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Serpico S, Manikath James R, Koizumi N, Ortiz J. Unintentional Injury Death Among Solid Organ Transplant Recipients: Trends and Risk Factors. Angiology 2024; 75:486-493. [PMID: 37040182 DOI: 10.1177/00033197231169918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Unintentional injury death (UID) is a leading cause of mortality worldwide, and individuals with chronic diseases are at higher risk. Though organ transplant can improve the lives of those with chronic disease, these individuals remain in suboptimal physical and mental health after surgery that predisposes them to UID. To quantify the scale of UID among solid organ transplant recipients, we performed a retrospective analysis using United Network of Organ Sharing data from adults who underwent kidney, liver or pancreas transplant between 2000-2021. Our study aimed to identify risk factors for UID in this cohort by comparing basic patient, donor, and transplant characteristics of the groups (UID or all other cause death). The largest proportion of UID was seen in the kidney group (.8%), followed by liver (.7%) and then pancreas (.3%). Male sex was the most significant risk factor among kidney and liver recipients. Whites had a higher risk for UID relative to their non-White counterparts in the kidney and liver groups. In both groups, advancing age conferred a protective effect, whereas higher functional status was a risk factor. Our findings shed new light on a significant source of mortality within the transplant population.
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Affiliation(s)
- Scott Serpico
- Department of Clinical Research, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Rosy Manikath James
- School of Public Policy and Gov't, George Mason University, Arlington, TX, USA
| | - Naoru Koizumi
- School of Public Policy and Gov't, George Mason University, Arlington, TX, USA
| | - Jorge Ortiz
- Department of Transplantation and Surgery, Erie County Medical Center, Buffalo, NY, USA
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Burke GW, Mitrofanova A, Fontanella AM, Vendrame F, Ciancio G, Vianna RM, Roth D, Ruiz P, Abitbol CL, Chandar J, Merscher S, Pugliese A, Fornoni A. Transplantation: platform to study recurrence of disease. Front Immunol 2024; 15:1354101. [PMID: 38495894 PMCID: PMC10940352 DOI: 10.3389/fimmu.2024.1354101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/29/2024] [Indexed: 03/19/2024] Open
Abstract
Beyond the direct benefit that a transplanted organ provides to an individual recipient, the study of the transplant process has the potential to create a better understanding of the pathogenesis, etiology, progression and possible therapy for recurrence of disease after transplantation while at the same time providing insight into the original disease. Specific examples of this include: 1) recurrence of focal segmental glomerulosclerosis (FSGS) after kidney transplantation, 2) recurrent autoimmunity after pancreas transplantation, and 3) recurrence of disease after orthotopic liver transplantation (OLT) for cirrhosis related to progressive steatosis secondary to jejuno-ileal bypass (JIB) surgery. Our team has been studying these phenomena and their immunologic underpinnings, and we suggest that expanding the concept to other pathologic processes and/or transplanted organs that harbor the risk for recurrent disease may provide novel insight into the pathogenesis of a host of other disease processes that lead to organ failure.
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Affiliation(s)
- George William Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Alla Mitrofanova
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | | | - Francesco Vendrame
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Rodrigo M. Vianna
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - David Roth
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Phillip Ruiz
- Transplant Pathology, Immunology and Histocompatibility Laboratory University of Miami Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Carolyn L. Abitbol
- Pediatric Nephrology & Hypertension, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jayanthi Chandar
- Pediatric Kidney Transplant, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Sandra Merscher
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
- Peggy and Harold Katz Family Drug Discovery Center, Department of Medicine, University of Miami - Miller School of Medicine, Miami, FL, United States
| | - Alberto Pugliese
- Department of Diabetes Immunology, Arthur Riggs Diabetes and Metabolism Research Institute, City of Hope, Duarte, CA, United States
| | - Alessia Fornoni
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
- Peggy and Harold Katz Family Drug Discovery Center, Department of Medicine, University of Miami - Miller School of Medicine, Miami, FL, United States
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Koimtzis G, Geropoulos G, Chalklin C, Karniadakis I, Szabo L, Ilham MA, Stephens M, Asderakis A, Khalid U. The influence of socioeconomic deprivation on outcomes in transplant patients infected with SARS-CoV-2 in Wales. Clin Transplant 2024; 38:e15245. [PMID: 38289884 DOI: 10.1111/ctr.15245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION SARS-CoV-2 infection has had a significant impact on vulnerable individuals including transplant patients. Socioeconomic deprivation negatively affects outcomes of many health conditions. The aim of this study was to evaluate the effect of socioeconomic deprivation on the incidence and severity of SARS-CoV-2 infection among Welsh transplant patients. METHODS This study is a retrospective, cross-sectional study on the transplant population of Wales. The Welsh Index of Multiple Deprivation (WIMD) was used to assess the influence of socioeconomic deprivation on outcomes of Welsh transplant patients who developed SARS-CoV-2 infection. Outcome measures were the incidence of SARS-CoV-2 infection, rates of hospital and ICU admission, development of acute kidney injury (AKI) and mortality. A logistic binomial regression analysis was used to correlate the various risk factors with the incidence of SARS-CoV-2 infection. RESULTS Two hundred and sixty-six (25%) of regular follow up patients had SARS-CoV-2 infection; of these 55 (20.7%) were admitted, 15 (5.6%) to ICU, 37 (13.9%) developed AKI, and 23 (8.6%) died. In a regression analysis, patients of younger age were associated with more (p = .001) and those with SPK (simultaneous pancreas kidney) transplant less chance of infection (p = .038), whereas social deprivation was not associated with the chance of infection (p = .14). In regression analysis increased social deprivation was associated with higher chance of AKI post SARS-CoV-2 (p = .049). CONCLUSIONS Socioeconomic deprivation did not affect the rates or severity of SARS-CoV-2 infection apart from the degree of AKI in Welsh Transplant patients. Adherence to the preventive measures for this high-risk population must continue to remain a priority.
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Affiliation(s)
- Georgios Koimtzis
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Georgios Geropoulos
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Christopher Chalklin
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Ioannis Karniadakis
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Laszlo Szabo
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Mohammed Adel Ilham
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Michael Stephens
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Argiris Asderakis
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
- Wales Kidney Research Unit, Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Usman Khalid
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
- Wales Kidney Research Unit, Division of Infection and Immunity, Cardiff University, Cardiff, UK
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Drury AM, Albunni H, Al-Haddad M, Powelson JA, Lutz A, Fridell JA. Role of gastric peroral endoscopic myotomy (GPOEM) in chronic gastroparesis management after pancreas transplantation. Clin Transplant 2024; 38:e15176. [PMID: 37922244 DOI: 10.1111/ctr.15176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 11/05/2023]
Abstract
Gastroparesis is a common complaint among patients with diabetes. Symptoms tend to improve following successful pancreas transplantation (PTx), but persist despite euglycemia in a subset of patients. We aimed to assess the benefit of gastric peroral endoscopic myotomy (G-POEM) in persistent gastroparesis following PTx. This was a single center retrospective review of all patients who underwent G-POEM for persistent gastroparesis following PTx. Patient demographics, pre and post procedure perception of symptom severity according to the patient assessment of upper gastrointestinal symptoms severity index (PAGI-SYM), gastroparesis cardinal symptom index (GCSI) score, and 36-item short form survey (SF36) score along with gastric emptying scintigraphy (GES) were analyzed. Seven PTx recipients underwent G-POEM for persistent gastroparesis symptoms. The majority were female. All reported nausea/vomiting, abdominal pain, bloating, and post prandial fullness prior to G-POEM. The post procedure survey scores improved in all patients although this was not significant. The improvement in gastric emptying on GES was statistically significant. G-POEM is a relatively new treatment option for gastroparesis. While it requires specialized proceduralist and training, we have documented improvement in the management of symptoms. With increasing experience, we anticipate more significant benefit in post PTx patients with persistent symptoms of gastroparesis undergoing G-POEM.
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Affiliation(s)
- Allison M Drury
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hashem Albunni
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Al-Haddad
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew Lutz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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5
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Kohanzadeh A, Sher A, Wind O, Liu Q, Srivastava P, Amin B, Mann R. Pancreatic Panniculitis: A Case Associated With Acute Pancreatic Allograft Rejection. Cureus 2024; 16:e52925. [PMID: 38274602 PMCID: PMC10810171 DOI: 10.7759/cureus.52925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 01/27/2024] Open
Abstract
We present a unique case of pancreatic panniculitis (PP) in a 42-year-old male with a history of pancreas-after-kidney (PAK) transplant. The patient developed PP due to acute pancreas allograft rejection. Clinical manifestations included fevers, myalgias, arthralgias, and tender erythematous subcutaneous nodules on the lower extremities. A recent hospital admission was noted for acute pancreas allograft rejection related to low tacrolimus levels. Rheumatological and infectious disease workups were negative. Skin nodule punch biopsy confirmed PP with lobular panniculitis, necrotic adipocytes, basophilic debris, and calcification. Pancreatic biopsy showed evidence of parenchymal acute cellular rejection. Lipase and amylase levels were elevated (1781 U/L and 881 U/L, respectively). Treatment involved pulse solumedrol and thymoglobulin for pancreatic rejection, alongside adjustments to immunosuppressive medications. This case highlights the rarity of PP in a PAK recipient and its association with acute pancreas allograft rejection. Importantly, it is the first reported case of PP occurring solely in the context of pancreas transplant rejection, without concurrent kidney damage or rejection. Prompt diagnosis and management led to the resolution of skin and systemic symptoms. In conclusion, this report presents a clinically relevant and unique case of PP resulting from acute pancreas allograft rejection in a PAK transplant recipient. The findings underscore the importance of early diagnosis and management for positive patient outcomes, serving as a reminder to consider underlying pancreatic pathology when encountering PP in transplant recipients.
