Pancreas transplantation. A new program

Sixteen pancreatico-duodenal transplants were performed on 15 insulin-dependent diabetics, aged 25-46, during a 20-month period beginning May 1, 1988. Fourteen patients received a combined cadaveric pancreas/renal transplant with bladder drainage. One patient received a second pancreas transplant 24 hours after the first pancreas graft failed due to portal vein thrombosis. One patient received a pancreas graft 3 years after kidney transplantation. Complications included five cases of hematuria, two bladder leaks, two wound infections, one cytomegalovirus pneumonia, three cases of graft pancreatitis, one pseudocyst, one urine reflux pancreatitis requiring conversion to pancreatico-enterostomy, and two late deaths. Average time to discharge was 17 days following transplant, with 2.9 re-hospitalizations per patient and an average of 38 in-hospital days during the first 6-12 months. Seventeen rejection episodes occurred in 12 patients, diagnosed by declining urine amylase and pH and/or finding of rejection on kidney biopsy. Patient and kidney graft survival is 87 per cent. Pancreas graft survival is 81 per cent (1-20 months follow-up). All patients are insulin-independent and normoglycemic. Mean glycosylated hemoglobin concentration is 4.0 +/- 0.9 post-transplant vs. 7.5 +/- 0.6 pretransplant. Mean serum creatinine is 1.4 +/- 0.7 mg/dl. A new program of pancreas transplantation can be successful in carefully selected diabetic patients, with special attention to avoidance of preservation injury to the pancreas during multiorgan donor procurement. Combined pancreatic/renal transplantation is believed to be the therapeutic treatment of choice in Type I diabetic patients who have impaired renal function and have no significant cardiovascular disease.     

Evidence that combined procurement of pancreas and liver grafts does not affect transplant outcome

We compared outcome after pancreas and liver transplantation when both organs were retrieved from the same donor to outcome when only one or the other organ was retrieved. A total of 166 cadaver pancreata were transplanted at our institution between November 1984 and August 1989; 64 were obtained from donors in whom the liver was also donated (LD), and 102 were retrieved from non-liver donors (non-LD). Of the 64 LD pancreata, 53 were the entire organ with a segment of duodenum and 11 were segmental. Both the superior mesenteric artery (SMA) and celiac axis (CA) were retained with the pancreas in 13, while in 40 pancreata the CA was retrieved with the liver and the blood supply to the pancreas was reconstructed [end-to-side anastomosis of splenic artery (SA) to SMA in 11 and a Y-graft of donor iliac bifurcation to SA and SMA in 29]; a graft of common iliac vein was used to extend the portal vein in 10. The technical failure rate was 8/64 (12%) in LD pancreata, and 13/102 (13%) in non-LD pancreata (P greater than 0.1). The overall pancreas allograft survival rate at 1 year was 76% for pancreata obtained from LD (n = 64) and 64% for technically successful transplanted pancreata obtained from non-LD (n = 102, P greater than 0.1). One-year actuarial patient survival was 95% in the LD group and 90% in the non-LD group (P greater than 0.1). Among the 64 livers from pancreas donors (PD), 20 were transplanted at our hospital, 42 were transported to other institutions, and 2 were not transplanted. Follow-up information regarding 47 primary orthotopic adult, whole liver PD recipients (18 at our hospital, 29 at other institutions) was available for analysis and was compared with information concerning 62 adult recipients of primary orthotopic whole livers from non-PD transplanted during the same period at our institution. The total PNF rate among 47 PD liver allografts was 2/47 (4%), compared with 1/62 (1%) for the livers from non-PD (P greater than 0.1). The technical failure rate for the PD group was 1/47 (2%) versus 5/62 (8%) in the non-PD group (P greater than 0.1). The overall liver allograft survival rate at 1 year was 75% for livers obtained from PD (n = 47) and 81% for livers obtained from non-PD (n = 62, P greater than 0.1). One-year actuarial patient survival was 88% in the PD group and 81% in the non-PD group (P greater than 0.1). We concluded that simultaneous procurement of liver and pancreas grafts had no significant detrimental effect on the rate of technical failure, or on allograft or patient survival after either pancreas or liver transplantation.     

