groups at 12 months (42% vs. 45%, p = 0.82) or 18 months (36% vs. 44%, p = 0.48). At 12 months, insulin dose was 9.0 (standard error 1.7) units/day and 7.9 (2.2) units/day in the sitagliptin and placebo groups, respectively (p = 0.67) and at 18 months 10.3 (1.9) and 7.1 (2.6) units/day, respectively (p = 0.32). Hemoglobin A1c levels and insulin secretory measures were similar in the two groups, as were adverse events. In conclusion, sitagliptin could be safely administered but did not improve metabolic outcomes after TPIAT.
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Affiliation(s)
- M D Bellin
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - G J Beilman
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - T B Dunn
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - T L Pruett
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - D E R Sutherland
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - S Chinnakotla
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - J S Hodges
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - A Lane
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - P Ptacek
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - K L Berry
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - B J Hering
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - A Moran
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
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7
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Rudolph EN, Dunn TB, Mauer D, Noreen H, Sutherland DER, Kandaswamy R, Finger EB. HLA-A, -B, -C, -DR, and -DQ Matching in Pancreas Transplantation: Effect on Graft Rejection and Survival. Am J Transplant 2016; 16:2401-12. [PMID: 26814363 DOI: 10.1111/ajt.13734] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/23/2015] [Accepted: 01/09/2016] [Indexed: 01/25/2023]
Abstract
To enhance selection of appropriate deceased donors for pancreas transplants, we sought to determine whether HLA matching improved posttransplantation outcomes. In this single-center study of 1219 pancreas transplants, we correlated posttransplantation outcomes with HLA-A, -B, -C, -DR, and -DQ matches and mismatches. Rejection was linearly correlated with the number of mismatches. The individual number of HLA mismatches reached significance at four or more with a 2.3- to 2.9-fold increase in rejection. The effect was most predominant with HLA-B (1.8-fold with one mismatch and 2.0-fold with two mismatches) and -DR (1.9-fold with two mismatches) loci, whereas HLA-A, -C, and -DQ matches or mismatches did not independently predict acute rejection. The affect was strongest in solitary pancreas transplants, with little impact for simultaneous pancreas and kidney (SPK). In contrast, HLA matching did not affect graft or patient survival rates but was associated with a reduced risk of opportunistic infection. Avoidance of acute rejection saved an estimated $32 000 for solitary pancreas recipients and $52 000 for SPK recipients in hospital costs. Our data do not support the use of HLA matching for predicting pancreas graft survival but do support its significance for the reduction of acute rejection, particularly for solitary pancreas recipients.
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Affiliation(s)
- E N Rudolph
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, MN
| | - T B Dunn
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, MN
| | - D Mauer
- Immunology/Histocompatibility Laboratory, University of Minnesota, Minneapolis, MN
| | - H Noreen
- Immunology/Histocompatibility Laboratory, University of Minnesota, Minneapolis, MN
| | - D E R Sutherland
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, MN
| | - R Kandaswamy
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, MN
| | - E B Finger
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, MN
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8
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Bellin MD, Moran A, Wilhelm JJ, O'Brien TD, Gottlieb PA, Yu L, Dunn TB. Development of Autoimmune-Mediated β Cell Failure After Total Pancreatectomy With Autologous Islet Transplantation. Am J Transplant 2015; 15:1991-4. [PMID: 25765064 DOI: 10.1111/ajt.13216] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/21/2014] [Accepted: 01/05/2015] [Indexed: 01/25/2023]
Abstract
Total pancreatectomy with islet autotransplantation (TPIAT) is performed for definitive treatment of chronic pancreatitis; patients are not diabetic before surgery, or have C-peptide positive pancreatogenous diabetes. Thus, TPIAT recipients are not traditionally considered at risk for autoimmune loss of the islet graft. We describe a 43-year-old female who underwent TPIAT with high mass islet graft of 6031 IEQ/kg, with no evidence of presurgical β cell autoimmunity who developed type 1 diabetes within the first year after TPIAT, resulting in complete loss of beta cell function. The patient had positive GAD and insulin autoantibodies at 1 year and 18 months after TPIAT, not present prior, and undetectable C-peptide after mixed meal and intravenous glucose tolerance testing at 18 months. Glucagon secretion was preserved, suggesting the transplanted alpha cell mass was intact. HLA typing revealed a DR3/DR4 class II haplotype. This case highlights the need to consider de novo type 1 diabetes in patients with unexpected islet graft failure after TPIAT.
