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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of simultaneous pancreas and kidney transplantation in Japanese individuals with type 1 diabetes and end-stage kidney disease

This single-center observational cohort study aimed to assess the potential benefits of simultaneous pancreas and kidney transplantation (SPK) in terms of mortality and kidney graft outcomes in Japanese individuals with type 1 diabetes (T1D) and end-stage kidney disease (ESKD). We first compared all-cause mortality rates between 78 SPK recipients and 108 non-transplanted individuals with T1D and ESKD. To mitigate the bias stemming from immortal time before receiving SPK, we utilized Cox regression models treating SPK as a time-dependent covariate. Next, we compared all-cause mortality rates and kidney graft loss rates between 65 SPK recipients and 58 kidney transplantation alone (KTA) recipients. Multivariate Cox hazard models and Fine and Gray competing-risk models were employed. SPK recipients experienced significantly lower all-cause mortality rates than non-transplanted individuals, even after accounting for immortal time bias (p = 0.015 by log-rank test, hazard ratio [HR] = 0.334, p = 0.025). When comparing SPK and KTA recipients, no statistically significant difference was observed in mortality rates (HR = 0.627, p = 0.588 by Cox model; HR = 0.385, p = 0.412 by Fine and Gray model) or kidney graft loss rates (HR = 0.612, p = 0.436 by Cox model; HR = 0.639, p = 0.376 by Fine and Gray model). Dysglycemia-associated mortality were observed in non-transplanted individuals and KTA recipients, but not in SPK recipients. These findings highlight the potential life-saving impact of SPK compared with intensive insulin therapy and dialysis. Additionally, this study suggests that both SPK and KTA may offer comparable outcomes. These findings have significant implications for clinical decision-making in the context of organ transplantation for individuals with T1D and ESKD.

Surgical complications after pancreatic transplantation: A computed tomography imaging pictorial review

Pancreatic transplantation is considered by the American Diabetes Association and the European Association for the Study of Diabetes an acceptable surgical procedure in patients with type 1 diabetes also undergoing kidney transplantation in pre-final or end-stage renal disease if no contraindications are present. Pancreatic transplantation, however, is a complex surgical procedure and may lead to a range of postoperative complications that can significantly impact graft function and patient outcomes. Postoperative computed tomography (CT) is often adopted to evaluate perfusion of the transplanted pancreas, identify complications and as a guide for interventional radiology procedures. CT assessment after pancreatic transplantation should start with the evaluation of the arterial Y-graft, the venous anastomosis and the duodenojejunostomy. With regard to complications, CT allows for the identification of vascular complications, such as thrombosis or stenosis of blood vessels supplying the graft, the detection of pancreatic fluid collections, including pseudocysts, abscesses, or leaks, the assessment of bowel complications (anastomotic leaks, ileus or obstruction), and the identification of bleeding. The aim of this pictorial review is to illustrate CT findings of surgical-related complications after pancreatic transplantation. The knowledge of surgical techniques is of key importance to understand postoperative anatomic changes and imaging evaluation. Therefore, we first provide a short summary of the main techniques of pancreatic transplantation. Then, we provide a practical imaging approach to pancreatic transplantation and its complications providing tips and tricks for the prompt imaging diagnosis on CT.

Pancreatic Transplantation: Surgical Anatomy and Complications

Pancreatic transplantation is a complex surgical procedure performed for patients with chronic severe diabetes, often performed in combination with renal transplantation. Vascular and exocrine drainage anatomy varies depending on the surgical technique. Radiology plays a critical role in the diagnosis of postoperative complications, requiring an understanding of grayscale/Doppler ultrasound as well as computed tomography and MR imaging. In this review, we detail usual surgical methods and normal postoperative imaging appearances. We then review the most common complications following pancreatic transplants, emphasizing diagnostic features of vascular (arterial/venous), surgical, and diffuse parenchymal pathologic conditions on multiple imaging modalities.

Pancreas transplantation improves the quality of life of Japanese type 1 diabetes patients with diabetic kidney disease

OBJECTIVES

Type 1 diabetes mellitus (T1DM) patients with diabetic kidney disease-induced kidney failure have a significantly impaired quality of life (QOL), resulting in a high level of physical, mental, and social anxiety. In this study, we evaluated the QOL of T1DM patients on the list for pancreas transplantation (PTx) at their registration, and determined whether PTx improved their QOL.

METHODS

There were 58 patients (men/women, 22/36; mean age, 42.8±8.0 years) with T1DM and who were registered on the waiting list for PTx. Quantitative QOL assessment was performed using the Medical Health Survey Short Form (SF-36) version 2. Changes in the QOL before and after PTx were also examined in 24 of these patients.

RESULTS

The mean value of each endpoint and the summary score of the SF-36 physical (PCS), mental (MCS), and role (RCS) components were all below the national normal level at PTx registration. No significant difference in QOL scores was observed in the intergroup comparison of 35 patients on dialysis, 13 patients without dialysis, and ten patients after kidney transplantation. The 24 patients who underwent PTx showed improvement in PCS, MCS, and most SF-36 scores.

CONCLUSION

T1DM patients waiting for PTx had a decreased QOL, regardless of dialysis, and PTx improved their QOL.

Simultaneous pancreas-kidney transplantation: which graft warns the most?

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPK) is still characterized by high rates of postoperative complications. This study aims to offer an in-depth characterization of early, medium-term, and late complications following SPK to derive insights for postoperative management and follow-up.

METHODS

Consecutive SPK transplantations were analysed. Pancreatic graft (P-graft)- and kidney graft (K-graft)-related complications were analysed separately. The global postoperative course was assessed in three timeframes (early, medium-term, and late) using the comprehensive complication index (CCI). Predictors of complications and early graft loss were explored.

RESULTS

Complications occurred in 61.2% of patients, and the 90-day mortality was 3.9%. The overall burden of complications was significantly high during admission (CCI 22.4 ± 21.1) and decreased gradually afterwards. P-graft-related complications burdened the most in the early postoperative course (CCI 11.6 ± 13.8); postoperative ileus and perigraft fluid collection were the most frequent complications, and pseudoaneurysms, haemorrhages, and bowel leaks were the major concerns. K-related complications were milder but represented the largest proportion of the CCI in the late postoperative timeframe (CCI 7.6 ± 13.6). No predictors of P-graft- or K-graft-related complications were found.

CONCLUSION

Pancreas graft-related complications represent the largest part of the clinical burden in the early postoperative timeframe but are negligible after 3 months. Kidney grafts have a relevant impact in the long term. The multidisciplinary approach to SPK recipients should be driven based on all graft-specific complications and tailored on a time-dependent basis.

Anatomical basis for pancreas transplantation via isolated splenic artery perfusion: A literature review

The variability of vascular anatomy of the pancreas underlines the difficulty of its transplantation. Research regarding the consistency of anatomical variations shows splenic arterial dominance in most cases. This can significantly improve transplantation success. A systematic literature review was performed according to the quality standards described in the AMSTAR measurement tool and the PRISMA guidelines. We valuated existing literature regarding the vascularization and blood perfusion patterns of the pancreas in terms of dominance and variability. The collected data was independently analyzed by two researchers. Variance of vascular anatomy was seen to be underreported in literature, though significant findings have been included and discussed in this study, providing valuable insight into the dynamics of pancreatic perfusion and feasibility of transplantation on several different supplying arteries. The splenic artery (SA) has a high percentage of consistency in all found studies (over 90%). High frequency of anastomoses between arterial pools supplying the pancreas can mediate sufficient blood supply through a dominant vessel, such as the SA, which is present in most cases. Pancreatic transplantation with isolated SA blood supply can provide sufficient arterial perfusion of the pancreas for stable transplant viability due to high anatomical consistency of the SA and vast communications with other arterial systems.