Underutilization of pancreas donors

BACKGROUND: Transplantation of the pancreas has become the treatment of choice for selected patients with type 1 diabetes mellitus. With the current shortage of cadaver donors and the increasing number of diabetic patients on the transplant waiting list, there is a critical need to optimally use all available pancreas grafts for transplantation. We have therefore explored the use of traditionally "less-than-ideal" pancreas donors, including pediatric (4-10 years), older (>or=45 years), obese (weight >or=200 lb), and non-heart-beating donors and donors with an elevated amylase (75% greater than normal values). METHODS: A total of 620 primary simultaneous pancreas-kidney transplantations were performed at our center. We analyzed the ratio of livers to pancreata transplanted at our center and compared this to the United Network for Organ Sharing database. Using univariate and multivariate analyses, we then assessed the impact of these less-than-ideal donors on patient survival, graft survival, and postsurgical complications after simultaneous pancreas-kidney transplantation. RESULTS: A substantial nationwide underutilization of pancreata from donor procurements is demonstrated in the United Network for Organ Sharing database. By using these less-than-ideal donors, the ratio of liver to pancreata procured can be reduced to 1.25:1. Graft survival was not significantly different in patients receiving transplants from obese, non-heart-beating, pediatric, or hyperamylasemic donors compared with grafts from ideal donors. However, grafts from donors 45 years of age or older had significantly lower 1- and 5-year graft survival rates (76% and 65% vs. 90% and 80%, P=0.006). CONCLUSIONS: This study demonstrates that utilization of pancreas grafts from selected, less-than-ideal donors results in good overall outcomes and could potentially expand the organ donor pool.     

Half-life analysis of pancreas and kidney transplants

Although graft and patient survival data are available for pancreas and kidney transplants, they are rarely reported in terms of half-life. Our aim was to determine whether a more relevant measure of outcome is patient and allograft half-life. Using the data from the Organ Procurement and Transplantation Network Registry on kidney and pancreas transplants from January 1988 to December 1996, patient and graft half-life and 95% confidence intervals were calculated and demographic variables compared. No significant differences were found between demographic variables. Kidneys transplanted in diabetics as a simultaneous kidney-pancreas (SPK) fared better than diabetics receiving a kidney alone (9.6 vs. 6.3 years). Pancreatic graft survival in an SPK pair was better than pancreas after kidney transplant or pancreas transplant alone (11.2 vs. 2.5 years). Because kidney and pancreatic grafts have a longer half-life when transplanted with their mate grafts, we should consider the relative benefits of SPKs over pancreas after kidney transplant or pancreas transplant alone to limit the loss of precious resources.     

Regeneration of beta cells in the native pancreata after syngeneic and allogeneic pancreas transplantations in spontaneously type 2 diabetic Torii rats

BACKGROUND: We previously demonstrated that syngeneic pancreas transplantation has a potential to reverse diabetes even in a rat model of type 2 diabetes mellitus, namely Spontaneously Diabetic Torii (SDT; RT1a). The onset of diabetes was significantly delayed in the pancreas transplant recipients. We speculated that perfect diabetic control achieved by pancreas transplantation showed a beneficial effect on the native pancreata & recipients. MATERIALS AND METHODS: Twenty-five-week-old diabetic SDT rats were divided into 3 groups: untreated controls and syngeneic and allogeneic transplant recipients. We transplanted pancreaticoduodenal grafts from nondiabetic 10-week-old SDT rats and from 10-week-old allogeneic Dark Agouti (DA; RT1a) rats using daily administration of FK506. RESULTS: Untreated SDT rats showed disappearance of pancreatic and duodenal homeobox-1 (PDX-1) expression in the pancreas and a marked decrease in beta-cell mass. Among syngeneic and allogeneic pancreas transplant recipients, islet-like cell clusters were found in the native pancreata. The beta-cell mass at 40 weeks of age was significantly increased in the native pancreata of recipients compared with age-matched controls. Interestingly, we observed the reexpression of PDX-1 in the nuclei of islet-like cell clusters. CONCLUSIONS: Our results indicated the benefits of avoiding glucose toxicity by pancreas transplantation which induced PDX-1 expression in the native pancreata of type 2 diabetic recipients, resulting in regeneration of beta cells in the native pancreata.     