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Affiliation(s)
- M D Bellin
- Department of Pediatrics, University of Minnesota, Minneapolis, MN.,University of Minnesota, Schulze Diabetes Institute, Minneapolis, MN
| | - A Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - J J Wilhelm
- University of Minnesota, Schulze Diabetes Institute, Minneapolis, MN
| | - T D O'Brien
- University of Minnesota, College of Veterinary Medicine, St. Paul, MN
| | - P A Gottlieb
- Barbara Davis Center for Childhood Diabetes, Aurora, CO
| | - L Yu
- Barbara Davis Center for Childhood Diabetes, Aurora, CO
| | - T B Dunn
- Department of Surgery, University of Minnesota, Minneapolis, MN
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9
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Orandi BJ, Garonzik-Wang JM, Massie AB, Zachary AA, Montgomery JR, Van Arendonk KJ, Stegall MD, Jordan SC, Oberholzer J, Dunn TB, Ratner LE, Kapur S, Pelletier RP, Roberts JP, Melcher ML, Singh P, Sudan DL, Posner MP, El-Amm JM, Shapiro R, Cooper M, Lipkowitz GS, Rees MA, Marsh CL, Sankari BR, Gerber DA, Nelson PW, Wellen J, Bozorgzadeh A, Gaber AO, Montgomery RA, Segev DL. Quantifying the risk of incompatible kidney transplantation: a multicenter study. Am J Transplant 2014; 14:1573-80. [PMID: 24913913 DOI: 10.1111/ajt.12786] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/17/2014] [Accepted: 03/17/2014] [Indexed: 01/25/2023]
Abstract
Incompatible live donor kidney transplantation (ILDKT) offers a survival advantage over dialysis to patients with anti-HLA donor-specific antibody (DSA). Program-specific reports (PSRs) fail to account for ILDKT, placing this practice at regulatory risk. We collected DSA data, categorized as positive Luminex, negative flow crossmatch (PLNF) (n = 185), positive flow, negative cytotoxic crossmatch (PFNC) (n = 536) or positive cytotoxic crossmatch (PCC) (n = 304), from 22 centers. We tested associations between DSA, graft loss and mortality after adjusting for PSR model factors, using 9669 compatible patients as a comparison. PLNF patients had similar graft loss; however, PFNC (adjusted hazard ratio [aHR] = 1.64, 95% confidence interval [CI]: 1.15-2.23, p = 0.007) and PCC (aHR = 5.01, 95% CI: 3.71-6.77, p < 0.001) were associated with increased graft loss in the first year. PLNF patients had similar mortality; however, PFNC (aHR = 2.04; 95% CI: 1.28-3.26; p = 0.003) and PCC (aHR = 4.59; 95% CI: 2.98-7.07; p < 0.001) were associated with increased mortality. We simulated Centers for Medicare & Medicaid Services flagging to examine ILDKT's effect on the risk of being flagged. Compared to equal-quality centers performing no ILDKT, centers performing 5%, 10% or 20% PFNC had a 1.19-, 1.33- and 1.73-fold higher odds of being flagged. Centers performing 5%, 10% or 20% PCC had a 2.22-, 4.09- and 10.72-fold higher odds. Failure to account for ILDKT's increased risk places centers providing this life-saving treatment in jeopardy of regulatory intervention.
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Affiliation(s)
- B J Orandi
- Departments of Surgery and Medicine, Johns Hopkins Hospital, Baltimore, MD
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10
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Wilhelm JJ, Bellin MD, Dunn TB, Balamurugan AN, Pruett TL, Radosevich DM, Chinnakotla S, Schwarzenberg SJ, Freeman ML, Hering BJ, Sutherland DER, Beilman GJ. Proposed thresholds for pancreatic tissue volume for safe intraportal islet autotransplantation after total pancreatectomy. Am J Transplant 2013; 13:3183-91. [PMID: 24148548 PMCID: PMC4087156 DOI: 10.1111/ajt.12482] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 07/17/2013] [Accepted: 07/18/2013] [Indexed: 01/25/2023]
Abstract
The simple question of how much tissue volume (TV) is really safe to infuse in total pancreatectomy-islet autotransplantation (TP-IAT) for chronic pancreatitis (CP) precipitated this analysis. We examined a large cohort of CP patients (n = 233) to determine major risk factors for elevated portal pressure (PP) during islet infusion, using bivariate and multivariate regression modeling. Rates of bleeding requiring operative intervention and portal venous thrombosis (PVT) were evaluated. The total TV per kilogram body weight infused intraportally was the best independent predictor of change in PP (ΔPP) (p < 0.0001; R(2) = 0.566). Rates of bleeding and PVT were 7.73% and 3.43%, respectively. Both TV/kg and ΔPP are associated with increased complication rates, although ΔPP appears to be more directly relevant. Receiver operating characteristic analysis identified an increased risk of PVT above a suggested cut-point of 26 cmH2O (area under the curve = 0.759), which was also dependent on age. This ΔPP threshold was more likely to be exceeded in cases where the total TV was >0.25 cm(3)/kg. Based on this analysis, we have recommended targeting a TV of <0.25 cm(3)/kg during islet manufacturing and to halt intraportal infusion, at least temporarily, if the ΔPP exceeds 25 cmH2O. These models can be used to guide islet manufacturing and clinical decision making to minimize risks in TP-IAT recipients.
