Jacek Ziaja

Impact of Pancreas Transplantation on the Quality of Life of Diabetic Renal Transplant Recipients

UNLABELLED Simultaneous pancreas and kidney transplantation (SPKT) is considered to be the best method of treatment for patients with chronic renal failure (CRF) resulting from insulin-dependent diabetes mellitus (IDDM). The aim of the study was to compare the quality of life (QOL) of patients with IDDM and CRF subjected to SPK or kidney transplantation alone (KTA). MATERIALS AND METHODS We analyzed 21 patients after SPKT with good function of both grafts. The results were compared with 17 patients with functioning kidney grafts. Minimal observation time was 6 months. QOL was evaluated using Kidney Disease and Quality of Life Short Form (KDQOL-SF), which was sent to recipients by post. Results were presented as medians and interquartile ranges of calculated scored KDQOL-SF points. RESULTS Observation time was 30 months (range, 6-85). Analyzed groups did not differ as regards patient age at transplantation or duration of diabetes and dialysis treatment before transplantation. After SPKT patients reported higher QOL compared with KTA as regards symptom/problem list, 90.91 (86.36-95.46) versus 84.09 (75.00-90.91; P = .04), effects of kidney disease, 90.63 (84.38-93.75) versus 81.25 (68.75-82.14; P = .001); cognitive function, 93.33 (86.67-100.00) versus 80.00 (73.33-93.33; P = .03); overall health, 80.00 (70.00-90.00) versus 50.00 (50.00-70.00; P = .001); physical functioning, 90.00 (75.00-100.00) versus 80.00 (55.00-85.00; P = .03); and pain, 100.00 (90.00-100.00) versus 67.50 (45.00-90.00; P = .005), respectively. CONCLUSION SPKT had a positive impact on selected parameters of QOL among patients with IDDM and CRF compared to KTA.

Risk Factors for Early Hemorrhagic and Thrombotic Complications After Kidney Transplantation

INTRODUCTION Clotting disturbances resulting from chronic renal failure do not remit immediately after successful kidney transplantation (KTx). Hemorrhagic and thrombotic complications after KTx increase the risk of transplanted kidney loss. The aim of the study was to analyze the influence of clotting system disturbances and applied antithrombotic prophylaxis on the development of hemorrhagic and thrombotic complications among KTx patients in the early postoperative period. MATERIALS AND METHODS Sixty seven KTx patients underwent measurement of plasma activated partial thromboplastin time (APTT); international normalized ratio; fibrinogen and D-dimer concentration; activity of antitrombin III; protein C and S, VIII, IX; and von Willebrand factors, as well as platelet counts. RESULTS A perigraft hematoma developed in 25.4% patients, of whom 4.5% required reoperation. Lower antithrombin III activity (96.2±27.6 vs 112.3±17.4, P=.02) on postoperative day (POD) 7 and higher fibrinogen concentration (4.41±2.03 vs 3.35±0.87, P=.01) and platelet count (269.8±117.5 vs 215.8±64.8, P=.03) on POD 14 were noted in recipients with a hematoma compared to those free of this complication. A perigraft hematoma developed in 57.9% patients undergoing antithrombotic prophylaxis and in 12.5% without this treatment (P=.0002). Among patients receiving unfractionated heparin, we observed extension of APTT on POD 1 (45.9±53.2 vs 30.9±7.5 seconds, P=.04), higher von Willebrand factor activity on POD 7 (348.8±122.2 vs 218.5±125.5, P=.02), and higher D-dimer concentrations POD 7 and 14 (1662±894 vs 757±708, P=.002 and 1614±1372 vs 672±532, P=.003, respectively). No significant differences were observed as regards to analyzed parameters between patients receiving low-molecular-weight heparin versus those not receiving antithrombotic prophylaxis. CONCLUSIONS Disturbances in analyzed parameters of hemostasis did not increase the risk of hemorrhagic and thrombotic complications in the early period after KTx. Antithrombotic prophylaxis increases the risk of hemorrhagic complications and should be introduced only for selected renal transplant recipients.

