Alcides Salzedas

Multivariate Analysis of Risk Factors for Early Loss of Pancreas Grafts Among Simultaneous Pancreas–Kidney Transplants

UNLABELLED To evaluate the risk factors for pancreas graft loss within 3 months postoperatively among 170 simultaneous pancreas-kidney transplantation (SPKT) we examined 38 variables. METHODS Twenty-two variables were related to recipients; 12 to donors and 4 to the surgical procedure. In addition the latest follow-up dates as well as the transplant and/or death dates. Independent variables were examined with reference to the dependent pancreatic loss variable, excluding losses owing to deaths. Variables with statistical significance were analyzed to predict early graft loss. RESULTS Univariate analyses determined the following significant variables: kidney cold ischemia time, older donors, non-white donors, death cause related to vascular disease, wound infection, and length of extended hospitalization. However, multivariate analysis showed that only donor age and kidney cold ischemia time were significant predictors for early pancreatic graft loss. CONCLUSION Donor age and kidney cold ischemia time were independently related to pancreatic loss after SPKT within 3 months posttransplantation.

Conversion from Cyclosporin to Tacrolimus in Paediatric Liver Transplant Recipients

Substitution of cyclosporin with tacrolimus should be considered for paediatric liver transplant recipients with cyclosporin-associated complications such as hypertension, gum hyperplasia, hirsutism, gynaecomastia and growth retardation, as well as recurrent or refractory acute rejection, chronic duct injury or chronic rejection. Continued experience with well tolerated drug administration and careful monitoring during drug substitution has limited drug toxicity associated with tacrolimus to a level comparable to or less than that associated with cyclosporin.Successful outcome with long term graft salvage has been reported in up to 80% of patients converted to tacrolimus because of acute rejection and 50% of patients converted because of chronic rejection. Nearly all children converted because of cyclosporin-related complications have a successful outcome.Additional benefits of conversion to tacrolimus include improvement in growth and resolution of hypertension, hirsutism and cushingoid facies. Complete corticosteroid withdrawal is possible in up to 78% of children post-conversion.Long term outcome in these patients may be optimised by conversion to tacrolimus at an early stage of acute or chronic transplant rejection in order to minimise the cumulative amount of immunosuppression. Avoidance of cyclosporin-related toxicity and minimisation of corticosteroid therapy may further improve patient compliance to drug therapy.

Mycophenolate Mofetil Versus Enteric-Coated Mycophenolate Sodium After Simultaneous Pancreas-Kidney Transplantation

INTRODUCTION Adverse gastrointestinal events are frequent after mycophenolate use. The objectives of the present study were to report the incidence of acute noninfectious diarrhea, to determine the risk factors, and to compare the severity of reactions between mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS) after simultaneous pancreas kidney transplantation (SPKT). METHODS We included 165 SPKT patients from December 2000 to May 2007. Uni- and multivariate analyses were performed, using acute noninfectious diarrhea as the dependent variable. P < .05 was considered significant. RESULTS Mean age and duration of dialysis and of diabetes were 34.9 +/- 8.2 years, 27.3 +/- 18.3 months, and 21.9 +/- 16.2 years, respectively. Sixty-three percent used MMF, 36.4% used EC-MPS, and 0.6% used azathioprine. Multivariate analysis showed that the duration of diabetes (P = .049, confidence interval [CI] 1.0- 1.13) and MMF use (P = .013, 95% CI 0.2-0.82) were the main determinants of acute diarrhea after SPKT. MMF dose reduction (79.2% vs 62.3%, P = .024) and severity of diarrhea associated with orthostatic hypotension were more pronounced among MMF than EC-MPS patients (42.4% vs 15.1%, P = .001). There was no difference between MMF and EC-MPS after dose reduction in relation to the occurrence of acute kidney rejection (30.8% vs 26.7%, P = .53). CONCLUSIONS Acute noninfectious diarrhea after SPKT was related to the duration of diabetes and to prescription of MMF. Preferential use of EC-MPS was associated with a lower necessity of dose reduction and less severe episodes of acute diarrhea compared with MMF, although dose reduction was equally associated with acute episodes of kidney rejection.

