Pancreas Kidney Research Articles

Protocol Duodenal Graft Biopsies Aid Pancreas Graft Surveillance

Histological evaluation of the pancreas graft is usually done on demand resulting in significant delays. This analysis reports on endoscopic protocol duodenal graft biopsies at regular intervals to determine feasibility, safety, and monitoring benefits. Protocol duodenal graft biopsies in 27 consecutive pancreas transplants (10 simultaneous pancreas kidney [SPK], 17 pancreas after kidney [PAK]) with a follow-up of a minimum of 12 months were performed at days 14, 30, 90, 180, 360, 430. University of Pittsburgh Medical Center classification for intestinal rejection was used. C4d staining was performed when antibody-mediated rejection was suspected. Overall patient and pancreas graft survival was 100% and 93% at a mean follow-up of 2.8 years. One hundred sixty-seven endoscopic biopsy procedures were performed in 27 grafts without any complication. Biopsies revealed rejection in 3 (30%) SPK recipients and in 15 (82%) of PAK recipients as early as 14 days posttransplant. Two patients underwent PAK retransplantation diagnosed with acute rejection at day 180. All except 1 recipient being treated for rejection, showed histological improvement following antirejection treatment. Following transient treatment success, a total of 3 pancreas grafts were lost for immunological reason. One loss was immediate despite antirejection treatment, 1 secondary to nonresolving rejection at 7 months and the third due to recurrent rejection 15 months posttransplantation. Additionally, biopsies detected vascular (venous thrombosis) and overimmunosuppression (cytomegalovirus infection) complications. Protocol graft duodenal biopsies detect complications after whole-organ pancreas transplantation, are useful in guiding therapy, and carry potential for improving outcome.

THE NUCLEAR FACTOR OF HEPATOCYTES 1β (HNF1β)–ASSOCIATED DISEASE. CLINIC, DIAGNOSTIC, TREATMENT (LITERATURE REVIEW AND CLINICAL OBSERVATION)

Hepatocyte nuclear factor 1β (HNF1β)-associated disease is a rare autosomal dominant disease caused by various mutations in the HNF1β gene coding the hepatocyte nuclear factor 1β. HNF1β is a transcription factor that is critical for the development of kidney urogenital tract, pancreas, liver, brain, and parathyroid gland. Renal phenotype or HNF1β- nephropathy appeared to be extremely heterogenic: multicystic renal dysplasia, renal hypoplasia, unilateral renal agenesis, horseshoe kidney, atypical familial juvenile hyperuricemic nephropathy, urinary tract malformations and tubular dysfunction. Extrarenal phenotype of HNF1β-associated disease could be maturity-onset diabetes of the young (MODY), pancreatic atrophy and exocrine pancreatic dysfunction, elevated liver enzymes, neonatal cholestasis, congenital abnormalities of the genital tract, hyperparathyroidism, neurological symptoms. The multisystem phenotype makes clinical verification of the diagnosis extremely difficult. In this article, we present a clinical observation of a child with HNF1β – associated disease. The first clinical presentation of HNF1β-associated disease was ultrasound changes in the kidneys (hyperechogenic kidneys?), which were detected by prenatal ultrasonography in pregnancy. Renal ultrasound revealed polycystic kidney disease in the first days of life and bilateral medullary nephrocalcinosis by the age of three. The clinical examination showed a reduced renal function and developed Fanconi syndrome (glycosuria, low molecular proteinuria, hypophosphatemia, aminoaciduria, hyperuricosuria) in the first year of life. Also the child had a non-constant asymptomatic elevation of liver enzymes, hyperparathyroidism, osteoporosis. The diagnosis was confirmed by the results of next generation sequencing which revealed novel heterozygous mutation in exon 4 of the HNF1b gene (chr17: 36091813C>T), p.Cys273Tyr (c.818G>A). The identified mutation was validated by Sanger sequencing. Validation by Sanger sequencing did not reveal a chr17: 36091813C>T mutation in parents, which suggested the appearance of a mutation in the child de novo.