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Affiliation(s)
- J J Wilhelm
- Department of Surgery, Schulze Diabetes Institute, University of Minnesota, St. Paul, MN
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11
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Abt PL, Marsh CL, Dunn TB, Hewitt WR, Rodrigue JR, Ham JM, Feng S. Challenges to research and innovation to optimize deceased donor organ quality and quantity. Am J Transplant 2013; 13:1400-4. [PMID: 23617244 DOI: 10.1111/ajt.12243] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 02/27/2013] [Accepted: 03/03/2013] [Indexed: 01/25/2023]
Abstract
Solid organ transplantation is encumbered by an increasing number of waitlisted patients unrequited by the current organ supply. Preclinical models suggest that advances in deceased donor management and treatment can increase the quantity and quality of organs available for transplantation. However, the science of donor intervention and the execution of high quality, prospective, multi-center, randomized-controlled trials are restricted by a myriad of logistical challenges mired in regulatory and ethical ambiguity. By highlighting the obstacles to conducting research in deceased donors, this report endeavors to stimulate the creation of a multi-disciplinary framework to facilitate the design, implementation and supervision of innovative trials that increase the quantity and/or quality of deceased donor organs.
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Affiliation(s)
- P L Abt
- Division of Transplantation, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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12
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Suszynski TM, Gillingham KJ, Rizzari MD, Dunn TB, Payne WD, Chinnakotla S, Finger EB, Sutherland DER, Najarian JS, Pruett TL, Matas AJ, Kandaswamy R. Prospective randomized trial of maintenance immunosuppression with rapid discontinuation of prednisone in adult kidney transplantation. Am J Transplant 2013; 13:961-970. [PMID: 23432755 PMCID: PMC3621067 DOI: 10.1111/ajt.12166] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/26/2012] [Accepted: 12/26/2012] [Indexed: 01/25/2023]
Abstract
Rapid discontinuation of prednisone (RDP) has minimized steroid-related complications following kidney transplant (KT). This trial compares long-term (10-year) outcomes with three different maintenance immunosuppressive protocols following RDP in adult KT. Recipients (n=440; 73% living donor) from March 2001 to April 2006 were randomized into one of three arms: cyclosporine (CSA) and mycophenolate mofetil (MMF) (CSA/MMF, n=151); high-level tacrolimus (TAC, 8-12 μg/L) and low-level sirolimus (SIR, 3-7 μg/L) (TACH/SIRL, n=149) or low-level TAC (3-7 μg/L) and high-level SIR (8-12 μg/L) (TACL/SIR(H) , n=140). Median follow-up was ∼7 years. There were no differences between arms in 10-year actuarial patient, graft and death-censored graft survival or in allograft function. There were no differences in the 10-year actuarial rates of biopsy-proven acute rejection (30%, 26% and 20% in CSA/MMF, TACH/SIRL and TACL/SIRH) and chronic rejection (38%, 35% and 31% in CSA/MMF, TACH/SIRL and TACL/SIRH). Rates of new-onset diabetes mellitus were higher with TACH/SIRL (p=0.04), and rates of anemia were higher with TACH/SIRL and TACL/SIRH (p=0.04). No differences were found in the overall rates of 16 other post-KT complications. These data indicate that RDP-based protocol yield acceptable 10-year outcomes, but side effects differ based on the maintenance regimen used and should be considered when optimizing immunosuppression following RDP.
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Affiliation(s)
- T M Suszynski
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - K J Gillingham
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - M D Rizzari
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T B Dunn
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - W D Payne
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - S Chinnakotla
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - E B Finger
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | | | - J S Najarian
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T L Pruett
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - R Kandaswamy
- Department of Surgery, University of Minnesota, Minneapolis, MN
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Finger EB, Radosevich DM, Bland BJ, Dunn TB, Chinnakotla S, Sutherland DER, Pruett TL, Kandaswamy R. Comparison of recipient outcomes following transplant from local versus imported pancreas donors. Am J Transplant 2012; 12:447-57. [PMID: 22070451 DOI: 10.1111/j.1600-6143.2011.03828.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The shortage of deceased donor organs for solid organ transplantation continues to be an ongoing dilemma. One approach to increase the number of pancreas transplants is to share organs between procurement regions. To assess for the effects of organ importation, we reviewed the outcomes of 1014 patients undergoing deceased donor pancreas transplant at a single center. We performed univariate and multivariate analyses of the association of donor, recipient and surgical characteristics with patient outcomes. Organ importation had no effect on graft or recipient survival for recipients of solitary pancreas transplants. Similarly, there was no effect on technical failure rate, graft survival or long-term patient survival for simultaneous kidney-pancreas (SPK) recipients. In contrast, there was a significant and independent increased risk of death in the first year in SPK recipients of imported organs. SPK recipients had longer hospitalizations and increased hospital costs. This increased medical complexity may make these patients more susceptible to short-term complications resulting from the longer preservation times of import transplants. These findings support the continued use of organ sharing to reduce transplant wait times but highlight the importance of strategies to reduce organ preservation times.
