Patients Undergoing Pancreas Transplantation Research Articles

Evolving Trends in the Management of Duodenal Leaks After Pancreas Transplantation: A Single-Centre Experience.

Duodenal leaks (DL) contribute to most graft losses following pancreas transplantation. However, there is a paucity of literature comparing graft preservation approach versus upfront graft pancreatectomy in these patients. We reviewed all pancreas transplants performed in our institution between 2000 and 2020 and identified the recipients developing DL to compare based on their management: percutaneous drainage vs. operative graft preservation vs. upfront pancreatectomy. Of the 595 patients undergoing pancreas transplantation, 74 (12.4%) developed a duodenal leak with a median follow up of 108months. Forty-five (61%) were managed by graft preservation strategies, with the rest being treated with upfront graft pancreatectomy. DL managed by graft preservation strategies had similar graft survival rates at 1 and 5-year compared to the matched cohort of population without DL (95% and 59% vs. 91% and 62%; p = 0.78). Multivariate analysis identified male recipient (OR: OR: 6.18; CI95%: 1.26-41.09; p = 0.04) to have higher odds of undergoing an upfront graft pancreatectomy. In appropriately selected recipients with DL, graft preservation strategies utilizing either interventional radiology guided percutaneous drainage or laparotomy with/without repair of leak can achieve comparable long-term graft survival rates compared to recipients without DL.

When pancreata fly: Outcomes and lessons learned from the development of a Pancreas Transplant Import Program.

To address long waitlist times and increase pancreas transplantation, our center has implemented a protocol for long-distance importation of pancreata. We conducted a retrospective review of pancreas transplantation at our institution from January 1, 2014, the start of our importation program, through September 30, 2021. Outcomes were compared between locally procured grafts and imported grafts, defined as grafts procured greater than 250 nautical miles (NM) from our center. Eighty-one patients underwent pancreas transplantation during the study time period; 19 (23.5%) received imported grafts. There were no significant differences in recipient demographics or type of transplant received. Mean distance of import was 644.2±234.0 NM. Imported grafts were more likely to be from pediatric donors<18 years old (p=.02) and a significantly higher proportion of imported grafts came from donors weighing<30kg (26.3vs. 3.2%, p=.007). Cold ischemic time was longer for imported grafts than for local grafts (13.4±2.3 h vs. 9.8±2.2 h, p<.01). There was no significant difference in deaths or graft losses within 90 days or at 1 year between groups. Centers should consider expanding criteria for acceptance of imported pancreata to increase the number of transplants and combat organ nonutilization.

Outcomes of pancreas transplantation in patients with underlying inflammatory bowel disease: a retrospective case series.

This was a retrospective case series of patients between January 1996 and July 2021, with all patients being followed up until December 2021. All consecutive patients with end-stage DM who underwent pancreas transplantation (alone, simultaneous with kidney transplantation or after kidney transplantation) and had pre-existing IBD were included in the study. A Comparison of 1-, 5-, 10-year survival was done with pancreas transplant recipients without underlying IBD using Kaplan-Meir curves. Of the total 630 pancreas transplants performed between 1996 and 2021, eight patients had IBD, mostly Crohn's disease. Following pancreas transplantation, two of the eight patients had duodenal leaks, with one a requiring graft pancreatectomy. The 5-year graft survival rate for the cohort was 75% compared to 81.6% for the overall cohort of patients undergoing pancreas transplantation (P=0.48) with a median graft survival of 48.4 months compared to 68.1 months in the latter (P=0.56). The findings of the series provide a snapshot of the outcome of pancreas transplantation in the background of IBD, suggesting a graft and overall patient survival rates comparable with pancreas transplantation in patients without underlying IBD, with further validation of the findings required in a larger cohort of patients in the future.

The best insulin delivery is a human pancreas.

