Pancreas-kidney Transplantation Research Articles

#2403 Impact of pregnancy on kidney transplant recipients

Abstract Background and Aims Kidney transplantation (KT) provides an opportunity to increase fertility in women with chronic kidney disease and gestational desire. Lack of knowledge about obstetric complications and implications for the graft may lead to discourage pregnancy for these women. Although the incidence of pregnancy is rising in women receiving KT, the impact that it may have on the graft function is unknown. Method We conducted an observational, retrospective, single-centre study of a cohort of kidney transplant recipients (KTR) who became pregnant between 2007 and 2022. Clinical and analytical parameters were evaluated before, during and after pregnancy. The main aim was to assess the long-term impact of pregnancy on the graft by analysing renal function 3 years after pregnancy. Results We included 25 women receiving a KT between 1990 and 2018, among which 72% (n = 18) were transplanted from a deceased donor. 2 women (8%) received a combined liver-kidney transplant and 2 women (8%) a simultaneous pancreas-kidney transplant. Maintenance immunosuppression before conception included teratogenic drugs in 68% of cases [12 of them (48%) received mycophenolate mofetil and 5 of them (20%), mTOR inhibitors]. Planned withdrawal was only applied in 50.0% of pregnancies (n = 15). 30 pregnancies were identified (5 patients had 2 post-transplant pregnancies). Median age at gestation was 35 years [interquartile range (IQR) 33-39]. 5 conceptions required assisted reproductive technology. The main complications were gestational hypertension in 4 KTR (13.3%) and preeclampsia in 7 pregnancies (23.3%). 60% of neonates (n = 18) were preterm births (36 [IQR 34-37] weeks of pregnancy at birth) and 44% (n = 12) had low birth weight (2530 [IQR 2283-2950] grams). No foetal malformations were described. Due to physiological changes, a significant increase in estimated glomerular filtration rate (eGFR) was observed in the first and the second trimester of pregnancy (61 [IQR 50-91] ml/min and 70 [IQR 50-90] ml/min, respectively vs. baseline eGFR 59 [IQR 47-77] ml/min; p 0.001]. However, eGFR was equal to the previous one in the third trimester of pregnancy (60 [IQR 44-69] ml/min vs. 59 [IQR 47-77] ml/min; p 0.322). Median proteinuria remained below 0.5 g/day throughout pregnancy, without significant variation. Immunosuppression regimen during pregnancy was mainly based on a combined therapy of steroids, calcineurin inhibitors and azathioprine (21 KTR, 70%). Tacrolimus dose increase (median 63.6% [IQR 33.3-90.0%]) was necessary to maintain proper drug levels throughout gestation. Kidney graft function showed a decline in the first and second year after pregnancy compared to baseline function (54 [IQR 35-77] ml/min and 55 [IQR 36-75] ml/min vs. 59 [IQR 47-77] ml/min; p 0.018 and p 0.021, respectively]. Nevertheless, by the third year post-pregnancy, eGFR was similar to the baseline function (62 [IQR 43-73] ml/min vs. 59 [IQR 47-77] ml/min; p 0.365]. Likewise, annual eGFR variation was comparable during 3 years before (+1.0 ml/min/year) and 3 years after pregnancy (−0.9 ml/min/year), hence no worsening was observed after gestation (p 0.78). No differences were observed in proteinuria either (baseline proteinuria 0.17 [IQR 0.13-0.3] g/day vs. third-year proteinuria 0.21 [IQR 0.15-0.34] g/day; p 0.938). Only 5 women had a baseline serum creatinine above current recommendations for pregnancy (>1.5 mg/dl) and only 3 women presented baseline proteinuria > 0.5 g/day. In this group (n = 7), pregnancy occurred later after KT (96.0 [IQR 80.9-213.0] vs. 46.0 [IQR 16.0-67.5] months; p 0.024). The only 2 graft losses in the cohort were in this group. Both were attributed to transplant glomerulopathy, and they occurred at years 3 and 5 after pregnancy. On the other side, in this group there were no other baseline differences or obstetrical complications [Table 1]. Conclusion Pregnancy does not normally affect graft function and it stabilises within 3 years after gestation. It is important to increase data on women with suboptimal graft function to determine the direct implications that pregnancy may have on these KTRs.