Parvovirus B19 status in liver, kidney and pancreas transplant candidates: A single center experience

BACKGROUND

Parvovirus B19 (B19V) is associated with a wide range of clinical manifestations. The major presentation is erythema infectiosum. However, a persistent infection may cause pure red cell aplasia and chronic anemia in immunocompromized patients. The B19V seroprevalence varies with age and geographical location.

AIM

To determine the B19V serological status and DNAemia in kidney, liver, and pancreas transplant candidates.

METHODS

Patients who underwent kidney, liver, or simultaneous kidney and pancreas/liver transplantation between January 2021 and May 2022 were included in the study. The serum samples were collected before transplantation. For detection of B19V DNA, a LightMix Kit B19V EC (TIB MOLBIOL, Berlin, Germany) was used. B19V IgM and IgG antibodies were detected using a commercial ELISA test (Euroimmun, Lübeck, Germany).

RESULTS

One hundred and thirty-one transplant candidates were included in the study, 71.0% male, with an average age of 53.27 years ± 12.71 years. There were 68.7% liver, 27.5% kidney, 3.0% simultaneous pancreas/kidney transplant (SPKT), and 0.8% simultaneous liver/kidney transplant recipients. No patients had detectable B19V DNA. B19V IgG seroprevalence was 77.1%. No acute or recent infections were detected (IgM antibodies). There was no difference in the mean age of seronegative and seropositive patients (51.8 years ± 12.9 years vs 53.7 years ± 12.7 years, t = -0.603; P = 0.548). Although seropositivity was lower in patients aged less than 30 years (66.6%) compared to the patients aged 30-59 years and > 60 years (80.4% and 78.1%, respectively), this difference was not significant. In addition, there was no difference in seropositivity between male and female transplant candidates, 76.3% and 78.9% (χ² = 0.104; P = 0.748). The seroprevalence did not differ among organ recipients, with 77.8%, 80.6%, and 50.0% for liver, kidney, and SPKT, respectively, (χ² = 5.297; P = 0.151). No significant difference was found in the seroprevalence in kidney transplant patients according to dialysis modality. Seroprevalence was 71.1% in hemodialysis patients, and 100% in peritoneal dialysis patients (χ² = 0.799; P = 0.372).

CONCLUSION

The B19V seroprevalence is expectedly high among kidney, liver, and pancreas transplant candidates, but there are still 22.9% of seronegative individuals who remain at risk for primary disease and severe manifestations. Further research should elucidate the necessity of B19V screening in peri-transplant management.

Pancreatic transplant surgery and stem cell therapy: Finding the balance between therapeutic advances and ethical principles

The latest achievements in the field of pancreas transplantation and stem cell therapy require an effort by the scientific community to clarify the ethical implications of pioneering treatments, often characterized by high complexity from a surgical point of view, due to transplantation of multiple organs at the same time or at different times, and from an immunological point of view for stem cell therapy. The fundamental value in the field of organ transplants is, of course, a solidarity principle, namely that of protecting the health and life of people for whom transplantation is a condition of functional recovery, or even of survival. The nature of this value is that of a concept to which the legal discipline of transplants entrusts its own ethical dignity and for which it has ensured a constitutional recognition in different systems. The general principle of respect for human life, both of the donor and of the recipient, evokes the need not to put oneself and one’s neighbor in dangerous conditions. The present ethical reflection aims to find a balance between the latest therapeutic advances and several concepts including the idea of the person, the respect due to the dead, the voluntary nature of the donation and the consent to the same, the gratuitousness of the donation, the scientific progress and the development of surgical techniques, and the policies of health promotion.

Endoscopic visualization of graft status in patients with pancreas transplantation

BACKGROUND

Enteric drainage into the recipient duodenum in pancreas transplantation (PT) can identify the graft duodenum by endoscopy. This study aimed to identify the characteristic endoscopic findings associated with graft failure or acute rejection in patients with PT.

METHODS

We reviewed the medical records of patients who underwent PT with duodenoduodenostomy (DD) between January 2015 and August 2019. During this period, there were 44 PTs with DD in 42 patients; 122 endoscopies were performed and analyzed.

RESULTS

Overall, pancreatic graft survival was 82% at a mean follow-up of 27 months (range 6-55 months). There were 8 graft failures and 10 acute rejections. In all 8 graft failures, a deep ulcer covered with fibrinous exudates of the graft duodenum was confirmed on endoscopy. Diffuse erythema inside the graft duodenum was observed in 8 of 10 acute rejections. The factors associated with acute rejection were elevated serum lipase level (OR 8.5, p = 0.02) and diffuse erythema inside the graft duodenum on endoscopy (OR 20.5, p < 0.01) in multivariate analysis.

CONCLUSIONS

In PT with DD patients, graft failure can be visualized by endoscopy, and diffuse erythema inside the graft duodenum may be a finding of acute rejection.

The dorsal pancreatic artery: A meta-analysis with clinical correlations

BACKGROUND/OBJECTIVES

The dorsal pancreatic artery is the main artery of the body and tail of the pancreas. Its origin and branching is highly variable. The aim of this study was to perform a meta-analysis to generate pooled prevalence data on the presence and origin of the dorsal pancreatic artery. Clinically important aspects of the dorsal pancreatic artery were summarised during the literature review.

METHODS

Major medical databases were searched. Data on the presence and point of origin of the dorsal pancreatic artery were extracted and quantitatively synthesised. The obtained data of anatomical based studies and computed tomography based studies were statistically analysed.

RESULTS

In total, 30 studies, comprising 2322 anatomical and computed tomography based cases were included. The dorsal pancreatic artery was present in 95.8% of cases. It originated from the splenic artery in 37.6% of cases, common hepatic artery in 18.3% of cases, coeliac trunk in 11.9% of cases and the superior mesenteric artery in 23.9% of cases. Other rare origins were present in 2.77% of cases. Multiple dorsal pancreatic arteries were found in 1,7% of cases. There was no significant difference in the presence or origin of the dorsal pancreatic artery between anatomical and computed tomography based studies.

CONCLUSION

The dorsal pancreatic artery is present in the vast majority of cases. Its origin and branching are highly variable. Multiplicity of the dorsal pancreatic artery is infrequent.

Validating the US pancreas donor risk index in a Norwegian population, a retrospective observational study

OBJECTIVES

Despite advances in immunosuppression and surgical technique, pancreas transplantation is still associated with a significant graft loss rate. The Pancreas Donor Risk Index (PDRI) is a pre-transplant scoring tool derived from a US population. We sought to validate the PDRI in a Norwegian population.

