Effect of pancreas transplantation on life expectancy, kidney function and quality of life in uraemic Type 1 (insulin-dependent) diabetic patients

The aim of our study was to evaluate the effects of haemodialysis, kidney transplantation and simultaneous kidney and pancreas transplantation on survival of diabetic subjects and on kidney function. 40 Type 1 (insulin-dependent) diabetic patients received a kidney transplantation: in 31 cases the kidney was transplanted simultaneously to a pancreas graft from the same donor (KP group), while in 9 cases the pancreas was not available (K group). 44 uraemic Type 1(insulin-dependent) diabetic patients on dialysis and in waiting list for kidney transplantation, constituted the control group (HD group). Patient survival rate 1, 3 and 5 years following transplantation was better in KP group (93%, 89%, 89%, respectively) than in K group (88%, 88%, 73%, respectively) and in HD group (88%, 62%, 51%, respectively). Kidney graft survival at 1, 3 and 5 years post-transplant was better in KP group (93%, 72%, 72%, respectively) than in K group (76%, 61%, 31%, respectively). 1 year after transplantation, patients of the KP group who had lost the pancreas for technical reasons (thrombosis) were included in the K group so as to evaluate the effect of the transplanted pancreas on long-term patient and kidney survival. Patient survival rate in the KP group (17 patients) at 2 and 4 years was 100%, while at the same intervals it was 78% in the K group (13 patients). Kidney graft function rate at 2 and 4 years was 93% in the KP group (17 grafts) and 54% and 27% respectively in the K group (14 grafts). Evaluation of quality of life in patients receiving a kidney and pancreas transplantation showed an improvement in psychological well-being, when compared to patients receiving a kidney transplantation alone. Physical well-being was similar in patients transplanted with kidney and pancreas or with kidney alone.     

Pancreas transplantation: The Minnesota experience

Between July 1978 and April 1987, a total of 182 pancreas transplants were performed at the University of Minnesota. For the first 100 cases (through October 1984), a variety of surgical techniques and immunosuppressive regimens were used, and 1 year patient and graft functional (insulin-independent) survival rates were 88% and 27%, respectively. From November 1984 to April 1987, a triple therapeutic drug regimen of cyclosporine, azathioprine, and prednisone was used for maintenance immunosuppression, and bladder drainage (BD) (n=39; 38 cadaver (CAD) and 1 related (REL) donor graffs) and enteric drainage (ED) (n=40;21 CAD and 19 REL donor grafts) techniques were compared in 59 nonuremic, nonkidney (NUNK) transplant reciplents, 21 recipients of previous kidney (PK) transplants and 8 uremic recipients of simultaneous pancreas and kidney (SPK) transplants. The survival rates were higher in recipients of BD CAD and ED REL than of ED CAD gratts (58% and 59% versus 29% at one year for all, and 84%, 84% and 40% for technically successful cases), but patient survival rates were similar (90%, 93% and 90% at one year). BD allows for early diagnosis of rejection based on urine amylase monitoring, and REL grafts are less prone to incite rejection; thus, we are currently performing only BD for grafts from CAD donors, while both techniques are used for REL donor grafts. Functional survival rates since November 1984 in the three categories of recipients of pancreas grafts transplanted by currently applied techniques were higher in NUNK and SPK than in the PK category (63% and 75% vs. 46% at 1 year), primarily because of a higher technical fallure rate in the latter category (the corresponding figures for technically successful transplants at 1 year were 81%, 100%, and 89%). Serial kidney biopsies have shown reduction of glomerular mesangial volume in recipients of functioning grafts, but this favorable finding is offset by the occurrence of lesions of cyclosporine nephrotoxicity. Retinopathy progressed during the first year in 44% of patients with functioning grafts, but neuropathy improved with significant increases in motor nerve conduction velocities. Pancreas transplants are currently being performed in patients whose complications of diabetes are thought to be more serious than the side effects of immunosuppression. Logn-term observations and comparison with a control group will be necessary to document the validity of this approach to other than kidney transplant recipients, because preliminary observations show mixed results in regard to the evolution of pathology in the various organ systems at risk for serious complications of either diabetes or immunosuppression.     

