Simultaneous pancreas-kidney transplantation: infectious complications and microbiological aspects

OBJECTIVE: The purpose of this study was to describe the clinical and microbiological characteristics of the infectious complications among simultaneous pancreas-kidney transplantations (SPKT). MATERIALS AND METHODS: Among the first 45 SPKT the mean age was 34 years (range, 21 to 49) and the mean duration of follow-up 13 months (range, 2 to 27 months). RESULTS: Twenty-three patients (51%) presented at least one to three episodes (1.7 mean) of infectious complications that needed hospitalization. The etiology of the infections included 71% bacterial (44% gram-negative rods and 27% gram-positive cocci), 16% viral (12% from CMV and 4% from Herpes sp) and 13% fungal (8% by Candida sp and 4% by others fungus). Wound and urinary infections were most frequent, occurring in 22% and 28% of the patients, respectively. All patients who were submitted to vesical drainage developed infections in contrast a rate of only 44% among patients undergoing enteric drainage. CONCLUSION: Infectious complications are the main cause of morbidity and mortality following simultaneous pancreas-kidney transplantation, especially with vesical drainage. The use of enteric drainage combined with administration of broad spectrum prophylactic antibiotics is recommended.     

胰肾联合移植术后外科并发症的临床分析

目的 分析胰肾联合移植术后外科并发症发生情况、手术治疗及结果.方法 统计2000年1月至2011年12月施行的胰肾联合移植术60例,根据术后是否发生外科并发症将受者分为并发症组及无并发症组,分析手术治疗的原因,评估再次手术对受者及移植物存活率的影响.结果 术后1年内,受者死亡原因主要为肺部感染(3例)、心脑血管意外(2例)、消化道出血(1例).感染及心脑血管意外是导致受者术后早期死亡的主要原因(5/6).56例胰腺手术成功,术后(14± 8)d完全停用胰岛素,外科并发症导致移植胰腺切除4例.15例移植肾功能恢复延迟,术后接受透析的时间为(33±12)d,其余受者肾功能均在术后2～7 d恢复正常,带移植物功能死亡是移植肾丢失的主要原因(3/6).外科并发症发生率为25％ (15/60).外科并发症主要包括:出血、切口感染、移植胰腺血管栓塞及移植胰胰腺炎,外科并发症降低了术后1年受者及移植胰腺的存活率,而对肾脏的存活率无明显影响.结论 胰肾联合移植术后外科并发症发生率高,明显降低了受者和移植胰存活率,是影响术后早期受者和移植胰存活的主要因素.     

胰肾一期联合移植

目的 总结胰肾联合移植治疗糖尿病并发晚期肾功能不全病人的疗效,并探讨分析术后并发症防治经验。方法 对５例糖尿病并发现期肾小功能不全者采用胰十二指肠肾一期联合移植。免疫抑掉方案采用激素,ＣｓＡ及硫唑嘌呤或激素,ＣｓＡ及骁悉三联用药。结果 联合移植后５例胰肾均发挥正常功能,病人均立即停用胰岛素,１例术后发生移植肾急性排斥以应,死于多器官功能衰竭,余４例分别发生胰周脓肿,急性胰腺炎,十二指肠瘘,血尿等并     

Simultaneous pancreas-kidney transplantation: Early complications and long-term outcomes — a single-center experience

IntroductionThis study aimed to assess the prevalence and severity of complications after simultaneous pancreas-kidney transplantation (SPKT) and to evaluate its influence on both grafts’ long-term results.MethodsThis was an observational, retrospective study including 39 consecutive SPKT cases from 2000–2018. Complications were classified into kidney-related and pancreas-related. The severity of complications was assessed using the modified Clavien-Dindo scale. Kaplan-Meier curve analysis and log-rank tests were used. Cox regression was performed for the multivariate analysis.ResultsAll 39 recipients had long-term type I diabetes. Twenty-one (53.8%) patients suffered a Clavien-Dindo ≥IIIa complication. Most complications were pancreas-related, with 17 (43.6%) patients suffering from one. Kidney-related major complications were seen in 11 (28.2%) patients. Patient survival at one, five, and 15 years was 89.7%, 87.1%, and 83.9%, respectively; kidney survival was 87.1%, 81.4%, and 73.6%, respectively; and pancreas survival was 76.9%, 71.3%, and 72%, respectively. Pancreas graft survival was influenced by the presence of major postoperative complications; patients and kidney graft survival were not.ConclusionsComplications after SPKT influence pancreas graft survival. Despite the high rate of complications, our results suggest that patient and kidney graft survival may not be affected by complications.     

