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1
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Campsen J, Zimmerman MA. Pancreas transplantation following donation after circulatory death. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Pancreas Transplantation in Minorities including Patients with a Type 2 Diabetes Phenotype. URO 2022. [DOI: 10.3390/uro2040026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: Prior to year 2000, the majority of pancreas transplants (PTx) were performed as simultaneous pancreas-kidney transplants (SPKTs) in Caucasian adults with end stage renal failure secondary to type 1 diabetes mellitus (T1DM) who were middle-aged. In the new millennium, improving outcomes have led to expanded recipient selection that includes patients with a type 2 diabetes mellitus (T2DM) phenotype, which excessively affects minority populations. Methods: Using PubMed® to identify appropriate citations, we performed a literature review of PTx in minorities and in patients with a T2DM phenotype. Results: Mid-term outcomes with SPKT in patients with uremia and circulating C-peptide levels (T2DMphenotype) are comparable to those patients with T1DM although there may exist a selection bias in the former group. Excellent outcomes with SPKT suggests that the pathophysiology of T2DM is heterogeneous with elements consisting of both insulin deficiency and resistance related to beta-cell failure. As a result, increasing endogenous insulin (Cp) production following PTx may lead to freedom checking blood sugars or taking insulin, better metabolic counter-regulation, and improvements in quality of life and life expectancy compared to other available treatment options. Experience with solitary PTx for T2DM or in minorities is limited but largely mirrors the trends reported in SPKT. Conclusions: PTx is a viable treatment option in patients with pancreas endocrine failure who are selected appropriately regardless of diabetes type or recipient race. This review will summarize data that unconventional patient populations with insulin-requiring diabetes may gain value from PTx with an emphasis on contemporary experiences and appropriate selection in minorities in the new millennium.
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Muñoz-Bellvís L, López-Sánchez J. Donor risk factors in pancreas transplantation. World J Transplant 2020; 10:372-380. [PMID: 33437670 PMCID: PMC7769731 DOI: 10.5500/wjt.v10.i12.372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/29/2020] [Accepted: 10/09/2020] [Indexed: 02/06/2023] Open
Abstract
The aim of the work was to analyze and expose the donor and recipient risk factors in pancreas transplantation. In the following paper, we exposed the 2018 Spanish Consensus Document on Donor and Recipient Selection Criteria for Pancreas Transplantation. An assessment of the previous Selection Criteria for Donors and Recipients of Pancreas Transplantation, published in 2005 by the Spanish Pancreas Transplant Group (GETP) and the National Transplant Organization (ONT) was performed. A literature review was performed using Cochrane Library, PubMed and Google Scholar databases. Some of the following terms were used for the literature search: “Diabetes Mellitus,” “Pancreas Transplantation,” “Insulin-Secreting Cells,” “Pancreas Allograft Thrombosis,” “Allograft Pancreatitis,” “Donors’ Risk Factors,” “Recipients’ Risk Factors,” “Pancreas Allograft Rejection” and “Pancreas Allograft Survival.” After an extended search, different inclusion criteria were established. Articles and documents with abstracts of full text and in English or Spanish language were selected. Subsequently, different scientific meetings took place during 2015 and 2016 by the GETP. Finally, the updated criteria were published by the GETP and ONT in 2018. Several risk factors have been described in pancreas transplantation that can be divided into donor risk factors: Advanced age (> 50 years); high body mass index (BMI) (> 30 kg/m2); cause of death (e.g., stroke); previous hyperglycemia; hyperamylasemia; cold ischemia time (greater than 8 or 12 h, depending on the type of donation); the use of vasopressors in the intensive care unit or cardiac arrest; and the macroscopic aspect of the pancreas allograft. The following are recipient risk factors: Advanced age (> 50 years); active smoking; high BMI (> 30 kg/m2); and peripheral artery disease or sensorimotor polyneuropathy. Based on the aforementioned parameters, different selection criteria have been established for the recipients depending on the type of pancreas transplantation. Knowledge of the risk factors for pancreas transplantation allows the establishment of reliable selection criteria for choosing donors and recipients.
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Affiliation(s)
- Luis Muñoz-Bellvís
- Department of General & Gastrointestinal Surgery, Hospital Universitario de Salamanca, Universidad de Salamanca, Salamanca 37007, Spain
- Salamanca Biomedical Research Institute (IBSAL), Universidad de Salamanca, Salamanca 37007, Spain
| | - Jaime López-Sánchez
- Department of General & Gastrointestinal Surgery, Hospital Universitario de Salamanca, Universidad de Salamanca, Salamanca 37007, Spain
- Salamanca Biomedical Research Institute (IBSAL), Universidad de Salamanca, Salamanca 37007, Spain
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Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
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Affiliation(s)
- Glauco Adrieno Westphal
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil. .,Hospital Municipal São José (HMSJ), Joinville, SC, Brazil. .,Centro Hospitalar Unimed, Joinville, SC, Brazil.
| | | | | | - Anderson Ricardo Roman Gonçalves
- Universidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville, SC, 89219710, Brazil.,Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370, Joinville, SC, 89202-050, Brazil
| | - Cátia Moreira Guterres
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245, Porto Alegre, RS, 90050-170, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Daiana Barbosa da Silva
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Daniela Ferreira Salomão Pontes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Diego Silva Leite Nunes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Edson Abdala
- Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP, 01246903, Brazil
| | - Felipe Dal-Pizzol
- Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária, 1105, Criciúma, SC, 88806000, Brazil.,Intensive Care Unit, Hospital São José, R. Cel. Pedro Benedet, 630, Criciúma, SC, 88801-250, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av. Brasil, 4365, Rio de Janeiro, RJ, 21040360, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ, 22281100, Brazil
| | - Flávia Ribeiro Machado
- Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R. Napoleão de Barros 737, São Paulo, SP, 04024002, Brazil
| | - Joel de Andrade
- Organização de Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior, 390, Florianópolis, SC, 88015130, Brazil
| | - Luciane Nascimento Cruz
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | | | | | - Regis Goulart Rosa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Roberto Ceratti Manfro
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Rosana Reis Nothen
- Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José do Rio Preto, SP, 15090000, Brazil
| | - Tatiana Helena Rech
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Thiago Lisboa
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Maicon Falavigna
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil.,National Institute for Health Technology Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St W, Hamilton, ON, Canada
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Spaggiari M, Di Bella C, Di Cocco P, Campara M, Galen K, Gheza F, Oberholzer J, Benedetti E, Tzvetanov I. Pancreas Transplantation From Pediatric Donors: A Single-Center Experience. Transplantation 2018; 102:1732-1739. [PMID: 29620617 DOI: 10.1097/tp.0000000000002208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Pancreas allografts from pediatric donors are considered less suitable due to the increased risk of surgical complications and reduced islet cell mass that may compromise function. METHODS All pancreatic transplants, procured from donors younger than 18 years, between January 2007 and March 2017, were included in the analysis. The grafts were subdivided into 3 groups by donor's weight: less than 30 kg, 30 to 60 kg, greater than 60 kg. Analysis of patient and graft survival was done between the groups, and subsequently between the pediatric cohort and the adult-donor control group. RESULTS Sixty-three pediatric-donor pancreas transplants were performed. The mean donor age and weight were of 12.10 ± 4.13 years and 47.8 ± 21.3 kg. Excellent metabolic control was achieved in 59 (93.65%) patients at the time of discharge and at a mean 5 year follow up, with the average hemoglobin A1c of 5.30 ± 0.61% and blood glucose level of 102.75 ± 20.70 mg/dL in those with a functioning graft. Nine graft losses were registered, of which one (1.6%) was due to arterial thrombosis. Eight (12.7%) patients experienced rejection. Overall graft survival and patient survival were of 85.7% and 92.1%, respectively, at a median follow-up of 37.07 months (minimum, 0.19 to maximum, 119.57). No differences among the 3 groups were identified. Long-term patient and allograft survival was comparable to that of the adult-donor pancreatic transplants. CONCLUSIONS Pediatric-donor pancreas demonstrated excellent short-term outcomes with no surgical complications and promising long-term outcomes despite the smaller islet mass. Pancreata from pediatric donors should not be marginalized and can offset worsening organ shortage.