The IKEM pancreas and islet transplant program as part of healthcare for type 1 diabetes patients: retrospective analysis of outcome from 1983 to 2010

Currently, 25-30 pancreas transplantations per year are carried out in type 1 diabetes (T1D) recipients residing in Czech Republic. Most of the recipients are transplanted together with kidney allografts, but pancreas is also transplanted alone in selected patients with brittle diabetes. Since 2005, the Institute for Clinical and Experimental Medicine (IKEM) islet transplant program was initiated as complementary therapeutic modality. The aim of this paper was to analyze the transplant program at our clinical center, and to examine the survival of recipients, and their pancreas, kidney, and islet grafts. Patient and graft survival rates were evaluated in the following three categories using Kaplan-Meier test: simultaneous pancreas and kidney transplantation (SPKTx), pancreas transplantation alone (PTA), and islet transplantation (ITx). Three hundred and ninety SPKTx, 34 PTA and 44 ITx were carried out between 1983 and 2010. One- and 5-year patient survival rates were 92 % and 81% in SPKTx, respectively. In SPKTx, the 1-year survival rate of pancreas grafts was 78%, and the 5-year rate was 66%. Kidney graft survival rates were 89% and 79%, respectively, after the same follow-up periods. In the PTA category, recipient survivals were 100% after 1 year, and 92% after 3 years. 70% and 65% of pancreatic grafts were working properly at 1 and 3-year follow-ups, respectively. To date, we have carried out 44 islet transplantations in 31 recipients. Islet function (C-peptide ≥ 0.2 ng/ml) was documented in 60% of recipients after 12 months. So far, only 3 patients remained free of exogenous insulin. While SPKTx is a well established treatment for uremic T1D patients, ITx represents an emerging complementary treatment modality. The latter is especially suitable for high-risk recipients, but routine clinical application is still hampered by the limited availability of usable organ transplants and viability of transplanted islets.     

Recent developments in pancreatic transplantation

At this moment there are more than 10,000 pancreases transplanted into those with diabetes mellitus worldwide. The introduction of new immunosuppressants and refined technical procedures have resulted in a survival of 90% of the grafts and patients. In most cases a simultaneous kidney transplant is performed in patients requiring haemodialysis or peritoneal dialysis. This results in a normal daily life without insulin injections or dialysis treatment. A successful pancreas transplantation in combination with a kidney transplantation can protect the transplanted kidney from diabetic changes. The day in, day out, quality of life of these patients is dramatically increased. The longest pancreas transplant known to be still working is now more than 20 years old. The results from the DCCT study (1) are demonstrating that tight blood sugar control, in those with type I diabetes reduces the complications of diabetes. This is best accomplished by transplanting pancreas grafts into diabetic patients.     

Simultaneous pancreas and kidney transplantation: a feasible procedure in selected patients.

We analyzed the overall results of 24 simultaneous pancreas and kidney transplantations (SPK), performed in our hospital between April 1986 and June 1990. All patients had type I diabetes mellitus and end-stage renal failure. We used bladder drainage of the pancreatic exocrine secretions through a duodenocystostomy. The blood vessels of both grafts were anastomosed to the iliac vessels. The immunosuppressive management was triple-therapy with cyclosporin, azathioprine and prednisone. All organs were transplanted without matching donors and recipients for HLA. At the time of transplantation, mean recipient age was 37 yr; the average duration of diabetes was 22 yr. After disappointing results in the first 4 patients, the pancreas was placed intraperitoneally instead of extraperitoneally and the antibiotic drug regimen was altered. In the second group (n = 20), patient survival was 100%; 1-yr pancreas and kidney graft survival were 65 and 62%, respectively. Duration of hospitalization and pancreas and kidney graft loss were positively correlated with the number of rejection episodes. After 1 yr of follow-up, the mean creatinine clearance was 62 ml/min and the mean HbA1c was 5.5%. Blood glucose levels and oral glucose tolerance tests were also normal. We conclude that patient and graft survival after SPK are satisfactory, although rejection-related morbidity is still a major problem.     