Immediate Retransplantation for Pancreas Allograft Thrombosis

Early pancreas allograft failure most commonly results from thrombosis and requires immediate allograft pancreatectomy. Optimal timing for retransplantation remains undefined. Immediate retransplantation facilitates reuse of the same anatomic site before extensive adhesions have formed. Some studies suggest that early retransplantation is associated with a higher incidence of graft loss. This study is a retrospective review of immediate pancreas retransplants performed at a single center. All cases of pancreas allograft loss within 2 weeks were examined. Of 228 pancreas transplants, 12 grafts were lost within 2 weeks of surgery. Eleven of these underwent allograft pancreatectomy for thrombosis. One suffered anoxic brain injury and was not a retransplantation candidate, one was retransplanted at 3.5 months and nine patients underwent retransplantation 1–16 days following the original transplant. Of the nine early retransplants, one pancreas was lost to heparin-induced thrombocytopenia, one recipient died with function at 2.9 years and the other grafts continue to function at 76–1137 days (mean 572 days). One-year graft survival for early retransplantation was 89% compared to 91% for all pancreas transplants at our center. Immediate retransplantation following pancreatic graft thrombosis restores durable allograft function with outcomes comparable to first-time pancreas transplantation.     

Kidney-pancreas transplantation: single-center experience at a university hospital in Turkey

INTRODUCTION: One treatment option for patients with type 1 diabetes mellitus with end-stage nephropathy is combined pancreas-kidney transplantation, which can be performed either simultaneously (SPK) or following kidney transplantation (PAK). PATIENTS AND METHODS: Between February 2003 and November 2004, 14 patients, including 10 males and 4 females of overall mean age of 31.3 +/- 6.1 years (range, 23-44 years), presented with end-stage renal disease secondary to type 1 diabetes mellitus. Five patients (35.7%) received SPK; 7 patients (50%) received PAK; and 2 patients (14.3%) received simultaneous pancreas and living-related kidney (SPLK) transplantations. RESULTS: Two among 14 pancreas grafts were lost in the early postoperative period secondary to venous thrombosis despite anticoagulation including 1 with poor portal drainage. Insulin therapy was reinitiated in 1 patient after a second rejection episode in the seventh postoperative month. By the ninth median follow-up month (range, 1-21 months), all kidney grafts were functioning. CONCLUSION: Our single-center short-term experience with 14 consecutive kidney-pancreas transplantations suggests that while the pancreas transplant is effective and safe to reestablish normoglycemia, this transplant creates additional surgical and immunosuppressive stresses on the patient.     

Improvement in short-term pancreas transplant outcome by targeted antimicrobial therapy and refined donor selection

Graft thrombosis and infectious complications are the main early causes of pancreatic allograft loss in recipients of whole vascularized pancreas transplants, resulting in loss rates up to 10 per cent in the first post transplant week. In this study we sought to determine if initiation of a standardized selection criteria and posttransplant chemoprophylaxis regimen could reduce the rate of early allograft loss; we compared the rate of early allograft loss after introduction of these changes. Of the 61 diabetic recipients who underwent these protocols, 50.8 per cent were female. Average age was 42.9 ± 7.4 years of age, average length of stay was 12.7 ± 8.7 days, with all transplants performed heterotopic to the right lower quadrant with venous drainage to the proximal external or common iliac vein. Organ donors were 21.4 ± 4.8 years of age, body mass index was 23.9 ± 2.8 kg/m(2), with a length of stay of 3.7 ± 1.6 days. One-week pancreatic allograft survival for the protocolized versus nonprotocolized patients was 100 per cent versus 96.7 per cent, 1 month was 98.4 per cent versus 93.4 per cent, and 1 year was 96.7 per cent versus 88.5 per cent, respectively. In the protocolized group there were two graft losses due to infectious complications and none due to thrombosis. Before initiation of the protocols patient survival at 1 year was 91.8 per cent and after was 100 per cent. Pancreas transplantation is arguably the most technically demanding organ transplant from a complication and loss standpoint. However, highly successful outcomes can be obtained with standardized protocols beginning pretransplant to reduce the incidence of posttransplant complications.     