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Affiliation(s)
- Mario Spaggiari
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Caterina Di Bella
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | | | - Maya Campara
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL
| | - Kelly Galen
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL
| | - Federico Gheza
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Jose Oberholzer
- Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Enrico Benedetti
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Ivo Tzvetanov
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
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Gasteiger S, Cardini B, Göbel G, Oberhuber R, Messner F, Resch T, Bösmüller C, Margreiter C, Schneeberger S, Maglione M. Outcomes of pancreas retransplantation in patients with pancreas graft failure. Br J Surg 2018; 105:1816-1824. [PMID: 30007018 PMCID: PMC6282534 DOI: 10.1002/bjs.10929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/17/2018] [Accepted: 06/01/2018] [Indexed: 12/23/2022]
Abstract
Background Pancreas retransplantation is still a controversial option after loss of a pancreatic graft. This article describes the experience of pancreas retransplantation at a high‐volume centre. Methods This was a retrospective observational study of all pancreas retransplantations performed in a single centre between 1997 and 2013. Pancreatic graft loss was defined by the return to insulin dependence. Risk factors for graft loss as well as patient and graft survival were analysed using logistic and time‐to‐event regression models. Results Of 409 pancreas transplantations undertaken, 52 (12·7 per cent) were identified as pancreas retransplantations. After a median follow‐up of 65·0 (range 0·8–174·3) months, 1‐ and 5‐year graft survival rates were 79 and 69 per cent respectively, and 1‐ and 5‐year patient survival rates were 96 and 89 per cent. During the entire follow‐up, 22 grafts (42 per cent) were lost. Patient survival was not associated with any of the donor‐ or recipient‐related factors investigated. Five‐year graft survival was better after simultaneous kidney–pancreas retransplantation than pancreas retransplantation alone: 80 per cent (16 of 20) versus 63 per cent (20 of 32) (P = 0·226). Acute rejection (odds ratio 4·49, 95 per cent c.i. 1·59 to 12·68; P = 0·005) and early surgical complications (OR 3·29, 1·09 to 9·99, P = 0·035) were identified as factors with an independent negative effect on graft survival. Conclusion Pancreas retransplantation may be considered for patients whose previous graft has failed. Good outcome in selected patients
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Affiliation(s)
- S Gasteiger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - B Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - G Göbel
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - R Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - F Messner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - T Resch
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - C Bösmüller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - C Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - S Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - M Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Long-term Effects of Delayed Graft Function on Pancreas Graft Survival After Pancreas Transplantation. Transplantation 2015; 98:1316-22. [PMID: 24839896 DOI: 10.1097/tp.0000000000000214] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Compared with the impact of delayed graft function (DGF) after renal transplantation, DGF after pancreas transplantation has not been fully evaluated. METHODS We retrospectively verified the impact of DGF on long-term pancreas graft survival in surgically successful cases. Pancreas graft failure was defined by the recipient's return to exogenous insulin administration. RESULTS Between May 2004 and April 2013, we performed 135 technically successful primary pancreas transplantations. Delayed graft function was defined as a total cumulative insulin requirement of 19 UI or greater within postoperative 7 days. Of the 135 recipients in our study cohort, 47 (34.8%) developed DGF after the pancreas transplantation. By multivariate analysis, DGF was found to be associated with a donor age of 30 years or older (odds ratio, 3.4; 95% confidence interval, 1.50-7.69; P=0.003) and the increased ratio of body mass index in a recipient to a donor (odds ratio, 26.1; 95% confidence interval, 2.53-270.0; P=0.006). There was a trend toward higher acute rejection (P=0.622) and mortality (P=0.49) rates in recipients with versus without DGF, although this did not reach statistical significance. Delayed graft function was found to be associated with a greater risk of overall pancreas graft failure (P=0.016) and death-censored graft failure (P=0.037). CONCLUSION Delayed graft function after pancreas transplantation was found to be associated with a greater risk of overall pancreas graft failure and death-censored graft failure.
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Drewitz KP, Loss M, Loss J, Apfelbacher CJ. Predictors of non-transplantation of adult donor organs--an observational study using routine data from Eurotransplant. BMC Health Serv Res 2014; 14:584. [PMID: 25421753 PMCID: PMC4260195 DOI: 10.1186/s12913-014-0584-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 11/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The majority of pancreases, offered in allocation, are not transplanted. This pancreas under-utilisation is a phenomenon observed in all transplant systems in North-America and Europe. It was the aim of this study to analyse factors predictive of pancreas non-transplantation in Germany. METHODS Routine Eurotransplant data of 3,666 deceased German donors (from 2002-2011) were used for multivariate modelling. Socio-demographic and medical factors were considered as independent variables in logistic regression models with non-transplantation as dependent variable. RESULTS Male gender, advanced age, overweight/obesity, long ICU stay, a history of smoking, non-traumatic brain death, elevated levels of sodium, serum glucose, lipase/amylase and the liver not being considered for procurement were significant independent predictors of non-transplantation. CONCLUSION In line with previous research, advanced age, high BMI, long ICU stay and the liver not being considered for procurement were the strongest predictors of pancreas non-transplantation in Germany. About three quarters of the variance remained unexplained, suggesting that factors not assessed or unknown may play a decisive role.