METHODS

We retrospectively retrieved donor data for 344 pancreas transplants undertaken in Norway between 2000 and 2019, utilising the Scandiatransplant database, and matched these to the respective recipients. The PDRI score was calculated for each transplanted pancreas, these were then stratified into quintiles. The association between the PDRI quintiles and 1-year graft survival was calculated, and this was repeated for the different types of pancreas transplantation. The association between PDRI as a continuous variable, and graft survival was determined. Donor and recipient data were compared to the original US population.

RESULTS

The overall 1-year graft survival was 82.7%. There were no significant differences in survival between the different PDRI quintiles. When viewed as a continuous variable, increased PDRI score was not associated with decreased graft survival. Significant differences between the Norwegian and US populations were found.

CONCLUSIONS

When applied to a Norwegian population, the PDRI score was unable to predict 1-year graft survival.

Impact of insulin therapy before donation on graft outcomes in pancreas transplantation: An analysis of the OPTN/UNOS database

AIMS

Information on the impact of insulin therapy before pancreas donation on pancreas outcomes is scarce. We aim to explore the influence of insulin therapy before donation on recipient and pancreas graft survival.

METHODS

Registry study including 12,841 pancreas recipients from the OPTN/UNOS registry performed between 2000 and 2017. Inverse probability of treatment weighting (IPTW) was used to account for covariate imbalance between recipients from a donor with and without insulin requirements.

RESULTS

A total of 7765 (60%) patients received a pancreas from a donor with insulin before donation (IBD). Pancreas graft survival (death-censored) was similar between recipients from IBD and non-IBD donors at 1, 5 and 10 years (89% vs 89%, 78% vs 79 and 69% vs 70%, respectively, P = 0.35). Recipients from IBD donors presented a similar 90-days pancreas graft survival. After IPTW weighting, IBD donors were neither associated with any post-transplant surgical complication (HR 1.11 [95% CI 0.98-1.24], P = 0.06), nor with risk for recipient death (HR 0.94 [95% CI 0.85-1.04], P = 0.26), nor pancreas graft failure (HR 1.06 [95% CI 0.98-1.16], P = 0.15).

CONCLUSIONS

Insulin therapy before donation in accepted pancreas donors was not associated, per se, with an impaired pancreas graft and patient survival.

A case of intraductal papillary mucinous neoplasm developing in the native pancreas after pancreas transplantation treated by total pancreatectomy

Post-transplant patients reportedly have a higher risk of de novo neoplasms. However, intraductal papillary mucinous neoplasm (IPMN) of the native pancreas after pancreas transplantation (PTx) has not been well investigated. The choice of treatment, especially invasive treatment, for de novo neoplasms in transplant patients should consider their impaired immunity. In this context, we present a case of IPMN developing in the native pancreas of a PTx patient. A 53-year-old man underwent a follow-up abdominal computed tomography scan 6 years after a simultaneous pancreas-kidney transplant for type 1 diabetes mellitus with end-stage diabetic nephropathy requiring hemodialysis. The scan revealed IPMN in the pancreas head; an enhancing internal solid component suggested a high risk of malignancy, indicating surgical resection. Partial pancreatectomy or pancreaticoduodenectomy was anatomically indicated, but considering the insulin-secreting ability of the transplanted pancreas and the potential high risk of postoperative pancreatic fistula due to immune impairment after partial pancreatectomy, total pancreatectomy (TP) was performed. The patient is alive with good pancreas graft function, no signs of indigestion for 18 months after TP, and no evidence of IPMN recurrence. This report should help clinicians characterize de novo IPMN in the native pancreas and determine IPMN therapeutic options for transplant patients.

Beneficial effects of posttransplant dipeptidyl peptidase-4 inhibitor administration after pancreas transplantation to improve β cell function

Purpose

Dipeptidyl peptidase-4 (DPP-4) inhibitors lower blood glucose levels and enhance the function of pancreatic β cells. Yet, it is unknown whether posttransplant administration of DPP4 inhibitors is beneficial for pancreas transplant recipients.

Methods

We thus retrospectively analyzed the records of 312 patients who underwent pancreas transplantation between 2000 and 2018 at Asan Medical Center (Seoul, Korea) and compared the metabolic and survival outcomes according to DPP-4 inhibitor treatment.

Results

The patients were divided into the no DPP-4 inhibitor group (n = 165; no treatment with DPP-4 inhibitors or treated for <1 month) and the DPP-4 inhibitor group (n = 147; treated with DPP-4 inhibitors for ≥1 month). There were no significant differences in levels of glucose, hemoglobin A1c, and insulin between the 2 groups during 36 months of follow-up. However, the level of C-peptide was significantly higher in the DPP-4 inhibitor group at 1, 6, and 24 months posttransplant (all P < 0.05). Moreover, the DPP-4 inhibitor group had significantly higher rates of overall (log-rank test, P = 0.009) and death-censored (log-rank test, P = 0.036) graft survival during a 15-year follow-up.

Conclusion

Posttransplant DPP-4 inhibitor administration may help improve the clinical outcomes including β cell function after pancreas transplantation.

Weight gain following pancreas transplantation in type 1 diabetes is associated with a worse glycemic profile: A retrospective cohort study

AIMS

Evaluate the weight trajectories after pancreas transplantation (PT) and their relationships with pancreas graft outcomes in type 1 diabetes (T1D).

METHODS

Retrospective cohort study. T1D individuals who underwent PT were recruited (T1D-PT; n = 194) and divided into three groups according to transplantation date: 1999-2004 (n = 57), 2005-2009 (n = 79), 2010-2015 (n = 58). For weight comparisons, a random sample of T1D without renal impairment was also recruited during 2015 (n = 61; T1D-control).

RESULTS

The median follow-up for the T1D-PT group was 11.1 years. Despite significant weight loss at 6 months (65.7 ± 12.4 vs. 64.1 ± 11.4 Kg; p < 0.001), a stepped increase was seen thereafter (60 months: 68.0 ± 14.0 Kg; p < 0.001). Participants from the 2010-2015 period showed higher weight gain (p < 0.001), outweighing that observed in the T1D-control (60 months: +4.69 ± 8.49 vs. -0.97 ± 4.59 Kg; p = 0.003). Weight gain between 6 and 36 months was directly associated with fasting glucose and HbA1c at 36 months, and with HbA1c at 60 months (p < 0.05). However, in Cox-regression models adjusted for age, sex, and several recipient and PT-related variables, the third tertile of weight gain between 6 and 36 months showed a non-significant increase in the graft failure/dysfunction (HR 2.33 [0.75-7.27]).

CONCLUSIONS

Weight gain post-PT was associated with glucose-related biochemical markers of graft dysfunction, which needs confirmation in further studies.

Pancreas-kidney transplantation: what every radiologist should know

Pancreas transplantation is a well-established treatment for patients with complicated diabetes mellitus and advanced renal failure. The most common procedure is simultaneous pancreas-kidney transplantation, in which the pancreas graft is positioned in the right pelvic region and the kidney graft is positioned in the left iliac fossa. Various imaging methods are used for the post-transplantation evaluation of the graft parenchyma and vascular anatomy, as well as for the identification of possible complications. As the number of cases increases, it is fundamental that radiologists understand the surgical procedure and the postoperative anatomy, as well as to recognize the possible postoperative complications and their imaging aspects, with the aim of providing the best guidance in the postoperative management of transplant recipients.