Pancreatic transplantation with delayed duct occlusion versus bladder drainage: long-term results

Between April 1985 and August 1990 a total of 51 combined pancreas kidney transplants and 6 single pancreas transplants were performed in 51 Type 1 (insulin — dependent) diabetic patients suffering from end-stage diabetic nephropathy and three patients with proliferative retinopathy. In 17 transplants the pancreatic duct was occluded with a mean delay of 53 days (Group 1). Because of a high incidence of local complications associated with a prolonged hospitalization this technique was abandoned despite favourable results: The actual survival rates for patients, pancreas and renal allografts at 1 year are 94%, 72% and 93%, respectively. From 1987 a total of 39 consecutive segmental pancreas grafts were anastomosed with the urinary bladder (Group 2). Pancreatic secretions were temporarily drained to the exterior in all patients via a duct catheter. Monitoring of the exocrine function including pancreatic secretion cytology and pancreatic secretion neopterin excretion proved to be reliable rejection markers. Survival rates at 1 year were calculated to be 90%, 74% and 89% for all patients, pancreas grafts and renal grafts. Apart from local complications in group I which did not cause any graft loss, the surgical complication rate was comparably low in both groups.     

门静脉回流技术在胰肾联合移植动物实验中的应用

目的研究门静脉回流技术在胰肾联合移植动物实验中的应用。方法 24只杂交长白猪随机分为体循环回流组(SVD)和门静脉回流组(PVD),每组内随机分为供、受体,经供体猪腹主动脉原位灌注,大块联合切取供体胰、节段十二指肠、左肾、脾脏。修剪移植肾脏、胰腺和十二指肠,左肾静脉与肠系膜上静脉吻合后．PVD组采用移植物门静脉与受体肠系膜上静脉吻合,SVD组采用移植物门静脉与下腔静脉吻合。各组腹主动脉与受体腹主动脉吻合,十二指肠内置人T型管、输尿管内置人脑室引流管自腹壁引出待Ⅱ期手术吻合。结果 SVD组和PVD组手术均很成功,供肾、胰植入受体后立即恢复良好的血液循环,并且迅速恢复功能,平均存活期分别为12d和14d。结论门静脉回流技术是可行的。     

Transplantation of the Pancreas

Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95?% across recipient categories, while insulin independence is maintained in some 85?% of simultaneous pancreas and kidney recipients and in nearly 80?% of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7?years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100?%) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.     

Kidney and kidney-pancreas transplantation in diabetic recipients

Type 1 as well as Type 2 diabetic patients in end-stage renal failure and with no contraindications to kidney transplantation have a greater probability of survival with a functioning kidney graft than if they remain on dialysis. Five-year patient and pancreas graft survival rates for simultaneous kidney-pancreas transplantation are currently 81 and 67% respectively. The main benefit of this operation is to achieve insulin independence and improved quality of life. However, surgical morbidity is higher and the immunosuppressive regimen more powerful than for kidney transplantation alone. The 5-year survival rate for kidney transplantation in Type 2 patients without severe cardiovascular disease is 81%, although a high incidence of peripheral vascular complications can be expected. Renal transplantation should be considered in diabetic patients with a life expectancy of more than 5 years, no contraindications to immunosuppressive treatment, and low perioperative risk. Combined kidney-pancreas transplantation should be considered in Type 1 patients under 50 years of age with no or moderate cardiovascular complications and a thorough understanding of the risks and benefits of the procedure.     

Outcome of pancreas transplantations in G?teborg, Sweden 1985–1990

During 1985 to 1990, 67 segmental pancreas transplantations with bladder drainage were performed. Fifty were combined pancreas and kidney and 17 were pancreas after kidney transplants. All patients were transplanted with the same technique. The 1-year actuarial pancreas graft survival for the combined patients with quadruple immunosuppressive therapy was 83% and the patient survival, 95%. The most important complications were infections, leakage from the pancreatico cystostoma and vascular complications.     