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Affiliation(s)
- E B Finger
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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14
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Dunn TB, Noreen H, Gillingham K, Maurer D, Ozturk OG, Pruett TL, Bray RA, Gebel HM, Matas AJ. Revisiting traditional risk factors for rejection and graft loss after kidney transplantation. Am J Transplant 2011; 11:2132-43. [PMID: 21812918 PMCID: PMC3184338 DOI: 10.1111/j.1600-6143.2011.03640.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Single-antigen bead (SAB) testing permits reassessment of immunologic risk for kidney transplantation. Traditionally, high panel reactive antibody (PRA), retransplant and deceased donor (DD) grafts have been associated with increased risk. We hypothesized that this risk was likely mediated by (unrecognized) donor-specific antibody (DSA). We grouped 587 kidney transplants using clinical history and single-antigen bead (SAB) testing of day of transplant serum as (1) unsensitized; PRA = 0 (n = 178), (2) third-party sensitized; no DSA (n = 363) or (3) donor sensitized; with DSA (n = 46), and studied rejection rates, death-censored graft survival (DCGS) and risk factors for rejection. Antibody-mediated rejection (AMR) rates were increased with DSA (p < 0.0001), but not with panel reactive antibody (PRA) in the absence of DSA. Cell-mediated rejection (CMR) rates were increased with DSA (p < 0.005); with a trend to increased rates when PRA>0 in the absence of DSA (p = 0.08). Multivariate analyses showed risk factors for AMR were DSA, worse HLA matching, and female gender; for CMR: DSA, PRA>0 and worse HLA matching. AMR and CMR were associated with decreased DCGS. The presence of DSA is an important predictor of rejection risk, in contrast to traditional risk factors. Further development of immunosuppressive protocols will be facilitated by stratification of rejection risk by donor sensitization.
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Affiliation(s)
- TB Dunn
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - H Noreen
- Department of Lab Medicine & Pathology, University of Minnesota, Minneapolis, Minnesota
| | - K Gillingham
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - D Maurer
- Department of Lab Medicine & Pathology, University of Minnesota, Minneapolis, Minnesota
| | - O. Goruroglu Ozturk
- Histocompatibility and Immunogenetics Lab, Emory University, Atlanta, Georgia
| | - TL Pruett
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - RA Bray
- Histocompatibility and Immunogenetics Lab, Emory University, Atlanta, Georgia
| | - HM Gebel
- Histocompatibility and Immunogenetics Lab, Emory University, Atlanta, Georgia
| | - AJ Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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15
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Dunn TB, Browne BJ, Gillingham KJ, Kandaswamy R, Humar A, Payne WD, Sutherland DER, Matas AJ. Selective retransplant after graft loss to nonadherence: success with a second chance. Am J Transplant 2009; 9:1337-46. [PMID: 19459828 PMCID: PMC3553599 DOI: 10.1111/j.1600-6143.2009.02625.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nonadherence (NA) is a difficult posttransplant problem that can lead to graft loss. A retransplant is controversial because of a fear of recurrent NA. We reviewed our center's data base and identified 114 kidney recipients who lost their graft to overt NA; of this group, 35 (31%) underwent a retransplant after a thorough reevaluation. We compared this NA retransplant group to a control group of second transplant recipients who did not lose their first graft to overt NA (non-NA) (n = 552). After 8 years of follow-up, we found no significant differences between the groups in actuarial graft or patient survival rates, renal function, or the incidence of biopsy-proven chronic rejection. However, 5 of 35 (14%) NA recipients versus 10 of 552 (2%) non-NA recipients lost their retransplant to NA (p = 0.0001). Twenty of 35 (57%) of the NA group exhibited repeat NA behavior after retransplant. We conclude that prior graft loss to NA is associated with increased graft loss to NA after retransplant. However, the majority of NA retransplant recipients did well-with overall long-term outcomes similar to those of the non-NA group. With careful patient selection and aggressive intervention, prior overt NA should not be an absolute contraindication to retransplantation.
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Affiliation(s)
- T B Dunn
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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16
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Matas AJ, Gillingham KJ, Humar A, Kandaswamy R, Sutherland DER, Payne WD, Dunn TB, Najarian JS. 2202 kidney transplant recipients with 10 years of graft function: what happens next? Am J Transplant 2008; 8:2410-9. [PMID: 18925907 PMCID: PMC2766174 DOI: 10.1111/j.1600-6143.2008.02414.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The ultimate goal of clinical transplantation is for the recipients to achieve long-term survival, with continuing graft function, that is equivalent to that of the age-matched general population. We studied subsequent outcome in kidney transplant recipients with 10 years of graft function. In all, 2202 kidney transplant recipients survived with graft function >10 years. For 10-year survivors, the actuarial 25-year patient survival rate for primary transplant living donor (LD) recipients was 57%; graft survival, 43%. For primary transplant deceased donor (DD) recipients, the actuarial 25-year patient survival rate was 39%; graft survival, 27%. The two major causes of late graft loss were death (with graft function) and chronic allograft nephropathy (tubular atrophy and interstitial fibrosis). The two major causes of death with function were cardiovascular disease (CVD) and malignancy. For nondiabetic recipients, the mean age at death with function from CVD was 54 +/- 13 years; for diabetic recipients, 53 +/- 7 years. By 20 years posttransplant, morbidity was common: >40% recipients had skin cancer (mean age for nondiabetic recipients, 53 +/- 13 years; for diabetics, 49 +/- 8 years), >10% had non-skin cancer (mean age for nondiabetic recipients, 53 +/- 16 years; for diabetics, 46 +/- 9 years), and >30% had CVD (mean age for nondiabetic recipients, 53 +/- 15 years; for diabetics, 47 +/- 9 years). We conclude that long-term transplant recipients have a high rate of morbidity and early mortality. As short-term results have improved, more focus is needed on long-term outcome.