Simultaneous Pancreas-Kidney Transplant From Donors After Brain Death vs Donors After Circulatory Death: A Single-Center Follow-up Study Over 3 Decades

BackgroundDespite an increase in the number of pancreas transplants in the Scandiatransplant region in the last decade, there continues to be a gap between demand and supply of transplantable organs. This imbalance has encouraged the transplant community to consider new sources of grafts, such as the reintroduction of donors after circulatory death (DCD) who were the standard donors in our center before 1988. Material and MethodsIn this long-term follow-up study, we compare 44 consecutive, simultaneous pancreas kidney transplants performed at Karolinska University Hospital between 1986 and 1991: 21 patients received DCD grafts and 23 received grafts from donors after brain death. ResultsBoth groups had similar donor and recipient characteristics, but cold ischemia times were significantly shorter in the DCD group. Warm ischemia times were very short compared with other studies on DCDs. Patient and graft survival rates were similar in both groups. ConclusionThis study suggests that controlled DCD pancreas and kidney grafts transplanted simultaneously can be a feasible option for reducing organ shortage without any negative impact on the long-term results.

The impact of a muscle pump activator on incisional wound healing compared to standard stockings and compression devices in kidney and kidney-pancreas transplant recipients: A randomized controlled trial.

We aimed to evaluate the impact of thrombo-embolic-deterrent + intermittent pneumatic compression (TED + IPC) vs. muscle pump activator (MPA) on incisional wound healing in kidney and simultaneous pancreas- kidney (SPK) transplant recipients. We conducted a single-centre, randomized controlled trial in which 104 patients (kidney n=94; SPK n=10) were randomly assigned to wear TED + IPC (n= 52) or MPA (n=52) for the first six days following surgery. Patient demographics, postoperative outcomes, and incisional wound images were taken using a HIPAA-compliant application on postoperative days (POD) 3, 5, and 30, and assessed using the validated Southampton Wound Care Score. There were no demographic differences between the groups. The MPA group had a significant improvement in wound healing on POD 3 (p=0.04) that persisted until POD 5 (p=0.0003). At POD 30, both groups were similar in wound healing outcomes (p=0.51). Bayesian inferential analysis revealed that the use of TED + IPC following transplantation had inferior outcomes compared to the use of MPA with sequential moderate evidence. The rate of complex wound infections was significantly greater in the TED + IPC group compared to the MPA group (29% vs. 12%, respectively; p=0.03). Patients were more satisfied with the use of a MPA device than TED + IPC. No major complications were encountered in either group. The use of a MPA device in the immediate postoperative period leads to a significant improvement in immediate and early wound healing, and decreased number of complex wound infections following kidney and SPK transplantation compared to standard TED + IPC therapy. Patients were more satisfied with the use of a MPA device than TED + IPC.

Inhibition of macrophage migration inhibitory factor attenuates inflammation and fetal kidney injury in a rat model of acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a severe disease during pregnancy that mostly occurs during the third trimester. It can lead to additional complications including preterm delivery and high fetal mortality. In this study, we investigated the protective effects of (S, R)-3-(4-hydroxyphenyl)-4, 5dihydro-5-isoxazole acetic methyl ester (ISO-1), an inhibitor of macrophage migration inhibitory factor (MIF), on fetal kidney injury associated with the maternal acute necrotizing pancreatitis (ANP) and its potential mechanisms in a rat model. The APIP rat model was induced by retrograde infusion of sodium taurocholate saline solution into biliopancreatic duct. ISO-1 was given by intraperitoneally injection 30 min before the model was induced. The levels of maternal serum amylase, lipase, tumor necrosis factor-α (TNF-α) and interleukins (IL)-1β were measured. Maternal pancreas and fetal kidney injury were evaluated, and the expressions of MIF, phospho-p38MAPK (p-p38), nuclear factor-κB (NF-κB), TNF-α, IL-1β in fetal kidneys were detected. The results showed that fetal rats exhibited obvious acute kidney injury during APIP, and pregnant rats pretreated with ISO-1 notably attenuated the lesions. ISO-1 also significantly reduced the expression of MIF and the activations of p38MAPK, NF-κB, as well as the levels of TNF-α and IL-1β. These results indicated that ISO-1 could attenuate fetal kidney injury in pregnant rats with ANP by inhibiting MIF mediated p38MAPK/NF-κB signal pathways to reduce inflammatory response.