Donor-Dependent Risk Factors for Early Surgical Complications After Simultaneous Pancreas-Kidney Transplantation

INTRODUCTION The success of simultaneous pancreas-kidney transplantation (SPK) depends in a large degree on avoidance of surgical complications in the early postoperative period. The aim of the study was to analyze the Pre-procurement Pancreas Allocation Suitability Score (P-PASS) and the deceased donor parameters included within it as risk factors for early surgical complications after SPK. MATERIAL AND METHODS Forty-six consecutive donors whose kidney and pancreas were simultaneously transplanted were included in the study. RESULTS Donor age was older among recipients who lost their pancreatic grafts: 30.4±6.9 versus 24.1±6.9 years. Donor age was also older among recipients who lost their pancreatic grafts or died compared with those discharged with a functioning graft: 29.3±5.7 versus 24.0±6.9 years. Donor body mass index (BMI) was higher among patients who died compared with those who were discharged: 25.3±1.1 versus 23.2±2.5 kg/m2. P-PASS was higher in patients who lost their pancreatic grafts (17.6±2.1 vs 15.2±1.8) or died (15.3±1.9 vs 17.2±1.9), or lost pancreatic graft or died (15.2±1.8 vs 17.0±2.2) or with intra-abdominal infections (IAI; 17.1±1.7 vs 15.0±1.8). The incidence of donors≥30 years old was higher among recipients with IAI (45.4% vs 14.3%; P=.04). An higher rate of donors with P-PASS>16 was revealed among patients who lost their pancreatic grafts (26.7% vs 3.2%), died (26.7% vs 3.2%), lost the pancreatic graft or died (33.3% vs 6.4%), or experienced IAI (46.7% vs 9.7%). Multivariate logistic regression analysis revealed P-PASS (odds ratio 2.57; P=.014) and serum sodium (odds ration, 0.91; P=.048) to be important predictors of IAI development. CONCLUSION Older age and higher BMI among deceased donors increased the risk of IAI, pancreatic graft loss, or recipient death after SPK. Transplantation of a pancreas from a donor with a low P-PASS score was associated with a lower risk of surgical complications after SPK.

Does simultaneously transplanted pancreas improve long-term outcome of kidney transplantation in type 1 diabetic recipients?

INTRODUCTION Simultaneous pancreas-kidney transplantation (SPK) is an alternative to kidney transplantation (KTx) for type 1 diabetic patients with end-stage kidney disease. However, a fair comparison of SPK and KTx is difficult because of significant differences in donor, recipient, and transplantation procedure parameters. The aim of this study was to compare the early and long-term outcomes of SPK versus KTx in southwest Poland. MATERIAL AND METHODS Thirty-five diabetic dialysis patients who had SPK and 64 patients who had KTx were included in the analysis. RESULTS SPK recipients were younger (38±6 years versus 42±9 years) and received organs from younger donors (25±7 versus 43±12 years) compared to the KTx group. They had shorter kidney cold ischemia time (9±2 hours versus 22±7 hours) but worse HLA class II mismatches (1.4±0.6 versus 1.0±0.5). In the early postoperative period, three patients died from the SPK group and one patient died from the KTx group. Additionally, two SPK patients lost their pancreatic grafts, and five KTx patients lost their kidney grafts. One-year patient survival rates for the SPK and KTx groups were 88% and 98%, respectively, and 5-year, 81% and 93%, respectively. One-year kidney graft survivals rates for the SPK and KTx groups were 100% and 89%, respectively, and 5-years, 89% and 81%, respectively. One-year insulin-free survival among SPK patients was 90% and the 5-year survival rate was 76%. Excretory function of the transplanted kidneys was better among SPK group; however, the difference reached statistical significance only in posttransplant years 2 and 3: 63.5±20.1 versus 50.3±19.7 and 64.9±12.9 versus 51.6±21.8 mL/min/1.73 m2 for SPK and KTx, respectively. CONCLUSIONS Normoglycemia in SPK recipients did not improve patient survival at 5 years. The worse HLA compatibility in the SPK group did not lead to impaired kidney graft survival compared to KTx. Better kidney graft function among SPK recipients probably resulted from a more restrictive donor selection.

Intraoperative resistance index measured with transsonic flowmeter on kidney graft artery can predict early and long-term graft function.