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Affiliation(s)
- Karl Philipp Drewitz
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany.
| | - Martin Loss
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93051, Regensburg, Germany.
| | - Julika Loss
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany.
| | - Christian Joachim Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany.
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Hau HM, Tautenhahn HM, Uhlmann D, Schmelzle M, Morgul MH, Schoenberg MB, Krenzien F, Jonas S, Bartels M. Single-center experience using organs after rescue allocation for pancreas transplant in the eurotransplant region. EXP CLIN TRANSPLANT 2014; 12:351-356. [PMID: 25095712 DOI: 10.6002/ect.2013.0281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVES Because of the shortage of available organs for transplants, graft allocation polices have been modified recently. This report deals with the effect of using organs after rescue allocation for pancreas transplant in a single center in the Eurotransplant Region to possibly expand the donor pool. MATERIALS AND METHODS A retrospective analysis was performed. Between 2007 and 2010, thirty-one pancreas transplants were performed at the University Hospital of Leipzig, in Leipzig, Germany. Among these, 7 cases used rescue organs. These organs had been officially offered to, but rejected by, at least 3 consecutive transplant centers. Donor/recipient and clinical/laboratory transplant/posttransplant outcomes from patients receiving rescue organs were collected and were compared with organs from conventional donors. RESULTS Mean donor age was greater in the rescue organ group than in the conventional donor group (28.3 ± 10.7 y vs 23.0 ± 12.5 y). During follow-up (2.3 ± 0.6 y rescue organ group vs 3.9 ± 1.2 y conventional donor group), patient, kidney, and pancreas graft survival rates were 85% in all 3 categories in the rescue organ group, whereas outcomes for conventional donors were 88%, 85%, and 83%. Incidences of pancreatic graft thrombosis, delayed graft function, acute and late rejection episodes (eg, perioperative complications) were comparable between groups. No differences existed between mean serum urea levels and mean HbA1c levels between groups 2 years after transplant. Whereas 2 years after surgery, mean serum creatinine levels (rescue organ group, 78.8 ± 21.0 μmol/L vs 114.3 ± 28.4 μmol/L in the conventional donor group) showed significant differences between groups. CONCLUSIONS Results are promising. Further pro-spective studies are warranted to evaluate routine transplant of organs after rescue allocation.
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Affiliation(s)
- Hans Michael Hau
- From the Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Germany
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10
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Sayed BA, Turgeon NA. Pancreas Transplantation of Non-Traditional Recipients. CURRENT TRANSPLANTATION REPORTS 2014. [DOI: 10.1007/s40472-014-0011-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mittal S, Sharples E, Lee F, Reddy S, Sinha S, Friend P, Vaidya A. App to reality: snapshot validation of the US Pancreas Donor Risk Index in a UK center. J Surg Res 2013; 183:841-5. [DOI: 10.1016/j.jss.2013.03.098] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 03/21/2013] [Accepted: 03/28/2013] [Indexed: 11/25/2022]
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12
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Kayler LK, Wen X, Zachariah M, Casey M, Schold J, Magliocca J. Outcomes and survival analysis of old-to-old simultaneous pancreas and kidney transplantation. Transpl Int 2013; 26:963-72. [PMID: 23819508 DOI: 10.1111/tri.12142] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 05/08/2013] [Accepted: 06/10/2013] [Indexed: 12/27/2022]
Abstract
Outcomes of old-donor simultaneous pancreas-kidney transplantation (SPKT) have not been thoroughly studied. Scientific Registry of Transplant Recipients data reported for SPKT candidates receiving dialysis wait-listed between 1993 and 2008 (n = 7937) were analyzed for outcomes among those who remained listed (n = 3301) and of SPKT recipients (n = 4636) using multivariable time-dependent regression models. Recipients were stratified by donor/recipient age (cutoff 40 years) into: young-to-young (n = 2099), young-to-old (n = 1873), old-to-young (n = 293), and old-to-old (n = 371). The overall mortality was 12%, 14%, 20%, and 24%, respectively, for those transplanted, and 50% for those remaining on the waiting list. On multivariable analysis, old-donor SPKT was associated with significantly higher overall risks of patient death, death-censored pancreas, and kidney graft failure in both young (73%, 53%, and 63% increased risk, respectively) and old (91%, 124%, and 85% increased risk, respectively) recipients. The adjusted relative mortality risk was similar for recipients of old-donor SPKT compared with wait-listed patients including those who subsequently received young-donor transplants (aHR 0.95; 95% CI 0.78, 1.12) except for candidates in OPOs with waiting times ≥604 days (aHR 0.65, 95% CI 0.45-0.94). Old-donor SPKT results in significantly worse graft survival and patient mortality without any waiting-time benefit as compared to young-donor SPKT, except for candidates with expected long waiting times.
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Affiliation(s)
- Liise K Kayler
- Department of Surgery, Montefiore Medical Center, Bronx, NY, USA
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14
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Steurer W, Bonatti H, Obrist P, Spechtenhauser B, Ladurner R, Mark W, Gardetto A, Margreiter R, Königsrainer A. Incidence of intraabdominal infection in a consecutive series of 40 enteric-drained pancreas transplants with FK506 and MMF immunosuppression. Transpl Int 2011. [DOI: 10.1111/j.1432-2277.2000.tb02018.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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15
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Can the Preprocurement Pancreas Suitability Score Predict Ischemia-Reperfusion Injury and Graft Survival After Pancreas Transplantation? Transplant Proc 2010; 42:4202-5. [DOI: 10.1016/j.transproceed.2010.09.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 09/09/2010] [Indexed: 11/18/2022]
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16
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Donor pancreata: evolving approaches to organ allocation for whole pancreas versus islet transplantation. Transplantation 2010; 90:238-43. [PMID: 20463635 DOI: 10.1097/tp.0b013e3181e25a40] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
As islet transplantation increasingly enters the clinical arena, its coexistence with vascularized pancreas transplantation makes it necessary to reassess the questions of donor selection and allocation. In answering these questions, one must put in the balance the short-term morbidity of pancreas transplantation with the long-term attrition of islet grafts. The preferential allocation of pancreases from obese and older donors for islet isolation has been based on their association with worse pancreas transplant outcomes and better islet isolation results in islet yields. In this overview, we show that transplanted islet mass does not necessarily correlate with graft function and make the case that donor selection criteria for islet transplantation, and hence allocation rules, may need to be redefined.
