Pancreas Transplant Patients Research Articles

Use of Dextran 40 After Pancreas Transplant May Reduce Early Inflammation and Significant Bleeding Compared to a Heparin-Based Protocol

BackgroundDextran 40 (D40) is a synthetic colloid with anticoagulant properties that is used instead of heparin after pancreas transplantation; however, there is a lack of evidence on which is more effective. Graft thrombosis and pancreatitis, which may be mediated through microthrombosis or macrothrombosis within the graft, remain significant complications after pancreas transplantation. We hypothesized that D40 reduces inflammation through its antithrombotic promicrocirculatory effects. We evaluated D40 compared to a heparin-based protocol by comparing postoperative complications and post-transplant levels of inflammation. Materials and MethodsData were collected retrospectively for pancreas transplant patients between December 2009 and August 2018. A total of 26 patients had been treated with the pre-dextran protocol and 37 had received D40. Postoperative complications and inflammatory markers (white cell count [WCC], C-reactive protein [CRP], and amylase) on postoperative days 1, 2, 3, and 7 were compared between groups. Potential confounders were also recorded. ResultsPatients in the D40 group had similar thrombosis rates but were less likely to have had graft loss as a result of thrombosis or substantial postoperative bleeding compared to the heparin-based protocol. The group who received D40 had significantly lower CRP and WCC on days 2, 3, and 7. The differences on days 3 and 7 remained when the results were adjusted for the significant confounders of cold ischemic time and donor age. ConclusionsD40 appears to be as effective as intravenous heparin at preventing graft thrombosis after pancreas transplant and to confer a reduced risk for bleeding. It may also reduce postoperative inflammatory processes, leading to reduced graft pancreatitis.

RE: Spinal Cord Ischemia Post-pancreas Transplant.

We read the article, “Spinal cord ischemia in pancreas transplantation: the UK experience,” by Phillips et al.1 In it, they reported 6 cases of spinal cord ischemia following pancreas transplantation since 2002 after performing a survey of all UK pancreas transplant units. Therefore, we attempted to determine the incidence of this complication in the United States using the Healthcare Cost and Utilization Project National Inpatient Sample, the largest database for hospital discharge. We identified 2346 pancreas transplant patients with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 52.8* (Transplant of Pancreas) between the years 2005–2014. Of the 1440 results (61.4%) that included kidney transplant, 0 contained a diagnosis of spinal cord ischemia (336.1-vascular myelopathies). Further investigation into patients receiving an MRI of the spinal cord with the relevant ICD 9 procedure code (88.93) again resulted in 0. This discrepancy suggests large databases may be unable to capture rare conditions. Therefore, we must emphasize the application of proper coding to maximize transparency.

Anti-Hla donor-specific antibody monitoring in pancreas transplantation: Role of protocol biopsies.

In kidney transplantation, de novo donor-specific antibodies (DSA) correlate with poor graft survival, and Consensus Guidelines recommend a protocol biopsy. In pancreas transplantation, DSA are also associated with poor graft outcomes; however, there are no recommendations on protocol biopsies. We started an antibody screening protocol on pancreas transplant patients at 0, 3, 6, 12months, and yearly. Patients with DSA or high MFI non-DSA were considered for protocol biopsies of both organs. Results: 143 pancreas recipients were screened. 84 patients had negative antibodies throughout the study, 11 patients were found to have antibodies at graft dysfunction, and 48 patients had positive antibodies at screening without acute organ dysfunction (study group). Among the 30 non-DSA patients, 9 had protocol simultaneous pancreas and kidney biopsies performed with negative results in all of them. In contrast, among the 18 DSA patients, 15 had these biopsies performed, and 47% presented with subclinical rejection of the kidney, the pancreas, or both. In addition, some of the DSA patients without a protocol biopsy presented with rejection during the first 15months of follow-up. Conclusion: We conclude that protocol biopsies of both grafts may play a role in the follow-up of pancreas transplant patients with de novo DSA appearance.

Long-term follow-up of beta cell replacement therapy in 10 HIV-infected patients with renal failure secondary to type 1 diabetes mellitus.