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Affiliation(s)
- Avraham Kohanzadeh
- Internal Medicine, Albert Einstein College of Medicine, New York City, USA
| | - Ariel Sher
- Dermatology, New York Medical College, New York City, USA
| | - Olivia Wind
- Dermatology, Mount Sinai Hospital, New York City, USA
| | - Qiang Liu
- Pathology and Laboratory Medicine, Montefiore Medical Center, New York City, USA
| | | | - Bijal Amin
- Dermatopathology, Montefiore Medical Center, New York City, USA
| | - Ranon Mann
- Dermatology, Montefiore Medical Center, New York City, USA
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Zachary J, Chen JM, Sharfuddin A, Yaqub M, Lutz A, Powelson J, Fridell JA, Barros N. Epidemiology and Risk Factors for Invasive Fungal Infections in Pancreas Transplant in the Absence of Postoperative Antifungal Prophylaxis. Open Forum Infect Dis 2023; 10:ofad478. [PMID: 37942464 PMCID: PMC10629350 DOI: 10.1093/ofid/ofad478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/20/2023] [Indexed: 11/10/2023] Open
Abstract
Background Invasive fungal infections (IFIs) remain a rare yet dreaded complication following pancreas transplantation. Current guidelines recommend antifungal prophylaxis in patients with 1 or more risk factors. At our center, single-dose antifungal prophylaxis is administered in the operating room but none subsequently, regardless of risk factors. Here we evaluate the 1-year incidence, outcome, and risk factors associated with IFI following pancreas transplantation. Methods A retrospective, single-center cohort study was conducted in patients who underwent pancreas transplantation between 1 January 2009 and 31 December 2019. Records were manually reviewed, and cases were adjudicated using consensus definitions. The 1-year cumulative incidence, mortality, and risk factors were analyzed by Kaplan-Meier method and differences between populations were assessed with Fisher test and Mann-Whitney U test. Results Three hundred sixty-nine recipients were included. Twelve IFIs were identified: candidiasis (8), aspergillosis (2), histoplasmosis (1), and cryptococcosis (1). Intra-abdominal infections were the most common presentation (5), followed by bloodstream infections (3), disseminated disease (2), pulmonary disease (1), and invasive fungal sinusitis (1). Median time to IFI was 64 days (interquartile range, 30-234 days). One-year cumulative incidence was 3.25% (95% confidence interval, 1.86%-5.65%). There were no significant differences between patients with or without IFI regarding type of transplant (P = .17), posttransplant dialysis (P = .3), rejection (P = .5), cytomegalovirus serostatus (P = .45), or reoperation (P = .19). For patients with IFI, the 1-year graft and patient survival rates were 58% versus 95% (P < .0001) and 75% versus 98.6% (P < .001), respectively. Conclusions Our study suggests that the use of a single-dose antifungal prophylaxis administered in the operating room but none subsequently does not result in an increased incidence of IFI following pancreas transplantation.
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Affiliation(s)
- Jessica Zachary
- Department of Pharmacy, Indiana University Health, Indianapolis, Indiana, USA
| | - Jeanne M Chen
- Department of Pharmacy, Indiana University Health, Indianapolis, Indiana, USA
| | - Asif Sharfuddin
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Muhammad Yaqub
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew Lutz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicolas Barros
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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7
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Alkhatib EH, Grundman JB, Adamusiak AM, Bellin MD, Brooks JP, Buckley KS, Janssen EM, Kitcharoensakkul M, McNerney KP, Pfeifer TL, Polk BI, Marks BE. Case Report: Insulin hypersensitivity in youth with type 1 diabetes. Front Endocrinol (Lausanne) 2023; 14:1226231. [PMID: 37929017 PMCID: PMC10624121 DOI: 10.3389/fendo.2023.1226231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Objective Immediate type I, type III, and delayed type IV hypersensitivity reactions to insulin are rare, but potentially serious complications of exogenous insulin administration required for the treatment of type 1 diabetes (T1D). Methods We present four cases of insulin hypersensitivity reactions occurring in youth with T1D and a literature review of this topic. Results Insulin hypersensitivity reactions included types I, III, and IV with presentations ranging from localized urticaria, erythematous nodules, and eczematous plaques to anaphylaxis with respiratory distress. Reactions occurred in youth with newly diagnosed T1D and in those with long-standing T1D who were using both injection and insulin pump therapy. Multidisciplinary care involving pediatric endocrinology and allergy/immunology utilizing trials of many adjunct therapies yielded minimal improvement. Despite the use of various treatments, including antihistamines, topical therapies, immunosuppressant medications, desensitization trials, and intravenous immune globulin, cutaneous reactions, elevated hemoglobin A1c levels, and negative effects on quality of life remain persistent challenges. One patient became one of the youngest pancreas transplant recipients in the world at age 12 years due to uncontrollable symptoms and intolerable adverse effects of attempted therapies. Conclusion Although rare, insulin hypersensitivity reactions negatively affect glycemic control and quality of life. These cases demonstrate the varying severity and presentation of insulin hypersensitivity reactions along with the limited success of various treatment approaches. Given the life-sustaining nature of insulin therapy, further studies are needed to better understand the underlying pathophysiology of insulin hypersensitivity and to develop targeted treatment approaches.
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Affiliation(s)
- Einas H. Alkhatib
- Department of Pediatric Endocrinology, Children’s National Hospital, Washington, DC, United States
| | - Jody B. Grundman
- Department of Pediatric Endocrinology, Children’s National Hospital, Washington, DC, United States
| | - Anna M. Adamusiak
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Melena D. Bellin
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
- Department of Pediatrics, Division of Endocrinology, University of Minnesota, Minneapolis, MN, United States
| | - Joel P. Brooks
- Department of Allergy and Immunology, Columbia University/New York-Presbyterian, New York, NY, United States
| | - Kevin S. Buckley
- Departments of Hematology/Oncology and Infectious Disease, Atrium Health Levine Children’s Hospital, Concord, NC, United States
| | - Erin M. Janssen
- Department of Rheumatology, Mott Children’s Hospital/University of Michigan, Ann Arbor, MI, United States
| | - Maleewan Kitcharoensakkul
- Departments of Pediatric Allergy and Pulmonary Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Kyle P. McNerney
- Department of Pediatric Endocrinology, Washington University School of Medicine, St. Louis, MO, United States
| | - Thea L. Pfeifer
- Department of Pediatric Endocrinology, Atrium Health Levine Children’s Hospital, Concord, NC, United States
| | - Brooke I. Polk
- Departments of Pediatric Allergy and Pulmonary Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Brynn E. Marks
- Department of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Wu D, Hanison J. Critical Care Length of Stay and Support Requirements for Patients Post pancreas Transplant. Prog Transplant 2023; 33:256-260. [PMID: 37518973 DOI: 10.1177/15269248231189875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Introduction: Pancreas transplant is one of the UK's less commonly done solid abdominal organ transplants. The transplant is reputed for its high-risk postsurgical complications due to multiple patients, procedures, and immunological factors. For this reason, patients are habitually admitted to the intensive care unit for postlaparotomy care, physiological support, and graft function monitoring during their immediate postoperative course. Project Aim: This program evaluation analyzed the trend in critical care length of stay and organ support requirements for patients following whole pancreas transplantation. The aim was to use these baseline data as performance metrics to enable a safer transition and Plan-Do-Study-Act (PDSA) cycles in improving the delivery of enhanced recovery service. Design: A retrospective chart review was performed using records from Phillips IntelliSpace Critical Care and Anaesthesia system to evaluate the institutional outcomes of patients < 18 years admitted to intensive care following pancreas transplantation between January 1, 2018, and December 31, 2021. Islet-cell transplant recipients were excluded as there is a different postoperative recovery. Results: The data suggested that although patients require a higher level of observations, blood pressure management, blood gas, and glucose monitoring during their first week of transplant, these patients did not routinely require the full range of critical care support. Conclusion: The present evaluation reported the organ support requirements for these transplant recipients. The results will generate further interest in enhanced recovery and service evaluation projects to streamline the postoperative care of these patients from the operating theatre back to the transplant wards.