Extreme Subcutaneous, Intramuscular and Inhaled Insulin Resistance Treated by Pancreas Transplantation Alone

Diabetes mellitus with resistance to insulin administered subcutaneously or intramuscularly (DRIASM) is a rare syndrome and is usually treated with continuous intravenous insulin infusion. We present here two cases of DRIASM in 16 and 18 years female patients that were submitted to pancreas transplantation alone (PTA). Both were diagnosed with type 1 diabetes as young children and had labile glycemic control with recurrent episodes of diabetic ketoacidosis. They had prolonged periods of hospitalization and complications related to their central venous access. Exocrine and endocrine drainages were in the bladder and systemic, respectively. Both presented immediate graft function. In patient 1, enteric conversion was necessary due to reflux pancreatitis. Patient 2 developed mild postoperative hyperglycemia in spite of having normal pancreas allograft biopsy and that was attributed to her immunosuppressive regimen. Patient 1 died 9 months after PTA from septic shock related to pneumonia. In 8 months of follow‐up, Patient 2 presented optimal glycemic control without the use of antidiabetic agents. In conclusion, PTA may be an alternative treatment for DRIASM patients.

Delayed Kidney Allograft Function after Simultaneous Pancreas-Kidney Transplantation

BACKGROUND Simultaneous pancreas-kidney transplantation (SPKT) is one of the treatments for insulin-dependent chronic renal failure patients. METHODS One-year patient and kidney allograft survival rates of 150 patients undergoing SPKT were subjected to Cox regression and Kaplan-Meier analyses. Uni- and multivariate methods identified risk factors involved in allograft and patient survival. RESULTS One-year patient and kidney allograft survival rates were 82% and 80%, respectively. Delayed graft function (DGF) (P = .001; hazard ratio [HR]5.41) and acute kidney rejection episodes (P = .016; HR 3.36) were related to 1 year patient survival as well as intra-abdominal infection (IAI) rates. (IAI). One-year kidney allograft survival was related to DGF (P = .013; odds ratio [OR] 3.39), acute rejection (P = .001; OR 4.74), and IAI (P = .003, OR 6.29). DGF was related to a time on dialysis >27 months (P = .046; OR 2.59), cold kidney ischemia time >14 hours (P = .027; OR 2.94), donor age >25 years (P = .03; OR 2.82), and donor serum sodium concentration >155 mEq/L (P < .0001; OR 1.09). Female kidney to male recipient in 17% of the cases did not increase the risk of DGF. We observed an important correlation between donor serum sodium and creatinine (P < .0001), which suggested undertreatment of diabetes insipidus secondary to brain death. CONCLUSIONS DGF, acute rejection, and IAI were the main determinants of survival after SPKT. Improving the care of deceased donors may reduce DGF occurrence.

Evaluation of the efficacy and reproducibility of cholangiopancreatography by magnetic resonance for detecting biliary complications following orthotopic liver transplantation

PURPOSE To evaluate the accuracy and reproducibility of magnetic resonance cholangiopancreatography (MRCP) in the detection of biliary complications in liver transplanted patients. METHODS A study was conducted, with blinded review of 28 MRCP exams of 24 patients submitted to liver transplantation. The images were reviewed by two independent observers, at two different moments, regarding the degree of biliary tree visualization and the presence or absence of biliary complications. The MRCP results were compared, when negative, to at least 3 months of clinical and biochemical follow-up, and when positive, to the findings at surgery or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS The degree of intrahepatic biliary tree visualization was considered good or excellent in 78.6% and 82.1% of the exams by the two observers and visualization of the donor duct, recipient duct and biliary anastomosis was considered good or excellent in 100% of the exams, by both observers. Six biliary complications were detected (21.4%), all of them anastomotic strictures. Intra and interobserver agreement were substantial or almost perfect (kappa k values of 0.611 to 0.804) for the visualization of the biliary tree and almost perfect (k values of 0.900 to 1.000) for the detection of biliary complications. MRCP achieved 100% sensitivity, 95.45% specificity, 85.7% positive predictive value and 100% negative predictive value for the detection of biliary complications. CONCLUSIONS MRCP is an accurate examination for the detection of biliary complications after orthotopic liver transplantation and it is a highly reproducible method in the evaluation of the biliary tree of liver transplanted patients.