The approach to transplantation in human immunodeficiency virus (HIV)-positive patients has been conservative due to fear of exacerbating an immunocompromised condition. As a result, HIV-positive patients with diabetes were initially excluded from beta cell replacement therapy. Early reports of pancreas transplant in patients with HIV described high rates of early graft loss with limited follow-up. We report long-term follow-up of islet or pancreas transplantation in HIV-positive type 1 diabetic patients who received a kidney transplant concurrently or had previously undergone kidney transplantation. Although 4 patients developed polyoma viremia, highly active antiretroviral therapy and adequate infectious prophylaxis were successful in providing protection until CD4+ counts recovered. Coordination with HIV providers is critical to reduce the risk of rejection by minimizing drug-drug interactions. Also, protocols for prophylaxis of opportunistic infections and strategies for monitoring and treating BK viremia are important given the degree of immunosuppression required. This series demonstrates that type 1 diabetic patients with well-controlled HIV and renal failure can be appropriate candidates for beta cell replacement, with a low rate of infectious complications, early graft loss, and rejection, so excellent long-term graft survival is possible. Additionally, patients with HIV and cardiovascular contraindications can undergo islet infusion.

Andrew Jay Drexler, in memoriam.

Andrew Jay Drexler, in memoriam.

First Experience With Rectus Sheath Block for Postoperative Analgesia After Pancreas Transplant: A Retrospective Observational Study

BackgroundStandard of care for postoperative analgesia after pancreas transplant has been thoracic epidural analgesia (TEA). A high incidence of venous graft thrombosis necessitated a change to a more aggressive anticoagulation protocol. To minimize the risk of epidural hemorrhages, we changed from TEA to rectus sheath block (RSB) in 2017. MethodsFrom June 2016 to December 2017, a total of 29 consecutive pancreas transplant recipients were included. Sixteen were treated with TEA and 13 were treated with RSB. In the TEA group, the catheter was inserted before induction of general anesthesia, and an epidural infusion was started intraoperatively. An ultrasound-guided RSB was performed bilaterally, and a bolus of local anesthetic was administered before an 18G catheter was inserted. The patients received intermittent local anesthetic boluses every 4 hours in addition to an intravenous patient-controlled analgesia with oxycodone. Both groups received oral acetaminophen and additional rescue opioids. ResultsThe administered amount of intravenous morphine equivalents (MEQ) was not significantly different between the RSB and TEA groups. The median MEQ consumption per day during the stay at the surgical ward was 23 mg MEQ/d (interquartile range [IQR], 14–33 mg MEQ/d) in the TEA group compared with 19 mg MEQ/d (IQR, 14–32 mg MEQ/d) in the RSB group (P = .4). The duration of the pain catheters was significantly longer in the RSB group. We had no complications related to insertion, use, or removal of the RSB or the TEA catheters, and overall patient satisfaction and comfort was good. ConclusionCompared with TEA, RSB was equally effective and safe for postoperative analgesia in heavily anticoagulated pancreas transplant patients.

1565. Lymphocyte Subsets as Predictors of Cytomegalovirus Infection After Transplantation

BackgroundCellular immunity plays a critical role in controlling cytomegalovirus (CMV) infection after solid-organ transplantation (SOT). We correlated lymphocyte subsets with the risk and course of CMV after SOT.MethodsWe studied 130 selected kidney, heart, lung, pancreas, liver and composite tissue transplant patients who had blood samples collected for immunologic testing. We abstracted absolute lymphocyte count (ALC) and CD4+ and CD8+ T cell subsets, and correlated them with CMV infection and disease. CMV infection was diagnosed by quantitative PCR in blood and other clinical samples, or histopathology.ResultsFifty-nine of 130 SOT patients developed CMV infection or disease. The median age was 57.5 years (IQR: 47.8–64). Gender distribution was equal. The median onset to CMV infection or disease was 10.5 months (IQR 5.5–18.7). The median ALC for the whole cohort was 565 (IQR, 310–1,083) cells/mm3. An ALC <630 cells/mm3 was correlated with CMV infection or disease (sensitivity 83%; specificity 70%). The median CD4+ T cell count for the whole cohort was 160.5 (IQR, 17.5–424.5) cells/mm3. Patients with CD4+ T cell count <196 cells/mm3 were at a higher risk of CMV infection or disease (sensitivity 88%; specificity 71%). The 59 SOT recipients with CMV infection or disease had a significantly lower median number of CD4+ T cells compared with those who did not develop CMV (29 vs. 325.5 cells/mm3, P < 0.0001). A median CD4+ T cell count <45 cells/mm3 was associated with CMV syndrome or tissue-invasive disease (sensitivity 66%; specificity 68%). Patients who had CMV relapse had significantly lower median CD4+ T cell count (9 vs. 68 cells/mm3, P = 0.005). There was no association between CD8+ T cell count and CMV infection or disease. However, T cell functional analysis was not considered in this analysis.ConclusionLower ALC and CD4+ counts, but not CD8+ T cell count, are significantly correlated with the risk and course of CMV infection and disease after SOT. These readily available clinical measures have the potential to assist in CMV disease management.Figure 1.CD4+ T cell in solid-organ recipients with and without CMV infection.Disclosures All authors: No reported disclosures.

