Simultaneous Pancreas And Kidney Transplantation Research Articles

Application of a specialist nurse-led multidisciplinary team model in the perioperative care of patients undergoing simultaneous pancreas and kidney transplantation: randomized controlled trial.

Simultaneous pancreas and kidney transplantation (SPKT) is an effective treatment option for individuals who suffer from both diabetes mellitus and renal failure. However, experiments exploring nurse-led multidisciplinary team management during the perioperative management of patients undergoing SPKT are currently limited. This study aims to explore the clinical performance of a transplant nurse-led multidisciplinary team (MDT) in the perioperative management of SPKT patients. A total of 218 patients who underwent SPKT were randomly assigned to either a control group (n=116) receiving conventional care or an intervention group (n=102) managed through a transplant nurse-led MDT approach. The incidence of postoperative complications, hospital stay, total hospitalization cost, readmission rate, and postoperative nursing quality were compared between these 2 groups. The intervention and control groups showed no significant differences in age, gender, and body mass index. Compared with the control group, the intervention group had a significantly lower incidence of postoperative pulmonary infection and gastrointestinal (GI) bleeding (27.6% vs. 14.7% and 31.0% vs. 15.7%, respectively, both P<0.05). Compared to the control group, the intervention group had significantly lower hospitalization costs, length of hospital stay, and readmission rate 30 days after discharge (32.98±9.10 vs. 36.78±15.36, 26.47±13.4 vs. 31.03±11.61 and 31.4% vs. 50.0%, respectively, all P<0.05). Additionally, the intervention group had significantly better quality of postoperative nursing care than the control group (11.61±0.69 vs. 9.64±1.42, P<0.01), the availability of infection control and prevention measures (11.74±0.61 vs. 10.53±1.11, P<0.01), the effectiveness of health education (11.73±0.61 vs. 10.41±1.06, P<0.01), the effectiveness of rehabilitation training (11.77±0.54 vs. 10.37±0.96, P<0.01), and the patient satisfaction with nursing care (11.83±0.42 vs. 10.81±1.08, P<0.01). The nurse-led MDT model for transplant patients can reduce complications, shorten hospital stays, and save costs. It also provides clear guidelines for nurses, improving care quality and aiding patient recovery. Chinese Clinical Trial Registry ChiCTR1900026543.

Vitreous hemorrhage in a pregnant woman with a history of simultaneous pancreas and kidney transplantation: A case report

Pregnancy after simultaneous pancreas and kidney transplantation (SPKT) carries a high risk of maternal and fetal complications. We report the case of a 39-year-old woman with three consecutive pregnancies with favorable outcomes after SPKT. Within the first year of SPKT, the patient had a spontaneous pregnancy. At 32weeks of gestation, she underwent an emergency cesarean section (CS) due to severe preeclampsia and HELLP syndrome. The infant was of average birth weight and was transferred to the neonatal intensive care unit for further management. A second unplanned pregnancy occurred almost nine months after the first. The antenatal assessments for fetal growth, blood glucose, and blood pressure were normal throughout follow-up. Early in her pregnancy, the patient developed an uneventful retinopathy of the left eye. At 37weeks of gestation, she underwent an elective CS due to a short inter-pregnancy interval and delivered a healthy baby with an average birth weight. At the age of 39years, the patient had a third unplanned pregnancy. She was diagnosed with seronegative antiphospholipid syndrome. She suffered from bilateral vitreous hemorrhage and was managed successfully with a minimally invasive laser treatment combined with an intravitreal injection of anti-vascular endothelial growth factor during her third trimester. At 35weeks of gestation, the patient presented with labor pain and underwent an emergency CS and delivered a healthy baby with an average birth weight. Pregnancy after SPKT requires a multidisciplinary approach with a careful workup.