胰、肾联合移植六例报告

目的 探讨胰、肾联合移植治疗糖病合并糖尿病肾病的疗效。方法 回顾分析近期施行的6例胰、肾联合移植手术的方法、疗效及并发症的防治。结果 6例患者分别于移植胰腺恢复血液循环后23h、第9d、17h、19h、第5d及1．5h停用外源性胰岛素,移植肾功能于术后第2－4d恢复正常;术后并发症有排斥反应和血尿,其中1例术后5d发生加速性排斥反应,抗排斥治疗无效,于术后11d切除移植胰、肾,其余5例均痊愈出院。结论 胰、肾联合移植是治疗胰岛素依赖型糖尿病及达到胰岛素依赖期的非胰岛素依赖型糖尿病合并糖尿病合并糖尿病肾病的有效方法;加强围手术期管理术后减少各种并发症、取得良好疗效的有效措施。     

胰腺十二指肠肾脏一期联合移植五例报告

目的 探讨胰腺十二指肠肾脏一期联合移植治疗I型糖尿病伴肾功能衰竭的治疗途径。方法 对我院开展的5例胰、肾一期联合移植病人进行回顾性分析。结果 5例病人中,3例术后胰腺及肾脏功能良好,未使用胰岛素,进正常饮食,血糖一直在正常范围,至今已分别生存20,14,11个月。其余2例病人中,1例术后第47d死于急性心功能衰竭,另1例因血栓形成,于术后33d切除移植的胰腺,但肾功能良好。结论 胰、肾联合移植是治疗I型糖尿病伴肾功能衰竭的有效方法之一,术后通常根据血糖、尿糖、尿淀粉酶、C肽及尿细胞学检查等指标改变,判断移植后胰腺及肾脏的功能情况。     

Simultaneous pancreas-kidney transplantation: analysis of rejection

The 3-year data concerning the occurrence of rejection episodes (RE) are reported herein. PATIENTS AND METHODS: Two hundred five simultaneous pancreas-kidney (SPK) transplantations were performed from May 1998 to September 2000, including 103 patients randomly assigned to tacrolimus (Tac) and 102 to cyclosporine microemulsion (CsA-ME). All patients received concomitant rATG induction therapy, mycophenolate mofetil (MMF), and short-term corticosteroids. RESULTS: After a follow-up of 3 years, acute rejection episodes occurred in 41 patients receiving tacrolimus and in 51 patients receiving CsA ME. The majority of first rejection episodes in both groups occurred during the first 6 months (93% and 90%, respectively) and in most cases were treated with corticosteroids (88% and 90%). Actuarial rejection-free graft survival was not significantly different between the two groups (54% and 44% at 3 years posttransplant). In a multivariate analysis, HLA compatibility (P = .003) and graft vessel extension (P = .0005) had a significant influence on rejection-free survival. Rejection influenced pancreatic graft survival (P = .01) and pancreatic graft loss owing to rejection influenced patient survival (P = .02). In the intent-to-treat analysis of early rejection, first moderate-to-severe episodes (1 of 40 versus 12 of 47; P = .004) and refractory episodes (2 of 40 versus 10 of 47; P = .03) were significantly lower with tacrolimus than with CsA ME. Pancreatic graft survival was worse among late rejectors (53%) than nonrejectors (86%; P = .002). In addition, serum creatinine was highest in late rejectors. In conclusion, Tac-based immunosuppressive therapy shows advantages over CsA ME in terms of the severity of acute rejection episodes among patients undergoing SPK transplantation.     

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.     

Simultaneous pancreas-kidney transplantation: five-year results from a single center

We report the 5-year results of our simultaneous pancreas-kidney transplantation (SPKT) program, started on May 2, 2000. Forty-two SPKT were performed on 42 type I diabetic patients with chronic renal failure. The procedure was performed with enteric diversion and vascular anastomosis to the iliac vessels. Immunosuppressive protocol included antithymocyte globulin, tacrolimus, mycophenolate mofetil, and steroids. The 24 women and 18 men had a mean age of 33.5 +/- 6.3 years and mean 22.8 +/- 14.2 years time of diabetes evolution. Forty patients had been on dialysis for 34.3 +/- 24.1 months, and two were preemptive transplantations. Acute rejection episodes were treated in eight patients (19.1%): in three cases they affected both organs; in two only the kidney was affected; and the other three were pancreas graft rejections. The incidence of postoperative complications requiring re-operation was 42.9%, mostly pancreas graft related. Two patients died, one due to cardiovascular disease; the other was transplant related. Three kidney grafts were lost, and the causes were immunologic, thrombosis, and patient death. Pancreas graft loss occurred in seven patients: thrombosis (n = 3); infection (n = 3); immunologic (n = 1). The patients with surviving grafts were doing well, with normal kidney and pancreas function: serum creatinine = 0.89 +/- 0.15 mg/dL; fasting blood glucose = 79 +/- 16 mg/dL; HbA1c = 4.7 +/- 1.1%. The 1-year patient, kidney, and pancreas survival rates were 97.3%, 94.6%, and 83.8% and 5-year values, 91.7%, 89.2%, and 78.7%, respectively. In conclusion, these results are similar to the most recent UNOS/IPTR reports, leading us to consider our experience with SPKT very positive.     