Pancreas grafts for transplantation from donors with hypertension: an analysis of the scientific registry of transplant recipients database

BackgroundWith the rising demands for pancreas transplantation, surgeons are trying to extend the donors pool and set up a more appropriate assessment system. We aim to evaluate the effect of donor hypertension on recipient overall and graft survival rates.MethodsTwenty-four thousand one hundred ninety-two pancreas transplantation patients from the Scientific Registry of Transplant Recipients database were subdivided into hypertension group (HTN, n = 1531) and non-hypertension group (non-HTN, n = 22,661) according to the hypertension status of donors. Recipient overall and graft survival were analyzed and compared by log rank test, and hazard ratios of predictors were estimated using Cox proportional hazard models.ResultsPatient overall and graft survival of non-HTN group were higher than that of the HTN group (both p < 0.001). The duration of hypertension negatively influenced both overall and graft survival rates (both p < 0.001). Multivariate analyses demonstrated that hypertension was an independent factor for reduced survival (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.01–1.18; p < 0.001). Other independent factors included recipient body mass index (HR, 1.02; 95% CI, 1.01–1.05; p < 0.001) and transplant type (pancreas after kidney transplants / pancreas transplant alone vs. simultaneous pancreas-kidney transplants; HR, 1.41; 95% CI, 134–1.55; p < 0.001).ConclusionsDonor hypertension is an independent factor for recipient survival after pancreas transplantation and could be considered in donor selection as well as post-transplant surveillance in clinical practice.

The Importance and Utility of Hemoglobin A1c Levels in the Assessment of Donor Pancreas Allografts.

Hemoglobin A1C (HbA1c) levels are often obtained in potential pancreas graft donors to assess the overall long-term functional glycemic control or the possibility of unrecognized diabetes. Although routinely measured, the impact of donor HbA1c levels on pancreas graft outcomes has not been reported. Here, we researched the relationship between donor HbA1c levels and postoperative pancreas graft survival. Data from 266 pancreas transplant patients including 182 simultaneous kidney-pancreas and 84 pancreas alone transplants were reviewed for the study. The patients were separated into groups according to their HbA1c levels (5 groups: HbA1c < 5.0, 5.0-5.4, 5.5-5.9, ≥6.0 % and not available, or 2 groups: HbA1c <5.7, ≥5.7%). Overall, death-censored and technically successful pancreas graft survival and rejection rates of each group were compared. In the case of technically successful graft survival, graft losses due to technical problems in the first 60 days were excluded. All groups were similar with regard to donor variables including age, sex, ABO blood type, ethnicity, donor type and recipient variables including recipient age, sex, induction agents and maintenance treatment. Mean follow-up time was 4.2 ± 1.97 years. The overall graft survivals and death censored graft survivals among groups were not statistically different from one other (P > 0.05). Additionally, excluding early technical losses in 18 patients did not reveal any differences in graft survivals. Patient survival and biopsy-proven acute rejections were statistically similar among HbA1c strata. This univariate retrospective analysis of a single center/organ procurement organization use of HbA1c shows that donor HbA1c levels between 3.5 and 6.2 in otherwise transplantable pancreata are not associated with different short-term outcomes.