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17
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18
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Vinkers M, Rahmel A, Slot M, Smits J, Schareck W. Influence of a Donor Quality Score on Pancreas Transplant Survival in the Eurotransplant Area. Transplant Proc 2008; 40:3606-8. [DOI: 10.1016/j.transproceed.2008.03.172] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 03/06/2008] [Accepted: 03/26/2008] [Indexed: 11/25/2022]
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19
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Schäffer M, Bartmann V, Wunsch A, Traska T, Schenker P, Michalski S, Viebahn R. [Simultaneous pancreas-kidney transplantation. Influence of donor and recipient gender]. Chirurg 2008; 78:928-35. [PMID: 17565475 DOI: 10.1007/s00104-007-1362-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Differences in graft survival due to gender have been reported after transplantation of the kidney, liver, and heart. However, little is known about the role of donor and recipient gender in simultaneous pancreas-kidney transplantation. METHODS Single-centre analysis was performed of first simultaneous pancreas-kidney transplantations performed between 1994 and 2005 at the Bochum Transplant Center in Germany (n=218). RESULTS Recipients of female donor organs exhibited acute organ rejections earlier and more frequently (P<0.05). Male recipients of organs from male donors had a lower risk of acute rejection than recipients of female donor organs (P<0.05). In addition to female donor gender, higher donor age and early kidney dysfunction were risk factors for perioperative rejection (P<0.05). Long-term kidney and pancreas function was best in male-donor-to-female-recipient transplants over the time periods of 7 and 3 years, respectively (P<0.05). Risk factors of long-term organ failure were: the need of revision laparotomy, organ rejection, and early postoperative organ dysfunction (P<0.05). CONCLUSION This is the first report of graft function after simultaneous pancreas-kidney transplantation looking specifically at gender differences with respect to donor and recipient. There was an increased risk of organ rejection of female donor organs.
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Affiliation(s)
- M Schäffer
- Knappschaftskrankenhaus Bochum-Langendreer, Chirurgische Universitätsklinik, In der Schornau 23-25, 44892 Bochum, Deutschland.
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20
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Pancreas and Islet Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Salvalaggio PR, Schnitzler MA, Abbott KC, Brennan DC, Irish W, Takemoto SK, Axelrod D, Santos LS, Kocak B, Willoughby L, Lentine KL. Patient and graft survival implications of simultaneous pancreas kidney transplantation from old donors. Am J Transplant 2007; 7:1561-71. [PMID: 17511681 DOI: 10.1111/j.1600-6143.2007.01818.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We investigated graft and patient survival implications of simultaneous pancreas kidney (SPK) transplant from old donors. Data describing patients with type 1 diabetes mellitus listed for an SPK transplant from 1994 to 2005 were drawn from Organ Procurement and Transplant Network registries. Allograft survival, patient survival and long-term survival expectations among SPK recipients from young (age <45 years) and old (age >/=45 years) donors were modeled by multivariate regression. We also examined predictors of reduced early access to young donor transplants. Of 16 496 eligible SPK candidates, 8850 patients (53.6%) received an SPK transplant and 776 (8.8%) of these transplants were from old donors. Reasonable 5-year, death-censored kidney (77.8 %) and pancreas (71.3%) survivals were achieved with old donors. SPK transplantation from both young and old donors predicted lower mortality compared to continued waiting. An additional expected wait of 1.5 years for a young donor equalized long-term survival expectations to that achieved with use of old donors. Early allocation of young donor transplants declined in the more recent era and varied by region, candidate age, blood type and sensitization. We conclude that old SPK donors should be considered for patients with decreased access to young donor transplants. Prospective evaluation of this practice is needed.
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Affiliation(s)
- P R Salvalaggio
- Center for Outcomes Research, and Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO, USA
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22
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Bonatti H, Tabarelli W, Berger N, Wykypiel H, Jaschke W, Margreiter R, Mark W. Successful management of a proximal pancreatic duct fistula following pancreatic transplantation. Dig Dis Sci 2006; 51:2026-30. [PMID: 17053956 DOI: 10.1007/s10620-006-9373-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Accepted: 04/01/2006] [Indexed: 01/05/2023]
Affiliation(s)
- H Bonatti
- Department of General and Transplant Surgery, University Hospital, 6020, Innsbruck, Austria.
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23
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Berger N, Guggenbichler S, Steurer W, Margreiter C, Mayer G, Kafka R, Mark W, Rosenkranz AR, Margreiter R, Bonatti H. Bloodstream infection following 217 consecutive systemic-enteric drained pancreas transplants. BMC Infect Dis 2006; 6:127. [PMID: 16895603 PMCID: PMC1570140 DOI: 10.1186/1471-2334-6-127] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Accepted: 08/08/2006] [Indexed: 11/21/2022] Open
Abstract
Background Combined kidney pancreas transplantation (PTx) evolved as excellent treatment for diabetic nephropathy. Infections remain common and serious complications. Methods 217 consecutive enteric drained PTxs performed from 1997 to 2004 were retrospectively analyzed with regard to bloodstream infection. Immunosuppression consisted of antithymocyteglobuline induction, tacrolimus, mycophenolic acid and steroids for the majority of cases. Standard perioperative antimicrobial prophylaxis consisted of pipercillin/tazobactam in combination with ciprofloxacin and fluconazole. Results One year patient, pancreas and kidney graft survival were 96.4%, 88.5% and 94.8%, surgical complication rate was 35%, rejection rate 30% and rate of infection 59%. In total 46 sepsis episodes were diagnosed in 35 patients (16%) with a median onset on day 12 (range 1–45) post transplant. Sepsis source was intraabdominal infection (IAI) (n = 21), a contaminated central venous line (n = 10), wound infection (n = 5), urinary tract infection (n = 2) and graft transmitted (n = 2). Nine patients (4%) experienced multiple episodes of sepsis. Overall 65 pathogens (IAI sepsis 39, line sepsis 15, others 11) were isolated from blood. Gram positive cocci accounted for 50 isolates (77%): Coagulase negative staphylococci (n = 28, i.e. 43%) (nine multi-resistant), Staphylococcus aureus (n = 11, i.e. 17%) (four multi-resistant), enterococci (n = 9, i.e. 14%) (one E. faecium). Gram negative rods were cultured in twelve cases (18%). Patients with blood borne infection had a two year pancreas graft survival of 76.5% versus 89.4% for those without sepsis (p = 0.036), patient survival was not affected. Conclusion Sepsis remains a serious complication after PTx with significantly reduced pancreas graft, but not patient survival. The most common source is IAI.
