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American Journal of Transplantation :... Mar 2019Simultaneous pancreas and kidney transplantation (SPKT) is an effective treatment option for patients with type 1 diabetes and end stage renal disease. Increasing...
Simultaneous pancreas and kidney transplantation (SPKT) is an effective treatment option for patients with type 1 diabetes and end stage renal disease. Increasing demands for organs for transplantation coupled with a rise in age and size of adult donors has led to greater utilization of pediatric donors, and with good outcomes. Nonetheless, there remains reticence among transplant surgeons to transplant pancreases from small pediatric donors despite the optimal characteristics and macroscopic features of the younger pancreas. We report a successful case of SPKT from a small pediatric donor and explore the aspects of potential concern that might have led some clinicians to decline these organs. We also discuss the measures taken to overcome potential obstacles to successful transplantation from this donor source, and the rationale behind them.
Topics: Adult; Child, Preschool; Death; Diabetes Mellitus, Type 1; Female; Graft Survival; Humans; Kidney Transplantation; Pancreas Transplantation; Tissue Donors; Tissue and Organ Procurement; Treatment Outcome
PubMed: 30063123
DOI: 10.1111/ajt.15044 -
American Journal of Transplantation :... Nov 2005While pancreas transplantation has evolved within two decades from a frustrating and poorly-accepted therapeutic option to a highly successful procedure, the respective... (Comparative Study)
Comparative Study Review
While pancreas transplantation has evolved within two decades from a frustrating and poorly-accepted therapeutic option to a highly successful procedure, the respective benefits of the successive surgical and immunosuppressive developments have remained unclear. The aim of this study was to determine using an evidence-based methodology, which novel approaches have contributed to the current results and whether pancreas transplantation is cost-effective. Out of 2481 articles, 102 analyzed either surgical or immunosuppressive aspects of pancreas transplantation. Urological complications were more frequent in bladder over enteric drainage (range: 62-63% vs. 12-20%, p = 0.0001), but without significant difference in patient or graft survival. Portal drainage was associated with a trend toward fewer complications and better hyperinsulinemia control over systemic drainage in retrospective studies. Immunosuppression combining induction therapy, a calcineurin inhibitor, mycophenolate mophetil (MMF) and corticosteroids were associated with a 40% decreased incidence of rejection (p = 0.01) and an increase in graft survival above 90% at 1 year (p < 0.05). Pancreas transplantation is highly cost-effective compared to conservative alternatives. We conclude that despite a paucity of large studies, enteric drainage should be recommended but the benefits of portal venous drainage remain debated. Quadruple immunosuppression protocols including induction therapy should be the standard regimen.
Topics: Evidence-Based Medicine; Humans; Immunosuppression Therapy; Islets of Langerhans Transplantation; Pancreas Transplantation; Treatment Outcome
PubMed: 16212628
DOI: 10.1111/j.1600-6143.2005.01069.x -
American Journal of Transplantation :... Feb 2006This study compared the effects of using two T-cell depleting antibodies, alemtuzumab (anti-CD 52, Campath-1H) and rabbit antithymocyte globulin (Thymoglobulin), as...
Alemtuzumab induction and prednisone-free maintenance immunotherapy in simultaneous pancreas-kidney transplantation comparison with rabbit antithymocyte globulin induction - long-term results.
This study compared the effects of using two T-cell depleting antibodies, alemtuzumab (anti-CD 52, Campath-1H) and rabbit antithymocyte globulin (Thymoglobulin), as induction immunosuppression for recipients of simultaneous pancreas-kidney transplantation given a prednisone-free maintenance regimen. We used a single-center, nonrandomised, retrospective, sequential study design to evaluate the efficacy and safety of alemtuzumab (n = 50) or antithymocyte globulin (n = 38) induction in combination with a prednisone-free, tacrolimus/sirolimus-based immunosuppression protocol. Kaplan-Meier analyses of long-term patient and graft survivals and rejection rates were determined according to induction agent. Secondary endpoints included the quality of renal allograft function, incidence of infectious and malignant complications, and cost considerations. Overall long-term patient and graft survival rates did not significantly differ between patients treated with alemtuzumab and antithymocyte globulin. Rejection rates were also nearly equivalent at 1 and 2 years. Viral infectious complications were statistically significantly lower in the alemtuzumab group. The cost of alemtuzumab induction was lower than antithymocyte globulin. Alemtuzumab induction followed by steroid-free maintenance therapy with a tacrolimus/sirolimus-based immunosuppression regimen provided an effective, safe and cost-conscious approach to SPK transplantation.