Donor Blood Tests do Not Predict Pancreas Graft Survival After Simultaneous Pancreas Kidney Transplantation; a National Cohort Study

Simultaneous pancreas-kidney (SPK) transplantation improves quality of life and limits progression of diabetic complications. There is reluctance to accept pancreata from donors with abnormal blood tests, due to concern of inferior outcomes. We investigated whether donor amylase and liver blood tests (markers of visceral ischaemic injury) predict pancreas graft outcome using the UK Transplant Registry (2016-2021). 857 SPK recipients were included (619 following brainstem death, 238 following circulatory death). Peak donor amylase ranged from 8 to 3300 U/L (median = 70), and this had no impact on pancreas graft survival when adjusting for multiple confounders (aHR = 0.944, 95% CI = 0.754–1.81). Peak alanine transaminases also did not influence pancreas graft survival in multivariable models (aHR = 0.967, 95% CI = 0.848–1.102). Restricted cubic splines were used to assess associations between donor blood tests and pancreas graft survival without assuming linear relationships; these confirmed neither amylase, nor transaminases, significantly impact pancreas transplant outcome. This is the largest, most statistically robust study evaluating donor blood tests and transplant outcome. Provided other factors are acceptable, pancreata from donors with mild or moderately raised amylase and transaminases can be accepted with confidence. The use of pancreas grafts from such donors is therefore a safe, immediate, and simple approach to expand the donor pool to reach increasing demands.

Pancreas Transplantation Outcome Predictions-PTOP: A Risk Prediction Tool for Pancreas and Pancreas-Kidney Transplants Based on a European Cohort.

For patients with complicated type 1 diabetes having, for example, hypoglycemia unawareness and end-stage renal disease because of diabetic nephropathy, combined pancreas and kidney transplantation (PKT) is the therapy of choice. However, the shortage of available grafts and complex impact of risk factors call for individualized, impartial predictions of PKT and pancreas transplantation (PT) outcomes to support physicians in graft acceptance decisions. Based on a large European cohort with 3060 PKT and PT performed between 2006 and 2021, the 3 primary patient outcomes time to patient mortality, pancreas graft loss, and kidney graft loss were visualized using Kaplan-Meier survival curves. Multivariable Cox proportional hazards models were developed for 5- and 10-y prediction of outcomes based on 26 risk factors. Risk factors associated with increased mortality included previous kidney transplants, rescue allocations, longer waiting times, and simultaneous transplants of other organs. Increased pancreas graft loss was positively associated with higher recipient body mass index and donor age and negatively associated with simultaneous transplants of kidneys and other organs. Donor age was also associated with increased kidney graft losses. The multivariable Cox models reported median C-index values were 63% for patient mortality, 62% for pancreas loss, and 55% for kidney loss. This study provides an online risk tool at https://riskcalc.org/ptop for individual 5- and 10-y post-PKT and PT patient outcomes based on parameters available at the time of graft offer to support critical organ acceptance decisions and encourage external validation in independent populations.

Progressive hyperparathyroidism post simultaneous pancreas-kidney transplantation in a long-term type 1 diabetes mellitus remission patient

Progressive hyperparathyroidism post simultaneous pancreas-kidney transplantation in a long-term type 1 diabetes mellitus remission patient

Features of pregnancy after simultaneous pancreas-kidney transplantation in patient with type 1 diabetes mellitus (clinical case)

Features of pregnancy after simultaneous pancreas-kidney transplantation in patient with type 1 diabetes mellitus (clinical case)

Effect of pretransplant dialysis modalities on pancreas-kidney transplant outcomes: A systematic review and meta-analysis.