Induction of apoptosis from exposure to aristolochic Acid

The genus Aristolochia gathers plants used in folk medicine which present in their composition the Aristolochic acids I and II Among the major toxicological events caused by Aristolochic acids is programmed cell death Aristolochic acid induced apoptosis occurs in target organs such as the liver kidney pancreas testis ovary intestine and lung Although it is beneficial for the cure of various diseases Aristolochias or Aristolochic acids I and II can also cause necrosis The objective of this work was to compile information about the effects of Aristolochic acids on the induction of apoptosis The present work makes an alert when consuming this herb and derivatives that possess Aristolochic acids

Feasibility of Laparoscopic Combined Para-Orthotopic Pancreas and Orthotopic Kidney Transplantation: Initial Research with a Pig Model.

BackgroundThe aim of this study was to investigate the feasibility of laparoscopic combined para-orthotopic pancreas and orthotopic kidney transplantation in a pig model.Material/MethodsTwelve white female pigs, (4–5 months old, weight range 40–45 kg) were used as donors and recipients, and 6 laparoscopic-combined pancreas and kidney transplantations were performed. After bilateral nephrectomy, the pancreatic artery and vein were anastomosed to the right renal artery and vein, respectively, and the pancreatic fluid was diverted to the duodenum or jejunum. The renal artery and vein were anastomosed to the left renal artery and vein, respectively. The ureter (or kidney pelvis) was anastomosed to the left native ureter (or kidney pelvis). The data of the operations were recorded, and grafts were inspected at autopsy.ResultsFour of the 6 recipient pigs underwent the entire procedure. The duodenum-to-duodenum anastomosis was unfinished in 1 case, and both the duodenum-to-duodenum and renal pelvis-to-pelvis anastomoses were left unperformed in another case. The mean recipient operative time was 429±43 minutes. The mean venous and arterial anastomotic times were 69±15 minutes and 37±18 minutes, respectively, for pancreas transplantation and 56±09 minutes and 42±06 minutes, respectively, for kidney transplantation. The time for renal pelvis-to-pelvis anastomosis was 56±13 minutes and for duodenum-to-duodenum anastomosis was 90±13 minutes. The mean blood loss for recipient pigs was 98±35 mL. An immediate viable blood supply was seen in the 4 pancreatic grafts and in the 5 kidney grafts during the operation by the appearance of a bright red color after revascularization. Five pancreatic grafts had autopsy-proven reliable artery anastomoses and 4 reliable vein anastomoses. All 6 kidney grafts had autopsy-proven reliable artery anastomoses; however, 1 had a vein anastomotic stricture.ConclusionsOur study showed that laparoscopic-combined para-orthotopic pancreas and orthotopic kidney transplantation in pigs is surgically possible.

1138. Retrospective Cohort Analysis of Amphotericin B Nephrotoxicity in Kidney Transplant Recipients

BackgroundTreatment of invasive fungal infections with amphotericin B is a concern in kidney transplant patients due to fear of allograft loss. Reluctance to use amphotericin B may lead to suboptimal therapy and poor treatment outcomes. The risk of amphotericin B-related nephrotoxicity and allograft dysfunction has not been studied in kidney transplant patients. Our aim was to study the association between amphotericin B and acute kidney injury (AKI) as defined by the Acute Kidney Injury Network classification, allograft loss and patient mortality in kidney transplant recipients.MethodsWe used SPSS to conduct a descriptive analysis of a retrospective cohort of 30 adult kidney transplant recipients who were admitted to Virginia Commonwealth University Medical Center and received treatment with amphotericin B from 2005 to 2015.ResultsThe median age in our cohort was 57. 40% were female, 60% were male. 60% had received a kidney transplant from a deceased donor; 13.3% from a living related donor; 13.3% from a living unrelated donor; and 13.3% had received a combined kidney–pancreas transplant. 63.3% of patients had received liposomal amphotericin B; 33.3% had received lipid-complex amphotericin B; 3.3% had received conventional amphotericin B. We found an association between cumulative amphotericin B doses above 5,000 mg and AKI, whereby 64.7% of patients exposed to less than 5,000 mg of amphotericin B developed AKI and 100% of patients exposed to more than 5,000 mg of amphotericin B developed AKI (P = 0.017). We did not find an association between cumulative amphotericin B doses above 5,000 mg and return to dialysis at 3 months and 12 months post-exposure (P = 0.436 and 0.288, respectively). We also did not find an association between such doses of amphotericin B and mortality at 30 and 90 days (P = 0.869 and 0.193, respectively).ConclusionIn the first descriptive analysis of a retrospective cohort of kidney transplant patients exposed to amphotericin B, our results suggest that the risk of nephrotoxicity may be significantly increased when a cumulative dose of 5,000 milligrams is exceeded. Our results also suggest that amphotericin B doses associated with nephrotoxicity in kidney transplant patients may not have an effect on allograft survival and patient mortality.Disclosures All authors: No reported disclosures.