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Affiliation(s)
- Dominic Wu
- Department of Anaesthesia and Intensive Care, Manchester University NHS Foundation Trust, Manchester, UK
| | - James Hanison
- Department of Anaesthesia and Intensive Care, Manchester University NHS Foundation Trust, Manchester, UK
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9
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Ahopelto K, Bonsdorff A, Grasberger J, Lempinen M, Nordin A, Helanterä I, Sallinen V. Pasireotide Versus Octreotide in Preventing Complications After Simultaneous Pancreas-Kidney Transplantation. Transpl Int 2023; 36:11255. [PMID: 37388858 PMCID: PMC10300274 DOI: 10.3389/ti.2023.11255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
In elective pancreatic surgery, somatostatin-analogues pasireotide and octreotide are variably used to reduce postoperative complications, but knowledge on their role in pancreas transplantation is limited. This study compared pasireotide and octreotide for their association with complications after simultaneous pancreas-kidney transplantation (SPK). This retrospective study included consecutive patients undergoing SPK's from July 2013 to July 2022. Between July 2013 and April 2020, octreotide was administered 0.1 mg s.c. once daily and between May 2020 and July 2022 pasireotide was administered 0.9 mg twice daily, both until third postoperative day. Complications within 90 days postoperatively were collected, and reoperation rate and Comprehensive Complication index (CCI) ≥ 33.7 (morbidity equal to one reoperation) were used as primary outcomes. Of the 213 patients undergoing SPK, 150 patients received octreotide and 63 pasireotide. Baseline characteristics were comparable. Reoperation rate was 25.3% (n = 38) and 17.5% (n = 11) (p = 0.213) and rate of CCI ≥ 33.7 was 40.7% (n = 61) and 30.2% (n = 19) (p = 0.148) in octreotide and pasireotide groups, respectively. When adjusted with donor BMI, pancreas donor risk index, and donor sex, receiving pasireotide translated into OR 0.49 (95% CI: 0.25-0.96 p = 0.037) for CCI ≥ 33.7. Pasireotide was independently associated with lower postoperative morbidity within 90 days of SPK compared to octreotide.
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Affiliation(s)
- Kaisa Ahopelto
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Akseli Bonsdorff
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juulia Grasberger
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marko Lempinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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10
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Wisel SA, Posselt AM, Szot GL, Nunez M, Santos-Parker K, Gardner JM, Worner G, Roll GR, Syed S, Kelly Y, Ward C, Tavakol M, Johnson K, Masharani U, Stock PG. A Multi-Modal Approach to Islet and Pancreas Transplantation With Calcineurin-Sparing Immunosuppression Maintains Long-Term Insulin Independence in Patients With Type I Diabetes. Transpl Int 2023; 36:11367. [PMID: 37359825 PMCID: PMC10285771 DOI: 10.3389/ti.2023.11367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
Long-term success in beta-cell replacement remains limited by the toxic effects of calcineurin inhibitors (CNI) on beta-cells and renal function. We report a multi-modal approach including islet and pancreas-after-islet (PAI) transplant utilizing calcineurin-sparing immunosuppression. Ten consecutive non-uremic patients with Type 1 diabetes underwent islet transplant with immunosuppression based on belatacept (BELA; n = 5) or efalizumab (EFA; n = 5). Following islet failure, patients were considered for repeat islet infusion and/or PAI transplant. 70% of patients (four EFA, three BELA) maintained insulin independence at 10 years post-islet transplant, including four patients receiving a single islet infusion and three patients undergoing PAI transplant. 60% remain insulin independent at mean follow-up of 13.3 ± 1.1 years, including one patient 9 years after discontinuing all immunosuppression for adverse events, suggesting operational tolerance. All patients who underwent repeat islet transplant experienced graft failure. Overall, patients demonstrated preserved renal function, with a mild decrease in GFR from 76.5 ± 23.1 mL/min to 50.2 ± 27.1 mL/min (p = 0.192). Patients undergoing PAI showed the greatest degree of renal impairment following initiation of CNI (56% ± 18.7% decrease in GFR). In our series, repeat islet transplant is ineffective at maintaining long-term insulin independence. PAI results in durable insulin independence but is associated with impaired renal function secondary to CNI dependence.
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Affiliation(s)
- Steven A. Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Andrew M. Posselt
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Gregory L. Szot
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Miguel Nunez
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Keli Santos-Parker
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - James M. Gardner
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Giulia Worner
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Shareef Syed
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Yvonne Kelly
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Casey Ward
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Medhi Tavakol
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Kristina Johnson
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Umesh Masharani
- Division of Endocrinology, University of California, San Francisco, San Francisco, CA, United States
| | - Peter G. Stock
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
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11
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Stathi D, Johnston T, Hyslop R, Brackenridge A, Karalliedde J. Diabetes technology including automated insulin delivery systems to manage hyperglycemia in a failing pancreatic graft: Case series of people with type 1 diabetes and a pancreas kidney or pancreas-only transplant. J Diabetes Investig 2023. [PMID: 37191402 DOI: 10.1111/jdi.14019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/28/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023] Open
Abstract
We share our experience of using continuous subcutaneous insulin infusion (CSII) therapy and diabetes technology in six people (5 men) with type 1 diabetes (mean duration 36 years), who developed hyperglycemia post-simultaneous kidney/pancreas (n = 5) or pancreas only (n = 1) transplant. All were on immunosuppression and multiple daily injections of insulin prior to CSII. Four people were started on automated insulin delivery, and two people on CSII and intermittently scanned continuous glucose monitoring. With diabetes technology, the median time in range glucose improved from 37% (24-49%) to 56.6% (48-62%), and similarly, glycated hemoglobin fell from 72.7 mmol/mol (72-79 mmol/mol) to 64 mmol/mol (42-67 mmol/mol; P < 0.05 for both) with no concomitant increase in hypoglycemia. Use of diabetes technology improved glycemic parameters in people with type 1 diabetes with failing pancreatic graft function. Early use of such technology should be considered to improve diabetes control in this complex cohort.
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Affiliation(s)
- Dimitra Stathi
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Thomas Johnston
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rebecca Hyslop
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anna Brackenridge
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Janaka Karalliedde
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
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12
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Al-Naseem AO, Attia A, Gonnah AR, Al-Naseem AOAS, Spiers HVM, Gruessner A, Leelarathna L, Thabit H, Augustine T. Pancreas Transplantation Today: Quo Vadis? Eur J Endocrinol 2023; 188:R73-R87. [PMID: 36929837 DOI: 10.1093/ejendo/lvad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 08/23/2022] [Accepted: 01/10/2023] [Indexed: 03/18/2023]
Abstract
Successful pancreas or islet transplantation is currently the only cure for type-1 diabetes mellitus. Since the first pancreas transplant in 1966, there have been various refinements of surgical technique along with improved immunosuppressive regimens, resulting in significantly improved outcomes, with contemporary research into graft monitoring and newer biomarkers, potentially lengthening graft survival rates further. Patients with insulin-dependent diabetes mellitus who are eligible for pancreas or islet transplantation represent a select group, the tip of the iceberg for a significant global diabetes disease burden. In the last fifty years there have been quantum advances in alternative technologies in diabetes therapy, both experimental and translational. Further development and improved access are required to treat the larger proportion of people suffering from diabetes. Emerging stem cell therapy is still experimental whereas alternatives including automated insulin delivery systems, islet cell transplantation are already used in some countries. While automated insulin delivery systems have increased in efficacy, they still do not achieve the near physiological control of blood sugar, which can be achieved by successful pancreas or islet transplantation. This state-of-the-art review provides a summary of pancreas and islet transplantation to its current place in diabetes therapy, along with alternative and future therapies, including the obstacles associated with the dissemination of these new therapies. With the advent of these modern cellular and technological advances, this review addresses the question: are we entering an era where whole organ pancreas transplantation could be replaced entirely by modern technological advances in diabetes therapy?
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Affiliation(s)
| | - Ahmed Attia
- Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Ahmed Reda Gonnah
- School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | - Harry V M Spiers
- Department of Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Angelika Gruessner
- Department of Medicine, Downstate Health Science University, Brooklyn, NY, United States of America
| | - Lalantha Leelarathna
- Manchester Diabetes, Endocrine and Metabolism Centre, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Hood Thabit
- Manchester Diabetes, Endocrine and Metabolism Centre, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Titus Augustine
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust
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13
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Lindner BK, Lakhani SA, Cooper M, Nguyen BM, Vranic G, Yi SY, Abrams P. Evaluation of a multidisciplinary, multimodal pain management protocol following pancreas transplantation. Clin Transplant 2023; 37:e14856. [PMID: 36398867 DOI: 10.1111/ctr.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/30/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients undergoing solid-organ transplantation demonstrate pain arising from both the surgical intervention and pre-existing comorbidities. High levels of opioid use both pre- and post-transplant are associated with unfavorable transplant outcomes. Patient education, multimodal therapy, and discharge planning have all been demonstrated to reduce opioid use after transplant. METHODS This is a single-center, retrospective study analyzing patients before and after implementation of a multimodal, multidisciplinary pain management protocol. Morphine milligram equivalents (MMEs) use during the index transplant hospitalization and the need for opioids at discharge was compared between the pre- and post-protocol groups. RESULTS A total of 52 patients were included in the study, 31 in the pre and 21 in the post-protocol groups. Inpatient MME use was reduced from 135.5 to 67.5 MMEs after protocol implementation. Additionally, the number of patients discharged on opioids following transplant decreased from 90.3% to 47.6%. Pain scores, length of stay (LOS), and return of bowel function was not different between groups. CONCLUSION The implementation of a multimodal, multidisciplinary pain management protocol significantly decreased opioid use during the post-surgical hospitalization and in the 6 months following transplantation. A combination of non-opioid analgesics, patient education, and discharge planning can be beneficial elements in pancreas transplant pain management.
