N. Parrott

Outcome of pancreas transplantation in recipients older than 50 years: a single-centre experience.

Background. Pancreas transplantation (PT) remains the only treatment that can restore insulin independence among insulin-dependent diabetics. An ageing population in developed countries has led to an increasing number of older patients who may be suitable for PT. Some investigators argue that PT in recipients older than 50 years has an inferior outcome compared with the younger group. Methods. The object of this study was to compare the outcomes of 31 PT in patients aged 50 and above 105 PT in recipients below 50 years performed between June 2001 and December 2007. Results. The incidence of general posttransplant complications were similar in both; 60% in less than 50 vs. 58% in more than or equal to 50, P=0.539. So, as the incidence of other surgical complication in the more than or equal to 50 group compared with less than 50 (graft thrombosis 13% vs. 11.5%; bleeding 19% vs. 6.7%; abdominal abscess 23% vs. 19%; pancreatic leak 13% vs. 9.6%). There was no significant difference in the incidence of urinary tract infection and early rejection in either group. However, the incidence of respiratory tract infection was significantly higher in more than or equal to 50 (38.7% in ≥50 vs. 9.6% in <50, P=0.003). One-year patient survival was 88% in more than or equal to 50 vs. 92% in less than 50 group, P=0.399; and pancreas graft survival rate was similar (79% in the ≥50 and 74% in <50, P=0.399). Conclusion. This study demonstrates that it is feasible to safely transplant potentional PT recipients aged 50 and above. However, good medical assessment and careful patient selection is strongly recommended.

Mortality in diabetes: pancreas transplantation is associated with significant survival benefit

BACKGROUND Pancreas transplantation in complicated type 1 (insulin dependent) diabetes mellitus improves the quality of life, increases longevity and stabilizes diabetic complications. There may be clinician reticence due to perceived poor outcomes with published associated mortality rates of 5-8% due to significant co-morbidities, particularly cardiovascular impairment. METHODS Retrospective analysis was performed on patients undergoing pancreas transplantation in a single centre since the programmes initiation [simultaneous pancreas kidney (SPK) = 148, pancreas after kidney (PAK) = 33 and pancreas transplant alone (PTA) = 11] compared with a control group accepted contemporaneously onto the waiting list. The primary endpoint was patient mortality. The risk factors including medical and diabetic history, demographics, transplant type and waiting time were analysed. RESULTS The waiting list mortality was 30% (35 of 120) compared with a mortality of 9% (20 of 193) post-transplantation (P < 0.001). Deaths on the waiting list compared with transplantation up to 1 year had a relative risk of 2.67 (95% CI: 0.81-3.51; P = 0.19), whilst those surviving >1 year had a relative risk of 5.89 of dying on the waiting list (95% CI: 1.70-3.20; P < 0.0005). There were no differences in terms of cardiovascular or renal-associated risk factors, nor in other potential confounding factors other than duration of diabetes (P = 0.02). Median survival from listing was shorter in younger patients (<50; P < 0.0001). CONCLUSIONS Type 1 diabetics with renal failure listed for pancreas transplantation are at a significant risk of mortality even without surgery. Transplantation offers considerable survival benefits, despite associated surgical and immunosuppressive risks. In selected patients, pancreas transplantation remains the benchmark treatment for type 1 diabetes mellitus.

Native nephrectomy for autosomal dominant polycystic kidney disease: before or after kidney transplantation?

Study Type – Therapy (case series)

Clinical response and temporal patterns of acute cellular rejection: relationship to chronic transplant nephropathy

Abstract The association between acute cellular rejection (ACR) and the development of chronic rejection has been the subject of much debate. Studies have suggested that the two phenomena may be linked, or, conversely that there may be no association at all. In order to clarify this relationship the outcome of 284 renal allografts were examined. The transplants were all performed at a single institution between April 1989 and December 1991, allowing a minimum follow up of 5 years. ACR was classified into three clinical response groups: (1) fully responsive to therapy (type 1 ACR), (2) partially responsive (type 2) and (3) ACR requiring treatment with ATG or OKT3 (type 3). Acute and chronic rejection were determined by histological (Banff) criteria. Chronic transplant nephropathy (CTN) occurred significantly more frequently in those with late ACR after day 60 than in those who had early rejection (53.5% versus 17.3%, respectively, P < 0.00001). Acute rejection that was fully responsive to therapy (type 1) had no association with CTN, but partially responsive rejection and rejection requiring seconD‐line treatment were both significantly associated with CTN (P < 0.0001 and P < 0.001, respectively). This study suggests that it is the clinical behaviour and response to treatment of ACR that is paramount in determining the onset of chronic rejection, and not the mere presence or absence of the clinical phenomenon.

Colorectal complications of end-stage renal failure and renal transplantation: a review.

Aim  End‐stage renal failure (ESRF) and renal transplant recipients are thought to be associated with an increased risk of colorectal complications.

