Shokouh-Amiri Mh

Results of pancreas transplantation with portal venous and enteric drainage.

PURPOSE The standard method for pancreatic transplantation involves drainage of exocrine secretions into the urinary bladder with venous outflow into the systemic circulation. Despite the high success rate associated with this approach, it often leads to complications, including chemical cystitis, reflux pancreatitis, metabolic acidosis, and hyperinsulinemia. The authors developed a new technique of pancreatic transplantation with portal drainage of endocrine secretions and enteric drainage of exocrine secretions (PE), which theoretically should be more physiologic. PROCEDURES All patients were insulin-dependent diabetics with end-stage renal disease who underwent combined kidney-pancreas transplantation. Between 1990 and 1994, 19 patients have been transplanted using intraperitoneal placement of the pancreas allograft with exocrine drainage into a Roux-en Y loop and venous drainage into the portal circulations (PE). A comparison group of all patients undergoing standard systemic-bladder (SB) transplantation between April 1989 and March 1993 (n = 28) also was studied. Patient follow-up ranges from 6 months to 5 years for the SB patients (mean = 2.5 years) and 6 months to 4 years for the PE patients (mean = 1.6 years). Routine follow-up includes documentation of the clinical course and detailed endocrine studies. FINDINGS Patient and graft actuarial survival at 1 and 3 years is no different for SB and PE patients. Urinary tract infections occurred in 89.3% of the SB patients (2.8/patient) versus 26.3% of the PE patients (0.25/patient, p < or = 0.0001). None of the PE patients experienced hematuria compared with 53.6% of the SB patients (p < or = 0.0001); however, two PE patients had melanotic episodes. The incidence of urinary retention and reflux pancreatitis was 32.1% versus 5.3% (p < or = 0.028) for SB and PE groups, respectively. Patients in the SB group required sodium bicarbonate therapy (mean = 55 mEq/day) although no PE patient required routine therapy; despite this, SB patients experienced more episodes of acidosis (44 vs. 5). Endocrine studies indicate no difference in glycosylated hemoglobin or fasting and stimulated glucose values throughout the follow-up period. In contrast, hyperinsulinemia was evident in both fasting and stimulated tests for the SB patients, with values consistently two- to fivefold higher than those of the PE group. CONCLUSIONS These results indicate that PE and SB pancreas transplantation are equivalent in terms of patient and graft survival and suggest that the PE approach is associated with a decreased incidence of metabolic and bladder-related complications. In addition, the PE approach eliminates the state of peripheral hyperinsulinemia that characterizes the SB procedure. Continued follow-up will be necessary to determine if long-term outcomes will differ for patients with PE and SB grafts.

Polyomavirus in kidney and kidney-pancreas transplant recipients

Abstract: Purpose. To report the incidence and clinical characteristics of polyomavirus (PV) nephritis in kidney (KTX) and kidney–pancreas transplant (KPTX) recipients.

Early improvement in cardiac function occurs for pancreas-kidney but not diabetic kidney-alone transplant recipients

Noninvasive M mode echocardiography with Doppler recording was prospectively performed on type I diabetic recipients of pancreas-kidney (n=20), pancreas-after-kidney (n=2), and kidney-alone (n = 11) allografts to determine whether the return of euglycemia by pancreas transplantation in the uremic diabetic person was associated with improved cardiac function. Each patient was studied preoperatively and at 6 and 12 months posttransplant. Echocardiographic parameters which were compared included measures of systolic function (shortening fraction), diastolic function (early/active peak velocity ratio, early/active integral ratio), and left ventricular geometric parameters (interventricular septal thickness, posterior wall thickness, left ventricular mass). The only statistically significant improvement observed for kidney-alone recipients was an increased shortening fraction from baseline (24.91%) to 6 months (32.13%, P ≤ 0.0188). In contrast, the pancreas group demonstrated sustained improvement in all outcomes with measures at 12 months consistently showing a significant improvement from baseline which was also significantly better than that reported for the kidney-alone group. This study showed stabilization of cardiac function by echocardiography for diabetic kidney-alone recipients, whereas significant improvement in function occurred for pancreas-kidney recipients. The improvement in cardiac function for pancreas recipients was seen at 6 months with continued improvement evident at 12 months.

Changes in Gastric Emptying in Recipients of Successful Combined Pancreas-Kidney Transplants

Gastroparesis causes gastric emptying disorders in patients with chronic diabetes mellitus and it results from reduced smooth muscle contractility secondary to autonomic dysfunction. Today there has been little objective evidence of improvement in gastric emptying following correction of both uremia and diabetes by combined kidney-pancreas transplantation. We used gastrointestinal symptom scores, solid gastric emptying tests and electrogastrography to evaluate the effect of combined kidney-pancreas transplantation on gastric emptying in 8 uremic diabetic patients. The mean age of the patients was 40 years (range: 30-51 years) and the mean duration of diabetes was 24 years (range: 16-30 years). The patients had been on dialysis up to 24 months. The pretransplant A1 mean was 6.5 before improving to 4.3 after transplantation. All patients were receiving exogenous insulin. Our study data indicate that uremic diabetics have a high prevalence of symptomatic gastrointestinal dysfunction including abnormalities of gastric emptying and gastric electrical activity. Following transplantation, the gastrointestinal symptomatology improved significantly. Significant improvement in the rate of gastric emptying also correlated with improvement in the symptom complex. Gastric electrical activity also improved during the follow-up period.

