Simultaneous Pancreas Transplantation Research Articles

Mortality Prediction in Recipients with Diabetes Mellitus and End Stage Renal Failure Undergoing Simultaneous Pancreas Transplant: A Focus on Cardiovascular Risk Factors

Mortality Prediction in Recipients with Diabetes Mellitus and End Stage Renal Failure Undergoing Simultaneous Pancreas Transplant: A Focus on Cardiovascular Risk Factors

Pancreas and Islet Transplantation

Pancreas and Islet Transplantation

Trasplante renal aislado o doble trasplante riñón-páncreas en pacientes con diabetes: indicaciones, ventajas y posibles complicaciones

Diabetic nephropathy is one of the main causes of renal failure and inclusion in a dialysis and transplant program. Kidney allograft can be made from a living or cadaver donor. Using living kidney transplant permits an early or preventive transplantation as compared to cadaver kidney allograft transplantation, which can be performed either as a single organ or combined with a pancreas transplantation. The choice of any kind of transplantation modality depends on age, type of diabetes and state of chronic diabetic complications. Each transplant modality has its advantages and disadvantages. Single kidney allograft is technically easier and less immunogenic, but it not allows complete metabolic control that can be achieved with simultaneous pancreas transplantation. The early complications are more frequent with kidney-pancreas transplant. But in the long-term, carbohydrate metabolism normalization achieved by the functioning pancreas allograft avoids recurrence of nephropathy in the kidney allograft, improves neuropathy and decreases cardiovascular mortality.

Laparoscopic‐assisted distal pancreatectomy and nephrectomy from a live donor

The simultaneous transplantation of pancreas and kidney from live donors is performed in select countries. One of the reasons for this reduced applicability is the invasiveness of the donor operation. We propose the method of laparoscopic-assisted operation to be performed on live donors with minimal invasion. The donor was placed in the right lateral decubitus position. A 7-cm upper midline incision was made, and a handport was installed in addition to two or three 12-mm ports. After the removal of the left kidney graft, the spleen and the distal part of the pancreas were completely mobilized. The splenic vein and artery were identified and mobilized. The donor was then rotated to a supine position. Dissection of the pancreatic parenchyma using ultrasound shears and ligation of the splenic vessels were performed through midline incision under direct vision. The distal part of the pancreas and the spleen were extracted. Since December 2007, 3 donors have undergone this operation. In all 3 cases, the postoperative course was uneventful, and both the renal and pancreatic grafts functioned well. This technique is minimally invasive and safe, and may become the standard method of live donor operation for simultaneous pancreas-kidney transplantation.

Impact of Current Transplantation Management on the Development of Cytomegalovirus Disease after Renal Transplantation

Current advances in transplantation practices may influence the development of cytomegalovirus (CMV) disease after renal transplantation. From September 2003 through February 2005, 1470 renal transplant recipients (55 of whom were kidney-pancreas transplant recipients) were prospectively studied in the 16 transplant centers affiliated with the Spanish Network of Infection in Transplantation, with use of an ad hoc-designed online database. Univariate and multivariate analyses with logistic regression were performed to detect risk factors for CMV disease. A total of 105 episodes of CMV disease (37 with visceral involvement) developed in 99 (6.7%) of 1470 patients. Attributable mortality appeared in 1 (1.0%) of 105 cases. Multivariate analysis showed that, apart from CMV serological mismatch, presence of rejection episodes, and the use of antilymphocitic drugs, a simultaneous pancreas transplantation (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.5-9), use of cyclosporine (OR, 1.7; 95% CI, 1.18-2.9), a donor >60 years of age (OR, 2.3; 95% CI, 1.5-3.7), and chronic graft malfunction (OR, 1.8; 95% CI, 1.14-2.9) were independently associated with CMV disease, whereas use of sirolimus had a protective effect (OR, 0.27; 95% CI, 0.1-0.78). Additional risk factors related to current transplantation practices influence the epidemiology of CMV after renal transplantation and should be taken into account in the design of prophylactic strategies in this population of kidney or kidney-pancreas recipients.

Bilateral sequential lung and simultaneous pancreas transplant: A new approach for the recipient with cystic fibrosis

Cystic fibrosis (CF) is an inherited disorder that presents in childhood as a multisystem disease. Pulmonary failure and pancreatic insufficiency, including CF related diabetes (CFRD) and exocrine insufficiency, are common complications of this disease. In this report we review the first three simultaneous lung and pancreas transplantations in CF patients with diabetes. Methods All three CF patients presented for evaluation for lung transplantation and had pancreatic insufficiency requiring enzyme supplementation and CFRD requiring insulin. All were severely malnourished and required nutritional supplementation. Surgical technique In each case, the allografts were procured from a single cadaveric donor. Bilateral lung transplantation was performed first using two separate thoracic incisions. The pancreas transplant was performed with systemic venous drainage and enteric exocrine drainage. Results The pancreas allografts all functioned normally with normoglycemia independent of insulin. As a result of the enteric drainage of the pancreas allograft, supplemental pancreatic enzymes were no longer required. Despite several complications detailed in the manuscript, all three remain independent of supplemental oxygen, insulin and pancreatic enzyme replacement at 4, 6 and 14 months of follow-up. Conclusion Simultaneous lung and pancreas transplantation in patients with CF can be performed successfully and provides the advantages of normoglycemia and improves nutrition for patients requiring lung transplantation.