Simultaneous pancreas-kidney transplantation: a single-center experience and prospective analysis

In patients with end-stage chronic kidney disease (CKD) and type 1 diabetes mellitus (DM 1), simultaneous pancreas-kidney (SPK) transplantation is currently considered the gold standard therapy. The aim of this study was to analyze and report the long-term clinical outcomes of the 23 SPK transplantations performed at our institution over an 84-month period (January 1, 2000 to December 31, 2006). A prospective analysis of these patients included donor, recipient, and transplantation characteristics. The only requirements for transplantation were blood group compatibility and a negative cross-match. Bladder drainage via pancreaticoduodenocystostomy was performed in all of the patients. Due to a pulmonary embolus 1 patient (4.3%) died at 2 months. The actuarial patient survival rates at 3 months and 1, 3, and 5 years were 95.6%. Causes for the renal graft loss were chronic allograft nephropathy in 3 cases (13%) and death of the patient in 1 case (4.3%). The actuarial censored renal allograft survival rates at 3 months and at 1 year were 100%, and at 3 and 5 years were 91.3%. Causes for the renal graft loss were chronic rejection in 1 case (4.3%) and patient death in 1 case (4.3%). The actuarial censored pancreatic allograft survival rates at 3 months and at 1 and 3 years were 100%, and at 5 years was 95.6%. The results of this work add further evidence that SPK is the gold standard therapy for selected patients with end-stage CKD due to DM 1.     

Simultaneous pancreas-kidney transplantation: analysis of donor factors

There are no urgent indications for simultaneous pancreas-kidney transplantation. So our policy is to harvest only a pancreas in good biologic condition. The criteria for acceptance of a pancreas donor are: age 15 to 40 years, ICU stay < 7 days, no clinical signs of infection, negative virologic status, no history of hypotension or cardiac arrest, serum amylase elevation below three times normal values, controllable hyperglycemia, no history of pancreatic disease, no history of abdominal trauma damaging the organ, no history of alcohol addiction, BMI < 25, no functional or anatomical lesions of the kidneys, and expected ischemia time less than 12 hours. The proper selection of a pancreas donor allows one to achieve good insulin secretion immediately after transplantation. In 2000 to 2002 all 20 pancreases transplanted at transplant center displayed immediate secretory function after transplantation.     

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目的 探讨胰肾联合移植治疗糖尿病伴糖尿病肾病的疗效。方法 总结了近期施行的３例胰肾移植手术的方法、疗铲及并发症的防治。结果 ３例病人移植后分别于术后２０小时、第９天、１５小时停用外源性胰岛素,于术后第２天及第４天肾功能恢复正常。术后仅出现排斥反应和血尿并发症。均痊愈出院,定期随访。结论 胰肾联合移植是治疗糖尿病伴糖尿肾的最有效方法。供胰肾原位灌注、快速整块切取、以预防为主、加强围手术期管理是减少各     

Simultaneous pancreas-kidney transplantation in Jehovah's Witness patients

The safety and efficacy of renal and liver transplantation has been reported for Jehovah's Witness (JW) patients, with patient, and graft survival similar to that of non-JW patients. We report our experience in five JW recipients of simultaneous pancreas-kidney transplants. None of the patients received transfusion of blood or blood products, either before or after transplant. Like the other solid organ transplants, patient, and graft survival was similar to that of the non-JW group. Specific technical issues related to the operative procedure include the use of the cell saver until the donor duodenum is opened (enteric contamination). Post-operatively, care should be taken to minimize drawing of blood and optimize erythrocyte synthesis with erythropoetin, folic acid, vitamin B12, and iron. Finally, it is critical that the pre-operative evaluation demonstrates sufficient cardiac reserve to allow the JW patient to tolerate a possible temporary anemic state.     