Long-term Metabolic Outcomes of Functioning Pancreas Transplants in Type 2 Diabetic Recipients

Limited data are available regarding the long-term metabolic outcomes of functioning pancreas transplants in patients with type 2 diabetes mellitus (T2DM). To compare the long-term effects of pancreas transplantation in terms of insulin resistance and β cell function, comparison of metabolic variables was performed between type 1 diabetes mellitus (T1DM) and T2DM patients from 1-month posttransplant to 5 years using generalized, linear-mixed models for repeated measures. Among 217 consecutive patients who underwent pancreas transplantation at our center between August 2004 and January 2015, 193 patients (151 T1DM and 42 T2DM) were included in this study. Throughout the follow-up period, postoperative hemoglobin A1c did not differ significantly between T1DM and T2DM patients, and the levels were constantly below 6% (42 mmol/mol) until 5 years posttransplant, whereas C-peptide was significantly higher in T2DM (P = 0.014). There was no difference in fasting insulin, homeostasis model assessment (HOMA) of insulin resistance, HOMA β cell, or the insulinogenic index between the groups. Furthermore, fasting insulin and HOMA-insulin resistance steadily decreased in both groups during the follow-up period. There was no significant difference in the insulin resistance or β-cell function after pancreas transplantation between T1DM and T2DM patients. We demonstrated that pancreas transplantation is capable of sustaining favorable endocrine functions for more than 5 years in T2DM recipients.

In-Hospital Cardiovascular Complications After Pancreas Transplantation in the United States from 2003 to 2012

Large database studies detailing the risk of perioperative cardiovascular complications after pancreas transplant has been limited, perhaps because these outcomes are not captured by transplant registries. Greater data on the incidence and risks of such outcomes could provide additional insight for referring physicians and inform potential recipients of their risk. We performed a serial, cross-sectional analysis of the National Inpatient Sample, the largest publicly available inpatient database in the United States, to assess for the risk of cardiovascular complications after pancreas transplants in the United States from 2003 to 2012 (n= 13,399). Using multivariable logistic regression models, the risk of cardiovascular outcomes after simultaneous pancreas-kidney transplants (SPK) was compared with solitary pancreas transplants (pancreas after kidney and pancreas transplant alone [PAK+ PTA]). The unadjusted prevalence of in-hospital cardiovascular complications was higher in SPK than PAK+ PTA (5.5% vs 3.7%, p <0.001). After multivariable adjustment, SPK remained associated with significantly higher odds of any cardiovascular complication (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.21 to 1.80, p= 0.01), and particularly stroke (OR 13.41, 95% CI 4.78 to 37.63, p <0.001), compared with PAK+ PTA. However, there was no difference in perioperative mortality (OR 0.78, 95% CI 0.54 to 1.12, p= 0.18). In conclusion, these findings highlight the association between uremia and stroke in pancreas transplant patients, as well as the need for improved preoperative cardiac risk assessment and perioperative management, especially in those who underwent SPK.

Simultaneous Pancreas and Kidney Transplantation-Is It a Treatment Option for Patients With Type 2 Diabetes Mellitus? An Analysis of the International Pancreas Transplant Registry.

Pancreas transplantation remains the best long-term treatment option to achieve euglycemia and freedom from insulin in patients with labile diabetes mellitus. It is an approved procedure for type 1 (T1DM), but it is still considered controversial for type 2 diabetes mellitus (T2DM). This study analyzed all primary deceased donor pancreas transplants in patients with T2DM reported to IPTR/UNOS between 1995 and 2015. Characteristics, outcomes, and risk factors over time were determined using univariate and multivariate methods. The focus was on simultaneous pancreas/kidney (SPK) transplants, the most common pancreas transplant category. Patient, pancreas, and kidney graft survival rates increased significantly over time and reached 95.8, 83.3, and 91.1%, respectively, at 3years posttransplant for transplants performed between 2009 and 2015. SPK is a safe procedure with excellent pancreas and kidney graft outcome in patients with T2DM. The procedure restores euglycemia and freedom from insulin and dialysis. Based on our results, SPK should be offered to more uremic patients with labile T2DM.