Simultaneous Liver and Pancreas Transplantation in Patients With Cystic Fibrosis

Background Improved survival in patients with cystic fibrosis (CF) has led to an increased incidence of extrapulmonary complications of this disease. Of these, cirrhosis and pancreatic insufficiency, including CF-related diabetes (CFRD) and exocrine insufficiency, are significant causes of morbidity and mortality. Liver transplantation is the treatment of choice for cirrhosis in this setting, but the addition of an isolated simultaneous pancreas transplant in patients with CFRD has not been reported. Methods Two female patients with CF underwent simultaneous pancreas and liver transplantation. Both had pancreatic insufficiency, CFRD, cirrhosis, and preserved renal function. In each case, the liver and pancreas were procured from a single cadaveric donor. The liver transplant was performed first. A lower midline extension was added for improved exposure of the iliac vessels. The donor pancreas transplant was performed with systemic venous drainage and enteric exocrine drainage. Immunosuppression included rabbit anti-thymocyte globulin, tacrolimus, mycophenolate mofetil, and early steroid withdrawal. Results Both patients recovered well with normal liver function, resolution of portal hypertension, and normal blood glucoses independent of insulin. As a result of the enteric exocrine drainage of the pancreas, they are now independent of supplemental pancreatic enzymes. Conclusions Simultaneous liver and pancreas transplantation in CF patients provides the advantages of normalization of glucose and improved nutrition for patients requiring liver transplantation and should be considered in CF patients with CFRD who require liver transplants.

How do patients experience their body after simultaneous pancreas-kidney transplantation?

Simultaneous transplantation of pancreas and kidney (SPK) has become a standard procedure for type 1 diabetics with terminal kidney failure. Patients often experience SPK as a dramatic event which mobilizes a complexity of affects such as anxiety, hope, and gratitude. Patients often have fantasies regarding their bodies after transplantation which are linked to massive affects. We investigated 8 non-selected patients in the first year after SPK by narrative interviews to study their experiences of transplantation. The interviews were audiotaped, transcribed and analysed according to Grounded Theory and ideal type analysis. Our patients had many different private theories and fantasies regarding transplantation. Patients' experiences were centred around themes of adoption of the transplanted organs and the protection of identity and self, and could be grouped into five ideal type sets. Bodily fantasies of our patients can be interpreted as specific adaptations to coping requirements after transplantation.

MORBIDITY OF PANCREAS TRANSPLANTATION DURING CADAVERIC RENAL TRANSPLANTATION

Simultaneous transplantation of the pancreas is an option for diabetic patients undergoing kidney transplantation to attempt to halt progression of diabetic complications, but the additional risk imposed by the procedure is unclear. Our aim was to determine the morbidity attributable to pancreas transplantation during simultaneous pancreas and kidney transplantation. We compared the first posttransplant year of 18 consecutive recipients of combined pancreas and kidney transplantation to 18 consecutive recipients of kidney transplantation alone. All patients received cadaver donor allografts between 1986 and 1989, and had type I diabetes mellitus with chronic renal failure. There were no differences in patient survival (94% both groups) or satisfactory renal allograft function (89% pancreas/kidney group, 83% kidney group) up to 18 months after transplantation. Eighty-eight percent of pancreas allografts were functioning satisfactorily at 18 months. There was a mean (+/- SD) of 1.5 +/- 1.0 acute rejection episodes per patient for the pancreas/kidney group compared to 0.8 +/- 6 for the kidney-only group (P less than 0.02). Cytomegalovirus infection and wound complications were each encountered more often after pancreas/kidney transplantation than kidney transplantation alone, and together with rejection accounted for a difference in days of hospitalization during the first year (71 +/- 34 vs. 27 +/- 13, P less than 0.001). We conclude that simultaneous pancreas transplantation during cadaver donor kidney transplantation accounted for more frequent rejection episodes, CMV infections, and wound complications. These complications resulted in more hospitalization for patients undergoing simultaneous pancreas/kidney transplantation than kidney transplantation alone.

Simultaneous Transplantation of Pancreas and Kidney in Patients with Advanced Diabetic Complications

From June 1983 to October 1985, 25 uremic diabetic patients aged 24 to 52 (mean 38) years were treated with combined pancreas and kidney transplantation. Mean duration of diabetes was 24 years, and end-stage renal disease was associated with severe extrarenal diabetic complications in all recipients. All transplants were harvested from cadaveric, heart-beating donors aged 5-55 years. The segmental pancreas transplant was duct-occluded with neoprene before it was transplanted to the left iliac fossa. Immunosuppressive treatment was given with cyclosporine and steroids in all cases while azathioprine was added in the last 5 cases. The one year survival of patient, kidney and pancreas was 96, 79 and 60 per cent respectively. Of 17 patients with functioning pancreas transplants, 13 are insulin independent and have normal or near normal glucose homeostasis. Based on the excellent patient survival and the improvement in quality of life experienced by the recipients, it is concluded that simultaneous transplantation of pancreas and kidney should be the treatment of choice for uremic diabetic patients when a living related kidney donor is unavailable.

Prevention of Kidney Graft Diabetic Nephropathy by Pancreas Transplantation in Man

Kidney graft biopsies were performed 2-3 yr after transplantation in eight type I (insulin-dependent) diabetic patients who had previously been subjected to kidney transplantation (six patients) or combined kidney and segmental pancreas transplantation (two patients). In five of the six patients that had undergone only kidney transplantation, light microscopic examination of the graft biopsy revealed changes compatible with diabetic nephropathy, and electron microscopic morphometry showed a thickening of the glomerular basement membrane (GBM). In the two patients who had been subjected to combined pancreas and kidney transplantation, the kidney graft biopsy showed no light microscopic changes suggestive of diabetic nephropathy, and electron microscopy showed no thickening of the GBM. Thus, it appears to be possible to prevent the recurrence of diabetic nephropathy in human kidney allografts by simultaneous pancreas transplantation.