We wanted to compare glycemic control post pancreas transplantation with newer therapeutic options. We conducted a retrospective analysis of pancreas transplantation at our institution from January 1, 2008, through September 30, 2021. All patients who underwent pancreatic transplantation were 18years and older. We compared pre-transplant glycemic control of those patients, whether self-monitoring or continuous glucose monitor to their post-transplant glycemic control. Outcomes were assessed by HgbA1C level at evaluation (eval), pretransplant (pre), within the first 5months posttransplant (post) and 1year post transplant (1year). One hundred and thirty-four patients underwent pancreas transplantation during the 14-year study period. Overall, 1-year patient and graft survival were 95% and 88%. The mean HgbA1C (%) for eval and pre were 8.5(SD±1.7) and 8.3(SD±1.7), which was significantly higher than post, and 1year at 5.1(SD±.6, p<.01) and 5.2(SD±.6, p<.01). Of those, 38 patients presented with continuous glucose monitors (CGM) +/- pump. Their mean HgbA1C(%) was 8.2(SD±1.5) at eval 8.1(SD±1.3). These were also significantly higher than post 5.0(SD±.6, p<.01), and 1year 5.1(SD±.5, p<.01). Pancreas transplant provides superior glycemic control to continuous glucose monitoring and remains the optimal therapy for appropriately selected patients with diabetes.

A comparative study of pancreas transplantation between type 1 and 2 diabetes mellitus.

Pancreas transplantation remains the best long-term treatment option to achieve physiological euglycemia and insulin independence in patients with labile diabetes mellitus (DM). It is widely accepted as an optimal procedure for type 1 DM (T1DM), but its application in type 2 DM (T2DM) is not unanimously acknowledged. In total, 146 diabetes patients undergoing pancreas transplantation were included in this study. Clinical data and outcomes were compared between the T1DM and T2DM groups. Majority (93%) of the pancreas transplantations in T2DM were for uremic recipients. Complications occurred in 106 (73%) patients, including 70 (48%) with early complications before discharge and 79 (54%) with late complications during follow-up period. Overall, rejection of pancreas graft occurred in 37 (25%) patients. Total rejection rate in T2DM recipients was significantly lower than that in T1DM. The short- and long-term outcomes for endocrine function in terms of fasting blood sugar and hemoglobin A1c levels and graft survival rates are comparable between the T2DM and T1DM groups. T2DM is not inferior to T1DM after pancreas transplantation in terms of surgical risks, immunological and endocrine outcomes, and graft survival rates. Therefore, pancreas transplantation could be an effective option to treat selected uremic T2DM patients without significant insulin resistance.

Endothelial function after pancreas transplantation—A single‐center observational study

Patients with diabetes mellitus treated with successful pancreas transplantation (PTX) normalize hyperglycemia, but are exposed to immunosuppressive drugs that may impair endothelial function. This study aimed to evaluate endothelial function in single PTX recipients. Flow-mediated dilatation (FMD) in the brachial artery was measured by ultrasound 8weeks after transplantation in single PTX (n=27) and compared with healthy controls (n=58), simultaneous pancreas and kidney recipients (n=9), and kidney transplant recipients with (n=41) and without (n=95) diabetes mellitus. Adjustments for age, gender, blood pressure, and body mass index were included in a linear regression model. Changes in FMD from before to 1year after transplantation were assessed in a subgroup of PTX recipients (n=9). Flow-mediated dilatation% in PTX recipients was not inferior to healthy controls (8.7±3.6 vs 7.7±3.3, P=.06) and simultaneous pancreas and kidney recipients (6.7±4.5, P=.24) in an adjusted model, and superior to kidney recipients with and without diabetes (3.0±3.0 and 4.8±3.3, respectively, both P<.005). FMD% improved significantly from eight weeks to one year after PTX, mean 7.9±4.2% vs 11.8±4.8% (N=9; P=.03). Flow-mediated dilatation is well preserved in patients undergoing pancreas transplantation and is not impaired when immunosuppressive drugs are introduced.

Assessing Pancreas Transplant Candidate Cardiac Disease: Preoperative Protocol Development at a Rapidly Growing Transplant Program.