Relationship of Urinary Biomarkers NAG, NGAL and KIM-1 to Kidney Transplantation Complications

Introduction: Kidney transplantation (KT) is the best choice for patients that suffer End Stage Renal Disease (ESRD), because of the better survival rate compared to patients under dialysis. Our objective should be to improve allograft survival by acting in a preemptive way. Methods: We analysed the urinary biomarkers NAG (N-acetyl glucosaminidase), NGAL (Neutrophil Gelatinase associated Lipocaine) and KIM-1 (Kidney Injury Molecule-1) in urine samples from 70 kidney or kidney and pancreas transplant patients. The samples were taken at post-transplant days +1, +3, +5, +7, and the day of renal stabilisation in the first 3 months. The biomarker levels were related to the different complications after KT, such as acute rejection, delayed graft function (DGF), cold ischemia time, toxic drugs for kidney and the renal function on the day of stabilisation. The statistical test used was Pearson c2. The 70th percentile was taken and a significant value was established if p < 0.05. The statistical program used was IBM SPSS version 20. Results: During the first week after KT, in theory renal function improves as measured by creatinine levels. However, increasing levels of the urinary biomarkers NAG, NGAL and KIM-1 indicate possible tubular damage or other pathology of the kidney. NGAL has shown to be a more sensitive marker than NAG and KIM-1 because it increases more than the other markers from the first day after KT. Urinary values of NGAL at post-transplant day 7 predict statistically significant probability of suffering DGF. Low NAG values at post-transplant day 3 have been related to a cold ischemia time of between 120 and 900 minutes, while high values in the first week post-transplant predict more renal function stabilisation time; the same occurs with NGAL. In this study KIM-1 did not show any relationship with the events described above. Conclusions: The use of the urinary biomarkers NAG and NGAL can help us act in a preemptive way to avoid the complications of KT. This could improve the global results of renal transplantation.Figure

Patient Tailored Crossmatch, Do Islet Cell and Pancreas Transplants Call for a Different Fit?

Introduction: We have previously demonstrated that pre-formed donor specific antibodies (DSA) to human leukocyte antigens (HLA) are associated with reduced islet function and survival but positive (pos) T and/or B cell flow crossmatch (FCXM) alone is not. (1) Thresholds for FCXM are established using HLA un-sensitized normal samples, which may not reflect serum background reactivity in all patient populations. Here we re-evaluated T and B cell FCXM pos thresholds using un-sensitized kidney and islet cell/pancreas transplant patient sera. Methods: The FCXM method includes incubating pronased treated donor lymphocytes with patient serum followed by detection of IgG antibody on the CD3 labelled donor T and CD19 labelled B cells. (2) Determination of routine positive (pos) threshold was determined by FCXM with 10 cells and 20 sera from un-sensitized normal donors. Patient FCXM data from July 2013 to December 2015 were examined. Calculated panel reactive antibody (cPRA) values were determined using the Canadian cPRA tool. A 0 cPRA was assigned to all patients with no HLA antibody determined by threshold of MFI 1000 and no evidence of reactivity pattern to HLA epitopes. The median channel value (MCV) shift above the negative control serum was determined for all FCXM and results were separated by donor peripheral blood (PBL) or spleen (SPL) source as per routine threshold determination. The mean and standard deviation (SD) were calculated for each patient and cell type. Results: A total of 1417 FCXM were performed; 367 patients had 0 cPRA. The total number of kidney and islet transplant patients was 166 and 63, respectively. The breakdown of PBL vs SPL cell source is shown Table 1. The FCXM pos cut-offs determined using the kidney sera are very similar to those established from normal controls. The pos thresholds calculated using islet/pancreas patient sera are higher. Conclusion: Islet and pancreas patient sera may have inherent, non-HLA specific reactivity to T and B cells, which affects the interpretation of FCXM. The current thresholds may result in false positive T and B FCXM in some islet and pancreas transplant patients. Our data suggest that the crossmatch must be interpreted in the context of HLA antibody specificity information. Higher pos thresholds for FCXM may be required in this patient population however an increased threshold requires validation in the setting of known DSA to ensure that false negative FCXM results do not result.Table 1: Flow cytometry crossmatch Tand B thresholds as established using serum from kidney vs. islet cell/pancreas transplant patients.