Pneumocystis jiroveci pneumonia in kidney and simultaneous pancreas kidney transplant recipients in the present era of routine post-transplant prophylaxis: risk factors and outcomes

BackgroundThe goal of this study was to identify predictors for development of Pneumocystis jirovecii pneumonia (PJP) in kidney and simultaneous kidney and pancreas transplant recipients in the present era of universal primary prophylaxis.MethodsWe reviewed adult recipients of kidney transplant or simultaneous pancreas and kidney transplant at the University of Wisconsin between January 1, 1994 and December 31, 2016. Patients diagnosed with PJP during this time frame were included. Controls were randomly selected from among those whose post-transplant course was not complicated by PJP, matched on time since transplant through incidence density sampling with a 3:1 ratio.Results28 (0.45%) of 6270 recipients developed PJP between 1994 and 2016. Median time since transplant was 4.6 years (interquartile range (IQR): 1.4–9.6 years). Affected recipients were older, had more HLA mismatches, and were more likely to have had BK viremia, CMV viremia and invasive fungal infections than matched controls. CMV viremia remained the only significant risk factor in multivariate analysis, and was a strong predictor (OR 6.27; p = 0.002). Ninety percent of the cases with prior CMV viremia had been diagnosed in the year preceding the diagnosis of PJP; among these, median time from diagnosis of CMV to diagnosis of PJP was 3.4 months (IQR: 1.74–11.5 months) and median peak CMV viral load prior to diagnosis of PJP was 3684.5 IU/mL (IQR: 1034–93,300 IU/mL). Additionally, 88.9% of patients with CMV in the preceding year had active infection at time of PJP diagnosis. Patient and graft survival were significantly worse at 2 years in recipients with PJP than our control group (42.4% vs. 88.5, and 37.9% vs. 79.9%; p < 0.001).ConclusionsDespite the low overall incidence of PJP in the era of universal prophylaxis, outcomes are poor. We suggest extending or re-initiating PJP prophylaxis for at least 6 months in the setting of CMV viremia due to the relatively low risk of therapy and potential significant impact on disease prevention.

The survival advantage of pancreas after kidney transplant.

Patient survival after pancreas after kidney transplant (PAK) has been reported to be inferior to patient survival after simultaneous pancreas-kidney transplant (SPK). The authors examine national data to further explore allograft (kidney and pancreas) and patient survival after PAK. Kaplan-Meier and Cox proportional hazard models were used to analyze Organ Procurement and Transplantation Network data from 1995 to 2010. The analysis compared PAK and SPK candidates and recipients. Kaplan-Meier analysis results showed that PAK after either a living or a deceased donor kidney transplant is associated with increased kidney graft survival compared with recipients with type 1 diabetes who received only a kidney. The best kidney allograft survival was for patients who received a living donor kidney followed by PAK. Receiving a living donor kidney was associated with increased pancreas allograft survival compared with receiving a deceased donor kidney. PAK transplant recipients who receive both organs have a survival advantage compared with uremic candidates who receive neither (SPK waitlist). Compared with uremic diabetic waitlist patients, SPK and PAK recipients showed similar overall patient survival. Successful PAK offers a survival advantage compared with receiving neither a kidney nor a pancreas transplant. These data also suggest that receiving a pancreas (after kidney) transplant may have a protective effect on the kidney allograft.