Topics: Acute Disease; Adult; Alemtuzumab; Animals; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Antibodies, Neoplasm; Antilymphocyte Serum; Diabetes Mellitus, Type 1; Female; Graft Rejection; Graft Survival; Humans; Immunosuppressive Agents; Immunotherapy; Kidney Failure, Chronic; Kidney Transplantation; Male; Middle Aged; Pancreas Transplantation; Peritoneal Dialysis; Prednisone; Rabbits; Renal Dialysis; Retrospective Studies; Survival Analysis
PubMed: 16426317
DOI: 10.1111/j.1600-6143.2005.01166.x -
American Journal of Transplantation :... Jun 2022Pancreas transplantation has an identity crisis and is at a crossroads. Although outcomes continue to improve in each successive era, the number of pancreas transplants...
Pancreas transplantation has an identity crisis and is at a crossroads. Although outcomes continue to improve in each successive era, the number of pancreas transplants performed annually in the United States has been static for several years in spite of increasing numbers of deceased donors. For most practitioners who manage diabetes, pancreas transplantation is considered an extreme measure to control diabetes. With expanded recipient selection (primarily simultaneous pancreas-kidney transplantation) in patients who are older, have a higher BMI, are minorities, or who have a type 2 diabetes phenotype, the controversy regarding type of diabetes detracts from the success of intervention. The absence of a clear and precise definition of pancreas graft failure, particularly one that lacks a measure of glycemic control, inhibits wider application of pancreas transplantation with respect to reporting long-term outcomes, comparing this treatment to alternative therapies, developing listing and allocation policy, and having a better understanding of the patient perspective. It has been suggested that the definition of pancreas graft failure should differ depending on the type of pretransplant diabetes. In this commentary, we discuss current challenges regarding the development of a uniform definition of pancreas graft failure and propose a potential solution to this vexing problem.
Topics: Diabetes Mellitus, Type 2; Graft Survival; Humans; Pancreas Transplantation; Pancreatic Diseases; Postoperative Complications; Tissue Donors; United States
PubMed: 35175669
DOI: 10.1111/ajt.17003 -
Transplantation Jun 2020The first simultaneous pancreas and kidney (SPK) transplant was performed in 1966. Early procedures were associated with significant morbidity and mortality and were... (Observational Study)
Observational Study
BACKGROUND
The first simultaneous pancreas and kidney (SPK) transplant was performed in 1966. Early procedures were associated with significant morbidity and mortality and were performed in very low numbers in select patients.
METHODS
This study includes all recipients of an SPK at the University of Wisconsin-Madison between 1986 and 1993, who were actively followed and had a functional pancreas allograft for >25 years as of October 31, 2018.
RESULTS
A total of 291 SPK were performed during the study period; of these, 39 patients still had a functional graft at last follow up and 9 (18.8%) pancreas grafts were lost due to patient death or graft failure after >25 years. At last follow up, all 39 patients with functional pancreas graft had at least one comorbidity, such as hypertension, hyperlipidemia, or coronary artery disease. Twenty-seven required enteric conversion; 11 patients experienced renal allograft failure (10 underwent a repeat kidney transplant); and 6 required amputation of part of the lower extremity. In the Cox regression analysis, bladder drained pancreas was associated with lower probability of prolonged pancreas graft survival (hazard ratio: 0.52; confidence interval: 0.32-0.85; P = 0.01).
CONCLUSIONS
With careful and detailed follow-up and attention to complications, some recipients of pancreas grafts have outstanding outcomes. As the number of pancreas recipients with prolonged graft survival may be rising, healthcare providers should be aware of the management of complications associated with this unique group of patients.
Topics: Adult; Comorbidity; Diabetes Mellitus, Type 1; Female; Follow-Up Studies; Graft Survival; Humans; Kidney Failure, Chronic; Kidney Transplantation; Male; Middle Aged; Pancreas; Pancreas Transplantation; Postoperative Complications; Survivors; Time Factors; Treatment Outcome
PubMed: 31568218
DOI: 10.1097/TP.0000000000002960 -
American Journal of Transplantation :... Jan 2018The number of pancreas transplants performed in the United States increased by 7.0% in 2016 over the previous year, the first such increase in more than a decade,...
The number of pancreas transplants performed in the United States increased by 7.0% in 2016 over the previous year, the first such increase in more than a decade, largely attributable to an increase in simultaneous kidney pancreas transplants. Transplant rates increased in 2016, and mortality on the waiting list decreased. The declining enthusiasm for pancreas after kidney (PAK) transplants persisted. The uniform definition of graft failure was approved by the OPTN Board of Directors in 2015 and will be implemented in early 2018. Meanwhile, SRTR continues to refrain from reporting pancreas graft failure data. The OPTN/UNOS Pancreas Transplantation Committee is seeking to broaden allocation of pancreata across compatible ABO blood types in a proposal out for public comment July 31 to October 2, 2017. A new initiative to provide guidance on the benefits of PAK transplants is also out for public comment.