Pancreas transplantation: International registry data

The International Pancreas Transplant Registry recelved information on 1,157 pancreas transplants between December 1966 and April 1987. The results have progressively improved (p < 0.001); graft and recipient survival rates at 1 year were 5% and 40% for 1966–1977 cases (N = 60), 20% and 71% for 1978–1982 cases (N = 205), and 43% and 80% for 1983–1987 cases (N = 92). In the 1983–1987 era, the graft survival rates have been similar (p > 0.1) for the three most common duct management techniques, 46% at 1 year for polymer injection (N = 281), 44% for intestinal drainage (N = 253), and 44% for bladder drainage (N = 297), as well as for whole (N = 364) versus segmental (N = 528) grafts (41% versus 45% at 1 yr) and whether the spleen was (N = 27) or was not (N = 865) included (32% versus 44% at 1 yr). A preservation time of < 6 hours (N = 557) was associated with higher graft functional survival rates than preservation times of 6 to 12 hours (N = 173) and > 12 hours (N = 67), 47%, 39%, and 35%, respectively at 1 year, but only the < 6 versus the 6 to 12 hour difference was significant (p < 0.01). Recipients immunosuppressed with both cyclosporine and azathioprine (N = 555) had higher graft functional survival rates than those immunosuppressed with cyclosporine without azathioprine (N = 268) or azathioprine without cyclosporine (N = 64), 49%, 38%, and 31% at 1 year for all cases and 66% (N = 423), 53% (N = 189), and 41% (N = 44) for technically successful cases. Recipients of grafts known to be mismatched for ≤ 3 HLA antigens at the A, B, and DR loci (N = 167) had higher graft survival rates than those known to be mismatched for ≥ 4 antigens (N = 361), 49% versus 39% at 1 year, and the difference was statistically significant for technically successful cases (p < 0.05), 66% (N = 123) versus 54% (N = 257) at 1 year. Pancreas graft survival rates were significantly (p < 0.003) higher in recipients of simultaneous kidney transplants (N = 565) than recipients of a pancreas after a kidney (N = 165) or a pancreas alone (N = 156), 49%, 37%, and 32% at 1 year, but the results are just the opposite in regard to patient survival, 76%, 87%, and 90% at 1 year (p < 0.001). There was not a statistically significant difference in graft survival rates for recipients of retransplants (N = 63) versus primary transplants (N = 829), 40% and 49% at 1 year, but patients survival rates were actually higher (p < 0.03) after retransplantation than after primary transplantation (92% vs. 79% at 1 yr). The application of pancreas transplantation for the treatment of diabetes is increasing as the results approach those achieved by transplantation of other solid organs.     

Outcomes of Simultaneous Pancreas-Kidney Transplantation in Type 2 Diabetic Recipients

Summary

Background and objectives

Type 2 diabetic patients with end-stage renal disease may receive a simultaneous pancreas-kidney (SPK) transplant. However, outcomes are not well described. Risks for death and graft failure were examined in SPK type 2 diabetic recipients.

Design, setting, participants, & measurements

Using the United Network for Organ Sharing database, outcomes of SPK transplants were compared between type 2 and type 1 diabetic recipients. All primary SPK adult recipients transplanted between 2000 and 2007 (n = 6756) were stratified according to end-stage pancreas disease diagnosis (type 1: n=6141, type 2: n=582). Posttransplant complications and risks for death and kidney/pancreas graft failure were compared.

Results

Of the 6756 SPK transplants, 8.6% were performed in recipients with a type 2 diabetes diagnosis. Rates of delayed kidney graft function and primary kidney nonfunction were higher in the type 2 diabetics. Five-year overall and death-censored kidney graft survival were inferior in type 2 diabetics. After adjustment for other risk factors, including recipient (age, race, body weight, dialysis time, and cardiovascular comorbidities), donor, and transplant immune characteristics, type 2 diabetes was not associated with increased risk for death or kidney or pancreas failure when compared with type 1 diabetic recipients.

Conclusions

After adjustment for other risk factors, SPK recipients with type 2 diabetes diagnosis were not at increased risk for death, kidney failure, or pancreas failure when compared with recipients with type 1 diabetes.     