Preserved insulin secretion and kidney function in recipients with functional pancreas grafts 1 year after transplantation: a single-center prospective observational study

Successful simultaneous pancreas and kidney transplantation (SPK) or pancreas transplantation alone (PTA) restores glycemic control. Diabetes and impaired kidney function are common side effects of immunosuppressive therapy. This study addresses glucometabolic parameters and kidney function during the first year. We examined 67 patients with functioning grafts (SPK n = 30, PTA n = 37) transplanted between September 2011 and November 2016 who underwent repeated oral glucose tolerance tests (OGTTs) 8 and 52 weeks after transplantation. Another 19 patients lost their graft the first year post-transplant and 28 patients did not undergo repeated OGTTs and could not be studied. All patients received ATG induction therapy plus tacrolimus, mycophenolate and prednisolone. Glomerular filtration rate was measured before and 8 and 52 weeks after transplantation by serum clearance methods. From week 8 to 52 after transplantation, mean fasting glucose decreased (SPK: 5.4 ± 0.7 to 5.1 ± 0.8 mmol/L, PTA: 5.4 ± 0.6 to 5.2 ± 0.7 mmol/L; both P < 0.05), and also 120-min post-OGTT glucose (SPK: 6.9 ± 2.9 to 5.7 ± 2.2 mmol/L; P = 0.07, PTA: 6.5 ± 1.7 to 5.7 ± 1.2 mmol/L; P < 0.05). Fasting C-peptide levels also decreased (SPK: 1500 ± 573 to 1078 ± 357 pmol/L, PTA: 1210 ± 487 to 1021 ± 434 pmol/L, both P < 0.005). Measured GFR decreased from enlistment to 8 weeks post transplant in PTA patients (94 ± 22 to 78 ± 19 mL/min/1.73 m2; P < 0.005), but did not deteriorate from week 8 to week 52 (SPK: 55.0 ± 15.1 vs 59.7 ± 11.3 ml/min/1.73 m²; P = 0.19, PTA: 76 ± 19 vs 77 ± 19 mL/min/1.73 m²; P = 0.74). Glycemic control and kidney function remain preserved in recipients with functioning SPK and PTA grafts 1 year after transplantation.

Australia and New Zealand Islets and Pancreas Transplant Registry Annual Report 2018-Pancreas Waiting List, Recipients, and Donors.

BackgroundThis is a synopsis of the registry report from the Australia and New Zealand islet and pancreas transplant registry. The full report is available at http://anziptr.org/reports/.MethodsWe report data for all solid organ pancreas transplant activity from inception in 1984 to end 2017. Islet-cell transplantation activity is reported elsewhere. Data analysis was performed using Stata software version 14 (StataCorp, College Station, TX).ResultsFrom 1984 to 2017 a total of 809 solid organ pancreas transplants have been performed in Australia and New Zealand, in 790 individuals. In 2017, 52 people received a pancreas transplant. By center, this was; Auckland (4), Monash (17), and Westmead (31). In 2017, 51 transplants were simultaneous pancreas kidney, whereas 1 was pancreas after kidney, and none were pancreas transplant alone.ConclusionsThe number of pancreas transplants performed in Australia and New Zealand was slightly lower in 2017 but continues to increase over time.

A Valine Mismatch at Position 129 of MICA Is an Independent Predictor of Cytomegalovirus Infection and Acute Kidney Rejection in Simultaneous Pancreas⁻Kidney Transplantation Recipients.

The polymorphic major histocompatibility complex class I chain-related molecule A (MICA) and its soluble form (sMICA) interact with activating receptor natural-killer group 2 member D (NKG2D) on natural-killer (NK) and T cells, thereby modifying immune responses to transplantation and infectious agents (e.g., cytomegalovirus). Two single-nucleotide polymorphisms (SNPs), rs2596538GA in the MICA promoter and rs1051792AG in the coding region (MICA-129Val/Met), influence MICA expression or binding to NKG2D, with MICA-129Met molecules showing higher receptor affinity. To investigate the impact of these SNPs on the occurrence of cytomegalovirus infection or acute rejection (AR) in individuals who underwent simultaneous pancreas–kidney transplantation (SPKT), 50 recipient-donor pairs were genotyped, and sMICA levels were measured during the first year post-transplantation. Recipients with a Val-mismatch (recipient Met/Met and donor Val/Met or Val/Val) showed shorter cytomegalovirus infection-free and shorter kidney AR-free survival. Additionally, Val mismatch was an independent predictor of cytomegalovirus infection and kidney AR in the first year post-transplantation. Interestingly, sMICA levels were lower in rs2596538AA and MICA129Met/Met-homozygous recipients. These results provide further evidence that genetic variants of MICA influence sMICA levels, and that Val mismatch at position 129 increases cytomegalovirus infection and kidney AR risk during the first year post-SPKT.