INTRODUCTION Resistive index (RI) measured by Doppler sonography in the early period after kidney transplantation is a well-known predictor of kidney transplant outcome. The purpose of this study was to analyze the impact of RI values calculated intraoperatively in renal allograft artery using transit time flowmetry (TTF) on both early and long-term kidney graft function. MATERIAL AND METHODS TTF was performed on 72 patients who received kidney grafts fed by a single artery. TTF was performed before wound closure. We excluded patients with an early acute rejection (n=8), an early graft loss (n=2), or primary graft nonfunction (n=1). Recipients were divided into RI tertile groups. The initial kidney graft function was defined as immediate (IGF), slow or delayed. Kidney graft estimated glomerular filtration rate (eGFR) was analyzed upon long-term follow-up. RESULTS Patients with a low RI (<0.57) showed the highest incidence of immediate graft function (65% versus 5.3%), whereas the high RI group (>0.70). Show the most frequent rate of delayed graft function (52.6% versus 15%). Recipients with low RI values displayed significantly better eGFR (by at least 12 mL/min/1.73 m2) than those with medium or high RI values at all analyzed times; subjects with medium or high RI showed similar eGFR at 48-months. CONCLUSION An high RI value measured intraoperatively was a valuable predictor of inferior early and long-term kidney graft function.

Impact of Early Lymph Node Procurement to Facilitate Histocompatibility Testing on Long-Term Cadaveric Kidney Graft Survival

BACKGROUND Prolonged cold ischemia time (CIT) is a clinically important causes of delayed graft function (DGF) after kidney transplantation. As DGF has been previously shown to have a deleterious influence on long-term graft survival, in the present study we analyzed the impact of early lymph node (LN) procurement on CIT, HLA mismatches, and long-term kidney graft outcome. MATERIALS AND METHODS We evaluated 394 consecutive cadaveric procedures performed from 2001 to 2006, including 289 recipients, in whom LN were obtained before kidney procurement seeking to shorten the total time for HLA typing and crossmatch procedures. RESULTS During 58±6 months, 24 patients died (918 [8.3%] in the early and 6 [5.7%] in late procurement group, P=ns) and 52 lost their kidney grafts (31 [10.7%] vs 21 [20%]; P=.025). Early procurement of LN performed in 73.4% of all kidney graft recipients shortened CIT by almost 7 hours (22.9 vs 16.1 hours; P<.001), with a nonsignificantly lower incidence of DGF (32.2% vs 41.0%; P=.13). However, a Cox proportional hazards regression model revealed that early procurement reduced the risk of death-censored kidney graft loss by roughly 40% (log-rank, P=.013). CONCLUSION Early LN procurement in significantly shorten CIT and subsequently reduced the risk of long-term kidney graft loss.

Late caliceal fistula after kidney transplantation.

Abstract  Caliceal fistula is a rare urological complication that can occur usually shortly after kidney transplantation (KTx). The occlusion of the renal accessory artery with subsequent necrosis of the kidney pole is the most common cause of the fistula development. We report a case of a 57‐year‐old man with reconstruction of two accessory renal arteries by anastomosis to the side of the main artery during graft placement complicated by late caliceal fistula, managed surgically. Directly after KTx good kidney graft function (serum creatinine concentration 151 µmol/L) was observed. The patient noticed protuberance and pain in the kidney graft area 5 months later. Diagnostic imaging revealed moderate urostasis and liquid collection in the region of the lower graft pole. Administration of a contrast medium through the inserted drain visualized a fistula of a lower renal calyx and ureteric stenosis. Percutaneous drainage was applied with subsequent stop of diuresis through the urethral catheter. During the surgery, the resection of a lower kidney graft pole necrosis was performed, with the closure of caliceal fistula. Simultaneously double pigtail ureteric stent was inserted. After the next two months the pigtail catheter was removed, and neither urostasis in the kidney graft nor liquid collection in the perigraft area were observed. The exceptionality of the case is the late caliceal fistula occurrence. We may only speculate, why it happened 5 months after KTx. The thrombosis of stenosed accessory artery is the most probable cause.

Histopathological Examination may be Useful for Assessment of Fibrosis and Lipomatosis of Pancreas Allograft Prior to Solid Organ Transplantation