Simultaneous pancreas-kidney transplantation: short- and long-term results

Simultaneous kidney and pancreas transplantation (SKPT) is the treatment of choice for a majority of type I diabetic patients with end-stage renal disease. With continual refinements in surgical technique and an evolving immunosuppressive arsenal, graft and patient survival have continually improved. The purpose of this study was to evaluate the short- and long-term results of SKPTs performed in 174 recipients from June 1985 to March 2003 including 37 segmental grafts with duct occlusion, 73 whole pancreas transplants with bladder diversion, and 64 whole pancreas grafts with enteric diversion. The series includes 160 cases with systemic drainage and 14 with portal drainage. In the segmental pancreas group, patient survival was 85%, 76%, and 53% with pancreas survival of 67%, 36%, and 15%, and kidney survival of 82%, 63%, and 15%, respectively, at 1, 5, and 10 years. Among the bladder diversion group, patient survival was 94%, 83%, and 73% pancreas survival 72%, 67%, and 65%, and kidney survival 89%, 78%, and 58%, respectively, 1, 5, and 10 years. Among the enter diversion group patient survival was 90% and 90% at 12 and 108 months, pancreas survival 80% and 65%, and kidney survival 85% and 85%, respectively. There were significant differences between curves of survival distribution according to the surgical technique applied for patients (P =.04), pancreas (P =.007), and kidney (P =.005). Based on the results from our study, the short- and long-term prognosis after SKPT is satisfactory, especially compared to the outcomes of long-term dialysis among patients with end-stage renal disease caused by type I diabetes.     

Infectious complications after simultaneous pancreas-kidney transplantation

Simultaneous pancreas-kidney transplantation (SPKT) improves long-term survival of insulin-dependent diabetes mellitus patients with diabetic nephropathy. The increasing success of SPKT is a result of improved surgical technique, better organ preservation, potent antirejection therapy, and effective use of antibiotics to prevent and treat infectious complications. However, morbidity and mortality following SPKT remain high mainly owing to infection. From 1988 to 2004, the 51 patients who underwent SPKT were 32 women and 19 men of mean age 34 +/- 4 years old with diabetes and end-stage renal disease. The mean duration of diabetes mellitus was 23 +/- 4 years. The incidence of HCV and HBV infections were 19.6% and 13.7%, respectively. Preoperative work-up included identification and elimination prior to surgery of potential sources of infection. All patients prior to SPKTx had been treated by dialysis (26 +/- 20 months). The kidneys were always placed into the left retroperitoneal space first; at the same time the pancreatic grafts were prepared on the back table. The reconstruction of the superior mesenteric and the splenic arteries was performed using a Y graft of donor iliac artery to the common or external donor's iliac artery. The pancreas was transplanted intraperitoneally to the right iliac vessels. The portal vein was sutured to the common or external iliac vein and the arterial conduit of donor iliac artery. In 20 of the patients, bladder drainage and in 31, enteric drainage was used for the pancreatic juice exterioration. Patients received immunosuppression with a calcineurin inhibitor (tacrolimus or cyclosporin), mycophenolic acid or azathioprine, and steroids. Antibody induction (alternatively anti-IL-2 monoclonal antibody or ATG) was used in last 38 patients. Antibacterial (tazobactam) and antifungal (fluconazole) as well as antiviral (gancyclovir) prophylactic treatment was given to all patients for 7 to 10 days after transplantation. Thirty-eight recipients are alive, 26 with function of both grafts; 8 with functioning kidney grafts; and 4 with nonfunctioning grafts on dialysis treatment from 1 to 14 years after transplantation. Thirteen patients (24.5%) died during the first year after transplantation. Infectious complications were the main cause of death. Systemic infections accounted for the death of five patients and CNS infection for death of another five patients. Three patients died with functioning grafts due to cardiopulmonary disorders (myocardial infarction, pulmonary embolus) early in the postoperative period. A total of 102 infections were diagnosed in 51 patients during the posttransplant course. Twenty-one episodes of CMV infection (systemic 20, duodenal site 1), 73 bacterial infections (systemic 13, pulmonary 13, urinary tract 15, intestinal 8, wound 23), and 8 fungal infections (central nervous system 5, gastrointestinal tract 3). Some patients had more than one type of infection. Overall mortality in the investigated group was 24.5%. Infectious complications were the main cause of death (77%), including systemic infection (38.5%) and CNS infection (38.5%). The predominant etiology of the systemic infections was bacterial. The etiology of CNS infections was fungal. In conclusion, infectious complications are the main cause of morbidity and mortality following SPKT. The early diagnosis of infection, particularly fungal complications, is necessary. The administration of broad-spectrum prophylactic antibiotics, antifungal, and antiviral agents is recommended.