Graft dysfunction in simultaneous pancreas kidney transplantation (SPK): Results of concurrent kidney and pancreas allograft biopsies.

Simultaneous pancreas and kidney transplants offer significant therapeutic advantages but present a diagnostic approach dilemma in the diagnosis of rejection. Because both organs are from the same donor, the kidney has been treated traditionally as the "sentinel" organ to biopsy, presumably representing the status of both allografts. Truly concurrent biopsy studies, however, are needed to confirm this hypothesis. We examined 101 concurrent biopsies from 70 patients with dysfunction in either or both organs. Results showed concurrent rejection in 23 of 57 (40%) of cases with rejection; 19 of 57 (33.5%) and 15 of 57 (26.5%) showed kidney or pancreas only rejection, respectively. The degree and type of rejection differed in the majority (13 of 23, 56.5%) of cases with concurrent rejection, with the pancreas more often showing higher rejection grade. Taking into account pancreas dysfunction, a positive kidney biopsy should correctly predict pancreas rejection in 86% of the instances. However, the lack of complete concordance between the 2 organs, the discrepancies in grade and type of rejection, and the tendency for higher rejection grades in concurrent or pancreas only rejections, all support the rationale for pancreas biopsies. The latter provide additional data on the overall status of the organ, as well as information on nonrejection-related pathologies.

Defining kidney allograft benefit from successful pancreas transplant: separating fact from fiction.

To define the natural history of kidney allograft loss related to recurrent diabetes following transplant, and to understand the potential benefit of pancreas transplantation upon kidney allograft survival. A postulated benefit of simultaneous pancreas kidney transplant is that, unlike kidney transplant alone, euglycemia from the added pancreas allograft may confer a nephroprotective benefit and prevent recurrent diabetic nephropathy in the renal allograft. Recent large database analyses and long-term histological assessments have been published that assist in quantifying the problem of recurrent diabetic nephropathy and answering the question of the potential benefits of euglycemia. Further data may be extrapolated from larger single-center series that follow the prognosis of early posttransplant diabetes mellitus as another barometer of risk from diabetic nephropathy and graft loss. Recurrent diabetic nephropathy following kidney transplant is a relatively rare, late occurrence and its clinical significance is significantly diminished by the competing risks of death and chronic alloimmune injury. Although there are hints of a protective effect upon kidney graft survival with pancreas transplant, these improvements are small and may take decades to appreciate. Clinical decision-making regarding pancreas transplant solely based upon nephroprotective effects of the kidney allograft should be avoided.

Outcomes of pancreas retransplantation in patients with pancreas graft failure.

BackgroundPancreas 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.MethodsThis 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.ResultsOf 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.ConclusionPancreas retransplantation may be considered for patients whose previous graft has failed.

Incidence of hospital-acquired infections following kidney, pancreas or kidney-pancreas transplantations: A surveillance-based study

