A Center-Based Approach to a Transplant Employment Program

The return to work after transplantation has been actively discussed in the transplant community for years. However, despite the desire for transplant practitioners to have recipients return to being healthy, contributing members of society as well as return to work, practitioners often passively support the sick role. We discovered that patients who are returning to work after transplantation may have been out of the work force for several years, and require assistance that we as healthcare providers were unable or untrained to provide. An employment specialist was added to the transplant staff and became a vital part of our attempts to create a proactive employment atmosphere and enhance our patients' quality of life. Adding an advocate for employment in our center has also facilitated the shift in our thinking and approach to care from the sick role to one of rehabilitation and from reactive to proactive. This change in attitude has assisted in empowering our recipients to feel as if they can truly resume a normal life.

Adipokines in type 1 diabetes after successful pancreas transplantation: normal visfatin and retinol-binding-protein-4, but increased total adiponectin fasting concentrations

OBJECTIVE

In type 1 diabetes mellitus (T1DM), the release of many hormones, not only from beta-cells, but also from adipocytes (adipokines) may be altered. After successful pancreas-kidney-transplantation (PKTx), T1DM patients can revert to a nondiabetic metabolism, but it is unclear whether alterations of adipokines are still present after PKTx.

DESIGN, PATIENTS AND MEASUREMENTS

Concentrations of adipokines [visfatin, retinol-binding protein-4 (RBP-4), adiponectin, high molecular weight (HMW) adiponectin] were measured at fasting in 10 PKTx and in 19 T1DM. Nondiabetic healthy controls (CON, n = 9) and six nondiabetic patients after kidney transplantation (KTx) were examined as control groups. In PKTx, KTx and CON, indices of insulin sensitivity (OGIS) and beta cell function (adaptation index, AI) were calculated from 75 g oral glucose tolerance test (OGTT) data.

RESULTS

Fasting serum visfatin (T1DM: 56 +/- 4 microg/l, PKTx: 42 +/- 6 microg/l, KTx: 39 +/- 3 microg/l, CON: 40 +/- 3 microg/l) and RBP-4 (T1DM: 490 +/- 26 microg/l, PKTx: 346 +/- 39 microg/l, KTx: 401 +/- 13 microg/l, CON: 359 +/- 36 microg/l) was increased by 40% and 36%, respectively (each P < 0.03) in T1DM only. Levels were positively correlated with HbA1c in all subjects (visfatin: r = 0.43, P < 0.004; RBP-4: r = 0.46, P < 0.03). Fasting plasma adiponectin was 80% higher in T1DM and in PKTx (T1DM: 18 +/- 2 mg/l, PKTx: 18 +/- 3 mg/l, KTx: 12 +/- 3 mg/l, CON: 10 +/- 1 mg/l; P < 0.04) and was positively correlated with diabetes duration (r = 0.37, P < 0.02). HMW/total adiponectin ratio was increased in T1DM (P < 0.02). PKTx displayed a normoglycaemic metabolism as insulin sensitive as CON, but AI was lower than in CON and KT (P < 0.01).

CONCLUSIONS

T1DM after successful PKTx show normal fasting visfatin and RBP-4 levels and HMW-adiponectin/adiponectin-ratio, which are elevated in T1DM, whereas total adiponectin levels are similarly increased in T1DM and PKTx patients.

[Simultaneous pancreas-kidney transplantation. First cases in Chile]

We report two insulin dependent diabetic patients with a past history of 21 and 30 years complicated with retinopathy, neuropathy and nephropathy with arterial hypertension and kidney failure. Simultaneous pancreas-kidney transplantation was done 8 and 18 months after starting hemodialysis, performing a double intraperitoneal implant with pancreato-duodeno-vesical anastomosis and contralateral kidney grafting with uretero vesical anastomosis using antireflux techniques. In the second case, a second kidney transplant from the same donor was needed, due to a thrombosis of renal vein. There was one rejection episode in each case but renal or pancreatic function was not impaired. Other observed complications were metabolic acidosis and hyperkalemia due to urine loss of bicarbonate, moderate arterial hypertension and bacterial and fungal infections. There was a graft dysfunction due to the association of vancomycin and cyclosporin. In conclusion, in the two presented patients, simultaneous pancreas-kidney transplantations were successful and they remain free of insulin or dialytic therapy 4 and 9 months after the operation.

Practical reduction of transplantation costs. Use of commercial transportation instead of charter aircraft for sharing pancreas grafts

OBJECTIVE

To demonstrate cost savings in pancreas transplantation through use of commercial organ transportation.

DESIGN

Retrospective study.

SETTING

Independent Organ Procurement Organization, Denver, Colo.

SUBJECTS

Forty-three consecutive pancreas grafts recovered by Colorado transplantation surgeons and transported via charter aircraft (53.4%) or commercial airlines (46.6%) to transplantation centers outside Colorado.

MEASUREMENTS

Actuarial graft survival at 1 year was calculated. Transportation costs were also obtained.

MAIN RESULTS

Transportation of organs via charter aircraft cost an average of $3658.37 compared with an average of $102.40 for commercial airline transportation (average cost difference, $3555.97). Graft survival was 73.9% for chartered grafts vs 80.0% for commercially shipped grafts. Mean preservation times were 13 hours 54 minutes for chartered grafts vs 17 hours 50 minutes for commercial transportation.

CONCLUSION

Our data demonstrated a significant cost savings when pancreas grafts were transported via commercial airlines instead of chartered aircraft. These cost savings were obtained without negative sequelae in clinical outcome, encouraging widespread use of commercial airlines for transporting shared pancreas grafts.

Quality of life of pancreas transplant recipients

The quality of life outcome of 131 pancreas transplant recipients who were 1 to 11 years post-transplant were studied. Patients with a functioning pancreas graft (n = 65) described their current quality of life and rated their health significantly more favourably than those with non-functioning grafts (n = 66). For example, of those patients with a functioning pancreas graft, 68% expressed overall satisfaction with their life, 89% felt healthier since their transplant, and 78% reported that they could care for themselves and their routine daily activities. In contrast, of those patients without a functioning graft, only 48% expressed overall satisfaction with life (p less than 0.01), only 25% felt healthier since their transplant (p less than 0.001), and only 56% indicated they could care for themselves and their daily activities (p less than 0.001). Regardless of graft function, the majority of patients were comfortable with their decision to have the transplant, and most of the patients with pancreas graft function reported that they would have another transplant if their graft failed. While successful pancreas transplantation may not elevate all diabetic patients to the level of health and function of the general population, these patients report a significantly better quality of life than do those patients who remain diabetic.

Rehabilitation and quality of life in diabetic patients after successful pancreas-kidney transplantation

Twenty-seven Type I diabetic patients in end-stage renal failure were followed after combined pancreas-kidney transplantation. All patients received duct-occluded segmental pancreas grafts. Clinical progression of extrarenal diabetic complications was studied in 11 patients with long-term functioning pancreatic and renal transplants (Group 1), and in 16 patients who had lost pancreatic graft function, but retained renal graft function (Group 2). Pretransplant, extrarenal diabetic complications were equally distributed in the two groups. In the follow-up period, however, the progress of these complications was less severe in patients with functioning pancreatic transplants. No differences were found between the groups concerning rehabilitation, working capacity, need of help or hospital admittance. It is suggested that pancreas transplantation performed in an earlier stage of diabetes before serious complications have developed, would probably improve rehabilitation and quality of life in these patients.