The impact of race on metabolic, graft, and patient outcomes after pancreas transplantation

BACKGROUND

Racial disparities following pancreas transplantation (PTX) are poorly defined.

METHODS

This was a large-scale, single-center, longitudinal cohort study including adult PTX recipients. Patients were grouped by race to allow for comparisons.

RESULTS

287 PTX recipients were included; 125 (43.5%) were African American (AA). At baseline, AAs had a significantly higher proportion of T2DM (19.4% vs. 5.7%, p = 0.001), were younger, and more likely to be female. AAs experienced significantly higher rates of pancreatic leaks and post-operative bleeding. PTX rejection was comparable, however, kidney rejection tended to be higher among AA SPKs. Long-term mean HgbA1C levels were significantly higher among AAs (6.9% vs. 6.3%, p = 0.039). Patient and graft survival was comparable between groups, but early patient survival tended to be lower in AAs.

CONCLUSIONS

This study demonstrated significant perioperative health disparities among AA PTX recipients, including poorer glycemic control and more early deaths, despite similar long-term patient and graft survival.

A retrospective single-center study

We explored glucometabolic and renal function after engraftment in all 159 consecutive patients with type 1 diabetes who received pancreas transplantation alone (PTA, n = 80) or simultaneous pancreas and kidney transplantation (SPK, n = 79) in Norway from 2012 until 2017. We report fasting levels of plasma glucose (FPG), C-peptide, eGFR and the homeostasis model assessment of insulin sensitivity (HOMA2(%S)) and beta-cell function (HOMA2(%B)) measured one to three times weekly during the first 8 and at 52 weeks after transplantation. One year after engraftment, in the PTA and SPK groups 52 and 64 were normoglycaemic without exogenous insulin, and two and zero patients were dead. Data at the 52-week visit were missing for 5 and 6 patients in the respective groups. During the first 8 weeks, FPG was lower, C-peptide and HOMA2(%S) were higher and eGFR was lower in the SPK group as compared with the PTA group (all p < .05). 30 out of 157 living patients needed insulin treatment 52 weeks after transplantation, 9/79 in the SPK group and 21/78 in the PTA group (p = .02). In conclusion, patients who underwent SPK showed lower insulin sensitivity, but higher insulin secretory capacity and lower mean blood glucose levels the first 8 weeks after transplantation. Also, a higher proportion of patients in the SPK group were insulin-free after 1 year, compared with the PTA group.

Current treatment options and challenges in patients with Type 1 diabetes: Pharmacological, technical advances and future perspectives

Type 1 diabetes mellitus imposes a significant burden of complications and mortality, despite important advances in treatment: subjects affected by this disease have also a worse quality of life-related to disease management. To overcome these challenges, different new approaches have been proposed, such as new insulin formulations or innovative devices. The introduction of insulin pumps allows a more physiological insulin administration with a reduction of HbA1c level and hypoglycemic risk. New continuous glucose monitoring systems with better accuracy have allowed, not only better glucose control, but also the improvement of the quality of life. Integration of these devices with control algorithms brought to the creation of the first artificial pancreas, able to independently gain metabolic control without the risk of hypo- and hyperglycemic crisis. This approach has revolutionized the management of diabetes both in terms of quality of life and glucose control. However, complete independence from exogenous insulin will be obtained only by biological approaches that foresee the replacement of functional beta cells obtained from stem cells: this will be a major challenge but the biggest hope for the subjects with type 1 diabetes. In this review, we will outline the current scenario of innovative diabetes management both from a technological and biological point of view, and we will also forecast some cutting-edge approaches to reduce the challenges that hamper the definitive cure of diabetes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Immunological Monitoring in Beta Cell Replacement: Towards a Pathophysiology-Guided Implementation of Biomarkers

PURPOSE OF REVIEW

Grafted beta cells are lost because of recurrence of T1D and/or allograft rejection, two conditions diagnosed with pancreas graft biopsy, which is invasive and impossible in case of islet transplantation. This review synthetizes the current pathophysiological knowledge and discusses the interest of available immune biomarkers.

RECENT FINDINGS

Despite the central role of auto-(recurrence of T1D) and allo-(T-cell mediated rejection) immune cellular responses, the latter are not directly monitored in routine. In striking contrast, there have been undisputable progresses in monitoring of auto and alloantibodies. Except for pancreas recipients in whom anti-donor HLA antibodies can be directly responsible for antibody-mediated rejection, autoantibodies (and alloantibodies in islet recipients) have no direct pathogenic effect. However, their fluctuation offers a surrogate marker for the activation status of T cells (because antibody generation depends on T cells). This illustrates the necessity to understand the pathophysiology when interpreting a biomarker and selecting the appropriate treatment.

Outcomes of pancreas transplantation in older versus younger recipients: a comparative analysis

PURPOSE

The feasibility of pancreas transplantation (PT) in older recipients remains a matter of debate. We examined the influence of recipient age on PT outcomes and identified the prognostic factors for older recipients.

METHODS

We compared the outcomes of PT in recipients aged < 50 years (younger group; n = 285) with those in recipients aged ≥ 50 years (older group; n = 94). Prognostic factors in the older group were analyzed by a logistic regression model and the influence of recipient age on survival outcomes were analyzed using propensity score matching.

RESULTS

The patient survival rate was significantly worse in the older group (P < 0.001). Patient death from infection or/and multiple organ failure or cardiac/cerebrovascular events was also more frequent in the older group than in the younger group (P = 0.012 and P = 0.045, respectively). A longer duration of diabetes was an independent risk factor of 1-year mortality in the older group. In a propensity score-matched comparison, the older recipients (n = 77) had significantly poorer survival than the younger recipients (n = 77) (P = 0.026).

CONCLUSIONS

PT should be considered with appropriate caution, especially for older recipients with a long duration of diabetes.

Human parvovirus B19-associated early postoperative acquired pure red cell aplasia in simultaneous pancreas-kidney transplantation: A case report

BACKGROUND

Acquired pure red cell aplasia (aPRCA) related to human parvovirus B19 (HPV B19) is rarely reported in simultaneous pancreas-kidney transplantation (SPKT) recipients; there has yet to be a case report of early postoperative infection. In this current study, we report the case of a Chinese patient who experienced the disease in the early postoperative period.

CASE SUMMARY

A 63-year-old man, with type 2 diabetes and end-stage renal disease, received a brain dead donor-derived SPKT. Immunosuppression treatment consisted of tacrolimus, prednisone, enteric-coated mycophenolate sodium (EC-MPS), and thymoglobulin combined with methylprednisolone as induction. The hemoglobin (Hb) level declined due to melena at postoperative day (POD) 3, erythropoietin-resistant anemia persisted, and reticulocytopenia was diagnosed at POD 20. The bone marrow aspirate showed decreased erythropoiesis and the presence of giant pronormoblasts at POD 43. Metagenomic next-generation sequencing (mNGS) of a blood sample identified HPV B19 infection at POD 66. EC-MPS was withdrawn; three cycles of intravenous immunoglobulin (IVIG) infusion therapy were administered; and tacrolimus was switched to cyclosporine. The HPV B19-associated aPRCA resolved completely and did not relapse within the 1-year follow-up period. The diminution in mNGS reads was correlated with Hb and reticulocyte count improvements.