Pancreas transplantation in crossmatch-positive recipients

BACKGROUND: Prolonged cold preservation time can unfavorably affect outcome in pancreas transplantation. To reduce this ischemic time, cadaver pancreas grafts, in selected cases, are sometimes transplanted before crossmatch results are known. We report our experience with pancreas transplants in recipients with either current or historically positive T- or B-cell crossmatches. METHODS: Crossmatch-positive pancreas transplants were identified using a computerized database. T-cell crossmatches were performed using an antihuman-globulin-augmented complement-dependent cytotoxicity (CDC) test; B-cell crossmatches were performed using an extended incubation CDC test. All patients received anti-T-cell induction therapy and either cyclosporine (1987-1993) or tacrolimus-based (1994-2001) immunosuppression. More recent recipients (2000-2001) also received intravenous gamma globulin and postoperative plasmapheresis. RESULTS: Between October 1, 1987 and March 31, 2001, of a total of 1076 pancreas transplants performed, 59 (5.48%) were crossmatch-positive. Of these, 8 had a current T-cell-positive crossmatch and 15 had a current B-cell-positive crossmatch. One recipient was both current B- and T-positive, and the rest were past B- and/or T-cell positive. One-year pancreas graft survival for current T- and B-cell crossmatch-positive transplants was 63% and 67%, respectively. T- or B-cell crossmatch-negative transplants had a 1-yr survival of 70%. In the T-cell crossmatch-positive group, four grafts are still functioning (follow-up range, 2-12 yr), one patient died with a functioning graft at 4 months, and four grafts failed (one each from pancreatitis, infection, primary nonfunction, and vascular thrombosis). No grafts were lost to rejection. In the B-cell crossmatch-positive group, six grafts are still functioning (follow-up range, 2-11 yr) and nine have failed (four from chronic rejection, three from vascular thromboses, and two from pancreatitis). Crossmatch-positive cases were significantly more likely to be retransplants (70.8%) than crossmatch-negative cases (14.8%, p < 0.0001). In a multivariate analysis, crossmatch positivity did not affect pancreas graft outcome, whereas retransplants had a significant impact on outcome (relative risk 1.84, p < 0.0001). CONCLUSIONS: (: i) Pancreas transplants performed in the setting of a positive current crossmatch may have long-term function. (ii) With current immunosuppressive protocols, graft loss from hyperacute and acute rejection may be prevented in current crossmatch-positive pancreas transplants. Chronic rejection was only seen in B-cell crossmatch-positive cases. (iii) High rates of technical graft loss in crossmatch-positive cases may reflect a high frequency of retransplants in this group.     

Donors with a maximum body weight of 50 kg for simultaneous pancreas-kidney transplantation