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Affiliation(s)
- Brian K Lindner
- MedStar Georgetown University Hospital, Department of Pharmacy, Washington DC, USA
| | - Shahzia A Lakhani
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington DC, USA
| | - Matthew Cooper
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington DC, USA
| | - Brian M Nguyen
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington DC, USA
| | - Gayle Vranic
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington DC, USA
| | - Soo Y Yi
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington DC, USA
| | - Peter Abrams
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington DC, USA
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14
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Fleetwood VA, Falls C, Ohman J, Aziz A, Stalter L, Leverson G, Welch B, Kaufman DB, Al-Adra DP, Odorico JS. Post-pancreatic transplant enteric leaks: The role of the salvage operation. Am J Transplant 2022; 22:2052-2063. [PMID: 35593379 DOI: 10.1111/ajt.17094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/11/2021] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 01/25/2023]
Abstract
Enteric drainage in pancreas transplantation is complicated by an enteric leak in 5%-8%, frequently necessitating pancreatectomy. Pancreatic salvage outcomes are not well studied. Risk factors for enteric leak were examined and outcomes of attempted graft salvage were compared to immediate pancreatectomy. Pancreas transplants performed between 1995 and 2018 were reviewed. Donor, recipient, and organ variables including demographics, donor type, ischemic time, kidney donor profile index, and pancreas donor risk index were analyzed. Among 1153 patients, 33 experienced enteric leaks (2.9%). Donors of allografts that developed leak were older (37.9y vs. 29.0y, p = .001), had higher KDPI (37% vs. 24%, p < .001), higher pancreas donor risk index (1.83 vs. 1.32, p < .001), and longer cold ischemic time (16.5 vs. 14.8 h, p = .03). Intra-abdominal abscess and higher blood loss decreased the chance of successful salvage. Enteric leak increased 6-month graft loss risk (HR 13.9[CI 8.5-22.9], p < .001). However, 50% (n = 12) of allografts undergoing attempted salvage survived long-term. After 6 months of pancreas graft survival, salvage and non-leak groups had similar 5-year graft survival (82.5% vs. 81.5%) and mortality (90.9% vs. 93.5%). Enteric leaks remain a challenging complication. Pancreatic allograft salvage can be attempted in suitable patients and accomplished in 50% of cases without significantly increased graft failure or mortality risk.
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Affiliation(s)
- Vidya A Fleetwood
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, Missouri, USA.,Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Cody Falls
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jakob Ohman
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Antony Aziz
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lily Stalter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bridget Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David P Al-Adra
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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15
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Li Z, Xiang J, Liu J, Wang L. Race does not predict pancreas graft failure after pancreas transplantation in the Modern Era. Clin Transplant 2021; 36:e14576. [PMID: 34964519 DOI: 10.1111/ctr.14576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 01/03/2021] [Revised: 11/28/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND African-American (AA) has historically been associated with inferior graft survival after pancreas transplantation. However, with the improvement of immunosuppression and surgical technique, we hypothesized that the racial disparity has been neutralized. METHODS We analyzed data from the Scientific Registry of Transplant Recipients (1989-2018). Using Kaplan-Meier estimation and Cox proportional hazards regression, we examined the influence of race on pancreatic graft survival. RESULTS Before 2009, AA recipients had a higher risk of pancreatic graft failure after adjusting for confounding factors (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.08-1.24), but the risks for Hispanic and Asian recipients were both comparable to their Caucasian counterparts. However, the risk of pancreatic graft failure in AA recipients dropped to 1% and was no longer significant since 2009 (HR: 1.01, 95%CI: 0.88-1.16). Interestingly, donor race showed similar results. Furthermore, the concordance statistic of the complete pancreas donor risk index (including donor race) was 0.582, whereas the concordance did not change when donor race was eliminated from the model. CONCLUSIONS AA and other races have shown similar pancreatic graft survival in the modern era. Furthermore, donor racial disparity also seems neutralized; thus, donor race should not be considered as an indicator of pancreatic donor quality. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Zhiwei Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jie Xiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianhua Liu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Li Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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16
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Souki FG, Chadha R, Planinsic R, Zerillo J, Nguyen-Buckley C, Smith N, Mandell MS, Sakai T, Nicolau-Raducu R. Recommendations From the Society for the Advancement of Transplant Anesthesiology Fellowship Committee: Core Competencies and Milestones for the Kidney/Pancreas Component of Abdominal Organ Transplant Anesthesia Fellowship. Semin Cardiothorac Vasc Anesth 2021; 26:15-26. [PMID: 34872395 DOI: 10.1177/10892532211058574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/16/2022]
Abstract
The Society for the Advancement of Transplant Anesthesia (SATA) is dedicated to improving patient care in all facets of transplant anesthesia. The anesthesia fellowship training recommendations for thoracic transplantation (heart and lungs) and part of the abdominal organ transplantation (liver) have been presented in previous publications. The SATA Fellowship Committee has completed the remaining component of abdominal transplant anesthesia (kidney/pancreas) and has assembled core competencies and milestones derived from expert consensus to guide the education and overall preparation of trainees providing care for kidney/pancreas transplant recipients. These recommendations provide a comprehensive approach to pre-operative evaluation, vascular access procedures, advanced hemodynamic monitoring, assessment of coagulation and metabolic abnormalities, operative techniques, and post-operative pain control. As such, this document supplements the current liver/hepatic transplant anesthesia fellowship training programs to include all aspects of "Abdominal Organ Transplant Anesthesia" recommended knowledge.
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Affiliation(s)
- Fouad G Souki
- Department of Anesthesiology, 12235University of Miami, Jackson Memorial Hospital, Miami, FL, USA
| | - Ryan Chadha
- Department of Anesthesiology, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Raymond Planinsic
- Department of Anesthesiology, 6595University of Pittsburgh Medical Center, Pittsburgh, AR, USA
| | - Jeron Zerillo
- Department of Anesthesiology, 5944Mount Sinai Medical Center, New York, NY, USA
| | | | - Natalie Smith
- Department of Anesthesiology, 5944Mount Sinai Medical Center, New York, NY, USA
| | - M Susan Mandell
- Department of Anesthesiology, 129263University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Tetsuro Sakai
- Department of Anesthesiology, 6595University of Pittsburgh Medical Center, Pittsburgh, AR, USA
| | - Ramona Nicolau-Raducu
- Department of Anesthesiology, 12235University of Miami, Jackson Memorial Hospital, Miami, FL, USA
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17
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Parajuli S, Kaufman DB, Djamali A, Welch BM, Sollinger HW, Mandelbrot DA, Odorico JS. Association of human leukocyte antigen mismatches between donor-recipient and donor-donor in pancreas after kidney transplant recipients. Transpl Int 2021; 34:2803-2815. [PMID: 34644422 DOI: 10.1111/tri.14138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 05/08/2021] [Revised: 09/24/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
The effects of HLA mismatching on pancreas outcomes among pancreas after kidney (PAK) recipients are undefined. Outcomes might potentially differ depending on whether there is a mismatch between pancreas donor and recipient (PD-R) or pancreas donor and kidney donor(PD-KD). All primary PAK at our centre were included in this study. Patients were divided into two groups based on the degree of HLA mismatching: low (L-MM) as 0-4 and high (H-MM) as 5-6. We analysed all (N = 73) PAK for PD-R mismatch and the subset of PAK for PD-KD mismatch (N = 71). Comparing PD-R L-MM (n = 39) and H-MM (n = 34) PAKs, we observed no difference in the rate of pancreas graft failure. There was also no difference in the rate of rejection (L-MM 33% vs. H-MM 41%) or the severity of rejection. However, we observed a significantly (P < 0.01) shorter time to acute pancreas rejection in the H-MM group (6.8 ± 8.7 mo) versus the L-MM cohort (29.0 ± 36.2 mo) (P < 0.001). Similar to the PD-R mismatched cohort, we did not observe a detrimental effect of HLA mismatching on graft outcomes in the PD-KD cohort; time to rejection was again shorter in the H-MM subset. In this study, we found no impact of HLA mismatch on either pancreas graft survival or rejection rates, though rejection occurred earlier in high mismatched PAK transplants.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Bridget M Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Hans W Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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18
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Blundell J, Shahrestani S, Lendzion R, Pleass HJ, Hawthorne WJ. Risk Factors for Early Pancreatic Allograft Thrombosis Following Simultaneous Pancreas-Kidney Transplantation: A Systematic Review. Clin Appl Thromb Hemost 2021; 26:1076029620942589. [PMID: 33052066 PMCID: PMC7573738 DOI: 10.1177/1076029620942589] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Simultaneous pancreas-kidney (SPK) transplantation remains the most effective treatment for providing consistent and long-term euglycemia in patients having type 1 diabetes with renal failure. Thrombosis of the pancreatic vasculature continues to contribute significantly to early graft failure and loss. We compared the rate of thrombosis to graft loss and systematically reviewed risk factors impacting early thrombosis of the pancreas allograft following SPK transplantation. We searched the MEDLINE, EMBASE, The Cochrane Library, and PREMEDLINE databases for studies reporting thrombosis following pancreas transplantation. Identified publications were screened for inclusion and synthesized into a data extraction sheet. Sixty-three studies satisfied eligibility criteria: 39 cohort studies, 22 conference abstracts, and 2 meta-analyses. Newcastle-Ottawa Scale appraisal of included studies demonstrated cohort studies of low bias risk; 1127 thrombi were identified in 15 936 deceased donor, whole pancreas transplants, conferring a 7.07% overall thrombosis rate. Thrombosis resulted in pancreatic allograft loss in 83.3% of reported cases. This review has established significant associations between donor and recipient characteristics, procurement and preservation methodology, transplantation technique, postoperative management, and increased risk of early thrombosis in the pancreas allograft. Further studies examining the type of organ preservation fluid, prophylactic heparin protocol, and exocrine drainage method and early thrombosis should also be performed.