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Affiliation(s)
- A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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17
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Alonso D, Dunn TB, Rigley T, Skorupa JY, Schriner ME, Wrenshall LE, Stevens RB. Increased pancreatitis in allografts flushed with histidine-tryptophan-ketoglutarate solution: a cautionary tale. Am J Transplant 2008; 8:1942-5. [PMID: 18786234 DOI: 10.1111/j.1600-6143.2008.02312.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We reviewed pancreas transplantation outcomes after Histidine-Tryptophan-Ketoglutarate (HTK) and University of Wisconsin (UW) preservation solution use between 2001 and 2007 at two transplant centers. While equivalence has been claimed for kidney and liver transplant outcomes after the use of HTK or UW preservation solution, consensus has not been reached on equivalence when flushing pancreata. Others have reported comparable patient and graft survival rates, but found an association between the use of HTK and an increase in the incidence of acute rejection and pancreatitis. In reviewing our experiences, we found in pancreata flushed with HTK a higher incidence of postoperative complications including graft pancreatitis, use of octreotide and a decreased rate of insulin-independence at hospital discharge. These findings prompted us to critically review our centers' experience to determine if there is a basis for suspecting a causal relationship.
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Affiliation(s)
- D Alonso
- Department of Surgery, Division of Transplantation, University of Nebraska Medical Center, Omaha, NE, USA
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18
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Harbell JW, Dunn TB, Fauda M, John DG, Goldenberg AS, Teperman LW. Transmission of anaplastic large cell lymphoma via organ donation after cardiac death. Am J Transplant 2008; 8:238-44. [PMID: 18021286 DOI: 10.1111/j.1600-6143.2007.02033.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recently, donation after cardiac death (DCD) has been encouraged in order to expand the donor pool. We present a case of anaplastic T-cell lymphoma transmitted to four recipients of solid organ transplants from a DCD donor suspected of having bacterial meningitis. On brain biopsy, the donor was found to have anaplastic central nervous system T-cell lymphoma, and the recipient of the donor's pancreas, liver and kidneys were found to have involvement of T-cell lymphoma. The transplanted kidneys and pancreas were excised from the respective recipients, and the kidney and pancreas recipients responded well to chemotherapy. The liver recipient underwent three cycles of chemotherapy, but later died due to complications of severe tumor burden. We recommend transplanting organs from donors with suspected bacterial meningitis only after identification of the infectious organism. In cases of lymphoma transmission, excision of the graft may be the only chance at long-term survival.
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Affiliation(s)
- J W Harbell
- Department of Surgery, New York University Medical Center, New York, NY, USA
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19
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Dunn TB, Kumins NH, Raofi V, Holman DM, Mihalov M, Blanchard J, Law WR, Rastellini C, Benedetti E. Multiple intrasplenic hepatocyte transplantations in the dalmatian dog. Surgery 2000; 127:193-9. [PMID: 10686985 DOI: 10.1067/msy.2000.102043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hepatocyte transplantation is an attractive potential treatment for liver-based inborn errors of metabolism and for fulminant hepatic failure. Dalmatian dogs have a metabolic error that results in hyperuricosuria. This report focuses on the effect of multiple, sequential intrasplenic transplants of fresh and cryopreserved hepatocytes in dalmatians. METHODS Dalmatians underwent intrasplenic hepatocyte transplantation with hepatocytes taken from healthy mongrels. Dalmatian urinary uric acid excretion was measured preoperatively, and this served as the control value. Three hepatocyte transplantations were performed at 30-day intervals--the first with freshly isolated cells, and both the second and the third with cryopreserved hepatocytes from the same donor. Urinary uric acid excretion was measured postoperatively twice per week. RESULTS The urinary uric acid excretion decreased an average of 54% after the first hepatocyte transplantation. The effect was transient and lasted an average of 22 days (range, 19-50 days). Subsequent intrasplenic hepatocyte transplantation with cryopreserved hepatocytes resulted in similar decreases in urinary uric acid excretion. Each transplant resulted in a significant decrease in urinary uric acid excretion when compared with baseline values (P = < .001). CONCLUSIONS Sequential intrasplenic hepatocyte transplantation is feasible in this model. This method provided a significant, but transient, correction in urinary uric acid excretion that was similar with either fresh or cryopreserved hepatocytes. A substantial biologic effect provided by cryopreserved hepatocytes has important implications in clinical hepatocyte transplantation.