O028 Multi-centre UK analysis after simultaneous pancreas and kidney transplantation in recipients with type 2 diabetes mellitus

Abstract Introduction Only 3.4% of simultaneous pancreas and kidney transplants (SPKT) in the UK are performed for recipients with T2DM. The aim of this study was to compare outcomes after SPKT for recipients with either T1DM or T2DM. Methods Data on all UK SPKTs from 2003–2019 were obtained from the NHSBT UK Transplant Registry (n=2,236). Current SPKT selection criteria for T2DM requires insulin treatment and recipient BMI&amp;lt;30kg/m2 at listing. Cases where the aetiology of diabetes was missing and recipients who had received a re-transplant were excluded, resulting in a final cohort of n=2,154. Graft (GS) and patient (PS) survival analyses were conducted using Kaplan-Meier plots and Cox regression models. Complications were compared using chi-squared analyses. Results The majority of SPKTs were performed in recipients with T1DM (95.6%, n=2,060), and 3.4% (n=94) were performed in T2DM recipients. Recipients with T2DM were statistically significantly more likely to be older (p&amp;lt;0.0001), male (p&amp;lt;0.0001), with a higher BMI (p=0.0191), and not requiring dialysis (p&amp;lt;0.0001). Univariate analysis showed comparable outcomes for GS and PS at 1yr (GS p=0.120; PS p=0.886) and 3yrs (GS p=0.316; PS p=0.237). Multi-variate analysis also showed comparable outcomes in GS (p=0.564, HR 1.221, 95%CI 0.619, 2.406) and PS (p=0.556, HR 1.280, 95%CI 0.563, 2.911). Common complications after SPKT were analysed and no statistically significant differences were seen between recipients. Conclusion This is the largest European study evaluating outcomes after SPKT comparing recipients with T1DM or T2DM. Carefully selected recipients with T2DM were shown to have comparable graft survival, patient survival and rates of complications. Take-home message Carefully selected recipients with T2DM were shown to have comparable graft survival, patient survival and rates of complications.

Early Experience Using Donor-derived Cell-free DNA for Surveillance of Rejection Following Simultaneous Pancreas and Kidney Transplantation.

Background.Allograft biopsy is the gold standard for diagnosing graft rejection following simultaneous pancreas and kidney (SPK) transplant. Intraperitoneal biopsies are technically challenging and can be burdensome to patients and the healthcare system. Donor-derived cell-free DNA (dd-cfDNA) is well-studied in kidney transplant recipients; however, it has not yet been studied in the SPK population.Methods.We hypothesized that dd-cfDNA could be utilized for rejection surveillance following SPK transplant. We prospectively collected dd-cfDNA in 46 SPK patients at a single institution.Results.There were 10 rejection events, 5 of which were confirmed with biopsy. The other 5 were treated based on dd-cfDNA and clinical data alone with favorable outcomes. Among all patients who did not have rejection, 97% had dd-cfDNA <0.5%. Dd-cfDNA may also help differentiate rejection from graft injury (ie, pancreatitis) with median values in rejection 2.25%, injury 0.36%, and quiescence 0.18% (P = 0.0006).Conclusions.Similar to kidneys, dd-cfDNA shows promise for rejection surveillance in SPK transplant recipients.

Pregnancy After Simultaneous Pancreas-Kidney Transplantation in Treatment of End-Stage Diabetes Mellitus: a Review.

The majority of patients with simultaneous pancreas and kidney transplant (SPKT) required transplantation owing to a long-standing history of insulin-dependent diabetes mellitus (IDDM). The disease causes multiple organ damage, impairs fertility, and affects quality of life. A successful kidney and pancreas transplant can improve health, ameliorate the consequences of pre-existent diabetes, and restore fertility. Good graft function, without any sign of rejection, and stable doses of immunosuppressant drugs are of utmost importance prior to the planned pregnancy. SPKT recipients who become pregnant may be at an increased risk for an adverse outcome and require meticulous multidisciplinary surveillance. We present experiences with SPKT pregnancies, traditional approaches, and recent considerations. In light of complex interactions between new anatomic relations and the impact of developing pregnancy and immunosuppressive medications, special stress is put on the risk of graft rejection, development of pregnancy complications, and potential harmful effects on fetal development. Recent recommendations in management of SPKT recipients who wish to commence pregnancy are presented as well. Key words: transplantation, pregnancy, pancreas, kidney, simultaneous pancreas and kidney transplantation (SPKT).