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Affiliation(s)
- Jian Blundell
- Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Sara Shahrestani
- Sydney Medical School, University of Sydney, New South Wales, Australia.,Department of Surgery, University of Sydney at Westmead Hospital, New South Wales, Australia
| | - Rebecca Lendzion
- Department of Surgery, University of Sydney at Westmead Hospital, New South Wales, Australia
| | - Henry J Pleass
- Sydney Medical School, University of Sydney, New South Wales, Australia.,Department of Surgery, University of Sydney at Westmead Hospital, New South Wales, Australia
| | - Wayne J Hawthorne
- Sydney Medical School, University of Sydney, New South Wales, Australia.,Department of Surgery, University of Sydney at Westmead Hospital, New South Wales, Australia.,The Centre for Transplant & Renal Research, Westmead Institute for Medical Research, New South Wales, Australia
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19
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Ozturk M, Ozkan O, Laeseke P, Kleedehn MG. Peripancreatic Fluid Collections After Pancreas Transplant: Safety and Efficacy of Percutaneous Drainage. AJR Am J Roentgenol 2021; 217:404-10. [PMID: 34036810 DOI: 10.2214/AJR.20.23059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this study was to evaluate the safety and efficacy of percutaneous drainage of peripancreatic fluid collections after pancreas transplant and to determine factors predicting a successful clinical outcome. MATERIALS AND METHODS. This single-center retrospective study included 28 patients who underwent percutaneous drainage for peripancreatic collections after transplant between January 2008 and December 2018. Clinical success was defined as drainage resulting in resolution of symptoms. Primary clinical success was defined as symptom resolution after the initial drainage procedure, and secondary success was defined as symptom resolution after additional drainage procedures. Operative intervention or death was considered clinical failure. Patient, collection, and procedural factors were assessed for their potential impact on the clinical outcome. RESULTS. Clinical success was achieved in 23 of 28 drainage procedures (82.1%), with primary success in 15 procedures. Of the five patients with failed drainage procedures, three required pancreatectomies, one required surgical washout, and one died from a disseminated infection. The median duration of drainage in the clinical success group was 25 days (range, 3-136 days), and patients with longer drainage periods had more successful outcomes (p = .04). Graft pancreatitis was diagnosed in five patients (17.9%) and was not associated with drainage outcome (p = .21). Collections were positive for bacterial growth in 13 patients (46.4%) and were high in amylase in 12 (42.9%). We observed drainage failure in collections with polymicrobial growth and in the presence of fistulas (p = .05 and p = .07, respectively). Patients with successful outcomes had smaller collection volumes (p = .045). No complications attributed to drainage were encountered. CONCLUSION. Percutaneous drainage is safe and effective for management of peripancreatic fluid collections after pancreas transplant.
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20
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Fridell JA, Bozic MA, Ulrich BJ, Lutz AJ, Powelson JA. Pancreas transplantation for cystic fibrosis: A frequently missed opportunity. Clin Transplant 2021; 35:e14371. [PMID: 34032335 DOI: 10.1111/ctr.14371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
Cystic fibrosis (CF) is an inherited autosomal recessive disorder. Despite optimized therapy, the majority of affected individuals ultimately die of respiratory failure. As patients with CF are living longer, extra-pulmonary manifestations may develop including pancreatic failure, which manifests as exocrine insufficiency, and CF-related diabetes (CFRD). Both of these can be managed through pancreas transplantation. Pancreas transplantation is usually performed in combination with another organ, most often with a kidney transplant for end-stage diabetic nephropathy. In the CF patient population, the two settings where inclusion of a pancreas transplant should be considered would be in combination with a lung transplant for CF pulmonary disease, or in combination with a liver for CF-related liver disease with cirrhosis. This report will discuss this topic in detail, including a review of the literature regarding combinations of lung/pancreas and liver/pancreas transplant.
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Affiliation(s)
- Jonathan A Fridell
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Molly A Bozic
- Department of Pediatric Gastroenterology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Benjamin J Ulrich
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrew J Lutz
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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21
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Weaver L, Parsikia A, Ortiz J. Colorectal Resection in Transplant Centers Benefits Kidney But Not Pancreas Transplant Recipients. Int J Angiol 2021; 30:139-147. [PMID: 34054272 DOI: 10.1055/s-0041-1727137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
As graft and patient survival rates improve, transplant recipients are likely to undergo colorectal surgery in their lifetime. Current literature on the surgical outcomes of colorectal resection in kidney and pancreas transplant recipients is sparse. This investigation identifies areas of surgical risk for kidney, pancreas, and pancreas-kidney transplant recipients undergoing colorectal resection at transplant and teaching centers. Multivariate logistic regression and linear regression tests computed odds ratios (OR) and coefficients of the linear regression using National Inpatient Sample data from 2005 to 2014 to identify differences in mortality, morbidity, length of stay (LOS), and total hospital charges among people with pancreas transplant alone (PTx), kidney transplant alone (KTx), pancreas and kidney transplant (PKTx), and nontransplant (non-Tx) undergoing colorectal resection in transplant and teaching centers. Of the 2,737,454 individuals who underwent colorectal resection, 138 PTx, 3,874 KTx, 130 PKTx, and 2,733,312 non-Tx met the inclusion criteria. Overall KTx, PTx, and PKTx were not more likely to suffer a mortality. However, PTx were more likely to suffer a mortality in transplant and teaching centers. Overall, PTx and PKTx had significantly higher morbidity odds ratios (PTx OR: 2.268, p = 0.002; PKTx OR: 2.578, p < 0.001) along with longer LOS and higher total hospital charges. KTx incurred no increased morbidity risk in transplant centers. Surgeons and transplant recipients should be aware of the increased morbidity and mortality risks when considering colorectal resection at different center types.
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Affiliation(s)
- Lauren Weaver
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Afshin Parsikia
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jorge Ortiz
- Department of Surgery, Albany Medical Center, Albany, New York
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22
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Fehrenbach U, Thiel R, Bady PD, Auer TA, Kahl A, Geisel D, Lopez Hänninen E, Öllinger R, Pratschke J, Gebauer B, Denecke T. CT fluoroscopy-guided pancreas transplant biopsies: a retrospective evaluation of predictors of complications and success rates. Transpl Int 2021; 34:855-864. [PMID: 33604958 DOI: 10.1111/tri.13849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/09/2020] [Accepted: 02/17/2021] [Indexed: 01/03/2023]
Abstract
To identify predictors of biopsy success and complications in CT-guided pancreas transplant (PTX) core biopsy. We retrospectively identified all CT fluoroscopy-guided PTX biopsies performed at our institution (2000-2017) and included 187 biopsies in 99 patients. Potential predictors related to patient characteristics (age, gender, body mass index (BMI), PTX age, PTX volume) and procedure characteristics (biopsy depth, needle size, access path, number of samples, interventionalist's experience) were correlated with biopsy success (sufficient tissue for histologic diagnosis) and the occurrence of complications. Biopsy success (72.2%) was more likely to be obtained in men [+25.3% (10.9, 39.7)] and when the intervention was performed by an experienced interventionalist [+27.2% (8.1, 46.2)]. Complications (5.9%) occurred more frequently in patients with higher PTX age [OR: 1.014 (1.002, 1.026)] and when many (3-4) tissue samples were obtained [+8.7% (-2.3, 19.7)]. Multivariable regression analysis confirmed male gender [OR: 3.741 (1.736, 8.059)] and high experience [OR: 2.923 (1.255, 6.808)] (biopsy success) as well as older PTX age [OR: 1.019 (1.002, 1.035)] and obtaining many samples [OR: 4.880 (1.240, 19.203)] (complications) as independent predictors. Our results suggest that CT-guided PTX biopsy should be performed by an experienced interventionalist to achieve higher success rates, and not more than two tissue samples should be obtained to reduce complications. Caution is in order in patients with older transplants because of higher complication rates.