INTRODUCTION: Pediatric donors are rarely used for simultaneous pancreas-kidney transplantation (SPK). But the age of the donors may be less important than the body weight (BW). Therefore we retrospectively analyzed our data on SPK donors with a maximum BW of 50 kg. METHODS: Between June 1994 and December 2003, 22 patients received SPK transplants from cadaveric donors with a maximum BW of 50 kg (range, 25-50 kg; median, 42.4 kg). The median donor-recipient weight ratio was 0.61 (range, 0.47-0.91). RESULTS: Two kidney grafts (9.1%) displayed delayed graft function (2 and 9 dialyses). One patient needed insulin for 2 days (<20 IU/d), and the other patient for 1 month at a maximum of 7 IU/d. Four pancreas grafts (18.2%) were lost owing to graft thrombosis. One-year survival for patients was 95.5%; for kidneys, 86.4%; and for the pancreas, 72.7%. After a median observation period of 78 months, 6 acute rejection episodes were observed in 5 patients (22.7%). Five acute rejections were treated successfully, but 1 patient lost both organs. Two patients died of severe infections, at 3 months and 3 years, respectively, after SPK. Four kidney and 3 pancreas grafts developed chronic allograft dysfunction. CONCLUSIONS: Our results show that 1-year graft function in this series was less than the results reported to the International Pancreas Transplant Registry. The Main reason for early pancreas loss was graft thrombosis (18.2%). After a median observation period of 78 months, pancreas graft survival was 59.1%.     

Ipsilateral placement of simultaneous pancreas and kidney allografts

The current standard technique for simultaneous kidney pancreas transplantation usually involves transplanting the pancreas to the right and the kidney to the left iliac system. Here we describe a previously unreported technique where both organs are transplanted to the right iliac system through a single midline incision. Forty-nine patients underwent simultaneous ipsilateral pancreas and kidney transplantation. All pancreas grafts were drained enterically. Overall patient, pancreas, and kidney survival were 96% (47/49), 92% (45/49), and 94% (46/49) respectively. The 45 patients with functioning grafts are insulin free and off of dialysis. Mean serum creatinine at 1, 3, 6, and 12 months was 1.7+/-1.3, 1.2+/-0.3, 1.3+/-0.3, and 1.3+/-0.4 mg/dL, respectively. The placement of the pancreas and kidney transplants on the same side is safe and does not compromise patient or graft survival. This approach preserves the left iliac system for future retransplantation if necessary.     

Abdominal Wall Transplantation: Surgical and Immunologic Aspects

Abdominal wall transplantation is a type of composite tissue allograft that can be utilized to reconstitute the abdominal domain of patients undergoing intestinal transplantation. We have presented herein combined experience and long-term follow-up results of a series of abdominal wall transplants performed at 2 institutions. A total of 15 abdominal wall transplants from cadaveric donors were performed in 14 patients at the end of intestinal transplant surgery or, in 2 cases, a few days after the primary intestinal transplant. The vascular supply was through the inferior epigastric vessels, from the iliac vessels in 12 cases and via a microsurgical technique in 3 cases. Immunosuppression consisted of induction with alemtuzumab and maintenance treatment with tacrolimus monotherapy. Two grafts lost to vascular thrombosis were removed. Five patients are still alive, although all deaths were unrelated to the abdominal wall transplant. There were 3 episodes of abdominal wall graft rejection, treated with steroids; the abdominal wall graft and the intestinal grafts experienced rejection independent from each other. In summary, abdominal wall transplantation is a feasible technique for recipients of intestinal or multivisceral transplants, when the closure of the abdominal cavity by primary intention is technically impossible.     

Rejection Profile of Recent Pediatric Renal Transplant Recipients Compared with Historical Controls: a Report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)

Historically, higher acute rejection rates, earlier first rejection, and an inability to reverse the rejection characterize pediatric renal transplantation. In recent years, short-term (1-year) graft survival of pediatric renal transplants has steadily improved. To test the hypothesis that these improvements were mediated by changes in acute rejection, we considered the rejection profile of patients who received a renal allograft between 1987 and 1989 (cohort A) and compared it with recipients transplanted between 1997 and 1999 (Cohort B). Cohort A comprised 1469 transplants and cohort B comprised 1189 transplants. Restricting the data to the first year of follow-up, rejection ratios were 1.6 and 0.7, respectively (p < 0.001). Sixty per cent of the later cohort (B) were rejection free at 1 year, compared with 29% for the earlier cohort (A) (p < 0.001). Controlling for donor source, the rejection reversal rate for the later cohort was significantly better than that of the early cohort (p < 0.001). Cumulative distribution of times to first rejection was significantly better for cohort B (p < 0.001). One-year graft survival for cohort B at 94% was significantly better than 80% for cohort A (p < 0.001). We conclude that the improved short-term graft survival is mediated by improvements in the rejection profile in more recently transplanted patients and that this may translate into a better half-life for pediatric renal transplant recipients who received an allograft in the years 1997-99.     