CONCLUSION

HPV B19-associated aPRCA can occur at an early period after SPKT. An effective therapy regimen includes IVIG infusion and adjustment of the immuno-suppressive regimen. Moreover, mNGS can be used for the diagnosis and to reflect disease progression.

Clinical impact of pancreas donor age on outcomes following pancreas transplantation: Analysis of a nationwide registry in Japan

OBJECTIVES

Clinical impact of pancreas donor age on pancreas transplantation (PTx) outcome has not been well investigated. Here we analyzed the nationwide PTx registry in Japan to assess posttransplant outcomes in donor age-stratified groups.

METHODS

This study included 410 cases of PTx performed in Japan between 2000 and 2019. Analyses were performed using clinical data from the Japan Pancreas Transplant Registry of Japan Society for Pancreas and Islet Transplantation.

RESULTS

The 410 PTx cases were classified based on donor age: <10 years (n = 10, 2.4%), 10-19 years (n = 30, 7.3%), 20-29 years (n = 64, 15.6%), 30-39 years (n = 75, 18.3%), 40-49 years (n = 114, 27.8%), 50-59 years (n = 90, 22.0%), and ≥60 years (n = 27, 6.6%). The incidence of early pancreas graft loss (8.9%, 36/410 cases) did not exhibit a significant linear correlation with donor age. Posttransplant pancreas graft survival (1-/3-/5-/10-year rates of 85.9%/80.6%/76.2%/67.4% among all cases) was also not significantly associated with donor age.

CONCLUSION

Pancreas donor age was not significantly associated with posttransplant outcome. This finding supports the use of expanded criteria donors, with regards to pancreas donor age, for PTx in cases of type 1 diabetes mellitus.

Back-table surgery pancreas allograft for transplantation: Implications in complications

To describe the main aspects of back-table surgery in pancreatic graft and the problems arising from poor technique. Back-table surgery for pancreatic graft is a complex, meticulous and laborious technique on which the success of implant surgery and perioperative results depends. The technique can be described in the following steps: Preparation of the sterile table, ex-situ inspection of the pancreas-spleen block, management of the duodenum, identification of the bile duct, preparation of the portal vein, preparation of the own graft arteries and anastomosis to the arterial graft, spleen management and graft preservation prior to implantation in the recipient. A careful inspection of the pancreas-spleen block should be performed. It is important to identify the stump of the main bile duct, the portal vein cuff, and the arrangement of the superior mesenteric artery and splenic artery. The redundant duodenum must be removed. The availability of a good venous cuff facilitates the portal vein anastomosis and the positioning of the graft, two key points to prevent thrombosis. The section line of the arteries must be clean, without atherosclerosis, to prevent arterial thrombosis. The superior and splenic mesenteric arteries are generally separated by dense fibrolymphatic tissue. The artery can be reconstructed by interposing a "Y" graft from the donor iliac artery; or with an end-to-end anastomosis between the splenic artery and the superior mesenteric artery. An exquisite technique of bench work helps to prevent the most feared complications of pancreas transplantation: Thrombosis and graft pancreatitis.

Factors affecting diabetic patient's long-term quality of life after simultaneous pancreas-kidney transplantation: a single-center analysis

PURPOSE

Pancreas transplantation (PT) is one of the few ways to restore euglycemia within diabetic patients; however, the high morbidity caused by surgical complications and the need for immunosuppressive therapy has raised controversy about PT improving the health-related quality-of-life (HRQoL). The aim of this study is to assess the long-term (≥ 5 years after PT) HRQoL and to identify the factors affecting it.

METHODS

A single-center, cross-sectional study of 49 sequential PT was performed. All patients conducted a telephone interview to fulfill the modification of Medical Outcome Health Survey Short Form questionnaire (SF-36v2) and were compared to similar post-PT studies from the literature.

RESULTS

Patients with a history of replacement renal therapy (RRT) or neuropathy undergoing a PT were associated to a worse bodily pain (P = 0.03) and physical function (P = 0.04), respectively, whereas those with retinopathy showed an improved Role Emotional (P = 0.04). Multivariate analysis revealed the presence of RRT as the only independent prognostic factor for a worse bodily pain [relative risk = 3.9; 95% confidence interval (1.1-14.6)], (P = 0.04). Furthermore, nearly all PT recipients (91.8%) claimed an overall better health than prior to PT.

CONCLUSION

Our study confirms that PT recipients' HRQoL improves after PT, showing similar HRQoL scores across different populations and suggests that patients in predialysis could benefit from an improved HRQoL if transplanted on the early stages of the disease.

[Clinical effect analysis of 146 cases of ipsilateral simultaneous pancreas and kidney transplantation]

Objective: To investigate the clinical effect of ipsilateral simultaneous pancreas and kidney transplantation (SPK). Methods: A total of 146 cases of SPK surgeries completed in the Second Affiliated Hospital of Guangzhou Medical University from September 2016 to June 2020 were selected to summarize the outcome, curative effect and complications of the operation. Results: The patients were followed up for 1 to 45 months. Good clinical results were obtained in 146 patients. Renal function indicators suggest that on the 7th day after operation, the serum creatinine returned to normal level [142.4 (108.6, 213.4)μmol/L]. The index of pancreatic function decreased to the normal level as expected. The level of blood amylase was 160.5(109.3, 249.8) U/L within 7 days after operation, and then decreased. The trend of urinary amylase was similar to that of blood amylase, which was 240(121.0, 370.0) U/L 7 days after operation, and glycosylated hemoglobin decreased to the normal level (5.8%±1.4%) 1 month after operation. The main medical complications were infection including pulmonary infection (26.03%, 38/146), urinary tract infection (26.03%,38/146), and abdominal infection (4.79%,7/146), acute rejection including renal graft rejection (5.8%,8/146), pancreas/duodenum rejection (18.49%,27/146), and renal graft combined pancreatic graft rejeciton (6.85%,10/146), as well as gastrointestinal bleeding (30.82%,45/146), of which 5 cases were severe bleeding (3.42%, 5/146). The main surgical complications were poor incision healing (10.27%, 15/146), serious surgical complications including arteriovenous thrombosis of the transplanted pancreas (2.05%, 3/146) and intestinal leakage (0.68%,1/146). The 1-year and 3-year patient, renal and pancreatic survival rates were both 92.5%, 91.5% and 89.5%, respectively, and despite the death, the 1-year, 3-year transplanted kidney survival rate was both 99.3%, and 95% for the the 1-year, 3-year pancreas survival rate. Conclusion: Strict preoperative evaluation of the function of large organs, reasonable surgical methods, perioperative anticoagulation, and prompt diagnosis of complications can achieve good clinical results for patients with SPK.