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Affiliation(s)
- Uli Fehrenbach
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Regina Thiel
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Timo A Auer
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Kahl
- Klinik für Nephrologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Geisel
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Enrique Lopez Hänninen
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Radiologie, Martin-Luther-Krankenhaus, Berlin, Germany
| | - Robert Öllinger
- Chirurgische Klinik, Campus Charité Mitte, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Chirurgische Klinik, Campus Charité Mitte, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bernhard Gebauer
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Timm Denecke
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Radiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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23
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Kovac D, Choe J, Liu E, Scheffert J, Hedvat J, Anamisis A, Salerno D, Lange N, Jennings DL. Immunosuppression considerations in simultaneous organ transplant. Pharmacotherapy 2021; 41:59-76. [PMID: 33325558 DOI: 10.1002/phar.2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/21/2020] [Accepted: 12/01/2020] [Indexed: 12/12/2022]
Abstract
Solid organ transplantation is a life-saving procedure for patients in the end stage of heart, lung, kidney, and liver failure. For patients with more than one failing organ, simultaneous organ transplantation has emerged as a viable treatment option. Immunosuppression strategies and outcomes for simultaneous organ transplant recipients have been reported, but often involve limited populations. Transplanting dual organs poses challenges in terms of balancing immunosuppression with immunologic risk and allograft damage from surgical complications. Furthermore, transplanting certain organs can impose considerations on the management of immunosuppression. For example, liver allografts may confer immunologic privilege and lower rates of rejection of other allografts. This review article evaluates immunosuppression strategies for simultaneous kidney-pancreas, liver-kidney, heart-kidney, heart-liver, heart-lung, lung-liver, and lung-kidney transplants. To date, no comprehensive review exists to address immunosuppressive strategies in simultaneous organ transplant populations. Our review summarizes the available literature and provides evidence-based recommendations regarding immunosuppression strategies in simultaneous organ transplant recipients.
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Affiliation(s)
- Danielle Kovac
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jason Choe
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Esther Liu
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Jenna Scheffert
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Anastasia Anamisis
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Nicholas Lange
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Douglas L Jennings
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA.,Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, New York, USA
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24
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Swensson J, Hill D, Tirkes T, Fridell J, Patel A. Contrast-Enhanced Ultrasound Versus Doppler Ultrasound for Detection of Early Vascular Complications of Pancreas Grafts. AJR Am J Roentgenol 2020; 215:1093-7. [PMID: 32960665 DOI: 10.2214/AJR.20.22858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE. The purpose of this study is to compare conventional duplex ultrasound and contrast-enhanced ultrasound (CEUS) for identifying vascular abnormalities in pancreas allografts in the immediate posttransplant setting. Identification of pancreas allografts at risk of failure may impact patient care because early intervention for vascular insufficiency can lead to graft salvage. MATERIALS AND METHODS. Two radiologists who were blinded to patient outcomes performed a retrospective analysis of the postoperative Doppler ultrasound and CEUS images of 34 pancreas grafts from transplants performed between 2017 and 2019. A total of 28 patients who did not require surgical reexploration were considered the control group. Six patients had surgically proven arterial or venous abnormalities on surgical reexploration. Each radiologist scored grafts as having normal or abnormal vascularity on the basis of image sets obtained using Doppler ultrasound only and CEUS only. Comparisons of both the diagnostic performance of each modality and interobserver agreement were performed. RESULTS. Both readers showed that CEUS had increased sensitivity for detecting vascular abnormalities (83.3% for both readers) compared with Doppler ultrasound (66.7% and 50.0%). For both readers, the specificity of CEUS was similar to that of Doppler imaging (81.6% and 78.9% for reader 1 and reader 2 versus 76.3% and 84.2% for reader 1 and reader 2). For both readers, the negative predictive value of CEUS was higher than that of Doppler ultrasound (96.9% and 96.8% for reader 1 and reader 2 versus 93.5% and 91.4% for reader 1 and reader 2). Interobserver agreement was higher for CEUS than for Doppler ultrasound (κ = 0.54 vs κ = 0.28). CONCLUSION. CEUS may provide radiologists and surgeons with a means of timely and effective evaluation of pancreas graft perfusion after surgery, and it may help identify grafts that could benefit from surgical salvage.
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25
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Dube GK, Husain SA, McCune KR, Sandoval PR, Ratner LE, Cohen DJ. COVID-19 in pancreas transplant recipients. Transpl Infect Dis 2020; 22:e13359. [PMID: 32515076 PMCID: PMC7300444 DOI: 10.1111/tid.13359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/27/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019 (COVID‐19) has become a pandemic since first being described in January 2020. Clinical manifestations in non‐transplant patients range from asymptomatic infection to severe pneumonia with acute respiratory distress syndrome, multiorgan system failure, and death. Limited reports in kidney transplant recipients suggest similar characteristics in that population. We report here the first case series of COVID‐19 infection occurring in pancreas transplant recipients.
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Affiliation(s)
- Geoffrey K Dube
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Kasi R McCune
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - P Rodrigo Sandoval
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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26
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Ryu JH, Ko HJ, Shim JR, Lee TB, Yang KH, Lee JH, Lee HJ, Kim T, Choi BH. Eosinophil-to-monocyte ratio is an excellent predictor of acute cellular rejection in pancreas transplant alone recipients. Clin Transplant 2020; 34:e13785. [PMID: 31957063 DOI: 10.1111/ctr.13785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/20/2019] [Accepted: 01/07/2020] [Indexed: 01/23/2023]
Abstract
Serum pancreatic enzymes (serum amylase and lipase) are sensitive markers for monitoring acute rejection in pancreatic transplant recipients. However, those enzymes are not specific, as their levels are elevated in other conditions. We evaluated the eosinophil-to-monocyte ratio (EMR) in peripheral blood as a biomarker of acute rejection in the clinical setting in recipients of pancreatic transplant alone. We performed 32 cases of pancreatic transplantation alone since 2015. Nine patients were diagnosed with rejection. Serum amylase and lipase levels and eosinophil and monocytes counts were analyzed and compared retrospectively between the non-rejection and rejection groups. The serum eosinophil count, eosinophil fraction of the complete blood count, and serum amylase and lipase levels were significant predictors of rejection according to the receiver operation characteristic (ROC) curve. However, the EMR was the best indicator of rejection based on the ROC curve (area under the curve 0.918, sensitivity 100%, specificity 76.2% at the cutoff value 0.80, P < .001). The combination of EMR and the lipase level had 100% sensitivity and 90.5% specificity. The EMR is a simple and excellent predictor of acute rejection in recipients of pancreatic transplant alone.
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Affiliation(s)
- Je Ho Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyo Jung Ko
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae Ryong Shim
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Tae Beom Lee
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kwang Ho Yang
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jung Hee Lee
- Department of Pathology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun Ji Lee
- Department of Laboratory medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Taeun Kim
- Department of Radiology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Byung Hyun Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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27
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Rofaiel G, Pan G, Martinez E, Kim R, Campsen J. Two-stage Enteric Exclusion to Salvage a Pancreas Transplant After an Early Post-transplant Leak. Cureus 2019; 11:e5379. [PMID: 31616610 PMCID: PMC6786838 DOI: 10.7759/cureus.5379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Early technical complications after pancreas transplantation are almost always unsalvageable. The two most common complications are vascular thrombosis and duodenal anastomotic leaks. We present a case of a duodenal stump leak that led to a large abscess and severe sepsis. The pancreas was salvaged by repairing the leak and creating a proximal diverting ileostomy. Several months later, the ileostomy was reversed. This was done by creating a defunctionalized Roux limb to exclude the pancreas. The patient healed well and continued to enjoy excellent glucose control.
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Affiliation(s)
- George Rofaiel
- Surgery, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, USA
| | - Gilbert Pan
- Surgery, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, USA
| | - Eryberto Martinez
- Surgery, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, USA
| | - Robin Kim
- Surgery, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, USA
| | - Jeffrey Campsen
- Surgery, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, USA
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28
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Haidar G, Green M. Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13595. [PMID: 31102546 DOI: 10.1111/ctr.13595] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 05/06/2019] [Accepted: 05/11/2019] [Indexed: 02/06/2023]
Abstract
This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.
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Affiliation(s)
- Ghady Haidar
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Green
- Departments of Pediatrics, Surgery & Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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29
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Rostambeigi N, Shrestha P, Dunn TB, Golzarian J, Khoshnoodi P, Rosenberg M, Talaie R. Recurrent Ectopic Variceal Bleed After Pancreas Transplantation With No Portal Hypertension: Case Report and Outcomes of Endovascular Onyx Embolization. Vasc Endovascular Surg 2019; 53:415-419. [PMID: 30929610 DOI: 10.1177/1538574419839255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 57-year-old male presented with intermittent gastrointestinal bleeding (GIB) 1 year after a successful simultaneous pancreas and kidney transplant. No source could be found after 5 tagged red blood cell studies, 3 computed tomographies (CTs), 7 endoscopies, and 4 catheter angiograms. Review of CTs showed pathologically enlarged superior mesenteric vein branches near a jejunal segment near pancreas graft. Transhepatic superior mesenteric venogram showed varicosities near jejunum, which were obliterated with ethylene vinyl alcohol (Onyx). Follow-up CTs confirmed complete obliteration, but he had more GIBs and eventually underwent native jejunal and donor duodenal resection. He has remained GIB-free for 12 months.