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Affiliation(s)
- T B Dunn
- Department of Surgery, University of Illinois at Chicago 60612, USA
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20
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Raofi V, Holman DM, Dunn TB, Fontaine MJ, Mihalov MM, Vitello JM, Asolati M, Benedetti E. Comparison of rejection rate and functional outcome of small bowel transplantation alone or in conjunction with the ileocecal valve versus combined small and large bowel transplantation. Clin Transplant 1999; 13:389-94. [PMID: 10515219 DOI: 10.1034/j.1399-0012.1999.130504.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Preservation of the ileocecal valve improves absorptive function and decreases the amount of small bowel needed for survival in patients with short gut syndrome. We compared the results of small and large bowel transplant (SLBTx), small bowel transplant only (SBTx), and SBTx with the ileocecal valve (ICVTx) in a porcine model. Total enterectomy was performed on 18 Yorkshire-Landrace pigs followed by orthotopic SBLTx (n = 6), SBTx (n = 6), and ICVTx (n = 6). A jejunostomy and an ileostomy were constructed for biopsies. Overall mean survival was 17 d with no statistically significant difference between groups. Rejection was seen in 6/6 SLBTx, 4/6 SBTx, and 4/6 ICVTx recipients. Acute rejection was seen in 84.3% of SLBTx, 52.3% of SBTx, and 42.5% of the ICVTx mucosal biopsy samples. Two cases of intra-abdominal infection were in the ICVTx group only. Weight loss was 147 g/d in the SLBTx group, 643 g/d in the SBTx group, and 393 g/d in the ICVTx group. While the functional outcome after SLBTx and ICVTx was noticeably better than the SBTx group, the increased rejection and intra-abdominal infection rates make transplanting the large bowel or the ileocecal valve a less attractive clinical option.
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Affiliation(s)
- V Raofi
- Department of Surgery, University of Illinois at Chicago Hospitals and Clinics, USA
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21
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Raofi V, Fontaine MJ, Mihalov ML, Holman DM, Dunn TB, Vitello JM, Asolati M, Kumins NH, Benedetti E. Comparison of jejunal and ileal surveillance biopsies in a porcine model of intestinal transplantation. Transplantation 1999; 68:188-91. [PMID: 10440385 DOI: 10.1097/00007890-199907270-00004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The optimal biopsy site of bowel allografts for rejection surveillance remains controversial. We compared the results of jejunal (JBx) and ileal (IBx) biopsies after bowel transplantation in a porcine model. METHODS Eighteen Yorkshire-Landrace pigs served as donors. Eighteen recipient pigs underwent total enterectomy followed by orthotopic small bowel transplantation with or without the colon. A jejunostomy and a Bishop-Koop ileostomy were constructed for biopsies. Immunosuppression consisted of FK506 (target level 10-15 ng/ml by enzyme immunoparticle assay) and prednisone administered via the jejunostomy. Simultaneous JBx and IBx were performed twice weekly. Acute rejection was graded as mild, moderate, or severe based on previously published criteria. RESULTS Mean overall survival after the transplant was 17.4 days. A total of 162 specimens were collected and evaluated for rejection (JBx, 81; IBx, 81). Acute rejection was detected in 41 JBx cases (50.7%) and 40 IBx cases (49.4%). The presence or absence of rejection was concordant between JBx and IBx in 70 of 81 case pairs (86.4%). Of the 11 discordant case pairs, 6 were JBx positive/IBx negative, whereas 5 were JBx negative/IBx positive. A total of 35 case pairs were synchronously positive, 24 (68.8%) of which demonstrated the same degree of rejection. CONCLUSIONS The correlation between JBx and IBx of bowel allografts in diagnosing the presence of acute rejection is quite good. However, performing IBx alone would have missed about 7.5% of the rejection episodes. Because the early treatment of rejection in bowel transplantation is of paramount importance, in selected cases, biopsies from both the ileum and jejunum should be considered if technically feasible.
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Affiliation(s)
- V Raofi
- Department of Surgery, University of Illinois at Chicago, 60612, USA
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22
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Raofi V, Holman DM, Coady N, Vazquez E, Dunn TB, Bartholomew AM, Pollak R, Benedetti E. A prospective randomized trial comparing the efficacy of tacrolimus versus cyclosporine in black recipients of primary cadaveric renal transplants. Am J Surg 1999; 177:299-302. [PMID: 10326847 DOI: 10.1016/s0002-9610(99)00042-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND We performed a prospective randomized trial to compare the efficacy and safety of tacrolimus (FK506) versus cyclosporine (CSA) in black primary cadaveric renal transplant (CRT) recipients. METHODS Between December 1994 and February 1997, 35 black primary CRT recipients were enrolled in this trial. All patients received 7 days of induction therapy with OKT3. Fourteen patients received FK506 and prednisone only. Twenty-one patients received CSA, azathioprine, and prednisone. The two groups were comparable in terms of age, gender, plasma renin activity, human leukocyte antigen mismatches, and cause of renal failure. RESULTS Patient and graft survival were 12 of 14 (86%) for the FK506 group and 20 of 21 (95%) for the CSA group (P = 0.71). Three patients died owing to cardiac events with functioning grafts. Acute rejection was 2 of 14 (14%) for the FK506 and 8 of 21 (38%) for the CSA group (P = 0.25). Two other patients on CSA were converted to FK506 as rescue for OKT3-resistant rejection. Mean serum cholesterol at 1 year was 198 +/- 45 mg/dL for the FK506 group and 244 +/- 49 mg/dL for the CSA group (P = 0.03). Mean serum creatinine at 1 year was 1.39 +/- 0.38 mg/dL for the FK506 group and 1.94 +/- 0.64 mg/dL for the CSA group (P = 0.02). CONCLUSION Patient and graft survival were similar in both groups at 1 year posttransplant. Although statistically not significant, the incidence of acute rejection was lower in the FK506 group. Furthermore, FK506-treated patients had significantly lower serum creatinine and cholesterol levels at 1 year posttransplant.