Presentation and outcome of mixed neuroendocrine non-neuroendocrine neoplasms of the pancreas

Background/objectivesMixed neuroendocrine non-neuroendocrine neoplasms (MiNEN) of the pancreas and periampullary region are extremely rare and heterogeneous malignancies. Literature is sparse, clinical management is not standardized and little is known about survival outcomes. The aim of this study was to identify pathological and radiological features of MiNEN and assess the outcome of surgical management.MethodsPatients undergoing surgery for pancreatic and periampullary MiNEN between 2001 and 2019 were retrospectively analysed based on a prospective database. Histological, radiological and clinical features were assessed. Survival was analysed in a nested case-control study and matched-pair analyses with pure neuroendocrine neoplasms (pNEN) and ductal adeno- or acinar cell carcinomas of the pancreas. A literature review with focus on survival after surgical resection was additionally performed.ResultsOf 13 patients with MiNEN, 5 had acinar-MiNEN and 8 adeno-MiNEN. Two of 5 (40%) acinar-MiNEN and one adeno-MiNEN patients had liver metastases. All but one adeno-MiNEN (88%) showed preoperative radiological features of pancreatic adenocarcinoma, 3 of 5 (60%) acinar-MiNEN exhibited mainly neuroendocrine features. No surgical mortality was observed. The 5-year overall survival rate in all MiNEN was 40%. Five-year survival rate was 58% in adeno-MiNEN and comparable to that of matched ductal adenocarcinomas (36%) and pNEN (48%). Five-year overall survival rate was 20% in acinar-MiNEN, compared to 39% in acinar carcinoma patients and 59% in matched pNEN patients.ConclusionsMiNEN are rare and difficult to distinguish from pure adenocarcinoma or neuroendocrine neoplasm preoperatively. Surgical resection would therefore be the treatment of choice in localized tumors.     

Living donor pancreas transplantation in Japan

Background/purpose

Living-donor pancreas transplants (LDPs) were introduced at Chiba-East National Hospital in 2004, and 12 LDPs have been performed at this institution to date. Based on the outcome of these 12 LDPs, the efficacy and safety of LDPs are herein discussed.

Methods

Twelve diabetic patients underwent LDPs; ten had simultaneous pancreas and kidney transplants from living donors, one had pancreas transplant after a kidney transplant from a living donor, and one had a pancreas transplant alone from a living donor. The donors were parents or brothers and the ABO blood types were incompatible in three LDPs. The procedures for the donor and recipient operations were performed according to the technique established by the University of Minnesota. Bladder drainage was used in 11 recipients and enteric drainage was used in one patient. Tacrolimus, basiliximab, mycophenolate mofetil, and prednisone were used for induction and immunosuppressive treatment. A splenectomy, double-filtered plasmapheresis, and plasma exchange were added in the ABO-incompatible LDPs.

Results

No complications were observed in the donors during hospitalization. The 1-year survivals of the patients, kidney grafts, and pancreas grafts were 100, 100, and 100%, respectively. The 3-year survivals were 91.7, 90, and 91.7%, respectively. Three patients developed leakage of pancreatic juice and one patient required a surgical procedure. Cytomegalovirus antigenemia was detected in five patients (42%).

Conclusions

Based on the excellent outcome of the LDPs at this institution, LDPs is therefore expected to become a promising option for the treatment of patients with severe diabetes.     

The impact of donor pancreas extraction time on graft survival and postoperative complications in pancreas transplant recipients

BackgroundSimultaneous pancreas kidney transplantation (SPK) is the best therapeutic option for patients with diabetes mellitus type 1 and end-stage renal disease. Recently, donor organ extraction time has been shown to affect kidney and liver graft survival. This study aimed to assess the effect of pancreas donor extraction time on graft survival and postoperative complications.MethodsWe retrospectively analyzed all pancreas transplants performed in two Eurotransplant centers. The association of pancreas extraction time with pancreas graft survival was analyzed by a Cox proportional hazards regression analysis after 3 months, 1 and 5 year. Besides, the effect of pancreas extraction time on the incidence of severe postoperative complications was analyzed.ResultsA total of 317 pancreas transplants were included in this study. Death-censored pancreas graft survival was 85.7% after one year and 76.7% after five years. Median pancreas donor extraction time was 64 min [IQR: 52–79 min]. After adjustment for potential confounders, death censored graft survival after 30 days (HR 1.01, 95% CI 0.9–1.03 (p = 0.23), 1 year (HR 1.01, 95% CI 0.99–1.03 (p = 0.22) and 5 years (HR 1.00, 95% CI 0.99–1.02 (p = 0.57) was not associated with pancreas donor extraction time. However, extraction time was significantly associated with a higher incidence of Clavien-Dindo ≥3 complications compared to Clavien-Dindo 1 + 2 complications: OR 1.012, 95% CI 1.00–1.02 (p = 0.039).ConclusionsOur findings suggest that although no effect on graft survival was found, limiting pancreas extraction time can have a significant impact on lowering postoperative complications.     