Donor risk factors in pancreas transplantation

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

Late complications of pancreas transplant

To summarize the long-term complications after pancreas transplantation that affect graft function, a literature search was carried out on the long-term complications of pancreatic transplantation, namely, complications from postoperative 3^rd mo onwards, in terms of loss of graft function, late infection and vascular complications as pseudoaneurysms. The most relevant reviews and studies were selected to obtain the current evidence on these topics. The definition of graft failure varies among different studies, so it is difficult to evaluate, a standardized definition is of utmost importance to know the magnitude of the problem in all worldwide series. Chronic rejection is the main cause of long-term graft failure, occurring in 10% of patients. From the 3rd mo of transplantation onwards, the main risk factor for late infections is immunosuppression, and patients have opportunistic infections like: Cytomegalovirus, hepatitis B and C viruses, Epstein-Barr virus and varicella-zoster virus; opportunistic bacteria, reactivation of latent infections as tuberculosis or fungal infections. Complete preoperative studies and serological tests should be made in all recipients to avoid these infections, adding perioperative prophylactic treatments when indicated. Pseudoaneurysm are uncommon, but one of the main causes of late bleeding, which can be fatal. The treatment should be performed with radiological endovascular approaches or open surgery in case of failure. Despite all therapeutic options for the complications mentioned above, transplantectomy is a necessary option in approximately 50% of relaparotomies, especially in life-threatening complications. Late complications in pancreatic transplantation threatens long-term graft function. An exhaustive follow-up as well as a correct immunosuppression protocol are necessary for prevention.

Immediate post-operative complications (I): Post-operative bleeding; vascular origin: Thrombosis pancreatitis

Simultaneous pancreas-kidney transplantation is the treatment of choice for insulin-dependent diabetes that associates end-stage diabetic nephropathy, since it achieves not only a clear improvement in the quality of life, but also provides a long-term survival advantage over isolated kidney transplant. However, pancreas transplantation still has the highest rate of surgical complications among organ transplants. More than 70% of early graft losses are attributed to technical failures, that is, to a non-immunological cause. The so-called technical failures include graft thrombosis, bleeding, infection, pancreatitis, anastomotic leak and pancreatic fistula. Pancreatic graft thrombosis leads these technical complications as the most frequent cause of early graft loss. Currently most recipients receive postoperative anticoagulation with the aim of reducing the rate of thrombosis. Hemoperitoneum in the early postoperative period is a frequent cause of relaparotomy, but it is not usually associated with graft loss. The incidence of hemoperitoneum is clearly related to the use of anticoagulation in the postoperative period. Post-transplant pancreatitis is another cause of early postoperative complications, less frequent than the previous. In this review, we analyze the most common surgical complications that determine pancreatic graft losses.

Complications during multiorgan retrieval and pancreas preservation

In pancreas transplantation, complications can arise at each step of the process, from the initial selection of donors and recipients through the surgical technique itself and the post-operative period, when lifelong immunosuppression is required. In the early steps, careful retrieval and preservation of the pancreas are crucial for the viability of the organ and ultimate success of the transplant. The pancreas is a low-flow gland, making it highly sensitive to transplantation conditions and presenting risk of pancreatitis due to periods of ischemia. The two groups of donors - after brain death (DBD) or after cardiac arrest (DCD) - require different strategies of retrieval and preservation to avoid or reduce the risk of complications developing during and after the transplantation. For DBD donor transplantation, multiorgan retrieval and cold preservation is the conventional technique. Asystole donor (DCD) transplantation, in contrast, can benefit from the newest technologies, such as hypothermic and especially normothermic preservation machines (referred to as NECMO), to optimize organ preservation. The latter has led to an increase in the pool of donors by facilitating recuperation of organs for transplantation that would have been discarded otherwise.

Applicability and reproducibility of the CPAT-grading system for pancreas allograft thrombosis

PURPOSE

Although pancreas allograft thrombosis (PAT) incidence has progressively decreased, it remains the most common cause of early graft failure. Currently, there is no consensus on documentation of PAT, which has resulted in a great variability in reporting. The Cambridge Pancreas Allograft Thrombosis (CPAT) grading system has recently been developed for classification of PAT. In this study we aimed to assess the applicability and validate the reproducibility of the CPAT grading system.

METHODS

This study is a retrospective cohort study. Selected for this study were all 177 pancreas transplantations performed at our center between January 1 st, 2008 and September 1 st, 2018 were included.

RESULTS

A total of 318 Computed Tomography (CT) images was reevaluated according the CPAT system by two local radiologists. Inter-rater agreement expressed in Cohen's kappa was 0.403 for arterial and 0.537 for venous thrombosis. Inter-rater agreement, expressed in the Fleiss' kappa, within clinically relevant thrombosis categories was 0.626 for Grade 2 and 0.781 for Grade 3 venous thrombosis.

CONCLUSIONS

Although not perfect, we believe that implementation of the CPAT system would improve current documentation on PAT. However, it is questionable whether identification of a small Grade 1 thrombosis would be relevant in clinical practice. Furthermore, a good quality CT scan, including adequate phasing, is essential to accurately identify potential thrombus and extend after pancreas transplantation.

Pancreas-on-a-Chip Technology for Transplantation Applications

PURPOSE OF REVIEW

Human pancreas-on-a-chip (PoC) technology is quickly advancing as a platform for complex in vitro modeling of islet physiology. This review summarizes the current progress and evaluates the possibility of using this technology for clinical islet transplantation.

RECENT FINDINGS

PoC microfluidic platforms have mainly shown proof of principle for long-term culturing of islets to study islet function in a standardized format. Advancement in microfluidic design by using imaging-compatible biomaterials and biosensor technology might provide a novel future tool for predicting islet transplantation outcome. Progress in combining islets with other tissue types gives a possibility to study diabetic interventions in a minimal equivalent in vitro environment. Although the field of PoC is still in its infancy, considerable progress in the development of functional systems has brought the technology on the verge of a general applicable tool that may be used to study islet quality and to replace animal testing in the development of diabetes interventions.

Impact of an older donor pancreas on the outcome of pancreas transplantation: single-center experience of the expansion of donor criteria

PURPOSE

The impact of using an older donor pancreas on the clinical outcomes of pancreas transplantation (PTx) is unknown. We investigated this by comparing the outcomes of PTx using older and younger donors in a single Japanese center, to expand the donor criteria.

METHODS

The subjects were 54 patients who received PTx from deceased donors in our institution. Posttransplant outcomes were analyzed based on donor age, with older donors defined as those aged ≥ 60 years.

RESULTS

The donors included six older (11.1%; aged 64 ± 4 years) and 48 younger donors (88.9%; aged 43 ± 12 years). There was no significant difference in the donor age between the recipients with vs. those without postoperative complications or between those with vs. those without early pancreas graft loss. Long-term outcomes, including overall, pancreas graft, and kidney graft survival after PTx, did not differ significantly between the older and younger donor groups. Graft age, defined as the age of the donor at the time of procurement plus the graft survival period, was not associated with graft loss.

CONCLUSION

Our results suggest that post-transplant outcomes of PTx using pancreas from older donors aged ≥ 60 years are comparable to those using pancreas from younger donors, and support expansion of the donor pool for transplantation therapy for type 1 diabetes mellitus.

Anticoagulation in simultaneous pancreas kidney transplantation - On what basis?

BACKGROUND

Despite technical refinements, early pancreas graft loss due to thrombosis continues to occur. Conventional coagulation tests (CCT) do not detect hypercoagulability and hence the hypercoagulable state due to diabetes is left untreated. Thromboelastogram (TEG) is an in-vitro diagnostic test which is used in liver transplantation, and in various intensive care settings to guide anticoagulation. TEG is better than CCT because it is dynamic and provides a global hemostatic profile including fibrinolysis.