P.137: Multi-centre UK Analysis After SPK in Recipients With Type 2 Diabetes Mellitus

Background: From 1994 - 2019 only 4% of simultaneous pancreas and kidney (SPK) transplants in the United Kingdom (UK) have been performed for recipients with Type 2 diabetes mellitus. The aim of this study was to compare outcomes after SPK transplantation for recipients with either Type 1 (T1DM) or Type 2 (T2DM) diabetes. Methods: Retrospective data on all UK SPK Transplants from 1994 - 2019 were obtained from the NHSBT UK Transplant Registry, n=2,236. Current SPK selection criteria for Type 2 diabetes mellitus specifically requires insulin treatment and recipient BMI less than 30kg/m2 at the time of listing. Cases where the aetiology of diabetes was missing or had been classified as ‘other’ rather than specifically Type 1 or Type 2 diabetes were excluded, as were recipients who had received a re-transplant, resulting in a final cohort of n=2,154. Graft and patient survival analyses were conducted using Kaplan-Meier plots and Cox regression models. Complications were compared using chi-squared analyses. Results: The majority of SPK transplants were performed in recipients with T1DM (95.6%, n=2,060), and 3.4% (n=94) were performed in recipients with T2DM. Recipients with T2DM were statistically significantly more likely to be older (p<0.0001), male (p<0.0001), with a higher body mass index (BMI) (p=0.0191) and not requiring dialysis (p<0.0001). Univariate analysis showed no statistically significant difference in graft (GS) or patient (PS) survival between recipients with T1DM or T2DM at 1 year (GS T1DM-88.9%, T2DM-85.1% p=0.120; PS T1DM-96.9% T2DM-96.8%, p=0.886) or 3 years (GS T1DM-85.2% T2DM-83.0%, p=0.316; PS T1DM-96.9%, T2DM-96.8% p=0.237). Multi-variate analysis also failed to reveal a statistically significant difference between graft (p=0.564, HR 1.221, 95%CI 0.619, 2.406) or patient (p=0.556, HR 1.280, 95%CI 0.563, 2.911) survival between these two cohorts. Common complications after pancreas transplant such as myocardial infarction, cerebrovascular accident, infection and rejection were analysed and again no statistically significant differences were seen between recipients regardless of type of diabetes.Conclusions: This is one of the largest national studies evaluating outcomes after SPK transplants comparing recipients with T1DM or T2DM. Carefully selected recipients with Type 2 diabetes were not shown to have any statistically significant difference in graft or patient survival and had comparable rates of complications.

Simultaneous Pancreas and Kidney Composite Graft Transplant

Purpose: Limited vascular access could be encountered in an obese or re-transplant patient. We described modifications that facilitated an en bloc simultaneous pancreas and kidney (SPK) composite graft transplant in an obese type 2 diabetic patient with renal failure under hemodialysis. Methods: At the back-table, the superior mesenteric artery and splenic artery of the pancreas graft were reconstructed with a long "Y" iliac artery graft. The smaller left renal artery is anastomosed end-to-side to the larger and longer common limb of the arterial Y graft and the shorter portal vein is anastomosed end-to-side to the longer graft left renal vein. Thus, this en bloc composite graft allowed to facilitate “real” SPK transplant using single common graft artery and vein for anastomosis to one recipient arterial and venous site. The en bloc pancreas and kidney composite graft was implanted by suturing the graft left renal vein to IVC and graft common iliac artery the recipient distal aorta. Exocrine drainage was provided by anastomosis of the graft duodenum to a roux-en-y jejunum limb in an side-to-side fashion. Immunosuppressants included basiliximab, tacrolimus, mycophenolate mofetil, and methylprednisolone. Results: The operative time was 7 hours with cold ischemic time of 6 hours and 25 min. and warm ischemic time of 47 min. The patient was discharged on postoperative day 20, with a serum creatinine level of 1.4 ng/ml and a blood glucose level of 121 mg/dL. Conclusion: En bloc pancreas and kidney composite graft might be an option for patients with limited vascular access.