Pancreas transplant rates, despite improving outcomes, have decreased over the past two decades. This is due, in part, to ageing, increasingly co-morbid pancreas transplant candidates. There is a paucity of published data regarding coronary artery disease (CAD) in this population. To inform peri-operative management strategies, we sought to understand the frequency of CAD among recipients of pancreas transplants at our center. Informed by these data, we sought to develop a standard protocol for evaluation. A retrospective review of pancreas transplants (solitary pancreas and simultaneous pancreas-kidney) was undertaken at the University of Maryland. Transplant outcomes and frequency of cardiac disease were analyzed. Current data were compared with historic controls. Over the study period, 59 patients underwent pancreas transplantation. Coronary architecture was assessed in 38 patients (64.4%). Discrete evidence of CAD was present in 28 of 39 patients (71.7%). All pancreas candidates (n = 21) who underwent left heart catheterization (LHC) demonstrated CAD (100%). No patients experienced myocardial infarction (MI) and no deaths resulted from cardiac disease in the early post-transplant period. Pancreas transplant candidates are at high risk for CAD. At a center in which pancreas transplant rates are increasing, a rigorous cardiac work up revealed that 71.7% of assessed recipients had CAD. Although asymptomatic, 6.8% required coronary artery bypass graft (CABG). Despite increasing age and co-morbid status, pancreas transplant recipients can enjoy excellent results if protocolized preoperative testing is used.

Infectious Complications in Pancreas Transplantation

In addition to the infectious risk associated with all solid organ transplants, pancreas transplantation poses some unique risks associated with surgical technique and host risk factors. This review highlights several key areas of infectious diseases that physicians must consider in patients undergoing pancreas transplantation. Surgical site infections are common after pancreas transplantation, and empiric antimicrobials, including antifungal coverage, are often needed to reduce the risk of these infections. Cytomegalovirus and Epstein-Barr virus (EBV) infections require close monitoring post-transplant, and we are just beginning to understand risk factors for post-transplant lymphoproliferative disorder, which is often associated with EBV infection in these patients. Pancreas transplantation can be a successful cure for diabetes, if post-transplant complications, including rejection and infection, can be appropriately managed. Recent use of pancreata from HIV- and HCV-positive donors has increased the pool of possible donors, and ideally, more centers will begin to use these organs. Islet cell transplantation and xenotransplantation are exciting new avenues of research for potential diabetes cures.

One-Year Blood Glucose Level is the Best Metabolic Marker for the Prediction of Late Pancreas Graft Failure

Aim The goal of this study was to explore whether donor and recipient’s characteristics, and one-year biological parameters could have a predictive value for the diagnosis of late pancreas graft failure. Methods 354 type 1 diabetic patients underwent pancreas transplantation between 2000 and 2015. Pancreas graft failure was defined as return to oral antidiabetics, permanent insulin-dependence. Recipient and donor characteristics were analyzed at the time of transplantation to determine potential risk factors for late graft dysfunction (after one year). Biological parameters such as HbA1c, fasting blood glucose, C-peptide, insulin, amylase, lipase, OGTT, Matsuda index, Beta score, HOMA IR and HOMA B, were analyzed one year after transplantation. Results 280 SPK, 38 PTA and 36 PAK were performed in 139 men and 215 women, with a mean age of 40 years. Median follow-up was 6 years. Patient survival was 96% at 1 year, 93% at 3 years and 87.5% at 5 years, whithout any significant difference between the three pancreas categories. Cardio-vascular diseases were the first cause of late recipient death. 111 patients experienced graft failure, 50 of them after the first year of transplantation. Pancreas survival was 80.5%, 70.7% and 67.5%, respectively at 1, 3 and 5 years, without any difference between the three categories. After the first year post-transplantation, death with a functioning graft occurred in 35.5% of patients with graft dysfunction. Donor death from cardiovascular cause was the only risk factor for late graft failure (OR 1,82 [1.05; 3.75], p=0,0345). One-year fasting blood glucose was the best predictive marker for a future graft dysfunction, especially when this value was over 5,4 mmol/l (OR 3.44 [1.80; 6.58] p=0.0002). 2-hour OGTT glucose level was also a risk factor for graft failure (OR 1.19 [1.04; 1.37] p=0,0109) while high Beta score (OR 0.62 [0.41; 0.94] p=0.0231) and high values of HOMA-B (OR 0.996 [0.992; 0.999] p=0,0483) were protective factors. Multivariate analysis identified a value of fasting blood glucose over 5.4 mmol/l (OR 4.24 [1.28; 14.04] p=0.0180) as the only significant risk factor. Graft survival was significantly different between patients with one-year blood glucose over or below 5.5 mmol/l: 85.2 vs 94.5% at 3 years and 72.3% vs 91.5% at 5 years (p<0,05), respectively. Conclusion Donor death from cardiovascular cause was the single risk factor for late graft failure among all donor and recipient’s base-line data. One-year fasting blood glucose level was the most significant biochemical parameter among patients at risk for graft failure, especially when the value was over 5,4 mmol/l. Two-hour OGTT glucose level, Beta score and HOMA B performed one year after transplantation are additional useful tools for identification of patients at risk. Whether medical intervention (i.e. GLP-1 analogue) among patients with still “normal glucose metabolism” could improve long-term graft survival requires prospective evaluation.