The impact of different pre-transplant dialysis modalities on post-transplant outcomes for pancreas-kidney transplantation is currently unclear. This study aims to assess the association between pretransplant dialysis modalities (hemodialysis and peritoneal dialysis) and outcomes following pancreas-kidney transplantation. We searched PubMed, EMBASE, and the Cochrane Library for relevant studies published from inception until December 1, 2023. We included studies that examined the relationship between pre-transplant dialysis modalities and clinical outcomes for pancreas-kidney transplantation. The primary outcomes considered were patient, pancreas and kidney graft survival, and intra-abdominal infection. A total of 13 studies involving 1503 pancreas-kidney transplant recipients were included. Pretransplant hemodialysis was associated with improved pancreas graft survival (hazard ratio = 0.71, 95% confidence interval [CI]: 0.51 - 0.99, I² = 12%) and a decreased risk of intra-abdominal infection (odds ratio [OR] = 0.69, 95% CI: 0.51 - 0.93, I² = 5%). However, no significant association was found between the dialysis modalities and patient or kidney graft survival. Furthermore, pre-transplant hemodialysis was linked to a reduced risk of anastomotic leak (OR = 0.32, 95% CI: 0.161 - 0.68, I² = 0%) and graft thrombosis (OR = 0.56, 95% CI: 0.33 - 0.96, I² = 20%). Pre-transplant hemodialysis is the preferred dialysis modality while awaiting pancreas-kidney transplantation, although well-designed prospective studies are needed to confirm these findings.

Abstract PO4-20-09: Successful outcome of locally advanced HR+HER2+ breast cancer treatment in a young female after pancreas-kidney transplantation. 3-year follow-up

Abstract Background Solid organs recipients with subsequent cancer comprise a group of patients with unmet medical needs: they lack any clinical trials or guidelines for treatment. There are only individual case reports in literature. Meanwhile their number is growing due to achievements in transplantology and improved cancer diagnosis. Case presentation А young 34-year-old female attended our center in September 2019 with a palpable mass and peau d'orange of the left breast. A core-needle biopsy of the left breast mass revealed invasive ductal carcinoma G3, estrogen receptor 7 (Allred), progesterone receptor 6 (Allred), HER-2 (3+), Ki-67 49%. Left axillary lymph node biopsy revealed metastatic breast cancer. After a complete examination the clinical stage was cT4bN1fM0, IIIB stage. The patient had a history of Type 1 diabetes mellitus since 2003 leading to multiple complications including terminal diabetic nephropathy, which required renal replacement therapy with the use of long-term hemodialysis since July 2014. The other complications consisted of severe retinopathy with corneal transplantation on the left eye in April 2013, an episode of right eye hemophthalmia in March 2016 with consequent loss of vision in the right eye, polyneuropathy, gastropathy and enteropathy. The patient underwent a simultaneous pancreas-kidney transplantation in April, 2016 and was on permanent immunosuppressive therapy with tacrolimus 8 mg daily and methylprednisolone 8 mg daily. The function of both transplants was satisfactory. This unique case was published by Pinchuk A. et al. in Transplant Proceedings, 2017 [doi: 10.1016/j.transproceed.2017.10.005]. A multidisciplinary approach was applied to tailoring treatment plan for this patient. Initially immunosuppressive therapy was modified: the patient discontinued methylprednisolone and started everolimus with simultaneous tacrolimus dose reduction (their doses adjusted according to blood concentrations). The tumor board decision was to start neoadjuvant therapy with regimen with the mildest and the most manageable toxicity profile and to avoid anthracyclines. From October to December 2019 the patient received 12 cycles of paclitaxel 80 mg/m2 day 1 weekly and 4 cycles of anti-HER2 dual blockade: trastuzumab 8 mg/kg day 1 followed by 6 mg/kg day 1 every 21 days + pertuzumab 840 mg day 1 followed by 420 mg day 1 every 21 days. Adverse events were: stomatitis grade 1, palmar-plantar erythrodysesthesia grade 1, diarrhea grade 2. Partial response was evaluated in the end of December 2019, but due to persistent skin edema, she was not a candidate for surgical treatment. The tumor board decision was to proceed with T-DM1 + pertuzumab based on the results of the KRISTINE trial [doi:10.1016/s1470-2045(17)30716-7]. From January to March 2020 the patient received 4 cycles of trastuzumab-emtansine 3,6 mg/kg day 1 every 21 days + pertuzumab 420 mg day 1 every 21 days. The patient tolerated this treatment with mild toxicity: ALT & AST increase grade 2 and diarrhea grade 2. Considering that the edema was significantly reduced, surgical treatment was planned. The patient underwent a modified radical mastectomy for left breast cancer on 14 of April 2020. The pathological stage was ypT1аN0 R0, RCB I. The patient continued trastuzumab emtansine until November 2020 (up to 1 year of anti-HER2 targeted therapy) in the adjuvant setting. In June 2020 she underwent locoregional radiation therapy. Tamoxifen with ovarian function suppression (LHRH agonists) for 5 years was started in June 2020. Fortunately, after 3 years of follow-up after surgery there is no evidence of disease and no delayed cancer treatment complications. Conclusion: Personalized multidisciplinary team decisions for cancer patients after organ transplantation are crucial to further improve the long-term outcome of these patients. Citation Format: Lyudmila Zhukova, Natalya Polshina. Successful outcome of locally advanced HR+HER2+ breast cancer treatment in a young female after pancreas-kidney transplantation. 3-year follow-up [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-20-09.