Evolving experience of hepatitis B virus prophylaxis in liver transplantation

Abstract: Passive immunoprophylaxis with hepatitis B immunoglobulin (HBIG) is important to prevent recurrence of hepatitis B virus (HBV) after orthotopic liver transplantation (OLT) for chronic HBV cirrhosis. With availability of lamivudine (3TC), the use of combination prophylaxis with long‐term HBIG/3TC has been shown to prevent short‐term HBV recurrence. This report compares HBV recurrence rates between groups receiving no/short‐term HBIG, long‐term HBIG alone, or HBIG/3TC prophylaxis, and describes HBIG requirements during the first 6 and 12 months in the latter two groups. This study involved patients undergoing OLT at the University of Tennessee‐Memphis between May 1990 and July 2001. During this period, 388 liver transplants were performed at our center. All hepatitis B surface antigen (HBsAg)‐positive recipients (n = 27) were included in this retrospective analysis. The groups were similar with regard to pre‐transplant demographic characteristics such as age, gender, weight, and pre‐transplant diagnosis. Owing to the retrospective study design, median follow‐up was longer for the no‐prophylaxis (5.6 years) and the HBIG‐alone (6.0 years) groups compared to the HBIG/3TC group (4.2 years). Patient survival was 50% in the no‐prophylaxis and 71% in the HBIG‐alone groups compared to 100% in the HBIG/3TC group (P = 0.09). When censored for death with a functioning graft, graft survival was 50% in the no‐prophylaxis and 86% in the HBIG‐alone group compared to 100% in the HBIG/3TC group (P = 0.07). The overall incidence of HBV recurrence in the no‐prophylaxis era was 100% and 21% in the HBIG‐alone era compared to 0% in the HBIG/3TC era (P < 0.001), despite similar mean and median HBIG trough titers in the HBIG‐alone and HBIG/3TC groups. The incidence of HBV recurrence in HBV DNA‐positive recipients was 100% in the no‐prophylaxis era, 30% in the HBIG‐alone era, and 0% in the HBIG/3TC era (P < 0.001). Recipients in the HBIG‐alone group had a nearly two‐fold increase in HBIG requirement at 6 and 12 months in order to maintain similar HBIG trough titers post‐transplant compared to recipients in the HBIG/3TC group despite similar pre‐transplant HBV serology. This increased HBIG requirement in the HBIG‐alone group resulted in a marked increase in the mean overall cost of HBV prophylaxis in this group (

Pancreas autotransplantation in pig with systemic or portal venous drainage : Effect on the endocrine pancreatic function after transplantation

47,367 at 6 months;

Human granulocytic ehrlichiosis in pancreas transplant recipients

84,280 at 12 months) compared to the HBIG/3TC group (

Retrospective evaluation of the risk of hepatitis B virus reactivation after transplantation

25,931 at 6 months;

Psychiatric complications after liver transplantation.

49,599 at 12 months). These data demonstrate an improvement in patient and graft survival rates in the group receiving combination HBIG/3TC prophylaxis compared to the HBIG‐alone and no‐prophylaxis groups. There was a significant reduction in HBV recurrence in the group receiving combination HBIG/3TC when compared to the groups receiving HBIG alone or no prophylaxis. Furthermore, we demonstrated that the addition of 3TC to the long‐term HBIG regimen led to elimination of the disparity previously described in HBV recurrence rates between HBV DNA‐positive and HBV DNA‐negative recipients. Importantly, our data demonstrates a complete lack of HBV recurrence in the HBIG/3TC group at a median follow‐up of 4.2 years. Additionally, the data show that the addition of 3TC to the post‐operative prophylaxis regimen resulted in a reduction in the requirement of HBIG at 6 and 12 months, which markedly reduced the overall cost of post‐transplant HBV prophylaxis.

Long-term outcomes in simultaneous kidney-pancreas transplant recipients with portal-enteric versus systemic-bladder drainage

The effect of the type of venous drainage of the graft on its endocrine function was studied in two groups of pigs after segmental pancrease autotransplantation. Group 1 comprised 10 pigs with portal venous drainage (PVD) and group 2 comprised 10 pigs with systemic venous drainage (SVD). The graft consisted of body and tail of the pancreas. The pigs were totally pancreatectomized. The pancreatic duct was occluded by neoprene injected into the duct. One week before and 1 and 3 months after transplantation, intravenous glucose tolerance (IVGTT) and meal stimulation tests (MST) were performed. Plasma glucose (PG), insulin (INS), C-peptide, glucagon (GLU),and pancreatic polypeptide (PP) were measured during the tests. All pigs had normal fasting PG, 1 and 3 months after PanTx, although MST disclosed significantly higher PG (P<0.05) during the test after transplantation. In the PVD group, a decrease in INS level during both test was recorded after PanTx (P<0.05), while in the SVD group a nonsignificant rise in INS level was recorded compared with before transplant. A significant difference (P<0.05) in INS levels were present both 1 and 3 mon. after PanTx between the two groups. Pigs with PVD showed a higher (P<0.05) C-peptide level than pigs with SVD during IVGTT. The initial significant rise in PP during MST and the initial fall in PP during IVGTT recorded in all pigs before transplantation were totally lost after transplantation in both groups. During the tests, PP remained steady and significantly lower than the pretransplantation levels in both groups. A significantly higher GLU level during both IVGTT and MST was observed in SVD compared with PVD 1 month after PanTx (P<0.05), being more pronounced during MST. This accentuated GLU concentration decreased by 3 months after transplantation, although it was still significantly greater than pretransplantation levels. We concluded that the unnatural mode of delivery of pancreas endocrine secretion to systemic rather than to portal circulation leads to derangements in pancreatic endocrine function in order to maintain glucose homeostasis. This may cause earlier exhaustion of islet cells. Segmental rather than whole organ and duct occlusion rather than exocrine drainage may further contribute to this, shortening the effective life of the graft.