Pancreas transplantation in older patients is safe, but patient selection is paramount.

Pancreas transplant outcomes have progressively improved. Despite this, some centers have continued to employ historical age limits for pancreas transplant candidates. We sought to determine the importance of chronological age in determining patient and graft survival rates after pancreas transplantation. A single-center, retrospective study of adult, deceased donor simultaneous pancreas and kidney (SPK) and solitary pancreas transplants (SP, including pancreas transplant alone and pancreas after kidney transplants) in recipients ≥55years (55+), occurring between July 1, 1999, and June 30, 2012, was performed. Seven-hundred and forty patients underwent pancreas transplantation, of which 28 patients were 55+. Patient survival was comparable for younger and older pancreas transplant recipients. Both non-death-censored and death-censored pancreatic graft survival rates were similar in younger and in older patients. Patients aged 45-54 and those aged 55+ had more frequent cardiovascular events than younger pancreas transplant recipients. There was no difference in renal graft survival for SPK patients when compared with diabetic kidney transplant alone recipients aged 55years and older. Older pancreas transplant recipients had acceptable long-term patient and graft survival rates, although complications may occur. Chronological age alone should not exclude a patient for pancreas transplant candidacy.

Virtual HLA Crossmatching as a Means to Safely Expedite Transplantation of Imported Pancreata.

Imported pancreata accumulate cold ischemia time (CIT), limiting utilization and worsening outcomes. Flow cytometric crossmatching (FXM) is a standard method to assess recipient and donor compatibility, but can prolong CIT. Single-antigen bead assays allow for detection of recipient donor-specific HLA antibodies, enabling prediction of compatibility through a "virtual crossmatch" (VXM). This study investigates the utility and outcomes of VXM after transplantation of imported pancreata. We retrospectively compared outcomes of 153 patients undergoing pancreas transplantation at our institution over a 3.5-year period. Three patient groups were analyzed based on geographic source of the pancreas graft and the type of prospective crossmatch performed: (1) imported VXM-only, n = 39; (2) imported VXM + FXM, n = 12; and (3) local VXM + FXM, n = 102. There were no episodes of hyperacute rejection and 1 episode of early antibody-mediated rejection (<90 days) in the imported VXM group. Death-censored graft survival, patient survival, and rejection rates were comparable among the recipient groups. For pancreata imported from United Network of Organ Sharing regions 3 and 4, proceeding to surgery without an FXM reduced CIT by 5.1 hours (P < 0.001). The time from organ arrival at the hospital to operation start was significantly shorter in the VXM-only group compared with the VXM + FXM group (P < 0.001). Virtual crossmatch helps minimize CIT without increasing rejection or adversely affecting graft survival, making it a viable method to increase pancreas graft utilization across distant organ sharing regions.