Surgical complications and technical failure of simultaneous pancreas-kidney transplantation: A 22-year experience from a single center.

Simultaneous pancreas-kidney transplantation (SPKT) is the best treatment for selected individuals with type 1 diabetes mellitus and end-stage renal disease. Despite advances in surgical techniques, donor and recipient selection, and immunosuppressive therapies, SPKT remains a complex procedure with associated surgical complications and adverse consequences. We conducted a retrospective study that included 263 SPKT procedures performed between May 2000, and December 2022. A total of 65 patients (25%) required at least one relaparotomy, resulting in an all-cause relaparotomy rate of 2.04 events per 100 in-hospital days. Lower donor body mass index was identified as an independent factor associated with reoperation (OR.815; 95% CI: .725-.917, p=.001). Technical failure (TF) occurred in 9.9% of cases, primarily attributed to pancreas graft thrombosis, intra-abdominal infections, bleeding, and anastomotic leaks. Independent predictors of TF at 90 days included donor age above 36 years (HR 2.513; 95% CI 1.162-5.434), previous peritoneal dialysis (HR 2.503; 95% CI 1.149-5.451), and specific pancreas graft reinterventions. The findings highlight the importance of carefully considering donor and recipient factors in SPKT. The incidence of TF in our study population aligns with the recent series. Continuous efforts should focus on identifying and mitigating potential risk factors to enhance SPKT outcomes, thereby reducing post-transplant complications.

Increase in lumbar spine but not distal radius bone mineral density in adults after pancreas kidney transplantation

Osteoporosis occurs in every third individual after simultaneous pancreas kidney transplantation (SPKT). Currently used bone measures insufficiently predict their fracture risk. Lumbar spine Trabecular bone score (TBS) and distal radius areal and volumetric bone mineral density (BMD) were monitored for the first time in patients with type 1 diabetes and chronic renal failure after SPKT with steroid-sparing protocol. In 33 subjects (mean age 43.4 ± 9.8 years), dual-energy X-ray absorptiometry and peripheral quantitative computed tomography were performed just after SPKT (baseline) and one and three years later. While TBS Z-scores increased (−1.1 ± 1.2 and −0.3 ± 1.0; p˂0.001, at baseline and year three, respectively), trabecular volumetric BMD Z-scores at distal radius metaphysis did not change during the study (−1.3 ± 1.3 and −1.3 ± 1.0; p = 0.38). Similarly, areal BMD Z-scores increased at lumbar spine, total hip and femoral neck (all p < 0.01), but not at the distal radius. SPKT induced bone measures' improvement at lumbar spine and hip but not at distal radius. Before suggesting changes in current clinical care, predictive value of individual bone measures or its combination for fracture risk assessment remains to be elucidated.