Small Bowel Perforation as the Initial Manifestation of Post-Transplant Lymphoproliferative Disorder in a Kidney and Pancreas Transplant Recipient: A Case Report

Post-transplant lymphoproliferative disorder (PTLD) comprises a broad spectrum of diseases and is a rare but serious complication of solid organ transplantation. We report the case of a 45-year-old simultaneous pancreas and kidney (SPK) transplant recipient with diffuse, early-onset PTLD, manifesting as jejunal perforation at 6 months after transplantation. The patient underwent urgent small bowel resection of the affected portion of jejunum. The surgical pathology report was significant for diffuse large B-cell lymphoma. Subsequently, the patient underwent a full workup, including upper and lower endoscopy and whole-body positron emission tomography that revealed involvement of the axial skeleton and multiple abdominal organs with sparing of the grafts. He was treated with rituximab and intrathecal methotrexate for central nervous system prophylaxis. The patient experienced complete resolution of disease by positron emission tomography 8 months after initial presentation. We found no previous report in the literature of intestinal perforation as the initial presentation of PTLD in SPK transplant recipients.

Changes in quality of life, health status and other patient-reported outcomes following simultaneous pancreas and kidney transplantation (SPKT): a quantitative and qualitative analysis within a UK-wide programme.

We examined quality of life (QoL) and other patient-reported outcome measures (PROMs) in 95 simultaneous pancreas and kidney transplant (SPKT) recipients and 41 patients wait-listed for SPKT recruited to the UK Access to Transplantation and Transplant Outcome Measures (ATTOM) programme. Wait-listed patients transplanted within 12months of recruitment (n=22) were followed 12months post-transplant and compared with those still wait-listed (n=19) to examine pre- to post-transplant changes. Qualitative interviews with ten SPKT recipients 12months post-transplant were analysed thematically. Cross-sectional analyses showed several better 12-month outcomes for SPKT recipients compared with those still wait-listed, a trend to better health utilities but no difference in diabetes-specific QoL or diabetes treatment satisfaction. Pre- to post-transplant, SPKT recipients showed improved treatment satisfaction, well-being, self-reported health, generic QoL and less negative impact on renal-specific QoL (ps<0.05). Health utility values were better overall in transplant recipients and neither these nor diabetes-specific QoL changed significantly in either group. Pre-emptive transplant advantages seen in 12-month cross-sectional analyses disappeared when controlling for baseline values. Qualitative findings indicated diabetes complications, self-imposed blood glucose monitoring and dietary restrictions continued to impact QoL negatively post-transplant. Unrealistic expectations of SPKT caused some disappointment. Measuring condition-specific PROMs over time will help in demonstrating the benefits and limitations of SPKT.

Geographic Disparities in Access to Simultaneous Pancreas and Kidney Transplant in the Pre- and Post-Pancreas Allocation System Eras.

The 2014 pancreas allocation system (PAS) intended to decrease geographic variability in listing practices for simultaneous pancreas and kidney (SPK) transplant and define eligibility criteria for those with type 2 diabetes mellitus (T2DM). Our primary aims were to evaluate geographic disparities in access to SPK and assess T2DM SPK listings in the pre- and post-PAS eras. Adult listings for SPK and kidney transplant (pre-PAS, January 2010 to October 29, 2014; post-PAS, October 30, 2014, to June 2, 2017) were identified in the Scientific Registry of Transplant Recipients. Multivariable logistic regression models tested associations of geography and/or diabetes mellitus type on the likelihood of SPK versus kidney transplant listing pre- and post-PAS. Competing risk models tested the likelihood of SPK transplantation within 2 years of listing for SPK. Among 41 205 listings (27 393 pre-PAS; 24 439 T2DM), univariate analysis showed reduced percentages for SPK post-PAS (22.1%-20.8%; P = 0.003). After adjusting for patient and center characteristics, geographic disparities declined slightly but persisted post-PAS (era by region interaction P < 0.001). The era by type of diabetes mellitus interaction effect was statistically significant (P = 0.039), reflecting that the proportions of SPK listings for T2DM increased in the post-PAS era (3.4%-3.9%; univariate P = 0.038), while those for type 1 diabetes mellitus remained statistically stable (47.9%-48.4%; univariate P = 0.571). Among people listed for SPK, geographic disparities in the cumulative incidence of transplantation within 2 years declined and the overall likelihood of transplantation increased in the post-PAS era (both P < 0.001). Geographic disparities in access to SPK declined slightly but persisted post-PAS. With new allocation change proposals and elimination of listing criteria for T2DM, further monitoring is warranted.