Pancreas transplantation: The Wake Forest experience in the new millennium.

To investigate the Wake Forest experience with pancreas transplantation in the new millennium with attention to surgical techniques and immunosuppression. A monocentric, retrospective review of outcomes in simultaneous kidney-pancreas transplant (SKPT) and solitary pancreas transplant (SPT) recipients was performed. All patients underwent pancreas transplantation as intent-to-treat with portal venous and enteric exocrine drainage and received depleting antibody induction; maintenance therapy included tapered steroids or early steroid elimination with mycophenolate and tacrolimus. Recipient selection was based on clinical judgment whether or not the patient exhibited measureable levels of C-peptide. Over an 11.25 year period, 202 pancreas transplants were performed in 192 patients including 162 SKPTs and 40 SPTs. A total of 186 (92%) were primary and 16 (8%) pancreas retransplants; portal-enteric drainage was performed in 179 cases. A total of 39 pancreas transplants were performed in African American (AA) patients; of the 162 SKPTs, 30 were performed in patients with pretransplant C-peptide levels > 2.0 ng/mL. In addition, from 2005-2008, 46 SKPT patients were enrolled in a prospective study of single dose alemtuzumab vs 3-5 doses of rabbit anti-thymocyte globulin induction therapy. With a mean follow-up of 5.7 in SKPT vs 7.7 years in SPT recipients, overall patient (86% SKPT vs 87% SPT) and kidney (74% SKPT vs 80% SPT) graft survival rates as well as insulin-free rates (both 65%) were similar (P = NS). Although mortality rates were nearly identical in SKPT compared to SPT recipients, patterns and timing of death were different as no early mortality occurred in SPT recipients whereas the rates of mortality following SKPT were 4%, 9% and 12%, at 1-, 3- and 5-years follow-up, respectively (P < 0.05). The primary cause of graft loss in SKPT recipients was death with a functioning graft whereas the major cause of graft loss following SPT was acute and chronic rejection. The overall incidence of acute rejection was 29% in SKPT and 27.5% in SPT recipients (P = NS). Lower rates of acute rejection and major infection were evidenced in SKPT patients receiving alemtuzumab induction therapy. Comparable kidney and pancreas graft survival rates were observed in AA and non-AA recipients despite a higher prevalence of a "type 2 diabetes" phenotype in AA. Results comparable to those achieved in insulinopenic diabetics were found in the transplantation of type 2 diabetics with detectable C-peptide levels. In the new millennium, acceptable medium-term outcomes can be achieved in SKPT and SPTs as nearly 2/3rds of patients are insulin independent following pancreas transplantation.

Pretransplant coronary artery disease associated with worse clinical outcomes in pancreas transplantation

Coronary artery disease (CAD) is common in patients with type I diabetes and may be associated with worse outcomes in patients undergoing pancreas transplantation (PT). This study evaluates PT patients to determine the pre transplant prevalence of CAD and assesses the post-transplant outcomes including complications and survival. This study is a retrospective review of PTs from 2003 to 2011. Diagnosis of CAD required cardiac catheterization. Outcomes included: myocardial infarction (MI), stroke, and survival. There were 405 transplants in 389 patients with median follow-up of 56 months. Pre transplant prevalence of CAD was 19% (n = 74). There was no increased risk of perioperative, 90-d or one-yr mortality for patients with CAD. The CAD group did have increased risk of MI (11% vs. 1%, p < 0.001) and stroke (8% vs. 3%, p = 0.02). Controlling for patient and donor age, and history of CAD, the CAD group had decreased patient survival at five yr (82% vs. 90%, p = 0.09, HR 1.77) by Cox regression. Patients with type I diabetes and CAD have increased risk of MI and stroke post-pancreas transplant, with decreased five-yr survival. Patients without CAD and a negative pre transplant cardiac evaluation carry a low risk of post-transplant MI.