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Affiliation(s)
- Natalie Berger
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Sigmund Guggenbichler
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Wolfgang Steurer
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Christian Margreiter
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Gert Mayer
- Clinical Division of Nephrology, Medical University, Innsbruck, Austria
| | - Reinhold Kafka
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Walter Mark
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | | | - Raimund Margreiter
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
| | - Hugo Bonatti
- Department of General and Transplant Surgery, Medical University, Innsbruck, Austria
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, USA
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24
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Berger N, Wirmsberger R, Kafka R, Margreiter C, Ebenbichler C, Stelzmueller I, Margreiter R, Steurer W, Mark W, Bonatti H. Infectious complications following 72 consecutive enteric-drained pancreas transplants. Transpl Int 2006; 19:549-57. [PMID: 16764633 DOI: 10.1111/j.1432-2277.2006.00293.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
New immunosuppressive protocols and advanced surgical technique resulted in an improved outcome of pancreatic transplantation (PTx) with infection remaining the most common complication. Seventy-two enteric-drained whole PTxs performed at the Innsbruck University Hospital between September 2002 and October 2004 were retrospectively analyzed. Prophylactic immunosuppression consisted of either the standard protocol consisting of single bolus antithymocyteglobulin (ATG) (Thymoglobulin, Sangstat or ATG Fresenius) induction (9 mg/kg), tacrolimus (TAC), mycophenylate mofetil (MMF) and steroids (38 patients) or a 4-day course of ATG (4 mg/kg) tacrolimus and steroids with MMF (n = 19), or Sirolimus (n = 15). Perioperative antimicrobial prophylaxis consisted of Piperacillin/Tazobactam (4.5 g q 8 h) in combination with ciprofloxacin (200 mg q 12 h) and fluconazole (400 mg daily). Ganciclovir was used for cytomegalovirus (CMV) prophylaxis if donor was positive and recipient-negative. Patient, pancreas, and kidney graft survival at 1 year were 97.2%, 88.8%, and 93%, respectively, with no difference between the groups. All retransplants (n = 8) and single transplants (n = 8) as well as all type II diabetics and nine of 11 patients older 55 years received standard immunosuppression (IS). The rejection rate was 14% and infection rate 46% with no difference in terms of incidence or type according to the three groups. Severe infectious complications included intra-abdominal infection (n = 12), wound infection (n = 7), sepsis (n = 13), respiratory tract infection (n = 4), urinary tract infection (n = 12), herpes simplex/human herpes virus 6 infection (n = 5), CMV infection/disease (n = 7), post-transplant lymphoproliferative disorder (PTLD, n = 3), invasive filamentous fungal infection (n = 4), Clostridial/Rotavirus colitis (n = 1), and endocarditis (n = 1). All four patients in this series died of infectious complications (invasive aspergillosis n = 2) (one with Candida glabrata superinfection), invasive zygomycosis (n = 1), PTLD (n = 1). Five grafts were lost (vascular thrombosis n = 3, pancreatitis n = 1, noncompliance n = 1). Infection represented the most frequent complication in this series and all four deaths were of infectious origin. Better prophylaxis and management of infections now should be the primary target to be addressed in the field of pancreas transplantation.
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Affiliation(s)
- N Berger
- Department of General, Thoracic and Transplant Surgery, Innsbruck University Hospital, Innsbruck, Austria
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25
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Ihm SH, Matsumoto I, Sawada T, Nakano M, Zhang HJ, Ansite JD, Sutherland DER, Hering BJ. Effect of donor age on function of isolated human islets. Diabetes 2006; 55:1361-8. [PMID: 16644693 DOI: 10.2337/db05-1333] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study intended to evaluate the impact of donor age on the function of isolated islets. Analysis of human islets from cadaveric donors (age 16-70 years) was performed using glucose-stimulated insulin release (GSIR) (n = 93), islet ATP content (n = 27), diabetic nude mouse bioassay (n = 72), and the insulin secretory function after single-donor clinical islet allotransplantation (n = 7). The GSIR index was significantly higher in younger donors (age < or =40 years) than in older donors and negatively correlated with the donor age (r = -0.535). Islet ATP was higher in younger donors (115.7 +/- 17.7 vs. 75.7 +/- 6.6 pmol/microg DNA). The diabetes reversal rate of mice with 2,000 IE was significantly higher in younger donors (96 vs. 68%). C-peptide increment to glucose during intravenous glucose tolerance test at days 90-120 after clinical transplantation showed negative correlation with donor age (r = -0.872) and positive correlation with the islet mass (r = 0.832). On the other hand, acute insulin response to arginine only showed correlation with the islet mass and not with donor age. These results show that insulin secretory response to glucose deteriorates with increasing age and that it may be related to changes in ATP generation in beta-cells.
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Affiliation(s)
- Sung-Hee Ihm
- Diabetes Institute for Immunology and Transplantation, Department of Surgery, University of Minnesota, MMC 195, 420 Delaware Street SE, Minneapolis, MN 55455, USA
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26
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Schulz T, Schenker P, Flecken M, Kapischke M. Donors with a maximum body weight of 50 kg for simultaneous pancreas-kidney transplantation. Transplant Proc 2005; 37:1268-70. [PMID: 15848691 DOI: 10.1016/j.transproceed.2004.12.252] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Pediatric donors are rarely used for simultaneous pancreas-kidney transplantation (SPK). But the age of the donors may be less important than the body weight (BW). Therefore we retrospectively analyzed our data on SPK donors with a maximum BW of 50 kg. METHODS Between June 1994 and December 2003, 22 patients received SPK transplants from cadaveric donors with a maximum BW of 50 kg (range, 25-50 kg; median, 42.4 kg). The median donor-recipient weight ratio was 0.61 (range, 0.47-0.91). RESULTS Two kidney grafts (9.1%) displayed delayed graft function (2 and 9 dialyses). One patient needed insulin for 2 days (<20 IU/d), and the other patient for 1 month at a maximum of 7 IU/d. Four pancreas grafts (18.2%) were lost owing to graft thrombosis. One-year survival for patients was 95.5%; for kidneys, 86.4%; and for the pancreas, 72.7%. After a median observation period of 78 months, 6 acute rejection episodes were observed in 5 patients (22.7%). Five acute rejections were treated successfully, but 1 patient lost both organs. Two patients died of severe infections, at 3 months and 3 years, respectively, after SPK. Four kidney and 3 pancreas grafts developed chronic allograft dysfunction. CONCLUSIONS Our results show that 1-year graft function in this series was less than the results reported to the International Pancreas Transplant Registry. The Main reason for early pancreas loss was graft thrombosis (18.2%). After a median observation period of 78 months, pancreas graft survival was 59.1%.
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Affiliation(s)
- T Schulz
- Department of Surgery, Knappschafts Hospital, Ruhr University, Bochum, Germany.