Combined pancreas and kidney transplantation improves survival in patients with end-stage diabetic nephropathy

The purpose of this study was to find out whether prolonged normoglycemia, as achieved by a successful pancreas transplantation, can improve survival in patients with insulin-dependent diabetes mellitus. A retrospective analysis of actual 10-yr patient survival rates was done for all renal graft recipients who were given transplants more than 10 yr ago but within the cyclosporin era (i.e. 1981-1988). The actual 10-yr patient survival rate in non-diabetic renal graft recipients was 72%, In recipients of pancreas and kidney grafts and with prolonged function of the pancreas graft, the survival rate was 60%, whereas in patients subjected to simultaneous pancreas and kidney transplantation, but where the pancreatic grafts failed within 2 yr, the survival rate was 33%. In diabetic recipients of kidney transplants alone, the survival rate was 37%. The patient survival rate was substantially higher in non-diabetic patients and patients with functioning pancreas grafts compared with diabetic patients with kidney transplants alone or with failed pancreas grafts. We speculate that the decrease in mortality was due to the beneficial effect of long-term normoglycemia on diabetic late complications.     

Intestinal transplantation: 1997 report of the international registry. Intestinal Transplant Registry

BACKGROUND: Small bowel transplantation is an evolving procedure. We reviewed the world experience since 1985 to determine the current status of this procedure. METHODS: All of the known intestinal transplant programs were invited to contribute to an international registry using a standardized report form. RESULTS: Thirty-three intestinal transplant programs provided data on 273 transplants in 260 patients who were transplanted on or before February 28, 1997. The number of procedures per year has increased at a linear rate since 1990, with 58 transplants performed in 1996. Two-thirds of the recipients were children or teenagers. The short gut syndrome was the most common indication for transplantation. The types of transplants included the small bowel with or without the colon (41%); the intestine and liver (48%); and multivisceral grafts (11%). The 1-year graft/patient survival for transplants performed after February 1995 was 55%/69% for intestinal grafts; 63%/66% for small bowel and liver grafts; and 63%/63% for multivisceral grafts. Transplants since 1991 and programs that had performed at least 10 transplants had significantly higher graft survival rates. Seventy-seven percent of the current survivors had stopped total parenteral nutrition (TPN) and resumed oral nutrition. CONCLUSIONS: Transplantation has become a lifesaving procedure for (1) patients with intestinal failure who cannot be maintained on total parenteral nutrution and (2) patients who require abdominal evisceration to completely remove locally aggressive tumors. The 5-year survival rate of intestinal transplantation with large series is comparable to lung transplantation.     

Pancreas transplantation. An initial experience with systemic and portal drainage of pancreatic allografts.