Tacrolimus- versus sirolimus-based immunosuppression after simultaneous pancreas and kidney transplantation: 5-year results of a randomized trial.

Tacrolimus, the cornerstone immunosuppression after simultaneous pancreas and -kidney (SPK) transplantation, may exert nephrotoxic and diabetogenic effects. We therefore prospectively compared in an open-label, randomized, monocentric, 5-year follow-up study, a tacrolimus- and a sirolimus-based immunosuppressive regimen. Randomization using the block method allowing a blind allocation was done at the time of surgery. All patients received anti-thymocyte globulin and maintenance therapy with tacrolimus, mycophenolate mofetil, and steroids. At month 3, tacrolimus was continued or replaced by sirolimus. The primary endpoint was kidney and pancreas graft survival at 1 and 5years. Fifty patients were included in the final analysis in each group. At 1 year, differences for kidney and pancreas graft survival between sirolimus and tacrolimus were 0% (90% confidence interval -4.61% to 4.61%) and 6% (90% confidence interval -6.32% to 18.32%), respectively. There was no difference in renal and pancreas graft survival at 5years. Thirty-four patients (68%) in the sirolimus group vs three (6%) in the tacrolimus group needed definitive withdrawal of the study drug. Despite noninferiority of sirolimus compared to tacrolimus for kidney and pancreas graft survival, the high rate of sirolimus discontinuation does not favor its use as cornerstone therapy after SPK transplantation (NCT00693446).

Major Adverse Cardiovascular Events Following Simultaneous Pancreas and Kidney Transplantation in the United Kingdom.

People with type 1 diabetes and kidney failure have an increased risk for major adverse cardiovascular events (MACE). Simultaneous pancreas and kidney transplantation (SPKT) improves survival, but the long-term risk for MACE is uncertain. We assessed the frequency and risk factors for MACE (defined as fatal cardiovascular disease and nonfatal myocardial infarction or stroke) and related nonfatal MACE to allograft failure in SPKT recipients with type 1 diabetes who underwent transplantation between 2001 and 2015 in the U.K. In a subgroup, we related a pretransplant cardiovascular risk score to MACE. During 5 years of follow-up, 133 of 1,699 SPKT recipients (7.8%) experienced a MACE. In covariate-adjusted models, age (hazard ratio 1.04 per year [95% CI 1.01-1.07]), prior myocardial infarction (2.6 [1.3-5.0]), stroke (2.3 [1.2-4.7]), amputation (2.0 [1.02-3.7]), donor history of hypertension (1.8 [1.05-3.2]), and waiting time (1.02 per month [1.0-1.04]) were significant predictors. Nonfatal MACE predicted subsequent allograft failure (renal 1.6 [1.06-2.6]; pancreas 1.7 [1.09-2.6]). In the subgroup, the pretransplant cardiovascular risk score predicted MACE (1.04 per 1% increment [1.02-1.06]). We report a high rate of MACE in SPKT recipients. There are a number of variables that predict MACE, while nonfatal MACE increase the risk of subsequent allograft failure. It may be beneficial that organs from hypertensive donors are matched to recipients with lower cardiovascular risk. Pretransplant cardiovascular risk scoring may help to identify patients who would benefit from risk factor optimization or alternative transplant therapies and warrants validation nationally.