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27
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Wullstein C, Woeste G, de Vries E, Persijn GG, Bechstein WO. Acceptance criteria of pancreas grafts: how do surgeons decide in Europe? Transplant Proc 2005; 37:1259-61. [PMID: 15848688 DOI: 10.1016/j.transproceed.2004.12.146] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Some donor factors, such as age, cause of death, and obesity, affect the outcomes of pancreas transplantation. Donors with a high-risk profile are usually not declined for pancreas donation. The purpose of our study was to investigate differences between accepted and refused pancreata after being procured and offered. METHODS In a retrospective study we analyzed all offered pancreata (n = 1360) in the "Eurotransplant Area" between May 25, 2002 and September 18, 2003. Included in this study were 525 pancreata transplanted (38.6%) and 608 pancreata refused for medical reasons (44.7%). A total of 227 pancreata (16.7%) refused for other than medical reasons were excluded from this analysis. RESULTS The significant differences in the donor profiles between transplanted and refused pancreata were cause of death (P < .001), donor age (P < .001), body mass index (BMI, P < .001), serum lipase and amylase (P < .05) at the time of procurement, and a history of smoking (P = .001) or alcohol abuse (P < .001). No differences were found for serum sodium (P = .188), blood leukocytes (P = .349), serum glucose at the time of procurement (P = .155), amylase and lipase at the time of admission (P = .34; P = .758), and vasopressor use at the time of admission or at the procedure (P = .802; P = .982). CONCLUSION Even after procuring and offering potentially good pancreata, nearly half the organs are refused for medical reasons. Acceptance criteria in the Eurotransplant region reveal a conservative attitude toward pancreas acceptance.
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Affiliation(s)
- C Wullstein
- Department of General and Vascular Surgery, Goethe University, Frankfurt, Germany.
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28
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Boggi U, Del Chiaro M, Signori S, Vistoli F, Amorese G, Croce C, Morelli L, Vanadia Bartolo T, Pietrabissa A, Barsotti M, Rizzo G, Mosca F. Pancreas transplants from donors aged 45 years or older. Transplant Proc 2005; 37:1265-7. [PMID: 15848690 DOI: 10.1016/j.transproceed.2005.01.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIMS Since donor age of 45 years or more is considered a relative contraindication for pancreas transplantation (PTx), we herein report our experience with these donors. METHODS Pancreases from donors aged 45 years or older were used in 16 of 147 PTx procedures (11%). The final decision to accept a graft for PTx was based mainly on the quality of visceral perfusion and the gross appearance of the pancreas and the vessels. There were 9 men and 7 women, ranging in age from 45 to 55 years (average, 48.9 years) who were donors, due to cerebrovascular accidents (n = 11; 68.7%). Among the donor group, 5 patients were receiving multiple vasopressor agents (31.2%), and 2 had a history of cardiac arrest (12.5%). Pancreases were transplanted either simultaneously with a cadaveric kidney (n = 6) or as solitary grafts (n = 10). RESULTS After a mean period of cold preservation of 616 minutes (range, 475 to 844 min), delayed endocrine function occurred in 1 recipient (6%), who subsequently achieved insulin independence. Two recipients died suddenly, with functioning grafts. Two further grafts were lost due to portal vein thrombosis (6%) or late arterial thrombosis (6%). Three patients required repeat surgery (18.7%). After a mean follow-up period of 26.6 months, actuarial 1-year and 5-year patient survival rates were 87.5%, with insulin independence in 81.2% and 67.7%, respectively. CONCLUSIONS Meticulous donor selection and short preservation times allow the safe use of pancreases procured from donors aged 45 years or older, thus expanding the donor pool for PTx procedures.
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Affiliation(s)
- U Boggi
- Centro Regionale di Riferimento per La Cura delle Molattie del Pancreas, University of Pisa, Pisa, Italy
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29
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Boggi U, Del Chiaro M, Vistoli F, Signori S, Vanadia Bartolo T, Gremmo F, Marchetti P, Coppelli A, Rizzo G, Mosca F. Pancreas transplantation from marginal donors. Transplant Proc 2004; 36:566-8. [PMID: 15110595 DOI: 10.1016/j.transproceed.2004.02.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Marginal donor organs are a supplementary source of grafts that has not been fully exploited for pancreas transplantation (PTx). METHODS A total of 100 PTx were performed with grafts procured from either 48 nonmarginal donors (NMD) or 52 marginal donors (MD), namely age greater than 45 years and/or severe hemodynamic instability at the time of procurement. PTx outcome was evaluated as the incidence of delayed endocrine pancreas function (DEPF), the complication rate, and the patient and graft survivals. RESULTS The DEPF rate was 6.2% for NMD as compared to 0 for MD (P >.05). Relaparotomy rate was 12.5% for NMD and 9.6% for MD (P >.05). Actuarial 1-year graft survival was 91.7% and 94.2% for NMD and MD, respectively (P >.05). Equivalent figures for patients were 97.9% and 98.1%, respectively (P >.05). CONCLUSIONS Pancreas from MD may be safely employed and significantly expand the donor pool for PTx.
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Affiliation(s)
- U Boggi
- Divisione di Chirurgia Generale e Trapianti, Università di Pisa, Pisa, Italy
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30
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Rhein T, Metzner R, Uhlmann D, Serr F, Caca K, Weinert D, Hauss J, Witzigmann H. Pediatric donor organs for pancreas transplantation: an underutilized resource? Transplant Proc 2004; 35:2145-6. [PMID: 14529870 DOI: 10.1016/s0041-1345(03)00749-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- T Rhein
- Department of Abdominal, Transplantation and Vascular Surgery, University of Leipzig, Leipzig, Germany.
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31
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van der Boog PJ, Ringers J, Paul LC, Jukema J, Baranski A, Lemkes HH, de Fijter JW. Simultaneous kidney-pancreas transplantation: The preferred option for patients with type I diabetes mellitus and approaching end-stage renal disease. Transplant Rev (Orlando) 2004. [DOI: 10.1016/j.trre.2004.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Tan M, Kandaswamy R, Sutherland DER, Gruessner RW, Gruessner AC, Humar A. Risk factors and impact of delayed graft function after pancreas transplants. Am J Transplant 2004; 4:758-62. [PMID: 15084171 DOI: 10.1111/j.1600-6143.2004.00408.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Delayed graft function (DGF) occurs after many pancreas transplants (PTx), but is poorly characterized. We studied its incidence, course, and impact in a series of 531 pancreas transplants. Between January 1997 and September 2002, we performed 531 technically successful primary PTx. Of these 531 recipients, 176 (33%) had DGF, defined by their need for exogenous insulin at the time of hospital discharge. The incidence of DGF was roughly equivalent in the three transplant categories: SPK (36%), PAK (32%), and PTA (31%) (p = NS). By 3 months posttransplant, only 19 (3.5%) of all recipients remained on insulin. Only three recipients (0.56%) did not achieve insulin independence. The mean donor age of recipients with DGF was 35.1 years vs. 28.8 years without DGF (p = 0.003). By multivariate analysis, the most significant risk factor for DGF was donor age > 45 years (RR = 4.3, p = 0.0001). For SPK recipients with DGF, graft survival was 87% at 1 year and 82% at 3 years posttransplant; without DGF, 94% at 1 year and 87% at 3 years (p = 0.07). For PAK and PTA recipients, no difference was noted. Acute rejection rates were somewhat higher in recipients with DGF, but this did not reach statistical significance.