Topics: Annual Reports as Topic; Graft Survival; Humans; Pancreas Transplantation; Registries; Tissue Donors; Tissue and Organ Procurement; United States; Waiting Lists
PubMed: 29292605
DOI: 10.1111/ajt.14558 -
American Journal of Transplantation :... Aug 2022Enteric drainage in pancreas transplantation is complicated by an enteric leak in 5%-8%, frequently necessitating pancreatectomy. Pancreatic salvage outcomes are not...
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.
Topics: Graft Survival; Humans; Kidney Transplantation; Pancreas Transplantation; Postoperative Complications; Retrospective Studies
PubMed: 35593379
DOI: 10.1111/ajt.17094 -
Acta Medica Portuguesa 2004A clinic case of simultaneous pancreas/kidney transplantation on a type 1 diabetic patient is described. A six years follow-up was made with both organs functionating... (Review)
Review
A clinic case of simultaneous pancreas/kidney transplantation on a type 1 diabetic patient is described. A six years follow-up was made with both organs functionating and a good quality of live. Then the authors make a review of the available surgical techniques, indications and complications of this form of treatment. A comparison between the Portuguese and the International experience was discussed.
Topics: Adult; Diabetes Mellitus; Follow-Up Studies; Humans; Kidney Transplantation; Male; Pancreas Transplantation
PubMed: 15636734
DOI: No ID Found -
Annals of the Royal College of Surgeons... Sep 2015Current risk prediction scoring systems in pancreas transplantation are limited to organ factors and are specific to predicting graft outcome. They do not consider...
INTRODUCTION
Current risk prediction scoring systems in pancreas transplantation are limited to organ factors and are specific to predicting graft outcome. They do not consider recipient factors or inform regarding recipient morbidity. The aim of this study was to assess the utility of commonly used general surgical risk prediction models (P-POSSUM [Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity], MODS [multiple organ dysfunction score], Charlson co-morbidity index, revised cardiac risk index, ASA [American Society of Anesthesiologists] grade and Waterlow score), and to correlate them with total length of hospital stay (LOS) and critical care unit (CCU) LOS, important surrogate markers of patient outcome.
METHODS
All risk prediction scores were calculated prospectively for all simultaneous pancreas and kidney (SPK) transplant recipients from November 2011 to October 2013, and correlated with outcome measures.
RESULTS
Overall, 57 SPK transplant recipients were analysed. The mean age was 42.0 years (standard deviation [SD]: 7.60 years), 27 (52%) were male and the mean body mass index was 25.43kg/m(2) (SD: 3.11kg/m(2)). The mean pancreas and kidney cold ischaemic times were 703 minutes (SD: 182 minutes) and 850 minutes (SD: 192 minutes) respectively. The median total LOS and mean CCU LOS was 17 days (range: 8-79 days) and 7 days (SD: 4.04 days) respectively. When correlated with risk prediction scores, Waterlow score was the only significant predictor of total LOS and CCU LOS (p<0.001 [Spearman's correlation] and p=0.001 [Pearson's correlation] respectively).
CONCLUSIONS
Preoperative risk prediction plays an important part in planning perioperative care. To date, no validated risk prediction scoring system exists for SPK transplantation. This prospective study indicates that Waterlow score identifies high risk individuals and has value in the prediction of outcome following SPK transplantation.
Topics: Adult; Cohort Studies; Female; Humans; Kidney Transplantation; Length of Stay; Male; Middle Aged; Pancreas Transplantation; Prospective Studies; Risk Assessment; Severity of Illness Index; Tissue Donors; Treatment Outcome; Young Adult
PubMed: 26274754
DOI: 10.1308/rcsann.2015.0001 -
Archivum Immunologiae Et Therapiae... Dec 2011Islet transplantation has the potential to cure type 1 diabetes. In recent years, the proportion of patients achieving initial insulin independence has improved, but... (Review)
Review
Islet transplantation has the potential to cure type 1 diabetes. In recent years, the proportion of patients achieving initial insulin independence has improved, but longer term outcomes remain poor compared to those for whole pancreas transplants. This review article will discuss factors affecting islet yield and viability leading up to transplantation and in the immediate post-transplant period.
Topics: Age Factors; Apoptosis; Diabetes Mellitus, Type 1; Graft Rejection; Humans; Hypoxia; Inflammation; Islets of Langerhans Transplantation; Pancreas Transplantation; Tissue and Organ Harvesting; Treatment Outcome
PubMed: 21984594
DOI: 10.1007/s00005-011-0143-0