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Affiliation(s)
- Nassir Rostambeigi
- 1 Department of Radiology, Division of Interventional Radiology, West Virginia University, Morgantown, WV, USA.,2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Prashant Shrestha
- 2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Ty B Dunn
- 3 Department of Surgery, Division of Transplantation, University of Pennsylvania, Philadelphia, PA, USA
| | - Jafar Golzarian
- 2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Pooria Khoshnoodi
- 4 Department of Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Michael Rosenberg
- 2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Reza Talaie
- 2 Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, MN, USA
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30
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Klasek R, Kuten SA, Patel SJ, Graviss EA, Nguyen DT, Hobeika MJ, Gaber OA, Podder H, Knight RJ. Unexplained fever after pancreas transplantation. Clin Transplant 2018; 32:e13351. [PMID: 30019349 DOI: 10.1111/ctr.13351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/09/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fever occurs frequently early after pancreas transplant, however, the exact cause is often undetermined. Limited data are available on pancreas recipients experiencing unexplained, noninfectious fever. This study aims to characterize unexplained fever (UF) in pancreas recipients and its effect on patient and graft outcomes. METHODS We performed a retrospective cohort study of UF among consecutive pancreas or simultaneous pancreas-kidney transplant recipients from 1 January 2011 to 31 August 2015. Classification of UF was based on the absence of positive cultures, radiologic findings, and other diagnostic features of infection or rejection. RESULTS Twenty-three of 92 (25%) patients experienced UF. The UF episode first occurred at a mean of 31 ± 17 days post-transplant and accounted for 34 admissions with an average length of stay of 5.1 ± 3.4 days. Intravenous corticosteroid was administered following confirmation of negative diagnostic tests in 77% of patients, with fever resolution occurring in all. No differences were seen in rates of biopsy-proven rejection, graft loss, death, or documented infections compared to UF-free patients during the first-year post-transplant. CONCLUSION UF is a common cause for readmission following pancreas transplantation. While the etiology of UF remains difficult to identify, UF occurrence was not associated with adverse outcomes during the first-year post-transplant.
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Affiliation(s)
- Robin Klasek
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Samantha A Kuten
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Samir J Patel
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Mark J Hobeika
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - Osama A Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - Hemangshu Podder
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - Richard J Knight
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
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31
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Descourouez JL, Jorgenson MR, Menninga N, Leverson G, Odorico J, Redfield R. Impact of intensive dosing of mycophenolate on pancreas allograft survival. Clin Transplant 2018; 32:e13293. [PMID: 29791046 DOI: 10.1111/ctr.13293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the effect of mycophenolate (mycophenolic acid, MPA) dose on pancreas allograft survival following simultaneous pancreas kidney (SPK) transplant. METHODS This was an observational study of adult SPK recipients transplanted between 1/1/2002 and 6/30/2015. Recipients were divided into cohorts based on MPA dose at discharge: high dose (HD), 1000 mg three times daily mycophenolate mofetil (MMF) and standard dose (SD), 1000 mg twice daily MMF. Primary outcome was pancreas allograft survival. Secondary endpoints included kidney allograft survival, pancreas allograft rejection, infection, time to initial dose decrease, and patient survival (PS). RESULTS In all, 453 patients met inclusion criteria: 324 in HD-MPA group and 129 in SD-MPA group. HD-MPA patients had higher rates of pancreas graft survival (P = .003). There were no differences in rates of pancreas allograft rejection (P = .8), kidney graft survival (P = .15), overall infection (P = .4), overall malignancy (P = .93), time to first dose reduction (P = .35), or patient survival (P = .3). In a multivariable analysis adjusted for differences between groups and known confounders, dosing group continued to significantly affect incidence of pancreas allograft failure (P = .02). CONCLUSIONS HD-MPA significantly impacted pancreas allograft survival in SPK recipients independent of graft rejection. Further studies are warranted to investigate the etiology of this finding and determine the optimal duration of HD-MPA associated with positive graft outcomes.
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Affiliation(s)
- Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Nathan Menninga
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Glen Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jon Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Robert Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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32
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Nacif LS, Rocha-Santos V, Claro LC, Vintimilla A, Ferreira LA, Arantes RM, Pinheiro RS, Andraus W, Alves VA, D’Albuquerque LC. Liver biopsy may facilitate pancreatic graft evaluation: Positive association between liver steatosis and pancreatic graft adipose infiltration. Clinics (Sao Paulo) 2018; 73:e49. [PMID: 29846412 PMCID: PMC5960076 DOI: 10.6061/clinics/2018/e49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 12/11/2017] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES The number of pancreatic transplants has decreased in recent years. Pancreatic grafts have been underutilized compared to other solid grafts. One cause of discard is the macroscopic appearance of the pancreas, especially the presence of fatty infiltration. The current research is aimed at understanding any graft-related association between fatty tissue infiltration of the pancreas and liver steatosis. METHODS From August 2013 to August 2014, a prospective cross-sectional clinical study using data from 54 multiple deceased donor organs was performed. RESULTS Micro- and macroscopic liver steatosis were significantly correlated with the donor body mass index ([BMI]; p=0.029 and p=0.006, respectively). Positive gamma associations between pancreatic and liver macroscopic and microscopic findings (0.98; confidence interval [CI]: 0.95-1 and 0.52; CI 0.04-1, respectively) were observed. Furthermore, comparisons of liver microscopy findings showed significant differences between severe versus absent (p<0.001), severe versus mild (p<0.001), and severe versus moderate classifications (p<0.001). The area under the receiver operating curve was 0.94 for the diagnosis of steatosis by BMI evaluation using a cut-off BMI of 27.5 kg/m2, which yielded 100% sensitivity, 87% specificity, and 100% negative predictive value. CONCLUSIONS We observed a positive association of macroscopic and microscopic histopathological findings in steatotic livers with adipose infiltration of pancreatic grafts.
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Affiliation(s)
- Lucas S. Nacif
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Vinicius Rocha-Santos
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Laura C.L. Claro
- Departamento de Patologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Agustin Vintimilla
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Leandro A. Ferreira
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rubens M. Arantes
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rafael S. Pinheiro
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Wellington Andraus
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Venancio A.F. Alves
- Departamento de Patologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Carneiro D’Albuquerque
- Divisao de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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33
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Rudolph EN, Dunn TB, Sutherland DER, Kandaswamy R, Finger EB. Optimizing outcomes in pancreas transplantation: Impact of organ preservation time. Clin Transplant 2017. [PMID: 28636074 DOI: 10.1111/ctr.13035] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 12/14/2022]
Abstract
Recent changes to pancreas graft allocation policy have increased the number of organs available for regional and distant sharing, which results in a corresponding increase in preservation time. We sought to systematically assess the impact of cold ischemia time (CIT) on outcomes post-transplant. A retrospective review of 1253 pancreas transplants performed at a single transplant center was performed to correlate CIT to transplant outcomes. The rate of technical failure (TF) increased with 20+ hours of CIT, with a 2.7-fold to 6.2-fold increased rate of TF for pancreas after kidney (PAK), simultaneous pancreas and kidney (SPK), and pancreas transplants overall. Long-term graft survival was best with <12 hours of CIT; graft failure increased 1.2-fold to 1.4-fold with 12-24 hours of CIT and 2.2-fold with 24+ hours. CIT had less influence on the pancreas transplant alone category than either SPK or PAK and had markedly more influence on grafts from older (age >25 years) and overweight (body mass index >25) donors. In the final analysis, grafts with <12 hours of CIT performed the best overall, and strategies that reduce CIT (such as early allocation, pre-recovery cross-matching, and chartered flights for organs) should be considered whenever possible.
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Affiliation(s)
- Ehren N Rudolph
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Ty B Dunn
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - David E R Sutherland
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Raja Kandaswamy
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Erik B Finger
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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34
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Ryu JH, Lee TB, Park YM, Yang KH, Chu CW, Lee JH, Choi BH. Culture-negative fever after pancreas transplantation. Transpl Infect Dis 2016; 19. [PMID: 27886427 DOI: 10.1111/tid.12642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/12/2016] [Accepted: 10/23/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Je Ho Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Tae Beom Lee
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Young Mok Park
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Kwang Ho Yang
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Chong Woo Chu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jung Hee Lee
- Department of Pathology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Byung Hyun Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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35
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Mittal S, Lee FJ, Bradbury L, Collett D, Reddy S, Sinha S, Sharples E, Ploeg RJ, Friend PJ, Vaidya A. Validation of the Pancreas Donor Risk Index for use in a UK population. Transpl Int 2016; 28:1028-33. [PMID: 25789920 DOI: 10.1111/tri.12563] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [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: 01/05/2015] [Revised: 01/22/2015] [Accepted: 03/10/2015] [Indexed: 01/07/2023]
Abstract
Pancreas graft failure rates remain substantial. The PDRI can be used at the time of organ offering, to predict one-year graft survival. This study aimed to validate the PDRI for a UK population. Data for 1021 pancreas transplants were retrieved from a national database for all pancreas transplants. Cases were categorized by PDRI quartile and compared for death-censored graft survival. Significant differences were observed between the UK and US cohorts. The PDRI accurately discriminated graft survival for SPK and was associated with a hazard ratio of 1.52 (P = 0.009) in this group. However, in the PTA and PAK groups, no association between PDRI quartile and graft survival was observed. This is the largest study to validate the PDRI in a European cohort and has shown for the first time that the PDRI can be used as a tool to predict graft survival in SPK transplantation, but not PTA or PAK transplantation.