胰肾联合移植治疗胰岛素依赖型糖尿病及终末期肾病的实验与临床研究

目的：探讨在我国进行胰肾联合移植（ＳＰＫＴ）的可行方法，并应用于临床。方法：在８０余次尸体供者腹腔多脏器联合摘取及动物实验的基础上，在临床施行ＳＰＫＴ３例，胰十二指肠移植于右髂窝，肾脏移植于左髂窝，腹主动脉与肠系膜上动脉袖片与髂外动脉端－侧吻合，门静脉与髂外静脉端－侧吻合，胰腺外分泌引流采用经膀胱途径。结果：１例已存活８个月，术后未用胰岛素，胰肾功能良好，无并发症，已恢复正常生活和工作；１例术后４７天死于脑出血，死亡时胰肾功能良好；１例术后４９天胰腺动脉血栓形成，死于坏死性胰腺炎。结论：ＳＰＫＴ是治疗糖尿病并发终末期肾病的一种切实可行的有效方法，它将成为治疗该病的一种安全、有效、常规治疗方法。     

A longitudinal molecular surveillance study of human polyomavirus viremia in heart, kidney, liver, and pancreas transplant patients

In this study of 263 heart, kidney, liver, and pancreas transplant patients, BK virus (BKV) and JC virus (JCV) DNAemia were observed most commonly in kidney and/or pancreas transplant patients (26%), although they were also observed, to a lesser extent, in heart (7%) and liver (4%) transplant patients. The majority of episodes of polyomavirus DNAemia were subclinical, although, in some cases, BKV DNAemia was associated with kidney rejection, and JCV DNAemia was accompanied by nonspecific symptoms. Hence, BKV and JCV DNAemia are not uncommon during the first year after kidney, heart, liver, and pancreas transplantation, and they could be associated with certain clinical syndromes in transplant patients.     

2011 update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the course of twenty-four years at the International Pancreas Transplant Registry (IPTR)

AIM: This study aimed to analyze the outcome of pancreas and pancreas-kidney transplantations based on the comprehensive follow-up data reported to the International Pancreas Transplant Registry (IPTR). METHODS: As of December 2010, more than 35,000 pancreas transplantations have been reported to the IPTR: more than 24,000 transplantations in the US and more than 12,000 outside the US. Cases with follow-up information until March 2011 were included in the analysis. RESULTS: Pancreas transplantations in diabetic patients were divided into 3 categories: those performed simultaneously with a kidney (SPK) (75%), those given after a previous kidney transplantation (PAK) (18%), and pancreas transplantation alone (PTA) (7%). The total number of pancreas transplantations steadily increased until 2004 but has since declined. The largest decrease was seen in PAK, which decreased by 50% from 2004 through 2010. Comparatively, the number of SPK decreased by 7% during this time. Era analysis of US transplantations between 1987 and 2010 showed changes in recipient and donor characteristics. Recipient age at transplantation increased significantly as well as transplantations in type 2 diabetes patients. The trend over time was towards tighter donor criteria. There was a concentration on younger donors, preferable trauma victims, with short preservation time. Surgical techniques for the drainage of the pancreatic duct changed over time, too. Now enteric drainage is the predominantly used technique in combination with systemic drainage of the venous effluent of the pancreas graft. Immunosuppressive protocols developed towards antibody induction therapy with tacrolimus and MMF as maintenance therapy. The rate of transplantations with steroid avoidance increased over time in all 3 categories. These changes have led to improved patient and graft survival. Patient survival now reaches over 95% at one year post-transplant and over 83% after 5 years. The best graft survival was found in SPK with 86% pancreas and 93% kidney graft function at one year. PAK pancreas graft function reached 80%, and PTA pancreas graft function reached 78% at one year. In all 3 categories, early technical graft loss rates decreased significantly to 8-9%. Likewise, the 1-year immunological graft loss rate also decreased: in SPK, the immunological 1-year graft loss rate was 1.8%, in PAK 3.7%, and in PTA 6.0%. CONCLUSIONS: Patient survival and graft function improved significantly over the course of 24 years of pancreas transplantation in all 3 categories. With further reduction in surgical complications and improvements in immunosuppressive protocols, pancreas transplantation offers excellent outcomes for patients with labile diabetes.     