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Affiliation(s)
- V Raofi
- Division of Transplantation, University of Illinois at Chicago, 60612, USA
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23
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Holman DM, Dunn TB, Ward M, Raofi V, Jovanovic B, Kumins NH, Lazda VA, Pollak R, Benedetti E. Pretransplant MLC in the presence of cyclosporine may predict renal allograft survival. Transplant Proc 1999; 31:746-7. [PMID: 10083318 DOI: 10.1016/s0041-1345(98)01752-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- D M Holman
- Department of Surgery, University of Illinois at Chicago 60612, USA
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24
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Dunn TB, Kumins NH, Holman DM, Raofi V, Blanchard J, Glimer T, Pollak R, Benedetti E. Multiple sequential transplantation of hepatocytes in the Dalmatian dog model. Transplant Proc 1999; 31:543-4. [PMID: 10083229 DOI: 10.1016/s0041-1345(98)01547-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- T B Dunn
- University of Illinois at Chicago, Department of Surgery, IL 60612, USA
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Dunn TB, Asolati M, Holman DM, Raofi V, Jovanovic B, Pollak R, Benedetti E. Long-term outcome of a prospective trial of steroid withdrawal after kidney transplantation. Surgery 1999; 125:155-9. [PMID: 10026748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Steroid withdrawal (SW) after kidney transplantation is desirable to avoid associated serious side effects. We studied the long-term outcome of a group of kidney transplant recipients who underwent SW. METHODS Between 1991 and 1993, kidney transplant recipients (N = 12) who had posttransplantation diabetes were entered in a prospective trial of SW. These patients were compared with a demographically similar comparison cohort (N = 66). End points of the study were patient and graft survival, incidence of late acute and chronic rejection, and changes in diabetes management. RESULTS Previously published data from the SW group at 15 months of follow-up indicated improvement in diabetes control without any adverse effect on patient or graft actuarial survival. At long-term follow-up (mean, 56 months) the improvement in diabetes management was not detectable. The incidence of late acute rejection in SW and cohort groups was 42% and 8%, respectively (P = .006). Likewise, the incidence of chronic rejection in the SW versus cohort group was 42% and 12%, respectively (P = .014). CONCLUSIONS Although SW appeared to be successful initially, our long-term data indicate that SW significantly increases the risk of late acute rejection and chronic rejection episodes without benefits in posttransplantation diabetes management. Steroid withdrawal in patients with posttransplantation diabetes should be approached with caution.
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Affiliation(s)
- T B Dunn
- Department of Surgery, University of Illinois at Chicago 60612, USA
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Kumins NH, Landau DS, Montalvo J, Zasadzinski J, Wojciechowski J, Jovanovich BD, Dunn TB, Baraniewski H, Schuler JJ. Expanded indications for the treatment of postcatheterization femoral pseudoaneurysms with ultrasound-guided compression. Am J Surg 1998; 176:131-6. [PMID: 9737617 DOI: 10.1016/s0002-9610(98)00159-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The purpose of this study was to define the factors that predict successful ultrasound-guided compression repair (UGCR) of postcatheterization femoral pseudoaneurysms (PA) and to determine risks for recurrence, the most appropriate follow-up, and the optimal management of compression failures and recurrences. METHODS A retrospective chart review was made. RESULTS UGCR thrombosed 52 of 60 PA (87%). Predictors of compression failure were PA size of 8 cm and an associated arteriovenous fistula (AVF). AVF was the only predictor of recurrence. All seven recurrences (13%) were discovered on the first follow-up scan. Four were thrombosed with additional UGCR. Late rescanning after a mean of 264 days identified no recurrences. Four anticoagulated patients failed initial UGCR but were thrombosed in another session when their anticoagulation was briefly reversed. CONCLUSIONS UGCR should be the initial management of PA because it is safe, effective, and durable. Temporary discontinuation of anticoagulation and multiple prolonged compression sessions may help treat recalcitrant cases. One follow-up scan is adequate for most patients. Recurrences should be initially treated with repeat UGCR.
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Affiliation(s)
- N H Kumins
- Division of Vascular Surgery, University of Illinois, Chicago, USA
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Affiliation(s)
- T B Dunn
- Department of Biology, Hamline University, St. Paul, Minnesota
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Stewart HL, Sass B, Deringer MK, Dunn TB, Liotta LA, Togo S. Pure yolk sac carcinoma of the mouse uterus: report of 8 cases. J Natl Cancer Inst 1984; 73:115-22. [PMID: 6588218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
This report covered the pathologic features, behavior, metastases, and results of transplantation of pure yolk sac carcinomas that were primary in the uterine horn of 8 mice; 6 mice were strain C3H and 2 were strain HR, and they varied from 10 to 23 months of age. Three of the mice had never been treated. Of the 5 that had, the treatment was different for each mouse. Therefore, treatment could not be correlated with tumor development. At least 5 mice were nulliparous; in fact they had never been mated, so in these some mechanism involving parthenogenesis must have been operative to account for the tumor. The tumors were identified as being primary in the uterus and occupied and distended the cavity of one uterine horn where they were polypoid or plaquelike. The neoplastic yolk cells replaced the endometrial stroma forming a support for the original endometrial glands. In time the tumor cells destroyed many of the endometrial glands. That the glands present in the primary uterine horn tumors were the original glands of the endometrium and not neoplastic glands was attested by their absence from the secondary neoplastic deposits in 4 mice in which the tumor had spread to areas outside the cavity of the uterus and from the neoplastic tissue of the tumor transplants in the recipient mice.