Background Bacterial hospital-acquired infections (HAI) are frequent complications of the early post-transplantation period. The most frequent infections are urinary tract infection, bacteremia and surgical site infection. The objective was to report the incidence of early HAI among kidney, pancreas or kidney-pancreas transplant recipients in a French university hospital. Methods An active standardized surveillance of HAI among kidney, pancreas or kidney-pancreas recipients was done in a university hospital of 800 beds (Lyon, France). All patients transplanted between October 1, 2013 and December 31, 2016 were followed during their hospital stay or up to 30 days post-transplantation. Data on patient characteristics, invasive devices, transplantation type, outcome in the unit and HAI were recorded. HAI included urinary tract infections, bacteremia, surgical site infections and pneumonia. Only the first infection per site and per patient was analyzed. Incidence rates were expressed per 1000 patient-days with their 95% confidence interval (95% CI). Multivariate Poisson regressions adjusted on gender, age, ASA score, transplantation type and time period were fitted to assess the risk of HAI. Results Overall, 568 transplanted patients accounting for 8800 patients-days were analyzed (489 kidney, 12 pancreas and 67 kidney-pancreas transplantation). Mean age was 51 years (range 19–80 y), 61% were men, mean BMI was 25 (range 15–38). Seven patients deceased (1%, none because of infection) and 50 undergone a revised surgery (4 for infectious complications); 17 grafts were removed (1 for infection). Mean length of stay, length of urinary catheterization and central venous catheterization were respectively 18 days (+14), 8 days (+6), and 10 days (+8). Donor type was living-related donor, unrelated living donor, brain death donor and cardiac arrest donor for respectively 10%, 3%, 77% and 59% of transplanted patients. Concerning deceased donor, preservation solution was contaminated for 39% of cases, with negative coagulase Staphylococcus identified in 59% of them. HAI incidence was 10.2 (95% CI: 7.2–11.3; N = 80) per 1000 patient-days, without difference according to the transplantation type (adjusted incidence rate ratio [aIRR] = 1.37; 95% CI: 0.71–2.65) in kidney vs. kidney-pancreas or pancreas recipients or time period (aIRR = 0.90; 95% CI: 0.80–1.02, per 1 semester). The 3 most frequent causative microorganisms were Escherichia coli (29%), Enterococcus faecalis (16%) and Enterobacter cloacae (13%). Enterobacteriaceae were found in 53% of HAI and 57% of them were resistant to third generation cephalosporin. Incidences of urinary tract infections, bacteremia and pneumonia were respectively 6.0 (95% CI: 4.6–7.8; N = 58), 2.4 (95% CI: 1.5–3.5; N = 23) and 0.7 (95% CI: 0.3–1.4; N = 7), without differences according to transplantation type after multivariate analysis. Surgical site infections concerned 3% of patients (incidence: 1.7; 95% CI: 1.0–2.7; N = 16) with higher incidence in kidney-pancreas or pancreas compared with kidney recipients (aIRR = 14.20; 95% CI: 3.31–60.85). Conclusion Fourteen percent of kidney and/or pancreas transplanted patients had developed at least one HAI during post-transplantation hospitalization. The most frequent type of HAI was urinary tract infection and the most frequent microorganism involved was Escherichia coli. Incidence rates varied according to infection site and according to transplantation type for SSI. Detailed description of HAI among those patients will help for preventive measures including antibiotic prophylaxis.

Survival Analysis After Kidney-Pancreas and Kidney Transplant in Argentina

Objective To assess survival after kidney-pancreas and kidney transplantation (Tx) using monorgan donors (P- Donor) and with pancreas retrieval (P+ Donor), in patients over the age of 18 in Argentina. Material and Methods The information about both kidney and kidney-pancreas transplant patients was obtained from SINTRA, or the period June 1, 1998 - December 31, 2015. Results 2303 patients were assessed, 58%were males.They received a kidney from a P+ donor, and 606 (26%) received a kidney-pancreas transplant. The median age of the kidney-pancreas recipients was 36.9, and 49.3 for P-, and 42.9 for P+ recipients. KP (kidney pancreas) donors had an average BMI of 23.7 < than kidney donors, whose values were 25.4 for P+ D, and 26.7 for P- D. 92% of the KP recipients had 0% PRA, whereas kidney transplant recipients were 90% for P+ D, and 91% for P-D. Patient survival at one year per group was as follows: 95% P+, 92%P- and 88% KP;and at five years 90% P+,83% P-y 76% KP. Overall survival for kidney grafts was 95% at 30 days; 88% at one year, and 70% at five years. Cox regression analysis for patient survival showed that recipient´s age >35evidenced a HR of 1.84 (CI 95% 1.34-2.52) p=<0.0001. The multivariate analysis showed that KP recipients had a HR of 2.7 (CI 95%1.48-4.93) as compared to kidney recipients, P+ and HR was 2.64 (CI 95%1.79-3.89) as compared to kidney recipients,P-. Recipient´s age >35 and a donor´s BMI >25 were associated with <patient´s survival, which was statistically significant; RP vs renal P+ y RP vs renal P-. When comparing KP transplant patients with kidney recipients, P-, more than 4 years on dialysis at the time of transplant was a risk factor with an HR of 1.43 (CI 95% 1.03-1.98). In the univariate analysis in kidney graft survival, donor´s BMI>25, CI time longer than 24 hours, CVA as the cause of death were unfavorable variables. Conclusions Although the variables related to both donor and recipient in kidney pancreas transplant show a more favorable scenario, patient´s survival in this groupis the lowest compared to other groups. This might be due to the presence of more comorbidity variables at the time of dialysis initiation and diabetes mellitus as the cause of kidney failure.