Mortality in diabetes: pancreas transplantation is associated with significant survival benefit

Pancreas transplantation in complicated type 1 (insulin dependent) diabetes mellitus improves the quality of life, increases longevity and stabilizes diabetic complications. There may be clinician reticence due to perceived poor outcomes with published associated mortality rates of 5-8% due to significant co-morbidities, particularly cardiovascular impairment. Retrospective analysis was performed on patients undergoing pancreas transplantation in a single centre since the programme's initiation [simultaneous pancreas kidney (SPK) = 148, pancreas after kidney (PAK) = 33 and pancreas transplant alone (PTA) = 11] compared with a control group accepted contemporaneously onto the waiting list. The primary endpoint was patient mortality. The risk factors including medical and diabetic history, demographics, transplant type and waiting time were analysed. The waiting list mortality was 30% (35 of 120) compared with a mortality of 9% (20 of 193) post-transplantation (P < 0.001). Deaths on the waiting list compared with transplantation up to 1 year had a relative risk of 2.67 (95% CI: 0.81-3.51; P = 0.19), whilst those surviving >1 year had a relative risk of 5.89 of dying on the waiting list (95% CI: 1.70-3.20; P < 0.0005). There were no differences in terms of cardiovascular or renal-associated risk factors, nor in other potential confounding factors other than duration of diabetes (P = 0.02). Median survival from listing was shorter in younger patients (<50; P < 0.0001). Type 1 diabetics with renal failure listed for pancreas transplantation are at a significant risk of mortality even without surgery. Transplantation offers considerable survival benefits, despite associated surgical and immunosuppressive risks. In selected patients, pancreas transplantation remains the benchmark treatment for type 1 diabetes mellitus.

Impact of Tacrolimus-Sirolimus Maintenance Immunosuppression on Proteinuria and Kidney Function in Pancreas Transplant Alone Recipients

Nephrotoxicity is a major complication with immunosuppression regimens used in transplantation. Calcineurin inhibitor-sparing or reduction regimens using sirolimus (SRL) have shown variable success in kidney transplantation. There is limited data on the role of SRL on native kidney function in pancreas transplantation. All patients undergoing pancreas transplantation from 2003 to 2010 were enrolled in this study (n=65). Patient demographic characteristics were identified and divided into two groups: those receiving tacrolimus (Tac) in combination with mycophenolate mofetil (MMF) and those maintained on a regimen of Tac and SRL with or without MMF. The slopes for estimated glomerular filtration rate (eGFR), serum creatinine level (sCr), and proteinuria changes over time were assessed between groups. Urine protein and creatinine ratio (uPr/uCr) was used to assess proteinuria. There was no difference in baseline demographic characteristics. Patients were followed for a median of 3 years. Baseline sCr and eGFR were similar between groups. Differences in uPr/uCr and rate of change in sCr and eGFR were not significant between the groups overall or for any specific time. There was worsening of sCr, eGFR, and uPr/uCr within the groups over the period of study. There were no significant differences when groups were split by age or gender or when the SRL group was split further based on MMF inclusion. Our study findings suggest that using a Tac-SRL regimen in patients with pancreas alone transplantation is a safe approach and may not lead to worsening proteinuria and kidney function when compared with regimens using Tac with MMF.