Use of donors at age extremes for simultaneous pancreas-kidney transplant

Introduction: There is a shortage of optimal pancreatic donors for simultaneous pancreas and kidney transplant (SPKT), as such there is interest in utilizing donors at extremes of age to expand the donor pool. We sought to evaluate outcomes in SPKT from pediatric donors (PDs) to older donors (ODs). Patients and Methods: We identified patients who underwent simultaneous pancreas and kidney transplant at a single, high-volume institution from 1988–2013. We evaluated for differences in transplant organ function (estimated glomerular filtration rate [GFR], serum glucose, and urine amylase), early (technical) graft loss, and patient and graft survival. Results: A total of 729 SPKT were performed during the study, with 32 PDs, 652 standard donors (SDs), and 45 ODs. Renal function was slightly worse in OD. Otherwise, graft function was similar between all three groups at up to 5 years. There was no difference in censored survival analyses for both kidney and pancreas allografts. There was comparable short-term and long-term patient survival among all groups. Conclusions: Overall, the use of pancreas from pediatric and ODs for SPKT has comparable outcome to SDs. Kidneys from donors above 50 may have lower GFR, but otherwise, have comparable long-term patient and graft survival.

Risk factors for surgical site infection after kidney and pancreas transplantation.

To evaluate the incidence of surgical site infection (SSI) in a cohort of pancreas transplant recipients and assess predisposing risk factors for SSI DESIGN: Retrospective cohort study SETTING: Single transplant center in CanadaPatientsPatients who underwent any simultaneous pancreas and kidney (SPK) or pancreas after kidney (PAK) transplant procedures between January 2000 and December 2015 METHODS: In this retrospective cohort evaluation of SPK or PAK recipients, we assessed the incidence of SSI and risk factors associated with superficial, deep, and organ/space SSI. Multivariate logistic regression was used to identify independent risk factors for SSI in SPK and PAK recipients. In total, 445 adult transplant recipients were enrolled. The median age of these patients was 51 years (range, 19-71 years), and 64.9% were men. SSIs were documented in 108 patients (24.3%). Organ/space SSIs predominated (59 patients, 54.6%), followed by superficial SSIs (47 patients, 43.5%) and deep SSIs (3 patients, 2.8%). Factors predictive of SSIs in the multivariate analysis were cold pancreas ischemic time (odds ratio [OR], 1.002; P=.019) and SPK transplant (compared to PAK transplant recipients; OR, 2.38; P=.038). Patients with SSIs developed graft loss more frequently (OR, 16.99; P<.001). Organ/space SSIs remain a serious and common complication after SPK and PAK. Prolonged cold ischemic time and SPK transplant were the risk factors predictive of SSIs. Appropriate perioperative prophylaxis in high-risk patients targeting the potential pathogens producing SSIs in kidney and/or pancreas transplant recipients and a reduction in cold ischemia may prove beneficial in reducing these SSIs.

Analysis of Hospitalizations in Simultaneous Pancreas-Kidney Transplant Recipients: A Single-center Experience in Poland

BackgroundEnd-stage renal disease due to type 1 diabetes mellitus appears to be a regular indication for simultaneous pancreas and kidney transplantation (SPKT). Although transplantation improves a patient's health condition, it does not mean that all complications will be eliminated. MethodsWe performed a retrospective analysis of 73 patients who underwent SPKT and follow-up between 1988 and 2015 at our institute. The number, duration, and reasons for hospitalization at 1, 5, 10, and 15 years after SPKT were analyzed. ResultsThe average number of hospitalizations at 1, 5, 10, 15 years after SPKT were 1.66, 0.39, 0.36, and 0.33, respectively. The main reason for hospitalization over the 15-year period was infections, at 32.4% (SD, 6.8%). Within the first year after SPKT, 6.8% of hospital admissions were caused by cytomegalovirus (CMV) infection. Over time, the percentage of hospitalizations for cardiovascular complications increased from 0.6% at 1 year to 29% at 12–15 years. Incidence of hospitalization due to cardiovascular complications correlated with a longer period of dialysis and a diagnosis of ischemic heart disease before transplant (r = 0.56, P = .004; r = 0.54, P < .0001, respectively). At 12–15 years after transplantation, 18.2% of hospitalizations were caused by secondary complications of diabetes. ConclusionThe most common reason for hospitalization after SPKT is infectious complications. In the first year posttransplant, there is a high percentage of CMV infections. Hospitalization associated with cardiovascular complications was found to be most common in the latter follow-up period and showed a correlation with longer dialysis period.