Belatacept Rescue Therapy in the Early Period After Simultaneous Kidney-Pancreas Transplantation.

Belatacept Rescue Therapy in the Early Period After Simultaneous Kidney-Pancreas Transplantation.

High burden of CMV infections after simultaneous pancreas-kidney transplantation—a nationwide cohort study

Cytomegalovirus (CMV) infections remain a common problem after solid-organ transplantation. We characterized the burden of CMV infections, and adverse events of CMV prophylaxis after simultaneous pancreas-kidney transplantation (SPK). We included all SPK patients (n = 236) since 2010 in our country. Immunosuppression was ATG, tacrolimus, mycophenolate, and steroids. Valganciclovir prophylaxis was given to all CMV D+/R− patients for six months, and to seropositive SPK patients for three months since February 2019. CMV DNAemia was monitored with quantitative PCR from plasma. Among D+/R− SPK recipients, post prophylaxis CMV infection was detected in 41/60 (68%) during follow-up. In seropositive SPK recipients with no prophylaxis, CMV infection was detected in 53/95 (56%), vs. 28/78 (36%) in those who received 3 months of prophylaxis (P = 0.01). CMV was symptomatic in 35 (15%) patients, of which 10 required hospitalization. Mean duration of viremia was 28 days (IQR 21–41). Leukopenia was detected in 63 (46%) of the 138 patients with valganciclovir prophylaxis. 7/122 (6%) of the CMV infections detected were defined as refractory to treatment, and three patients had confirmed ganciclovir resistance. SPK recipients experience a high burden of CMV infections despite CMV prophylaxis. Leukopenia is common during valganciclovir prophylaxis.

WCN24-332 Single Center Experience of Simultaneous Kidney Pancreas Transplants: Benefit for Type 2 Diabetic CKD Patients

WCN24-332 Single Center Experience of Simultaneous Kidney Pancreas Transplants: Benefit for Type 2 Diabetic CKD Patients

Indices of Nutrition Status of Kidney and Pancreas Transplant Candidates

Nutritional assessment is used to implement early nutritional interventions and reduce complications associated with malnutrition, which plays a crucial role in improving postoperative outcomes for patients undergoing pancreas and/or kidney transplantation. ObjectiveThe aim of this study was to analyze the nutritional status (NS) in patients eligible for kidney transplantation (KTx) and simultaneous kidney-pancreas transplantation (SPKTx). MethodsWe analyzed the database of hospitalized patients from 2020 to 2023 to identify preoperative parameters of NS in patients eligible for KTx and SPKTx. A total of 59 patients participated in the study, all of whom were candidates for KTx-23 or SPKTx-36. The study population consisted of 35 women (W) and 24 men (M), with an overall mean age of 44.8 ± 10.2 years (43.5 ± 10.2 years for W and 46.2 ± 10.9 years for M). Both groups included patients on hemodialysis (n = 34) and peritoneal dialysis (n = 12), and patients in the predialysis period (pre-emptive, n = 13). The examined parameters included Onodera's prognostic nutritional index (PNIO), the nutritional risk index (NRI), proper body mass calculated using the Lorenz formula, and the neutrophil-to-lymphocyte ratio (NLR). All patients were assessed according to the NRS 2002 scale. ResultsAnalysis of the obtained results revealed that the NLR was only one differentiating parameter between Ktx and SPKtx group. Multivariate analysis adjusted for patients’ age and gender, comparing quantitative NS indicators was performed. Albumin serum concentration was not dependent on patients’ group (KTx/SPKTx) neither age nor gender P = .382. BMI was dependent on patients’ age and gender, but not a group (KTx/SPKTx) P = .008. PNIO, NRI, and NRL were not dependent on patients’ group (KTx/SPKTx) neither age nor gender. ConclusionsAdditional effort should be devoted to the development of a proper nutrition plan for SPKTx a especially in peritoneal dialysis patients. Toward patients on the waiting list, the regular assessment of nutritional status should be performed which is not a rule in dialysis centers. SPKTx candidates in the perioperative period should receive proper nutrition taking into account their caloric and protein needs.