Evolution of Native Kidney Function After Pancreas Transplantation Alone

IntroductionThis study investigated changes in kidney function over time among a cohort of patients undergoing pancreas transplantation alone (PTA) from January 2002 to December 2011. Patients and MethodsTen of eighteen PTA patients bearing functioning grafts for at least 1 year were recruited for the analysis. Primary endpoints were changes in mean serum creatinine (SCr, mg/L) and mean estimated glomerular filtration rate (eGFR) using the 4-variable Levey-MDRD equation (mL/min/1.73 m2) comparing baseline (pretransplantation) to 6-month, 1-year, 3-year, and 5-year posttransplantation values. Mean follow-up time was 75.7 ± 20.5 months (range, 46–106.5). ResultsBaseline eGFR was 89.3 ± 27.9 (range, 58–145). eGFR decreased to 75.7 ± 26.2, 71 ± 20.6, 66.5 ± 14.8, and 62.1 ± 11.2 at 6 months, 1, 3, and 5 years representing −15.2%, −20.5%, −15.8%, and −22.6% percentage decreases respectively (P < .05 for all pairwise comparisons). The Baseline SCr was 8.6 ± 2.3 mg/L (range, 5–13). SCr progressively increased to 10.1 ± 3, 10.5 ± 3.1, 10.9 ± 3.1, and 11.3 ± 1.7 at 6 months, 1, 3, and 5 years a 17.1%, 22%, 16.6%, and 19.9% increase respectively (P < .05 for all pairwise comparisons). One of ten, 2/8, and 3/7 patients displayed an eGFR <60 at transplantation versus 3 and 5 years thereafter, respectively. No patient developed a SCr > 25 mg/L or eGFR <30 or needed dialysis or kidney transplantation. Five of ten patients had micro-albuminuria or proteinuria before transplantation. Tacrolimus levels were within recommended therapeutic ranges over time. ConclusionKidney function deteriorated significantly after PTA. Understanding of risk factors for the development of renal impairment is important to preserve kidney function and to select appropriate candidates for PTA.

Measurement of transplanted pancreatic volume using computed tomography: reliability by intra- and inter-observer variability

Unlike other solid organ transplants, pancreas allografts can undergo a substantial decrease in baseline volume after transplantation. This phenomenon has not been well characterized, as there are insufficient data on reliable and reproducible volume assessments. We hypothesized that characterization of pancreatic volume by means of computed tomography (CT) could be a useful method for clinical follow-up in pancreas transplant patients. To evaluate the feasibility and reliability of pancreatic volume assessment using CT scan in transplanted patients. CT examinations were performed on 21 consecutive patients undergoing pancreas transplantation. Volume measurements were carried out by two observers tracing the pancreatic contours in all slices. The observers performed the measurements twice for each patient. Differences in volume measurement were used to evaluate intra- and inter-observer variability. The intra-observer variability for the pancreatic volume measurements of Observers 1 and 2 was found to be in almost perfect agreement, with an intraclass correlation coefficient (ICC) of 0.90 (0.77-0.96) and 0.99 (0.98-1.0), respectively. Regarding inter-observer validity, the ICCs for the first and second measurements were 0.90 (range, 0.77-0.96) and 0.95 (range, 0.85-0.98), respectively. CT volumetry is a reliable and reproducible method for measurement of transplanted pancreatic volume.

Up-Regulation of ICAM-1 During Cold Ischemia Triggers Early Neutrophil Infiltration in Human Pancreas Allograft Reperfusion

Background Graft pancreatitis is induced by ischemia/reperfusion injury in which neutrophil infiltration is believed to be a crucial early event. This observation suggests the presence of adhesion molecules already at the time of reperfusion. Therefore, this study was performed to evaluate the pattern of ICAM-1 and P-Selectin expression on human pancreas allografts following cold ischemia and reperfusion. Patients and Methods We performed an analysis of pancreas biopsy specimens taken from 13 patients undergoing pancreas transplantation compared with pancreas specimens from 10 patients following resection. Cryostat sections were stained with monoclonal antibodies against CD11b, a neutrophil marker, and the adhesion molecules ICAM-1 and P-Selectin. Results Extensive infiltration of CD11b-positive cells was detected in venules and capillaries of pancreas allografts after reperfusion (18.38 ± 0.87) compared with controls (T1 4.22 ± 0.55) or with tissue specimens at about 10 hours of cold ischemia (2.60 ± 0.35; P < .001). Similarly, the pattern of P-Selectin showed a moderate expression before organ harvest (1.54 ± 0.21) and in samples during cold ischemia (1.46 ± 0.24) followed by a significantly greater number of P-Selectin–positive cells after reperfusion (2.54 ± 0.18; P = .005). ICAM-1 was only weakly expressed on the surface of the venular endothelium in all controls (0.77 ± 0.12). In contrast to P-Selectin, ICAM-1 showed prominent up-regulation during cold ischemia (2.23 ± 0.23; P < .001) with no further increase after reperfusion (2.23 ± 0.17). Conclusion The data suggested that ICAM-1 was already up-regulated during cold ischemia, possibly representing the mechanism of early neutrophil infiltration observed in human pancreatic ischemia/reperfusion injury.

