E.B. Rangel

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.

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.

Simultaneous Pancreas-Kidney Transplantation: Which Organ Should Be Transplanted First?

Simultaneous pancreas-kidney transplantation (SPKT) has been accepted as treatment for type I diabetic patients with end-stage renal disease. Its success depends largely on the surgical technique. This study sought to compare groups of SPKT with initial pancreas implantation versus initial kidney implantation. From December 2000 to September 2006, 151 SPKT were performed by a single center. In 85 cases, the pancreas was implanted first (group 1), and in 66 cases the order was inverted (group 2). Variables were implantation sequence, pancreas and kidney ischemia time, donor age, venous drainage, previous donor peritoneal dialysis, and recipient age and gender. Outcome variables included pancreas vascular thrombosis, 3-month graft survival, 3-month patient survival, pancreas rejection episodes, intra-abdominal infection, diabetes control and reoperations. We observed a 10.6% incidence of vascular thrombosis in group 1 but none in group 2 (P = .005). In groups 1 and 2, the 3-month pancreas survivals were 74.1% and 89.4% (P = .022), and the mean hospital stays were 24.3 and 15.8 days, respectively (P = .002). Our results suggested that, when 2 different teams are involved in SPKT, with >1 exposure and the need for retractor replacement, the kidney should be transplanted first, because the pancreas may be damaged during the surgical procedure.

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.

Asynchronous Kidney Allograft Loss After Simultaneous Pancreas-Kidney Transplantation: Impact on Pancreas Allograft Outcome at a Single Center

OBJECTIVE We analyzed the clinical evolution of pancreas allografts in simultaneous pancreas-kidney transplantation (SPKT) cases after asynchronous kidney allograft loss and kidney retransplantation at a single non-United States center. PATIENTS AND METHODS We performed a retrospective analysis of 168 SPKT from December 2000 to June 2007. RESULTS The 5-year kidney allograft survival rate was 71%. Excluding cases of death with a functioning graft after SPKT (n = 35; 74.4%), 12 kidney allografts were lost due to acute rejection (n = 7; 15%) or chronic allograft nephropathy (n = 5; 10.6%). Delayed graft function contributed to kidney allograft loss. Five of 12 patients underwent kidney retransplantation. Sixty percent of pancreas allografts were lost after this procedure, which was attributed to either the diabetogenic effects of the immunosuppressive regimen or to the perioperative stress. Oral glucose tolerance tests performed before kidney retransplantation identified patients with good pancreas allograft function versus those with intolerance on glucose tests who received reduced glucocorticoid doses. CONCLUSIONS In SPKT, pancreas allograft function was seriously affected by kidney retransplantation. Oral glucose tolerance tests performed before kidney retransplantation were helpful to assess beta-cell function and suggest prescription of lower steroid doses to decrease the pancreas allograft dysfunction.

Opções técnicas utilizadas no transplante pancreático em centros brasileiros

OBJETIVO: Analisar o perfil dos principais centros de transplantes do Brasil, quanto as opcoes tecnicas no transplante de pâncreas. METODO: Foi encaminhado um questionario por correio eletronico (email) para um membro de cada equipe de 12 centros de transplante do Brasil, com casuistica minima de um transplante de pâncreas. O questionario continha 10 perguntas, abordando aspectos controversos e nao padronizados. RESULTADOS: A maioria dos centros (90,9%) utiliza incisao mediana. O orgao de escolha a ser implantado primeiro foi principalmente o rim, em 63% dos centros. Em relacao a drenagem venosa, 90,9% utilizam a drenagem sistemica. A ligadura da veia iliaca interna e realizada em 54,5% dos centros. A maioria dos centros (90,9%) utiliza a drenagem enterica para transplante combinado pâncreas-rim. Para o transplante de pâncreas isolado, apenas cinco centros responderam, sendo que dois utilizam a drenagem enterica e tres a vesical. A utilizacao de dreno na cavidade abdominal ocorre em 63% dos centros. Em 72,7% dos centros e realizada algum tipo de inducao na imunossupressao para o transplante combinado pâncreas-rim, sendo a imunossupressao basica a associacao de tacrolimus (FK506), micofenolato mofetil (MMF) e corticoide. A antibioticoprofilaxia e realizada por todos os centros e profilaxia para fungos e realizada por seis centros (54,5%). Oito centros (72,7%) utilizam algum tipo de profilaxia para trombose vascular, em esquemas diversos. CONCLUSAO: Existem diversos caminhos tecnicos na conducao do transplante pancreatico. A falta de padronizacao dificulta a analise e a comparacao dos resultados. Apesar dessa heterogeneidade das equipes, observamos uma tendencia para a realizacao de incisao mediana, drenagem venosa sistemica e exocrina enterica, com a utilizacao de algum tipo de profilaxia para trombose vascular nos transplantes combinados pâncreas-rim.

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.

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.