BACKGROUND The results of pancreas transplantation depend in a large degree on appropriate pancreas allograft donor selection. Several risk factors of early surgical complications or pancreas allograft loss following transplantation have been identified, but the final decision on pancreas harvesting for transplantation belongs to the surgeon. In the present study we aimed to assess whether histopathological examination may be utilized for detection of fibrosis and lipomatosis in tissue from a potential pancreas allograft. Additionally, we aimed to test whether presence of pancreatic fibrosis and lipomatosis may be explained solely by donor age and/or body mass index (BMI). MATERIAL AND METHODS Pancreata retrieved from 50 deceased organ donors referred to our institution and not transplanted between 2010 and 2013 were used for the present study. Tissue samples were excised from pancreata, fixed in formalin, and embedded in paraffin. Presence and intensity of pancreatic fibrosis and lipomatosis were assessed semi-quantitatively. RESULTS Fibrosis was found in the majority of study samples (72%), but it was usually mild or moderate. Lipomatosis was present in 34% of the study cases. Presence of fibrosis was more frequent in older donors, but was still not rare in donors under 40 years old. Presence of lipomatosis did not seem to be significantly related to donor age. Neither pancreatic fibrosis nor lipomatosis was related to donor BMI. CONCLUSIONS There is no clear relationship between histological parenchymal changes in potential pancreas allograft and donor age and BMI. Histopathological assessment of pancreatic fibrosis and/or lipomatosis can potentially facilitate decision making on pancreas allograft acceptance for solid organ transplantation.

Influence of Experience Acquired by a Liver Transplantation Center on Extension of Donor Acceptance Criteria

BACKGROUND Liver transplantation (LTx) is the only effective treatment for end-stage liver failure. Due to the ongoing lack of organs available for transplantation, there is a tendency to extend liver donor selection criteria. The aim of the study was to determine whether extension of donor acceptance criteria with increasing experience in LTx occurred at our transplant center. METHODS This retrospective analysis included 288 donors harvested between 2005 and 2016. The donors were divided chronologically into 4 equally sized groups. They were assessed in subsequent groups according to sex, age, height, body mass index (BMI), cause of death, amount of days spent in the intensive care unit, number of episodes of cardiac arrest before organ removal, and results of laboratory and virologic tests. RESULTS A statistically significant increase in the age of accepted donors was observed between group 2 and group 4 (median 40 vs 45 years, P < .05). There was a significant increase in the acceptance of anti-HBc-positive donors (0% in group 1 vs 7% in group 4). The remaining parameters did not show statistically significant differences. CONCLUSION Experience acquired by our transplant center during the period of analysis did not lead to extension of liver donor acceptance criteria. Statistically significant differences for liver donor age and virologic profile (anti-HBc) between groups were observed; however, overall analysis did not confirm a clear tendency to extend liver donor acceptance criteria at this center.

Type 1 diabetic patients have better endothelial function after simultaneous pancreas–kidney transplantation than after kidney transplantation with continued insulin therapy

The purpose of this study was to analyse the influence of simultaneous pancreas–kidney or kidney transplantation on endothelial function and systemic inflammation in type 1 diabetic patients with end-stage renal disease. In 39 simultaneous pancreas–kidney, 39 type 1 diabetic kidney and 52 non-diabetic kidney recipients, flow-mediated dilatation was measured. Additionally, blood glycated haemoglobin, serum creatinine and lipids, plasma nitrites ( NO 2 − ) and nitrates, asymmetric dimethylarginine, soluble vascular cell adhesion molecule-1, intercellular adhesion molecule-1, and E-selectin, high-sensitivity C-reactive protein, tumour necrosis factor-α, interleukin 1β and interleukin 6 concentrations were assessed. During 58 ± 31 months follow-up period, flow-mediated dilatation and NO 2 − were greater in simultaneous pancreas–kidney than in type 1 diabetic kidney recipients [10.4% ± 4.7% vs 7.7% ± 4.2%, p < 0.05 and 0.94 (0.74–1.34) vs 0.24 (0.20–0.43) μmol/L, p < 0.01, respectively]. In type 1 diabetic patients after simultaneous pancreas–kidney or kidney transplantation, NO 2 − correlated with flow-mediated dilatation (r = 0.306, p < 0.05) and with blood glycated haemoglobin (r = −0.570, p < 0.001). The difference in NO 2 − was linked to blood glycated haemoglobin and estimated glomerular filtration rate, whereas the difference in flow-mediated dilatation was linked to NO 2 − . The levels of inflammatory markers (except soluble vascular cell adhesion molecule-1) were similar in simultaneous pancreas–kidney and type 1 diabetic kidney recipients. Improved endothelial function in type 1 diabetic patients with end-stage renal disease after simultaneous pancreas–kidney compared to kidney transplantation is associated with normalisation of glucose metabolism but not with improvement in plasma pro-inflammatory cytokines.