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Sass B, Dunn TB. Classification of mouse mammary tumors in Dunn's miscellaneous group including recently reported types. J Natl Cancer Inst 1979; 62:1287-93. [PMID: 286104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A classification of mouse mammary tumors in Dunn's miscellaneous group including recently reported types is presented. Adenocarcinoma type Y, first reported in (C3H X Y)F1 mice, is characterized by tubules that branch at acute angles and are lined by cuboidal epithelium. Adenocarcinoma type L is characterized by alcelike appearance and has projections of tumor cells with cytoplasmic vacuoles into lumina. Undifferentiated carcinomas in strains SWR/J and BABL/c contain sheetlike masses of epithelial cells with very little tendency to form glands but which may contain foci of cells with keratohyaline granules. Pale cell carcinomas, which occur in strain GR mice, are hormonally responsive and are characterized by the presence of pale cells and cystic spaces lined by basophilic cells. Foci of cells with acidophilic hyaline bodies and keratohyaline granules and with intercellular bridges distinguish this neoplasm from adenocarcinoma type B. A second hormonally responsive mammary tumor in strain GR mice is adenocarcinoma type P, which consists mainly of acini lined by a single layer of polyhedral cells. Carcinosarcomas of BALB/c mice have a myxoid stoma and, also containing glands, resemble mixed mammary tumors of the bitch. Criteria for differentiating trichoepitheliomas from mammary tumors are discussed.
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Dunn TB. Barbiturates and fractures. Br Med J 1977; 2:1088-9. [PMID: 922449 PMCID: PMC1631812 DOI: 10.1136/bmj.2.6094.1088-d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Dunn TB. Intramural research pioneers, personalities, and programs: the early years. J Natl Cancer Inst 1977; 59:605-16. [PMID: 328905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Stewart HL, Dunn TB, Schneider JH, Deringer MK, Grieb SD, Chavez E. Registry of experimental cancers of the National Cancer Institute. J Natl Cancer Inst 1976; 56:447-50. [PMID: 946434 DOI: 10.1093/jnci/56.2.447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
This report describes the organization and functions of the Registry of Experimental Cancers and gives the chronology of events that led to its establishment. Currently 21,500 accessions have been coded; the vast majority are spontaneous and induced cancers, chiefly of rodents, and also a wide variety of nonneoplastic diseases. Accessions are accepted from contributors working in laboratories in this country and abroad. The material is available for study by responsible scientists, and a limited number of study sets is available for loan on request.
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Stewart HL, Deringer MK, Dunn TB, Snell KC. Malignant schwannomas of nerve roots, uterus, and epididymis in mice. J Natl Cancer Inst 1974; 53:1749-58. [PMID: 4474412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Stewart HL, Dunn TB. Leslie Foulds. Cancer Res 1974; 34:2831. [PMID: 4606721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Dunn TB, Elliott A. Funds for the Hospital Service. West J Med 1974. [DOI: 10.1136/bmj.2.5915.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Dunn TB. Psychogeriatric Services. West J Med 1971. [DOI: 10.1136/bmj.3.5769.308-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Jackson JL, Sanford KK, Dunn TB. Neoplastic conversion and chromosomal characteristics of rat embryo cells in vitro. J Natl Cancer Inst 1970; 45:11-23. [PMID: 5449209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Dunn TB. Normal and pathologic anatomy of the adrenal gland of the mouse, including neoplasms. J Natl Cancer Inst 1970; 44:1323-89. [PMID: 11515453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
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Andervont HB, Dunn TB. Amyloidosis in wild house mice during inbreeding and in hybrids derived from inbred strains and wild mice. J Natl Cancer Inst 1970; 44:719-27. [PMID: 11515440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
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Smith GH, Andervont HB, Dunn TB. Attempts to detect nodule-inducing virus in strain RIII mice. J Natl Cancer Inst 1970; 44:657-71. [PMID: 11515435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
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Dunn TB. Cancer of the uterine cervix in mice fed a liquid diet containing an antifertility drug. J Natl Cancer Inst 1969; 43:671-92. [PMID: 4898047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Dunn TB. Comparative aspects of hematopoietic neoplasms of rodents. Natl Cancer Inst Monogr 1969; 32:43-7. [PMID: 5350273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Dunn TB. Neoplastic properties of animal cell lines--summary. Natl Cancer Inst Monogr 1968; 29:555-7. [PMID: 4890062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Muñoz N, Dunn TB. Primary and transplanted endometrial adenocarcinoma in mice. J Natl Cancer Inst 1968; 41:1155-74. [PMID: 5688093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Dunn TB. Mast cell neoplasms of mice. Natl Cancer Inst Monogr 1968; 32:285-7. [PMID: 5738229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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