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Affiliation(s)
- Miguel Tan
- Department of Surgery, University of Minnesota, Minnesota, MN, USA
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33
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Krieger NR, Odorico JS, Heisey DM, D'Alessandro AM, Knechtle SJ, Pirsch JD, Sollinger HW. Underutilization of pancreas donors. Transplantation 2003; 75:1271-6. [PMID: 12717215 DOI: 10.1097/01.tp.0000061603.95572.bf] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Transplantation of the pancreas has become the treatment of choice for selected patients with type 1 diabetes mellitus. With the current shortage of cadaver donors and the increasing number of diabetic patients on the transplant waiting list, there is a critical need to optimally use all available pancreas grafts for transplantation. We have therefore explored the use of traditionally "less-than-ideal" pancreas donors, including pediatric (4-10 years), older (>or=45 years), obese (weight >or=200 lb), and non-heart-beating donors and donors with an elevated amylase (75% greater than normal values). METHODS A total of 620 primary simultaneous pancreas-kidney transplantations were performed at our center. We analyzed the ratio of livers to pancreata transplanted at our center and compared this to the United Network for Organ Sharing database. Using univariate and multivariate analyses, we then assessed the impact of these less-than-ideal donors on patient survival, graft survival, and postsurgical complications after simultaneous pancreas-kidney transplantation. RESULTS A substantial nationwide underutilization of pancreata from donor procurements is demonstrated in the United Network for Organ Sharing database. By using these less-than-ideal donors, the ratio of liver to pancreata procured can be reduced to 1.25:1. Graft survival was not significantly different in patients receiving transplants from obese, non-heart-beating, pediatric, or hyperamylasemic donors compared with grafts from ideal donors. However, grafts from donors 45 years of age or older had significantly lower 1- and 5-year graft survival rates (76% and 65% vs. 90% and 80%, P=0.006). CONCLUSIONS This study demonstrates that utilization of pancreas grafts from selected, less-than-ideal donors results in good overall outcomes and could potentially expand the organ donor pool.
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Affiliation(s)
- Nancy R Krieger
- Division of Organ transplatation, Department of Surgery, University of Wisconsin Medical School, Madison, WI 53792, USA
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Hariharan S, Pirsch JD, Lu CY, Chan L, Pesavento TE, Alexander S, Bumgardner GL, Baasadona G, Hricik DE, Pescovitz MD, Rubin NT, Stratta RJ. Pancreas after kidney transplantation. J Am Soc Nephrol 2002; 13:1109-1118. [PMID: 11912273 DOI: 10.1681/asn.v1341109] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Sundaram Hariharan
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - John D Pirsch
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Christopher Y Lu
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Laurence Chan
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Todd E Pesavento
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Steven Alexander
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Ginny L Bumgardner
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Giacomo Baasadona
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Donald E Hricik
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Mark D Pescovitz
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Nina T Rubin
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Robert J Stratta
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
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Drachenberg CB, Papadimitriou JC, Farney A, Wiland A, Blahut S, Fink JC, Philosophe B, Schweitzer E, Lal T, Anderson L, Bartlett ST. Pancreas transplantation: the histologic morphology of graft loss and clinical correlations. Transplantation 2001; 71:1784-91. [PMID: 11455259 DOI: 10.1097/00007890-200106270-00014] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Graft losses due to leaks, bleeding, thrombosis, infections, and early pancreatitis are grouped together under the category of technical failure. Among these complications, massive vascular thrombosis continues to be the most important cause of early graft loss due to technical failure. Pathological evaluation of most allografts lost early in the posttransplantation period shows vascular thrombosis with associated proportional parenchymal necrosis. The morphological findings in allografts that are considered to be lost due to technical failure has not been systematically addressed. In particular, the role of acute rejection in early graft loss has not been well studied. METHODS Seventy-four consecutive pancreas graft pancreatectomies were studied histologically to evaluate for thrombosis (recent versus organized), type of vessel involved by thrombosis (arteries, veins, or both), acute rejection grade, chronic rejection grade, endotheliitis, transplant arteritis, coagulation necrosis, acute pancreatitis, presence of infectious organisms, transplant (obliterative) arteriopathy, neoplasia, relative proportions of alpha and beta islet cells, and immunoglobulin and complement deposition. The histological findings were correlated with donor and recipient data as well as clinical presentation. RESULTS In 23 out of 39 grafts lost in the first 4 weeks posttransplantation, the only pathological changes found were vascular thrombosis and bland ischemic parenchymal necrosis. In these cases, no underlying vascular pathology or any other specific histological change was identified. Most of these grafts (78%) were lost in less than 48 hr and all in the first 2 weeks posttransplantation. Massive vascular thrombosis occurring in an otherwise histologically normal pancreas was the most common cause of graft loss in the first 4 weeks posttransplantation (59%). In most of the remaining cases (33%), although the clinical presentation suggested technical failure, there was clear histological evidence that the massive thrombosis resulted from vascular injury due to immune damage (acute and hyperacute rejection). Increased incidence of early graft thrombosis was seen in grafts from older donors and longer cold ischemia times. After the first month posttransplantation, graft pancreatectomies revealed a wider variety of pathological processes that included severe acute rejection, combined acute and chronic rejection, chronic rejection, and infections. Acute and chronic vascular thrombosis in large and small vessels was commonly seen at all times posttransplantation; chronic, organized thrombosis was strongly associated with chronic rejection. CONCLUSIONS (a) Early acute thrombosis occurring in a histologically normal pancreas defines a true technical failure. This study showed that acute rejection leading to massive thrombosis, which clinically simulates technical failure, results in a significant proportion of early graft losses. (b) Systematic histological evaluation of failed grafts is absolutely necessary for the accurate classification of the cause of graft loss. (c) There is morphological evidence that chronically ongoing thrombosis is an important, common, contributing factor for late graft loss.