Assessing the influence of graft loss on 4-year patient survival after simultaneous pancreas-kidney transplantation: Kaplan-Meier versus Competing Risk Analysis model.

Graft loss increases the risk of patient death after simultaneous pancreas-kidney (SPK) transplantation. The relative risk of each graft failure is complex due to the influence of several competing events. This retrospective, single-center study compared 4-year patient survival according to the graft status using Kaplan-Meier (KM) and Competing Risk Analysis (CRA). Patient survival was also assessed according to five eras (Era 1: 2001-2003; Era 2: 2004-2006; Era 3: 2007-2009; Era 4: 2010-2012; Era 5: 2012-2015). Between 2000 and 2015, 432 SPK transplants were performed. Using KM, patient survival was 86.5% for patients without graft loss (n=333), 93.4% for patients with pancreas graft loss (n=46), 43.7% for patients with kidney graft loss (n=16), and 25.4% for patients with pancreas and kidney graft loss (n=37). Patient survival was underestimated using KM versus CRA methods in patients with pancreas and kidney graft losses (25.4%vs. 36.2%), respectively. Induction with lymphocyte depleting antibodies was associated with 81% reduced risk (HR.19, 95% CI.38-.98, p=.0048), while delayed kidney function (HR 2.94, 95% CI 1.09-7.95, p=.033) and surgical complications (HR 2.94, 95% CI 1.22-7.08, p=.016) were associated with higher risk of death. Four-year patient survival increased from Era 1 to Era 5 (79%vs. 87.9%, p=.047). In this cohort of patients, kidney graft loss, with or without pancreas graft loss, was associated with higher mortality after SPK transplantation. Compared to CRA, the KM model underestimated survival only among patients with pancreas and kidney graft losses. Patient survival increased over time.

O172: Donor blood tests and pancreas outcome in simultaneous pancreas kidney transplantation, a national cohort study

Abstract Introduction Simultaneous pancreas-kidney (SPK) transplantation improves quality of life in people with diabetes and end-stage renal disease, and limits the progression of diabetes related complications. Many surgeons are reluctant to accept the pancreas of a donor with raised amylase, due to concern of potentially inferior outcomes. We aim to ascertain whether donor amylase and liver blood tests (a marker of visceral ischaemic injury) predict pancreas transplant outcome. Methods This retrospective cohort study used the NHS registry on adult SPK transplantation (2016-2021). Adjusted regressions models assessed the effect of donor amylase and liver blood tests on pancreas transplant outcome. Results 857 SPK recipients were included (619 following brainstem death, 238 following circulatory death). Peak donor amylase ranged from 8-3300U/L (median=70). Donor peak amylase had no significant impact on pancreas graft survival when adjusting for multiple confounders (aHR=0.944, 95% CI=0.754-1.81). Median peak alanine transaminase and aspartate transaminase was 67U/L and 72U/L (range 8-5930 and 0-7910U/L). Neither of these influenced pancreas graft survival in multivariable models (aHR=0.967, 95% CI=0.848-1.102 and aHR=0.908, 95% CI=0.771-1.070, respectively). Restricted cubic splines were used to assess the relationship between donor blood tests and pancreas graft survival without assuming linear relationships; these confirmed neither amylase, nor transaminases, significantly impact on pancreas transplant outcome. Conclusions Donor amylase and transaminases do not predict transplant outcomes. Therefore, raised donor amylase or transaminases should not be considered a barrier to organ utilisation. The use of pancreas grafts from donors with hyperamylasaemia is a safe, immediate, and simple approach to expand the donor pool.