Diabetic Foot Complications Despite Successful Pancreas Transplantation.

It is known that successful pancreas transplantation enables patients with diabetes to maintain a normal glucose level without insulin and reduces diabetes-related complications. However, we have little information about the foot-specific morbidity in patients who have undergone successful pancreas transplantation. The purpose of this study was to investigate the prevalence and predisposing factors for foot complications after successful pancreas transplantation. This retrospective study included 218 patients (91 males, 127 females) who had undergone pancreas transplantation for diabetes. The mean age was 40.7 (range, 15-76) years. Diabetes type, transplantation type, body mass index, and diabetes duration before transplantation were confirmed. After pancreas transplantation, the occurrence and duration of foot and ankle complications were assessed. Twenty-two patients (10.1%) had diabetic foot complications. Fifteen patients (6.9%) had diabetic foot ulcer and 7 patients (3.2%) had Charcot arthropathy. Three patients had both diabetic foot ulcer and Charcot arthropathy. Three insufficiency fractures (1.4%) were included. Mean time of complications after transplantation was 18.5 (range, 2-77) months. Creatinine level 1 year after surgery was higher in the complication group rather than the noncomplication group ( P = .02). Complications of the foot and ankle still occurred following pancreas transplantation in patients with diabetes. Level III, comparative study.

Genetic predictors of long-term graft function in kidney and pancreas transplant patients.

Kidney and pancreas transplantation have helped transform the lives of people with end-stage renal failure and individuals with type 1 diabetes who have poor glycaemic control/severe secondary complications, respectively. Despite an improvement in immunosuppressive regimes, operative techniques and decreased initial rejection rates, there has been little improvement in long-term graft survival rates over the past decade. Whilst limited progress has been made in establishing clinical markers of graft function, several genetic markers of long-term graft function have been identified. These genetic markers have the potential to (i) assist in selecting marginal donor organs for transplantation, (ii) provide better understanding of the mechanisms behind graft loss enabling identification of new, or repurposing, current treatments to extend graft function and (iii) provide a window of opportunity to identify and treat individuals before graft failure has occurred. This review will discuss the different genetic variants screened for a role in predicting transplant longevity, examine their findings and limitations and introduce where the future of genetic research within the transplantation field lies.

Fluorescent Strips of Electrospun Fibers for Ratiometric Sensing of Serum Heparin and Urine Trypsin

"Turn-on" or "turn-off" probes remain challenges in the establishment of sensitive, easily operated, and reliable methods for in situ monitoring bioactive substances. In the current study, electrospun fibrous strips are designed to provide straightforward observations of ratiometric color changes with the naked eye in the presence of serum heparin or urine trypsin. A tetraphenylethene (TPE) derivative is constructed and along with phloxine B is grafted on fibers, followed by protamine adsorption to induce static quenching of phloxine B and aggregation-induced emission of the TPE derivative. The presence of heparin or trypsin removes protamine to restore the fluorescence of phloxine B at 574 nm (I574) and relieve the emission of the TPE derivative at 472 nm (I472). The grafting densities of phloxine B and the TPE derivative are essential to achieve the optimal fluorescence-intensity ratio of I574/I472 for the ratiometric detection of heparin and trypsin. Under illumination by an ultraviolet lamp, the fibrous mats turn from cyan to green in the presence of heparin at 0.4 U/mL and to a bright yellow at 0.8 U/mL, which is feasible in sensing serum heparin levels during postoperative and long-term care of patients after cardiovascular surgery. The protamine digestion results in similar color transitions with increasing trypsin levels up to 8 μg/mL, indicating the potential for monitoring urine trypsin levels of pancreas transplant patients. The color strips based on the ratiometric fluorescent response indicate advantages in lowering the detection limit and improving the accuracy and reproducibility, bearing great potential for a real-time and naked-eye detection of bioactive substances as self-test devices.