Death Receptor in the First Year after Simultaneous Pancreas/Kidney Transplantation

Background: Simultaneous pancreas/kidney transplants require a long graft survival and recipient with to achieve more benefits than risks. In order to access the risk for this procedure, we evaluate the risk factors of death receptor with one year postoperatively in 292 simultaneous pancreas/kidney transplants evaluated 22 variables. Materials and Methods: Twenty-two variables were selected for the study, nine from receivers, eight from donors and five variables related to the surgical procedure. To determine the survival of patients, we evaluated dates of transplants, the latest consultation and dates of deaths. All independent variables were compared with the dependent variable: patient lost in a year. Those with statistical significance through univariate analyzes, were also analyzed by multiple logistic regression technique in an attempt to develop a mathematical model capable of predicting 1-year patient loss. Results: Relatively to the loss of patient in one year, the multivariate analysis identified body mass index receptor (p ≤ 0.008) and induction therapy (negative factor p ≤ 0.008) as independent risk factors. Conclusion: Based on the results of this research can be concluded that the independent variables related to one year loss of receptor are: body mass index of the donor and induction therapy.

Intestinal Obstruction Due to Internal Hernia Following Pancreas Transplantation

BACKGROUND Simultaneous pancreas-kidney transplantation has evolved as the best treatment for type 1 diabetic patients at end-stage renal disease. The surgical complication rate is high, which is an important barrier to the success of this procedure. The frequent complications that require relaparotomies include fistulas, graft thromboses, and intra-abdominal abscesses. Intestinal obstructions after pancreas transplantation due to internal herniation are not common. PURPOSE The objective of this article was to review the literature about this problem and describe our personal experience in pancreas transplantation. METHODS We examined the cases of small bowel obstruction secondary to an internal hernia after following 292 pancreas transplantations in our center from 2000 to 2009 as well as performed a Medline literature review. RESULTS Only 2 articles described the diagnosis and treatment of internal hernias after pancreas transplantation. However, both contribution were from the same center reporting the same 3 cases, with surgical versus radiologic perspectives. We have described our 2 cases of young pancreas-kidney transplant patients who presented with acute intestinal obstruction due to internal hernia. CONCLUSION Although internal hernias are rare, they are potentially fatal and difficult to diagnose when they occur after pancreas transplantation. Detection with early surgery demands a high degree of clinical vigilance.

The evolution of diabetic chronic complications after pancreas transplantation.

Pancreas transplantation is an invasive procedure that can restore and maintain normoglycemic level very successfully and for a prolonged period in DM1 patients. The procedure elevates the morbimortality rates in the first few months following the surgery if compared to kidney transplants with living donors, but it offers a better quality of life to patients.Although controversial, several studies have shown the stabilization or the improvement of some of the chronic complications related to diabetes, as well as the extra number of years of life that patients submitted to a double pancreas-kidney transplantation may gain.Recent studies have demonstrated clashing outcomes regarding isolated pancreas transplantations, a fact which reinforces the need for a more discerning selection of patients for this procedure.

Erratum to: Duodenum-Stomach Anastomosis: a New Technique for Exocrine Drainage in Pancreas Transplantation

Journal of Gastrointestinal Surgery, January 19th, 2012 Regarding the article “Duodenum-Stomach Anastomosis: a New Technique for Exocrine Drainage in Pancreas Transplantation” by Linhares MM, Beron RI, Gonzalez AM, Tarazona C, Salzedas A, Rangel E, Sá JR, Melaragno C, Goldman SM, Souza MG, Sato NY, Matos D, Lopes-Filho GJ, Medina JO which appears in the online first articles of Journal of Gastrointestinal Surgery (January 19th, 2012). There is an error in the spelling of the sixth author’s name. The correct name is Rangel EB.