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Affiliation(s)
- C B Drachenberg
- Department of Surgery, University of Maryland School of Medicine, 29 South Greene Street, Baltimore, MD 21201, USA
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Sutherland DE, Gruessner RW, Dunn DL, Matas AJ, Humar A, Kandaswamy R, Mauer SM, Kennedy WR, Goetz FC, Robertson RP, Gruessner AC, Najarian JS. Lessons learned from more than 1,000 pancreas transplants at a single institution. Ann Surg 2001; 233:463-501. [PMID: 11303130 PMCID: PMC1421277 DOI: 10.1097/00000658-200104000-00003] [Citation(s) in RCA: 421] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine outcome in diabetic pancreas transplant recipients according to risk factors and the surgical techniques and immunosuppressive protocols that evolved during a 33-year period at a single institution. SUMMARY BACKGROUND DATA Insulin-dependent diabetes mellitus is associated with a high incidence of management problems and secondary complications. Clinical pancreas transplantation began at the University of Minnesota in 1966, initially with a high failure rate, but outcome improved in parallel with other organ transplants. The authors retrospectively analyzed the factors associated with the increased success rate of pancreas transplants. METHODS From December 16, 1966, to March 31, 2000, the authors performed 1,194 pancreas transplants (111 from living donors; 191 retransplants): 498 simultaneous pancreas-kidney (SPK) and 1 simultaneous pancreas-liver transplant; 404 pancreas after kidney (PAK) transplants; and 291 pancreas transplants alone (PTA). The analyses were divided into five eras: era 0, 1966 to 1973 (n = 14), historical; era 1, 1978 to 1986 (n = 148), transition to cyclosporine for immunosuppression, multiple duct management techniques, and only solitary (PAK and PTA) transplants; era 2, 1986 to 1994 (n = 461), all categories (SPK, PAK, and PTA), predominantly bladder drainage for graft duct management, and primarily triple therapy (cyclosporine, azathioprine, and prednisone) for maintenance immunosuppression; era 3, 1994 to 1998 (n = 286), tacrolimus and mycophenolate mofetil used; and era 4, 1998 to 2000 (n = 275), use of daclizumab for induction immunosuppression, primarily enteric drainage for SPK transplants, pretransplant immunosuppression in candidates awaiting PTA. RESULTS Patient and primary cadaver pancreas graft functional (insulin-independence) survival rates at 1 year by category and era were as follows: SPK, era 2 (n = 214) versus eras 3 and 4 combined (n = 212), 85% and 64% versus 92% and 79%, respectively; PAK, era 1 (n = 36) versus 2 (n = 61) versus 3 (n = 84) versus 4 (n = 92), 86% and 17%, 98% and 59%, 98% and 76%, and 98% and 81%, respectively; in PTA, era 1 (n = 36) versus 2 (n = 72) versus 3 (n = 30) versus 4 (n = 40), 77% and 31%, 99% and 50%, 90% and 67%, and 100% and 88%, respectively. In eras 3 and 4 combined for primary cadaver SPK transplants, pancreas graft survival rates were significantly higher with bladder drainage (n = 136) than enteric drainage (n = 70), 82% versus 74% at 1 year (P =.03). Increasing recipient age had an adverse effect on outcome only in SPK recipients. Vascular disease was common (in eras 3 and 4, 27% of SPK recipients had a pretransplant myocardial infarction and 40% had a coronary artery bypass); those with no vascular disease had significantly higher patient and graft survival rates in the SPK and PAK categories. Living donor segmental pancreas transplants were associated with higher technically successful graft survival rates in each era, predominately solitary (PAK and PTA) in eras 1 and 2 and SPK in eras 3 and 4. Diabetic secondary complications were ameliorated in some recipients, and quality of life studies showed significant gains after the transplant in all recipient categories. CONCLUSIONS Patient and graft survival rates have significantly improved over time as surgical techniques and immunosuppressive protocols have evolved. Eventually, islet transplants will replace pancreas transplants for suitable candidates, but currently pancreas transplants can be applied and should be an option at all stages of diabetes. Early transplants are preferable for labile diabetes, but even patients with advanced complications can benefit.
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Affiliation(s)
- D E Sutherland
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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38
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Harland RC. Pancreas Transplantation. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Bonham CA, Kapur S, Dodson SF, Dvorchik I, Corry RJ. Potential use of marginal donors for pancreas transplantation. Transplant Proc 1999; 31:612-3. [PMID: 10083259 DOI: 10.1016/s0041-1345(98)01579-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- C A Bonham
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pennsylvania 15213, USA
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40
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Van der Werf WJ, Odorico J, D'Alessandro AM, Knechtle S, Becker Y, Collins B, Pirsch J, Hoffman R, Sollinger HW. Utilization of pediatric donors for pancreas transplantation. Transplant Proc 1999; 31:610-1. [PMID: 10083258 DOI: 10.1016/s0041-1345(98)01578-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Kapur S, Bonham CA, Dodson SF, Dvorchik I, Corry RJ. Strategies to expand the donor pool for pancreas transplantation. Transplantation 1999; 67:284-90. [PMID: 10075595 DOI: 10.1097/00007890-199901270-00017] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Our organ procurement organization has been forced to liberalize the donor criteria in order to expand the donor pool for pancreas transplantation. In this report, we describe our experience using whole organ pancreatic grafts from "marginal" donors, which include grafts obtained from donors over 45 years of age and from donors who were identified to be hemodynamically unstable at the time of organ retrieval. METHODS A prospective study was performed between July 1994 and March 1998, during which time 137 pancreas transplants were performed at our center using organs procured by our own surgeons (organs sent by other teams were excluded). The rapid en bloc technique was used exclusively. The use of pancreatic grafts from marginal donors was analyzed for short-term and overall graft survival, and for delayed graft function and complications. RESULTS Overall pancreas graft survival for our series was 83%, with a mean follow-up of 23 months. There were 22 pancreas grafts from donors over 45 years of age, 13 of whom were greater than 50 years of age. The actual graft survival rate of the over-45 donor group was 86%. Fifty-one grafts were removed from hemodynamically unstable donors on high-dose vasopressors. The actual graft survival in this group was 86%. There was no significant difference found in graft survival between recipients of pancreatic grafts from marginal and nonmarginal donors. Delayed graft function was exhibited by more recipients of grafts from donors on high-dose vasopressors (P<0.05), but this had no effect on long-term graft survival and endocrine function. Recipients of marginal donor grafts did not have higher rates of complication compared to recipients of nonmarginal grafts. CONCLUSIONS Based on our results, we currently employ a graft selection strategy not limited by donor age or hemodynamic stability. Our selection of pancreas organs for transplantation is based on careful inspection of the pancreas and determination of the adequacy of the ex vivo flush. Our results suggest that the current pancreas donor pool may be expanded substantially.
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Affiliation(s)
- S Kapur
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pennsylvania, USA
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