Broadened Allocation of Pancreas Transplants Across Compatible ABO Blood Types

BackgroundCurrent Organ Procurement and Transplantation Network (OPTN) policy restricts certain blood type-compatible simultaneous pancreas and kidney (SPK) transplants. Using the Kidney Pancreas Simulated Allocation Model, we examined the effects of 5 alternative allocation sequences that allowed all clinically compatible ABO transplants. MethodsThe study cohort included kidney (KI), SPK, and pancreas alone (PA) candidates waiting for transplant for at least 1 day between January 1, 2010, and December 31, 2010 (full cohort), and kidneys and pancreata recovered for transplant during the same period. Additionally, because the waiting list has shrunk since 2010, the study population was reduced by random sampling to match the volume of the 2015 waiting list (reduced cohort). ResultsCompared with the current allocation sequence, R4 and R5 both showed an increase in SPK transplants, a nearly corresponding decrease in KI transplants, and virtually no change in PA transplants. Life-years from transplant and median years of benefit also increased. The distribution of transplants by blood type changed, with more ABO:A, B, and AB transplants performed, and fewer ABO:O across all transplant types (KI, SPK, PA), with the relative percent changes largest for SPK. DiscussionBroadened ABO compatibility allowances primarily benefitted SPK ABO:A and AB candidates. ABO:O candidates saw potentially reduced access to transplant. The simulation results suggest that modifying the current allocation sequence to incorporate broadened ABO compatibility can result in an increase in annual SPK transplants.

First Canadian experience with donation after cardiac death simultaneous pancreas and kidney transplants.

Compared with neurologic determination of death (NDD) donor organs, donation after cardiac death (DCD) donor organs have traditionally been considered of inferior quality owing to warm ischemia experienced during procurement. We present, to our knowledge, the first analysis of simultaneous pancreas and kidney (SPK) transplants using DCD donor organs in Canada. We carried out a retrospective cohort study of SPK transplants from 13 DCD and 68 NDD donors performed between October 2008 and July 2016. In all patients immunosuppression was induced with thymoglobulin and continued with tacrolimus, mycophenolate mofetil and prednisone maintenance therapy. Donor and recipient characteristics of DCD and NDD groups were similar with respect to age, sex, body mass index, kidney and pancreas cold ischemia times, and donor terminal creatinine. Mean DCD graft warm ischemia time was 0.5 (range 0.4-0.7) hours. Median follow-up was 2.2 (range 0.1-6.7) years and 2.7 (range 0.3-6.3) years for the DCD and NDD groups, respectively. The DCD and NDD groups were similar with regards to recipient percent panel reactive antibody and presence of human leukocyte antigen antibodies. The groups also received similar total doses of thymoglobulin. In total 38% of patients in the DCD group experienced renal delayed graft function (DGF) compared with 10% in the NDD group (p = 0.027). There were 7 cases of pancreas graft thrombosis requiring relaparotomy in the NDD group compared with none in the DCD group. No patients from either group required insulin at any time after transplant. Although the estimated glomerular filtration rate (eGFR) was lower in the DCD than the NDD group on postoperative days 7 and 14 (p = 0.025), no difference was noted on day 30 or through 4 years after transplant. No differences were seen between the groups with respect to amylase, lipase, or glycosated hemoglobin (HbA1c) up to 4 years after transplant, or in kidney, pancreas, or patient survival at any time after transplant. Our results show that, apart from a higher renal DGF rate, SPK transplants with DCD donor organs have comparable outcomes to standard transplants with NDD donor organs.

Simultaneous pancreas and kidney transplantation: Incidence and risk factors for amputation after 10-year follow-up.