Allograft Trauma in Transplant Recipients. A Case Series

Introduction We are witnessing an age of violence. There is a parallel increase in transplant activity as well. Kidney and pancrese allografts are placed in illiac fossa making them vulnerable to injury. There are only a handful of case reports describing the results of trauma in transplant recipients. We present our experience of managing traumatic allograft injuries in kidney and kidney pancreas allograft recipient. Materials and Methods We describe the outcome of two of our transplant recipients who were exposed to major trauma and managed in different ways. Case 1 A 46 year old male who had undergone a renal transplant 18 years ago, presented following a road traffic accident and was noted to have tenderness at the graft site. Computerised tomographic (CT) scan revealed an isolated grade III laceration of upper pole of transplant kidney with a perinephric haematoma. The patient remained heamodynamically stable and a repeat CT scan on day 3 did not show any increase in the perinephric collection.There was an initial increase in his serum creatinine but this subsequently improved and he was discharged on the 6th day. His subsequent clinical course remained uneventful with graft function returning to base line at 6 months follow up. Case 2 A 45 year old male with a simultaneous pancreas kidney transplant done 29 months ago presented following a fall from the second floor. Tenderness was noted over the renal allograft and an urgent CT scan revealed a haematoma with a grade III laceration of the renal graft.Rest of the abdomen and transplanted pancreas were unremarkable. Patient remained unstable heamodynamically despite adequate resuscitation. After optimization, a follow-up CT scan showed an increase in the size of perinephric haematoma and extravasation of contrast suggestive of an active bleed. It was decided to perform an angiogram and embolization of the bleeding vessel using micro coils. A follow-up doppler scan showed preservation of global perfusion apart from a small avascular area in the upper pole. The patient was discharged with stable graft function on day 10 and no complications identified at 6 months follow up. Conclusion Basic principle of resuscitation should be applied in managing traumatic injuries in transplant recipients. Life of the patient takes precedence over the allograft. These cases highlight the importance of close clinical monitoring, serial imaging and the role of interventional radiology in the management of trauma in transplant recipients.

Endoscopic Intervention can Prevent Reoperation in Patients After Pancreas Transplantation – The Advantage of the Duodenoduodenal Anastomosis

Introduction Since the first pancreas transplantation in 1966, surgical techniques have vastly evolved. Nowadays, in most transplant centres, the preferred type of anastomosis is the one with the small intestine. However, when the duodenoduodenal anastomosis was introduced, it has become a highly beneficial type of anastomosis and is now routinely performed in our Centre. Materials and Methods We performed 193 pancreas transplantations since 2004 until September 2017. Among these patients we performed 164 duodenoduodenal and 29 duodenojejunal anastomoses. Results Among all 164 patients with duodenoduodenal anastomosis 141 were Simultaneous Pancreas Kidney transplantations (SPK), 21 Pancreas Transplantations Alone (PTA) and 2 Pancreas After Kidney (PAK) transplantations. Endoscopic intervention due to anastomotic bleeding was necessary in 32 cases. Only in one case it wasn’t successful and the patient had to be reoperated. In group of patients with duodenojejunal anastomosis the reoperation due to GI bleeding was necessary in 2 patients. Conclusion Duodenoduodenal anastomosis is a safe option of enteric drainage that provides many advantages. It enables easy, non-invasive endoscopic access to the transplanted duodenum and possible intervention in case of GI bleeding.