Relaparotomy After Pancreas Transplantation: Causes and Outcomes

Surgical complications after pancreas transplantation, and subsequently relaparotomies, are frequently associated with graft loss, important morbidities, and occasionally patient death. From March 1995 to September 2008, 118 diabetic patients underwent pancreas transplantation: 109 simultaneous pancreas-kidney and nine pancreas after kidney. There were 68 men and 50 women. Mean age at transplantation was 37.8 +/- 7.8 years (range = 25-66). We analyzed donor and recipient characteristics, rate of relaparotomies, risk factors, as well as patient and graft survivals. Forty patients (33.9%) underwent one or more relaparotomies. The causes for relaparotomy were: graft thrombosis in 15 patients (12.7%), bleeding in 14 (11.9%), duodenal stump leak in 7 (5.9%), severe pancreatitis and/or abscess in 5 (4.2%), and small bowel obstruction in 3 (2.5%). Graft pancreatectomy was performed in 52.5% (21 patients). The causes of graft loss were: graft thrombosis in 15 patients (12.7%), bleeding in 14 (11.9%), and duodenal stump leaks in 7 (5.9%). Mortality rate after relaparotomy was 3.38% (four patients). Relaparotomy rate for thrombosis was higher among the portoiliac than the portocaval vein anastomosis group (20.0% vs 10.2%; P = NS), and significantly higher for the bladder drainage than the enteric drainage technique (18.2% vs 5.8%; P < .05). Patients without relaparotomy experienced a significantly higher 5-year graft survival rate than those who underwent relaparotomy (87.2% vs 37.9%; P < .001), but 5-year patient survivals were similar (96.8% without relaparotomy vs 89.6% with relaparotomy). Abdominal complications and the necessity for relaparotomy were associated with important morbidity and significantly reduced pancreas graft survival.

Conversion From Bladder to Enteric Drainage for Complications After Pancreas Transplantation

Bladder drainage (BD) of exocrine secretions is associated with urological and pancreatitis complications. Herein we have analyzed our experience with conversion from BD to enteric drainage (ED). From March 1995 to September 2008, 118 patients underwent pancreas transplantation. There were 68 men and 50 women of a overall mean age at transplantation of 37.8 years. There were 66 patients with bladder drainage (BD) and 52 with enteric drainage (ED). Eight of 66 BD pancreas recipients (12.1%) underwent ED conversion. The mean time from pancreas transplantation to ED conversion was 29.3 +/- 30.6 months (range, 1-91 months). The major indications for conversion were recurrent reflux pancreatitis and chronic urinary tract infections in 7 patients; metabolic acidosis in 8; urethritis with severe perineoscrotal swelling in 1; and duodenocystostomy leak in 1. A comparative analysis of converted ED and not converted BD showed only a significantly prolonged period in the intensive care unit for patients who needed ED conversion (89 vs 47 hours; P < .01). Only 1 patient showed a duodenoenteric leak and peritonitis after conversion that required removal of the pancreas graft. The remaining 7 patients did not develop any postoperative complications and are currently well, showing normal pancreas graft function at a mean follow-up of 51.7 months after ED conversion. Patient and graft survivals were 100% and 87.5%, respectively. After ED conversion all urological complications disappeared; patients discontinued the use of oral bicarbonate. ED conversion in pancreas transplant recipients with urological and reflux pancreatitis complications was a safe, effective procedure.