Influence of Donor and Recipient Ages in Survival of Simultaneous Pancreas-Kidney Transplantation

IntroductionSimultaneous pancreas-kidney transplantation (SPKT) is a well treatment for patients with insulin-dependent diabetes and end-stage renal disease. Donor age is a barrier to the acceptance of organs. Age matching has been extensively studied in kidney transplantation; however, there are no studies in graft survival after SPKT. We aimed to study the combined influence of the ages of the donors and recipients in graft survival after SPKT. Material and MethodsDonors and recipients are classified as younger (age <40 years) or older (age ≥40 years). There were four study groups (young-young, young-old, old-young, and old-old). They were evaluated retrospectively for demographic and clinical characteristics of donors and recipients and the long-term survival between 2001 and 2012 of kidney pancreas transplantation patients at our center. ResultsA total of 115 transplantations were performed. The four groups had 55 young-young, 40 young-old, 10 old-young, and 10 old-old patients. Serious complications occurred in 32%, 42%, 30%, and 40%, respectively, and deaths were 2%, 5%, 0%, and 20%, respectively, in the groups. Pancreas graft survival at 3 years for each group was 80%, 87, 5%, 90%, and 60%, respectively, and kidney graft survival was 92.7%, 90%, 90%, and 70%, respectively. Panel-reactive antibodies (PRAs) >30% were associated with poor graft survival, and serious postoperative complications associated with poor pancreas-kidney graft survival. ConclusionsIn conclusion, both younger and older recipients show excellent long-term graft and patient survival after SPKTs from younger donors. We recommended that older-recipient SPKT be transplanted from younger donors because older recipients who have been transplanted from older donors had decreased survival.

Pancreas transplantation in unconventional recipients.

Advances in surgical technique and immunosuppression have significantly improved outcomes after pancreas transplantation, and as a result pancreas transplants increasingly are being performed for indications other than type 1 diabetes mellitus. This review summarizes the current literature on pancreas transplantation in unconventional recipient populations. An increasing body of work suggests that pancreas transplantation can be performed with good outcomes in patients with type 2 diabetes mellitus and those 50 years of age and older. Obesity appears detrimental to patient and pancreas graft survival, and bariatric surgery prior to transplantation may be of increasing interest and relevance. There are limited data yielding mixed outcomes on pancreas transplantation in patients with HIV or hepatitis C virus. However, rapidly improving antiviral therapies are prolonging survival in patients with HIV and chronic hepatitis C virus infections and may increase the number of candidates available for pancreas transplantation in these populations in the future. Despite limited literature in these patient populations, pancreas transplantation may be a viable treatment option for endocrine pancreas failure in appropriately selected patients regardless of disease cause or age.

Long-Term Outcomes of Kidney and Simultaneous Pancreas–Kidney Transplantation in Recipients With Type 1 Diabetes Mellitus: Silesian Experience

BackgroundKidney transplantation (KTx) markedly reduces mortality in patients with end-stage kidney disease (ESKD) caused by type 1 diabetes mellitus (T1DM). The outstanding issue is whether transplantation should be limited only to KTx, with further insulinotherapy, or combined with pancreas transplantation in patients with ESKD/T1DM. The goal of this study was to compare the results of simultaneous pancreas–kidney transplantation (SPKTx) and deceased donor KTx and to identify factors affecting patient and kidney graft survival in patients with ESKD/T1DM. MethodsEighty-seven deceased donor KTx and 66 SPKTx operated on in the Silesia region of Poland between 1998 and 2013 were included in the retrospective analysis. ResultsDuring the mean 6.7 ± 3.6 years of follow-up, fewer cardiovascular episodes were observed in SPKTx recipients than in KTx recipients (1.5% vs 12.6%; P < .05). Five-year patient survival (80.7% in SPKTx vs 77.5% in KTx) and kidney graft survival (66.1% in SPKTx vs 70.4% in KTx) did not differ between study groups. There were no differences in patient survival (log-rank test, P = .99) or kidney graft survival (P = .99) based on Kaplan-Meier curves. Multivariable Cox proportional hazard analysis failed to identify factors explaining patient and kidney graft survival. Five-year pancreas graft survival was 58.9%. SPKTx recipients had significantly higher estimated glomerular filtration rates during the 7-year posttransplant period and less frequently developed proteinuria (6.1% vs 23%; P < .01). ConclusionsPancreas transplantation reduced cardiovascular risk and prevented the development of proteinuria but did not improve patient and kidney graft survival in recipients with T1DM in the 7-year follow-up period.