Islet cell transplantation: current status in the UK

Up to a third of patients with type 1 diabetes have impaired awareness of hypoglycaemia, putting them at a six‐fold higher risk of severe hypoglycaemia, requiring third‐party assistance. Following the success of a Diabetes UK funded research programme, islet transplantation is centrally funded at seven UK sites.

Successful renal transplant during the first trimester of pregnancy.

We wish to report a successful outcome of pregnancy diagnosed with 24 h of renal transplantation at 6-week gestation. The patient was a 27-year-old woman, with end-stage renal failure secondary to reflux nephropathy, who received a 110-mismatched cadaveric renal transplant. Both the recipient and the donor were cytomegalovirus (CMV)-negative and the left kidney was transplanted into the right iliac fossa with a standard anastomosis, following a total ischaemia time of 29 h and 30 min. The kidney started functioning immediately and she was given basiliximab (Simulect, Novartis, Camberley, UK) induction therapy and methylprednisolone 1 g i.p. Twelve hours following transplant, her urinary output fell slightly and an ultrasound was performed to assess the graft. This revealed that the kidney was well perfused and unexpectedly also revealed the presence of a viable intrauterine pregnancy of approximately 6-week gestation. Despite extensive counselling regarding the risks of pregnancy in this situation, the patient was delighted and keen to continue with the pregnancy. A paucity of information regarding the use of Simulect in pregnancy prompted a decision to withhold the second dose and a duel immunosupression regime of azathioprine and tacrolimus was commenced. In view of her previous history of thrombosis, she was also treated with low-molecularweight heparin. The patient made a rapid post-operative recovery and was discharged 7 days following the transplantation. At the time of discharge, her serum creatinine was 60 lmol/l. The patient remained well throughout the first and second trimesters, with stable renal function (serum creatinine range 60–81 lmol/l in the second trimester) and no episodes of acute rejection. Her blood pressure remained consistently normal and she never required antihypertensive treatment. Repeated detailed ultrasound examination showed normal fetal anatomy and growth. During the third trimester her serum creatinine climbed slowly and at 36 weeks suddenly increased to 141 lmol/l. Her tacrolimus levels were within the normal range and her blood pressure was normal. Labour was therefore electively induced and a healthy live born-male infant weighing 2.25 kg (25th Individualized Birth Centile [1]) was delivered normally. Following delivery, her serum creatinine slowly decreased and 6 weeks post-natally was 109 lmol/l. The patient had first presented with renal failure at 16week gestation in her first pregnancy 2 years earlier. One twin died in utero at 17-week gestation and she subsequently underwent medical termination at 18-week gestation. Following this, two unsuccessful attempts were made at fistula formation in her left arm, but on both occasions the vessels thrombosed. She therefore commenced continuous ambulatory peritoneal dialysis (CAPD) and at the time of admission for transplantation she had a serum creatinine of 486 lmol/l and a glomerular filtration rate (GFR) of 10 ml/min/l. Her periods had been infrequent whilst on dialysis and she had been amenorrhoic for 5 months prior to transplantation. Whilst pregnancy following renal transplant is well documented, spontaneous pregnancy in women with endstage renal failure undergoing dialysis is rare. Estimates of the frequency of conception in dialysis patients range from 0.3% to 0.5% per year [2,3]. Impaired ovulation and amenorrhea, which may be related to uremia or to co-morbidities of chronic renal failure, are common [4]. However, there is a widespread impression that conception among dialysis patients is becoming more frequent because of advances in dialysis techniques. The management of pregnant patients undergoing dialysis remains difficult [5–7]. Advances in care and surveillance have led to improved pregnancy outcomes in such patients in recent years. Nevertheless, fetal mortality in pregnant women on dialysis is still extremely high. Frequent perinatal complications include miscarriage, preterm delivery, perinatal and infant death, or other adverse sequelae [8,9]. This is in marked contrast to pregnancy outcomes in women who have undergone transplantation. The US Renal Data System shows that since 1991 only 16–37% of pregnancies in dialysis patients have resulted in live births compared with up to 63% of pregnancies among women with a transplant. Indeed recent reports suggest that after the first trimester, the majority (94%) of pregnancies to allograft recipients are successful. However, concerns remain regarding the possible adverse interaction between

Principles of Renal Transplantation

Renal transplantation is regarded as the primary treatment for all patients with established grade 5 chronic kidney disease (CKD), requiring replacement, as long as they are medically fit for the procedure. In practice, only around 40–50% of the UK renal failure population are fit enough for surgery. The Renal Association (RA) guidelines suggest that patients should be offered kidney transplantation if it offers a likelihood of increased life expectancy following grafting. The RA guidelines also recommend that patients should be listed within 6 months of starting dialysis, and both RA and the British Transplant Society (BTS) recommend transplantation prior to commencement of dialysis wherever possible.