Pancreas Transplant Registry: history and analysis of cases 1966 to October 1986

From December 1966 to October 1986, 1001 pancreas transplants in 932 diabetic patients were reported to the International Pancreas Transplant Registry. One year actuarial graft function (insulin-independent) and recipient survival rates for all cases were 35% and 75%, respectively. In an analysis by era of 1966-77 (n = 64), 1978-82 (n = 201), 1983-84 (n = 298) and 1985-86 (n = 438) cases, 1 year graft function rates were 3, 21, 39, and 44% and recipient survival rates were 42, 72, 76, and 83, respectively (p less than 0.05 all comparisons, except 1983-84 vs. 1985-86). In an analysis of 1983-1986 cases only (n = 736), the overall 1 year graft function and patient survival rates were 42 and 79%, respectively. During this period, graft functional survival rates were similar (p greater than 0.8) for the most common duct management methods, 43% for duct injection (n = 254), 42% for enteric drainage (n = 254), and 47% for bladder drainage (n = 196) at 1 year. Graft function rates were also similar (p greater than 0.6) for whole (n = 280) and segmental (n = 456) pancreas transplants (41 vs. 42% at 1 year). Functional survival rates according to duration of preservation for grafts stored less than 6 h (n = 460), 6-12 h (n = 146) and greater than or equal to 12 h (n = 52) were 46, 39, and 30% at 1 year, and the difference was significant for the less than 6 vs. the 6-12 h preservation time (p = 0.023). Graft functional survival rates were significantly higher (p less than 0.05) in recipients who received azathioprine (AZA) and cyclosporine (CSA) in combination (n = 408) than in those who received CSA without azathioprine (n = 262) or AZA without cyclosporine, (n = 56), with 1 year graft functional survival rates of 47, 38, and 34%, respectively. For technically successful grafts, the functional survival rates were also significantly higher (p less than 0.05) in recipients treated with CSA + AZA (n = 309) than in those who received CSA without azathioprine (n = 186) or AZA without cyclosporine (n = 44), with 1 year function rates of 63, 53, and 41%, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)     

Laparoscopic-assisted distal pancreatectomy and nephrectomy from a live donor

Background

The simultaneous transplantation of pancreas and kidney from live donors is performed in select countries. One of the reasons for this reduced applicability is the invasiveness of the donor operation. We propose the method of laparoscopic-assisted operation to be performed on live donors with minimal invasion.

Method

The donor was placed in the right lateral decubitus position. A 7-cm upper midline incision was made, and a handport was installed in addition to two or three 12-mm ports. After the removal of the left kidney graft, the spleen and the distal part of the pancreas were completely mobilized. The splenic vein and artery were identified and mobilized. The donor was then rotated to a supine position. Dissection of the pancreatic parenchyma using ultrasound shears and ligation of the splenic vessels were performed through midline incision under direct vision. The distal part of the pancreas and the spleen were extracted.

Results

Since December 2007, 3 donors have undergone this operation. In all 3 cases, the postoperative course was uneventful, and both the renal and pancreatic grafts functioned well.

Conclusion

This technique is minimally invasive and safe, and may become the standard method of live donor operation for simultaneous pancreas–kidney transplantation.