O236: The Impact of HLA Matching on Pancreas and Simultaneous Pancreas-Kidney (SPK) Transplantation Outcomes

Abstract Background This study evaluates the controversial impact of human leukocyte antigen (HLA) matching on pancreas graft survival and acute rejection. Methods Utilizing a large-scale multi-center database (UNOS/OPTN), we identified 8,005 pancreas and 7,850 simultaneous pancreas-kidney (SPK) transplant patients. Patients were classified into HLA matched (0-3 mismatches) and mismatched (4-6 mismatches) groups. Subsequently, utilizing multivariate Cox analysis, we evaluated risk-adjusted outcomes, represented through Kaplan-Meier survival curves. We also examined differences in graft survival and acute rejection based on transplant type (SPK or pancreas alone) within the same HLA mismatch group. Findings There were no significant differences in pancreas graft survival or acute rejection observed between HLA matched and mismatched groups for both pancreas and SPK transplant recipients (P &amp;gt; 0.05). However, among HLA mismatched patients, pancreas patients exhibited a 629-day lower pancreas graft survival than SPK patients (3774 vs. 4403 days, P &amp;lt; 0.001) and had a higher likelihood of experiencing acute rejection post-transplant (P &amp;lt; 0.001). Similarly, within the HLA matched groups, pancreas patients showed lower graft survival compared to SPK patients (3774 vs. 4403 days, P &amp;lt; 0.001); however, their acute rejection rates did not significantly differ (P &amp;gt; 0.05). Interpretation Although HLA matching was not associated with improved pancreas graft survival or a reduction in acute rejection, the results suggest a potential protective effect of the kidney in SPK transplants against the consequences of HLA mismatching. This underscores the clinical significance of considering the kidney component in donor-recipient matching for pancreas transplantation.

O169: The impact of time to death in donors after circulatory death on recipient outcome in simultaneous pancreas-kidney transplantation

Abstract Background Agonal times can vary between organ donors after circulatory death (DCD) following withdrawal of treatment, which leads to variable warm ischaemic damage to pancreas grafts. Currently there is little evidence supporting procurement team standdown times based on donor time to death (TTD). We examined what impact TTD had on pancreas graft outcomes following DCD transplantation. Methods Data were extracted from the UK transplant registry from 2014 to 2022. TTD was defined as withdrawal of life-sustaining treatment to donor asystole; asystolic time was the time from asystole to aortic perfusion. Predictors of graft loss were fitted into a Cox proportional hazards model. Adjusted restricted cubic spline (RCS) models were generated to further delineate the relationship between TTD and outcome. Statistical significance was set at P&amp;lt;0.05. Results 375 DCD simultaneous kidney-pancreas transplant recipients were included. Median TTD was 13-minutes (IQR 10 to 16-minutes), median asystolic time was 13-minutes (IQR 11 to 15-minutes). Increasing TTD was not associated with poorer graft survival (aHR 0.98, 95% CI 0.68-1.41, P=0.901). Increasing asystolic time was significantly associated with worse graft survival in the TTD model (aHR 2.51, 95%CI 1.16-5.43, P=0.020). RCS modelling confirmed there was no relationship between TTD and graft survival, however a non-linear relationship was demonstrated between asystolic time and graft survival. Conclusion We found no evidence that TTD impacts pancreas graft survival in DCD SPK transplantation, however increasing asystolic time was significant predictors of graft loss. Procurement teams should attempt to minimise asystolic time to reduce ischaemic injury to the pancreas graft.

Incidence, Risk Factors, and Outcomes of Posttransplant Erythrocytosis Among Simultaneous Pancreas-Kidney Transplant Recipients.