AIM

To compare the outcomes between TEG and CCT (prothrombin time, activated partial thromboplastin time and international normalized ratio) directed anticoagulation in simultaneous pancreas and kidney (SPK) transplant recipients.

METHODS

A single center retrospective analysis comparing the outcomes between TEG and CCT-directed anticoagulation in SPK recipients, who were matched for donor age and graft type (donors after brainstem death and donors after circulatory death). Anticoagulation consisted of intravenous (IV) heparin titrated up to a maximum of 500 IU/h based on CCT in conjunction with various clinical parameters or directed by TEG results. Graft loss due to thrombosis, anticoagulation related bleeding, radiological incidence of partial thrombi in the pancreas graft, thrombus resolution rate after anticoagulation dose escalation, length of the hospital stays and, 1-year pancreas and kidney graft survival between the two groups were compared.

RESULTS

Seventeen patients who received TEG-directed anticoagulation were compared against 51 contemporaneous SPK recipients (ratio of 1: 3) who were anticoagulated based on CCT. No graft losses occurred in the TEG group, whereas 11 grafts (7 pancreases and 4 kidneys) were lost due to thrombosis in the CCT group (P = 0.06, Fisher’s exact test). The overall incidence of anticoagulation related bleeding (hematoma/ gastrointestinal bleeding/ hematuria/ nose bleeding/ re-exploration for bleeding/ post-operative blood transfusion) was 17.65% in the TEG group and 45.10% in the CCT group (P = 0.05, Fisher’s exact test). The incidence of radiologically confirmed partial thrombus in pancreas allograft was 41.18% in the TEG and 25.50% in the CCT group (P = 0.23, Fisher’s exact test). All recipients with partial thrombi detected in computed tomography (CT) scan had an anticoagulation dose escalation. The thrombus resolution rates in subsequent scan were 85.71% and 63.64% in the TEG group vs the CCT group (P = 0.59, Fisher’s exact test). The TEG group had reduced blood product usage {10 packed red blood cell (PRBC) and 2 fresh frozen plasma (FFP)} compared to the CCT group (71 PRBC/ 10 FFP/ 2 cryoprecipitate and 2 platelets). The proportion of patients requiring transfusion in the TEG group was 17.65% vs 39.25% in the CCT group (P = 0.14, Fisher’s exact test). The median length of hospital stay was 18 days in the TEG group vs 31 days in the CCT group (P = 0.03, Mann Whitney test). The 1-year pancreas graft survival was 100% in the TEG group vs 82.35% in the CCT group (P = 0.07, log rank test) and, the 1-year kidney graft survival was 100% in the TEG group vs 92.15% in the CCT group (P = 0.23, log tank test).

CONCLUSION

TEG is a promising tool in guiding judicious use of anticoagulation with concomitant prevention of graft loss due to thrombosis, and reduces the length of hospital stay.

Short and long-term metabolic outcomes in patients with type 1 and type 2 diabetes receiving a simultaneous pancreas kidney allograft

BACKGROUND

In contrast to insulin-dependent type 1 diabetes mellitus (T1DM), the indication for Simultaneous pancreas-kidney transplantation (SPK) in patients with type 2 diabetes mellitus (T2DM) is still ambiguous and wisely Eurotransplant (ET) only granted transplant-permission in a selected group of patients. However, with regard to improvement of metabolic conditions SPK might still be a considerable treatment option for lean insulin dependent type 2 diabetics suffering from renal disease.

METHODS

Medical data (2001-2013) from all consecutive T1DM and T2DM patients who received a SPK or kidney transplant alone (KTA) at the University Hospital of Leipzig were analyzed. Donor, recipients and long-term endocrine, metabolic and graft outcomes were investigated for T1DM and T2DM-SPK recipients (transplanted upon a special request allocation by ET) and T2DM patients who received a KTA during the same period.

RESULTS

Eighty nine T1DM and 12 T2DM patients received a SPK and 26 T2DM patients received a KTA. Patient survival at 1 and 5 years was 89.9 and 88.8% for the T1DM group, 91.7 and 83.3% for the T2DM group, and 92.3 and 69.2% for the T2DM KTA group, respectively (p < 0.01). Actuarial pancreas graft survival for SPK recipients at 1 and 5 years was 83.1 and 78.7% for the T1DM group and 91.7 and 83.3% for the T2DM group, respectively (p = 0.71). Kidney allograft survival at 5 years was 79.8% for T1DM, 83.3% for T2DM, and 65.4% for T2DM KTA (p < 0.01). Delayed graft function (DGF) rate was significantly higher in type 2 diabetics received a KTA. Surgical, immunological and infectious complications showed similar results for T1DM and T2DM recipients after SPK transplant and KTA, respectively. With regard to the lipid profile, the mean high-density lipoprotein (HDL)- cholesterol levels were significantly higher in T1DM recipients compared to T2DM patients before transplantation (p = 0.02) and remained significantly during follow up period.

CONCLUSION

Our data demonstrate that with regard to metabolic function a selected group of patients with T2DM benefit from SPK transplantation. Consensus guidelines and further studies for SPK transplant indications in T2DM patients are still warranted.

Management of vascular and nonvascular complications following pancreas transplantation with interventional radiology

Pancreas transplantation exposes to high rates of complications, either vascular (thrombosis, stenosis, pseudoaneurysm, arteriovenous fistula) or nonvascular (fluid collection, graft rejection). With advances in percutaneous and endovascular techniques, interventional radiologists are increasingly involved in the management of these complications. In this article, we review the anatomical considerations relevant to pancreas transplantation, the techniques used for image-guided interventions for vascular and nonvascular complications, and the expected outcomes of these interventions.

Perioperative considerations for kidney and pancreas-kidney transplantation

Kidney transplantation is the treatment of choice in patients with end-stage renal disease, as it improves survival and quality of life. Living donor kidney transplant prior to pancreas transplantation, or simultaneous pancreas and kidney transplantation are discussed. Patients usually present comorbidities and extensive preoperative workups are recommended, especially cardiac assessment, though type and frequency of surveillance is not established. Nephroprotective strategies include adequate fluid status and goal-directed therapy. The conventional use of diuretics has not demonstrated a real nephroprotective effect at follow-up. Thromboprophylaxis regimes, especially for the pancreatic graft outcome, are of importance. Notably, transplantation in the obese population has increased in recent decades. Strict preoperative evaluation and pulmonary considerations must be kept in mind. Finally, robotic kidney transplant is a recent approach that presents anesthetic challenges, mainly related to steep Trendelenburg position and fluid restriction.

Machine perfusion in abdominal organ transplantation: Current use in the Netherlands

Scarcity of donor organs and the increment in patients awaiting a transplant increased the use of organs from expanded criteria donors or donation after circulatory death. Due to the suboptimal outcomes of these donor organs, there is an increased interest in better preservation methods, such as ex vivo machine perfusion or abdominal regional perfusion to improve outcomes. This state-of-the-art review aims to discuss the available types of perfusion techniques, its potential benefits and the available evidence in kidney, liver and pancreas transplantation. Additionally, translational steps from animal models towards clinical studies will be described, as well as its application to clinical practice, with the focus on the Netherlands. Despite the lack of evidence from randomized controlled trials, currently available data suggest especially beneficial effects of normothermic regional perfusion on biliary complications and ischemic cholangiopathy after liver transplantation. For ex vivo machine perfusion in kidney transplantation, hypothermic machine perfusion has proven to be beneficial over static cold storage in a randomized controlled trial, while normothermic machine perfusion is currently under investigation. For ex vivo machine perfusion in liver transplantation, normothermic machine perfusion has proven to reduce discard rates and early allograft dysfunction. In response to clinical studies, hypothermic machine perfusion for deceased donor kidneys has already been implemented as standard of care in the Netherlands.