The incidence of amputation after simultaneous pancreas and kidney (SPK) transplantation ranges from 9.5% to 23% after 5years of follow-up. The objective of this study was to investigate the incidence and risk factors for amputation in SPK transplant patients compared to kidney transplantation alone (KTA) after a minimum follow-up of 10years. An analysis was performed on a prospectively maintained database of 81 SPK transplants and 43 KTA consecutively performed in one center for insulin-dependent diabetes mellitus between December 1992 and January 2006. Primary outcome variables were incidence of amputation per patient, total number of amputations, and type of amputation performed. Data are presented as a mean±standard deviation. Seven patients (9%) in the SPK cohort and one patient (2%) in the KTA cohort underwent amputation (P<.001). One amputee had pancreas allograft failure prior to amputation. Fifteen amputations were performed in total and four patients required ≥2 amputations. The latency period between transplantation and amputation was 133.57±49.43months in the SPK cohort and 168months in the KTA group. The incidence of amputation after SPK transplantation is approximately 9% after 10-year follow-up. Patients are at a significantly greater risk of amputation after SPK transplantation compared to KTA for type 1 diabetes despite insulin independence.

Pancreas After Islet Transplantation: A First Report of the International Pancreas Transplant Registry

Pancreas after islet (PAI) transplantation is a treatment option for patients seeking insulin independence through a whole-organ transplant after a failed cellular transplant. This report from the International Pancreas Transplant Registry (IPTR) and the United Network for Organ Sharing (UNOS) studied PAI transplant outcomes over a 10-year time period. Forty recipients of a failed alloislet transplant subsequently underwent pancreas transplant alone (50%), pancreas after previous kidney transplant (22.5%), or simultaneous pancreas and kidney (SPK) transplant (27.5%). Graft and patient survival rates were not statistically significantly different compared with matched primary pancreas transplants. Regardless of the recipient category, overall 1- and 5-year PAI patient survival rates for all 40 cases were 97% and 83%, respectively; graft survival rates were 84% and 65%, respectively. A failed previous islet transplant had no negative impact on kidney graft survival in the SPK category: It was the same as for primary SPK transplants. According to this IPTR/UNOS analysis, a PAI transplant is a safe procedure with low recipient mortality, high graft-function rates in both the short and long term and excellent kidney graft outcomes. Patients with a failed islet transplant should know about this alternative in their quest for insulin independence through transplantation.

A prospective cohort study of risk prediction in simultaneous pancreas and kidney transplantation.

Current risk prediction scoring systems in pancreas transplantation are limited to organ factors and are specific to predicting graft outcome. They do not consider recipient factors or inform regarding recipient morbidity. The aim of this study was to assess the utility of commonly used general surgical risk prediction models (P-POSSUM [Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity], MODS [multiple organ dysfunction score], Charlson co-morbidity index, revised cardiac risk index, ASA [American Society of Anesthesiologists] grade and Waterlow score), and to correlate them with total length of hospital stay (LOS) and critical care unit (CCU) LOS, important surrogate markers of patient outcome. All risk prediction scores were calculated prospectively for all simultaneous pancreas and kidney (SPK) transplant recipients from November 2011 to October 2013, and correlated with outcome measures. Overall, 57 SPK transplant recipients were analysed. The mean age was 42.0 years (standard deviation [SD]: 7.60 years), 27 (52%) were male and the mean body mass index was 25.43kg/m(2) (SD: 3.11kg/m(2)). The mean pancreas and kidney cold ischaemic times were 703 minutes (SD: 182 minutes) and 850 minutes (SD: 192 minutes) respectively. The median total LOS and mean CCU LOS was 17 days (range: 8-79 days) and 7 days (SD: 4.04 days) respectively. When correlated with risk prediction scores, Waterlow score was the only significant predictor of total LOS and CCU LOS (p<0.001 [Spearman's correlation] and p=0.001 [Pearson's correlation] respectively). Preoperative risk prediction plays an important part in planning perioperative care. To date, no validated risk prediction scoring system exists for SPK transplantation. This prospective study indicates that Waterlow score identifies high risk individuals and has value in the prediction of outcome following SPK transplantation.