Posttransplant erythrocytosis (PTE) is a well-known complication of kidney transplantation. However, the risk and outcomes of PTE among simultaneous pancreas-kidney transplant (SPKT) recipients are poorly described. We analyzed all SPKT recipients at our center between 1998 and 2021. PTE was defined as at least 2 consecutive hematocrit levels of >51% within the first 2 y of transplant. Controls were selected at a ratio of 3:1 at the time of PTE occurrence using event density sampling. Risk factors for PTE and post-PTE graft survival were identified. Of 887 SPKT recipients, 108 (12%) developed PTE at a median of 273 d (interquartile range, 160-393) after transplantation. The incidence rate of PTE was 7.5 per 100 person-years. Multivariate analysis found pretransplant dialysis (hazard ratio [HR]: 3.15; 95% confidence interval [CI], 1.67-5.92; P < 0.001), non-White donor (HR: 2.14; 95% CI, 1.25-3.66; P = 0.01), female donor (HR: 1.50; 95% CI, 1.0-2.26; P = 0.05), and male recipient (HR: 2.33; 95% CI, 1.43-3.70; P = 0.001) to be associated with increased risk. The 108 cases of PTE were compared with 324 controls. PTE was not associated with subsequent pancreas graft failure (HR: 1.36; 95% CI, 0.51-3.68; P = 0.53) or kidney graft failure (HR: 1.16; 95% CI, 0.40-3.42; P = 0.78). PTE is a common complication among SPKT recipients, even in the modern era of immunosuppression. PTE among SPKT recipients was not associated with adverse graft outcomes, likely due to appropriate management.

A Rare Cause of Gastrointestinal Bleeding in a Kidney-Pancreas Transplant Recipient – Case Report

Kidney-pancreas transplantation is the preferable therapeutic option for patients with type 1 diabetes mellitus and end-stage kidney disease. We describe the case of a 35-year-old pancreas-kidney transplant recipient with dual-graft failure that presents with massive hematochezia and hemodynamic instability, evolving into hemorrhagic shock. The diagnostic assessment revealed a fistula between a pseudoaneurysm of the right common iliac artery and the adjacent transplanted duodenum segment, a rare but life-threatening cause of gastrointestinal bleeding in these patients. An endoprosthesis was placed into the iliac artery, prophylactic antibiotics were instituted, and a pancreatic transplantectomy was performed in a second procedure. This case highlights that the diagnostic workup of gastrointestinal bleeding in pancreas-kidney transplant recipients must include the possibility of arterio-enteric fistulas, which is more frequent in the presence of pancreatic graft failure, as was the case of our patient. Endovascular exclusion is the advocated treatment. Pancreatic graft transplantectomy could also be a possible approach for patients with a failed pancreas but it is highly controversial due to potential risks.

Clinical outcomes of simultaneous pancreas-kidney transplantation in elderly type II diabetic recipients

The effect of age on outcomes after simultaneous pancreas-kidney transplantation (SPK) among type II diabetes (T2DM) recipients remains inconclusive. This study aimed to analyze the relationship between the age at time of transplantation and mortality, graft loss and metabolic profiles of T2DM SPK recipients. A retrospective cohort consisting of T2MD SPK recipients in a single transplant center was established. The baseline clinical characteristics and outcomes were collected and analyzed based on the age groups divided by 55-year-old. Time-to-event data analysis was performed using Kaplan-Meier method, and competing risk method was adopted to calculate the cumulative incidence of graft loss. A mixed regression model was applied to compare metabolic outcomes including glycated hemoglobin (HbA1c), fasting blood glucose, triglyceride, cholesterol, low-density lipoprotein, and higher estimated glomerular filtration rate (eGFR). 103 T2DM SPK recipients were included, of which 35 were > = 55 years old and 68 were < 55 years old. Baseline characteristics were comparable between age groups. The results indicated that comparable 5-year survival outcomes between groups with functioning grafts perioperatively. Additionally, no relationship of age with graft loss, complications and metabolic outcomes was detected.