Predictive factors of posttransplant glucose intolerance in Japanese patients with type 1 diabetes after pancreas transplantation

Pancreas transplantation (PTx) has been performed worldwide for patients with type 1 diabetes accompanied with end-stage renal disease or uncontrollable glycemic fluctuation. Nevertheless, risk factors of posttransplant glucose intolerance, which is responsible for progress of diabetic complications, remains unclear, especially in cases without pancreatic graft function loss. Therefore, this study was conducted to search for predictive factors of future glucose tolerance in PTx recipients without pancreatic graft function loss. Subjects were selected from among 41 Japanese patients with type 1 diabetes who received PTx between 2000 and 2016 in Osaka University Hospital, and 24 subjects free from rejections and thromboses were analyzed. Several examinations to evaluate insulin secretion and insulin sensitivity within 6 months after transplantation (initial examination) were performed. Glucose tolerance was evaluated by 120-minute post-load plasma glucose level during 75-g oral glucose tolerance tests (OGTT), referred to as PG_OGTT120, at the initial examination and between 1 year and 2 years posttransplantation (maintenance period). The initial examination factors that were correlated with PG_OGTT120 in the maintenance period were PG_OGTT120 [r = 0.52 (p = 0.01)], insulinogenic index [r = -0.65 (p < 0.01)], and the ratio of incremental area under the curve of insulin to that of plasma glucose (iAUCR) calculated from data of OGTT [r = -0.65 (p < 0.01)]. Insulinogenic index [β = -0.28 (p = 0.02)] and iAUCR [β = -0.29 (p = 0.02)] were still significantly correlated with PG_OGTT120 in the maintenance period after adjustment for PG_OGTT120 at the initial examination. In conclusion, insulinogenic index and iAUCR from OGTT performed in the early posttransplantation period were predictive factors of future glucose intolerance.

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

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

Effects of simultaneous pancreas-kidney transplantation and kidney transplantation alone on the outcome of peripheral vascular diseases

Background

The effects of Simultaneous Pancreas Kidney Transplantation (SPKT) on Peripheral Vascular Disease (PVD) warrants additional study and more target focus, since little is known about the mid- and long-term effects on the progression of PVD after transplantation.

Methods

101 SPKT and 26 Kidney Transplantation Alone (KTA) recipients with insulin-dependent diabetes mellitus (IDDM) were retrospectively evaluated with regard to graft and metabolic outcome. Special subgroup analysis was directed towards the development and progression of peripheral vascular complications (PVC) (amputation, ischemic ulceration, lower extremity angioplasty/ bypass surgery) after transplantation.

Results

The 10-year patient survival was significantly higher in the SPKT group (SPKT: 82% versus KTA 40%; P < 0.001). KTA recipients had a higher prevalence of atherosclerotic risk factors, including coronary artery disease (P < 0.001), higher serum triglyceride levels (P = 0.049), higher systolic (P = 0.03) and diastolic (P = 0.02) blood pressure levels. The incidence of PVD before transplantation was comparable between both groups (P = 0.114). Risk factor adjusted multivariate analysis revealed that patients with SPKT had a significant lower amount (32%) of PVCs (32 PVCs in 21 out of 101 SPKT; P < 0.001) when compared to the KTA patients who developed a significant increase in PVCs to 69% of cases (18 PVCs in 11 out of 26 KTA; P < 0.001). In line mean values of HbA_1c (P < 0.01) and serum triglycerides (P < 0.01) were significantly lower in patients with SPKT > 8 years after transplantation.

Conclusion

SPKT favorably slows down development and progression of PVD by maintaining a superior metabolic vascular risk profile in patients with IDDM1.

Pancreas Transplantation from Donors after Circulatory Death: an Irrational Reluctance?

PURPOSE OF REVIEW

Beta-cell replacement is the best therapeutic option for patients with type 1 diabetes. Because of donor scarcity, more extended criteria donors are used for transplantation. Donation after circulatory death donors (DCD) are not commonly used for pancreas transplantation, because of the supposed higher risk of complications. This review gives an overview on the pathophysiology, risk factors, and outcome in DCD transplantation and discusses different preservation methods.

RECENT FINDINGS

Studies on outcomes of DCD pancreata show similar results compared with those of donation after brain death (DBD), when accumulation of other risk factors is avoided. Hypothermic machine perfusion is shown to be a safe method to improve graft viability in experimental settings. DCD should not be the sole reason to decline a pancreas for transplantation. Adequate donor selection and improved preservation techniques can lead to enhanced pancreas utilization and outcome.

Pancreas transplantation with isolated splenic artery blood supply - Single center experience

BACKGROUND

The blood supply of the native pancreas by three arterial lines from the celiac trunk system (splenic artery and common hepatic artery) and the superior mesenteric artery forces surgeons to perform vascular reconstruction to provide sufficient intra-organ blood flow into the graft. The purpose of our study was to assess the possibility of pancreas transplantation with an isolated splenic artery blood supply.

METHODS

From January 2012 to July 2018, simultaneous pancreas-kidney transplantation (SPKT) was performed in 21 patients. Gender: male - 11 (52,4%), female 10 (47,6%). Recipients aged 26 to 54, the median age was 38 [34; 42] years. In 6 (28,6%) recipients, the organ perfusion was carried out through the splenic artery alone; in the rest, it was performed through the splenic and inferior pancreaticoduodenal artery exiting from the superior mesenteric artery of the graft. The transplant function, the quality of carbohydrate metabolism compensation, the objective characteristics of intra-organ blood flow was assessed.

RESULTS

There were no statistically significant differences in the volume blood flow characteristics revealed by CT-perfusion and laboratory data in the study groups.

CONCLUSIONS

Based on the assessment of the function and quality of blood supply to the transplant, the possibility of performing pancreas transplantation with an isolated splenic artery blood supply had been proved.

Islet Transplantation Alone Versus Solitary Pancreas Transplantation: an Outcome-Driven Choice?

PURPOSE OF REVIEW

In patients with type 1 diabetes with extreme glycemic variability, the restoration of pancreas endocrine function is potentially and completely achieved with islets of Langerhans (tissue derived from whole organ) or pancreas (whole organ) transplantation. The aim of our review is to report on the latest studies and to highlight the benefits and risks of the two procedures, providing clearer, more selective, evidence-based clinical indications that also consider the impact on the degenerative complications of diabetes as a potential benefit.

RECENT FINDINGS

Clinical experience in this field has been dynamic over the last three decades, and has been characterized by the development of more standardized protocols and a clearer definition of clinical outcome. On the contrary, the recommendations thus far are not well delineated and tend to overlap, and the past ADA position statement for pancreas transplant alone has also been applied to islet transplant alone, without differentiation. Both outcome-driven and non-outcome-driven criteria are considered in the conclusions, in an attempt to streamline indications for islet-alone or pancreas-alone transplantation.