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Affiliation(s)
- Shruti Mittal
- Oxford Transplant Centre, Oxford University Hospital NHS Trust, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Fang Jann Lee
- Oxford Transplant Centre, Oxford University Hospital NHS Trust, Oxford, UK
| | | | | | - Srikanth Reddy
- Oxford Transplant Centre, Oxford University Hospital NHS Trust, Oxford, UK
| | - Sanjay Sinha
- Oxford Transplant Centre, Oxford University Hospital NHS Trust, Oxford, UK
| | - Edward Sharples
- Oxford Transplant Centre, Oxford University Hospital NHS Trust, Oxford, UK
| | - Rutger J Ploeg
- Oxford Transplant Centre, Oxford University Hospital NHS Trust, Oxford, UK
| | - Peter J Friend
- Oxford Transplant Centre, Oxford University Hospital NHS Trust, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, Oxford, UK
| | - Anil Vaidya
- Oxford Transplant Centre, Oxford University Hospital NHS Trust, Oxford, UK
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36
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Echenique IA, Stosor V, Gallon L, Kaufman D, Qi C, Zembower TR. Prolonged norovirus infection after pancreas transplantation: a case report and review of chronic norovirus. Transpl Infect Dis 2015; 18:98-104. [PMID: 26460906 DOI: 10.1111/tid.12472] [Citation(s) in RCA: 25] [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: 07/11/2015] [Revised: 08/27/2015] [Accepted: 09/12/2015] [Indexed: 02/04/2023]
Abstract
Norovirus is a major cause of self-limited gastroenteritis worldwide. Prevention and treatment are thwarted by rapid viral evolution, and thus supportive care remains the mainstay of therapy. Chronic infection in immunocompromised hosts is increasingly described. We report a case of norovirus infection lasting 2543 days in a pancreas transplant recipient. Serial fecal specimens were obtained, from which a map of genetic relatedness was derived. The clinical course was complicated by renal failure that progressed to end-stage renal disease. Minimization of immunosuppression was associated with resolution of the infection. Subsequently, the patient experienced a suspected allograft rejection that did not compromise pancreas function. The patient later underwent living-related renal transplantation without recurrence of enteritis.
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Affiliation(s)
- I A Echenique
- Division of Infectious Disease, Cleveland Clinic Florida, Weston, Florida, USA
| | - V Stosor
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - L Gallon
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - D Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - C Qi
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Clinical Microbiology Laboratory, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - T R Zembower
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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37
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Mujtaba MA, Fridell J, Book B, Faiz S, Sharfuddin A, Wiebke E, Rigby M, Taber T. Re-exposure to beta cell autoantigens in pancreatic allograft recipients with preexisting beta cell autoantibodies. Clin Transplant 2015; 29:991-6. [PMID: 26289931 DOI: 10.1111/ctr.12619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2015] [Indexed: 11/28/2022]
Abstract
Re-exposure to beta cell autoantigens and its relevance in the presence of donor-specific antibodies (DSA) in pancreatic allograft recipients is not well known. Thirty-three patients requiring a pancreas transplant were enrolled in an IRB approved study. They underwent prospective monitoring for DSA and beta cell autoantibody (BCAA) levels to GAD65, insulinoma-associated antigen 2 (IA-2), insulin (micro-IAA [mIAA]), and islet-specific zinc transporter isoform-8 (ZnT8). Twenty-five (75.7%) had pre-transplant BCAA. Twenty had a single antibody (mIAA n = 15, GAD65 n = 5); five had two or more BCAA (GAD65 + mIAA n = 2, GAD65 + mIAA+IA-2 n = 2, GA65 + mIAA+IA-2 + ZnT8 = 1). No changes in GAD65 (p > 0.29), IA-2 (>0.16), and ZnT8 (p > 0.07) were observed between pre-transplant and post-transplant at 6 or 12 months. A decrease in mIAA from pre- to post-6 months (p < 0.0001), 12 months (p < 0.0001), and from post-6 to post-12 months (p = 0.0002) was seen. No new BCAA was observed at one yr. Seven (21.0%) developed de novo DSA. The incidence of DSA was 24% in patients with BCAA vs. 25% in patients without BCAA (p = 0.69). Pancreatic allograft function of patients with vs. without BCAA, and with and without BCAA + DSA was comparable until last follow-up (three yr). Re-exposure to beta cell autoantigens by pancreas transplant may not lead to increased levels or development of new BCAA or pancreatic allograft dysfunction.
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Affiliation(s)
- Muhammad Ahmad Mujtaba
- Division of Nephrology/Transplant, Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jonathan Fridell
- Division of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benita Book
- Transplant Immunology Lab, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sara Faiz
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Asif Sharfuddin
- Division of Nephrology/Transplant, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric Wiebke
- Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark Rigby
- Transplant Immunology Lab, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Taber
- Division of Nephrology/Transplant, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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38
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Abstract
Pancreatic transplantation, performed alone or in conjunction with kidney transplantation, is an effective treatment for advanced type I diabetes mellitus and select patients with type II diabetes mellitus. Following advancements in surgical technique, postoperative management, and immunosuppression, pancreatic transplantation has significantly improved the length and quality of life for patients suffering from pancreatic dysfunction. While computed tomography (CT) and magnetic resonance imaging (MRI) have more limited utility, ultrasound is the preferred initial imaging modality to evaluate the transplanted pancreas; gray-scale assesses the parenchyma and fluid collections, while Doppler interrogation assesses vascular flow and viability. Ultrasound is also useful to guide percutaneous interventions for the transplanted pancreas. With knowledge of the surgical anatomy and common complications, the abdominal radiologist plays a central role in the perioperative and postoperative evaluation of the transplanted pancreas.
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Affiliation(s)
- Matthew T Heller
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Puneet Bhargava
- Department of Radiology, University of Washington Harborview Medical Center, Seattle, Washington, USA
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39
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Mittal S, Page SL, Friend PJ, Sharples EJ, Fuggle SV. De novo donor-specific HLA antibodies: biomarkers of pancreas transplant failure. Am J Transplant 2014; 14:1664-71. [PMID: 24866735 DOI: 10.1111/ajt.12750] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [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: 11/05/2013] [Revised: 03/18/2014] [Accepted: 03/19/2014] [Indexed: 01/25/2023]
Abstract
This study assesses the role of posttransplant HLA antibody monitoring in the surveillance of pancreas transplant recipients. Four hundred thirty-three pancreas transplants were performed at the Oxford Transplant Centre 2006-2011 (317 simultaneous pancreas kidney [SPK] and 116 isolated pancreas [IP]). HLA antibody monitoring was performed at 0, 6 and 12 months and annually and during clinical events. There was no association between pancreas graft failure and recipient or donor characteristics. Posttransplant antibody status, available for 354 (81.8%) of recipients, demonstrated that 141 (39.8%) developed de novo HLA antibodies, of which 52 (36.9%) were de novo donor-specific HLA antibodies (DSA) (34 SPK, 18 IP). The development of antibodies to donor HLA, but not to nondonor HLA, was significantly associated with poorer graft outcomes, with 1- and 3-year graft survival inferior in SPK recipients (85.2% vs. 93.5%; 71.8% vs. 90.3%, respectively; log-rank p = 0.002), and particularly in IP recipients (50.0% vs. 82.9%; 16.7 vs. 79.4%, respectively; log-rank p = 0.001). In a multivariate analysis, development of de novo DSA emerged as a strong independent predictor of pancreas graft failure (hazard ratio 4.66, p < 0.001). This is the largest study to examine de novo HLA antibodies following pancreas transplantation and clearly defines a high-risk group in need of specific intervention.
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Affiliation(s)
- S Mittal
- Oxford Transplant Centre, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
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40
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Mittal S, Page S, Chen M, Procter J, Gilbert J, Sharples E, Friend P, Fuggle S. Vessel rejection secondary to human leucocyte antigen antibodies directed against the arterial conduit following pancreas transplantation from a separate donor. Transpl Int 2014; 27:e58-62. [PMID: 24617346 DOI: 10.1111/tri.12308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 02/20/2014] [Revised: 02/21/2014] [Accepted: 03/05/2014] [Indexed: 12/17/2022]
Abstract
Whole-organ pancreas transplantation is typically carried out using a Y-graft derived from the donor iliac vessels. We describe a case in which a 31-year-old male underwent a simultaneous pancreas-kidney transplant, but in which vessels from a different donor were used for the arterial anastomosis of the pancreas graft. Although initially there was good function, 18 months post-transplant the patient was admitted with diabetic ketoacidosis secondary to pancreas graft failure. Radiological investigations revealed complete occlusion of the vascular Y-graft, and laboratory investigations demonstrated donor-specific human leucocyte antigen (HLA) antibodies directed against HLA mismatches of the vessel donor. This case highlights the risks of using allogeneic vascular material for surgical anastomoses.
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Affiliation(s)
- Shruti Mittal
- Oxford Transplant Centre, Oxford University Hospitals NHS Trust, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
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