Pancreas transplantation has evolved dramatically since its introduction in 1966. As new centers for transplantation have developed, the evaluation of complications associated with pancreas transplantation has led to advances in surgical technique. Furthermore, surgical alterations of the pancreas resulting from transplantation (systemic release of insulin and denervation) are of unproven consequence on glucose metabolism. Since 1988, the authors have performed 21 transplants (16 combined pancreas/kidney, 3 pancreas alone, which includes 1 retransplantation, 1 pancreas after previous kidney transplant, and 1 "cluster") in 20 patients aged 18 to 49 years; mean, 35 +/- 1 years. Overall patient survival is 95%. Three pancreatic grafts failed within the first year because of technical failure; one additional pancreas was lost to an immunologic event on postoperative day 449, for an overall pancreatic graft survival of 81%. No renal grafts were lost. To evaluate causes of graft failure, demographic data were compared, which included age and sex of the donor and the recipient, operative time, intraoperative blood transfusion, and ischemic time of the graft. No statistically significant differences were found between groups except for ischemic time (11.7 +/- 6.4 hours for the technical success group versus 19.8 +/- 3.7 hours for the technical failure group; p less than 0.05 by unpaired Student's t test). Quadruple immunosuppression was used, which included prednisone, cyclosporine, azathioprine, and antilymphoblast globulin. A mean of 1.2 (range, 0 to 3) rejection episodes per patient occurred. Mean hospital stay was 24 +/- 11 days. Surgical and infectious complications were evaluated by comparing the technical success (TS) group (n = 17) with the technical failure (TF) group. Surgical complications in the TS group revealed a mean of 1.3 episodes per patient, whereas the TF group had 3.7 episodes per patient. The TS also had a reduced incidence of infectious complications compared with the TF (1.7 versus 4.3 episodes per patient). Cytomegalovirus was common in both groups, accounting for 11 infectious episodes, and occurred on a mean postoperative day of 38. Mean postoperative HbA1C levels dropped to 5 +/- 1% from 11 +/- 3%. The authors developed a new technique that incorporates portal drainage of the pancreatic venous effluent in three recipients. Preoperative metabolic studies disclosed a mean fasting glucose of 211 +/- 27 mg/dL and a mean stimulated glucose value of 434 +/- 41 mg/dL for all patients; the mean fasting insulin was 23 +/- 4 microU/mL.(ABSTRACT TRUNCATED AT 400 WORDS)     

CAPD and renal transplantation

Continuous ambulatory peritoneal dialysis (CAPD) is believed to improve the immune competence of end-stage renal failure patients and to increase the risk of graft rejection following subsequent renal transplantation. At this centre, 220 consecutive renal transplants have been studied in patients treated by either CAPD or haemodialysis (HD). Patient and graft survival was not significantly different for the two treatment groups over a five year follow-up. When only first cadaver recipients were considered (152 grafts) one-year graft survival (non-immunological failures excluded) was 77 per cent for CAPD and 79 per cent for HD patients (P greater than 0.05). Time on dialysis and number of pre-operative transfusions were significantly greater for the HD patients (P less than 0.05). A group of HD and CAPD patients were identified as being matched for age, sex, HLA, A, B, DR antigen matches, pre-operative transfusions and time-on dialysis. One-year graft survival of the CAPD patients was 82 per cent and for the HD patients 61 per cent. Studies of patient lymphocyte function and plasma suppressive activity in vitro revealed no differences between CAPD and HD treated patients. CAPD is not an immunological risk factor in renal transplantation and its continued use in the preparation of patients for transplantation is recommended.     

Perspectives in the clinical application of pancreas transplantation in the diabetic

Until June 1983 a total of 280 human pancreatic transplantations had been performed world-wide. Until July 1983, 57 were functioning (22%), 11% for more than 12 months. During the past 5 years a steady increase in the number of segmental transplants has been observed. In most cases simultaneous transplantation of pancreas and kidney was performed (144 cases), in 65 cases the pancreas was transplanted metachronously after kidney grafting, and in 64 cases pancreatic transplantation was performed alone. Currently, segmental or whole pancreatic transplantation is the favoured procedure. Islet transplantation has been disappointing because of the difficulty in procuring sufficient numbers of islets from an adult pancreas followed by immunological destruction of the transplanted islets. Most pancreas grafts have been procured from cadavers, but the favoured segmental technique allows living related donors to be used. After rejection the graft does not always have to be removed and exogenous insulin administration may be resumed, either permanently or until re-transplantation can be accomplished. Life-long immunosuppression is needed after transplantation and currently pancreatic allograft survival rates for cyclosporin (CSA) and azathioprine-treated patients have been similar. The longest survival of a living diabetic recipient with a functioning pancreas is 5 1/2 years. Some authors have recently claimed improvement and stabilization of impaired nerve conduction and diabetic retinopathy after pancreatic transplantation.     

Experience with 49 segmental pancreas transplants in 45 diabetic patients

Forty-nine pancreas transplants were performed in 45 patients between July 23, 1978 and May 14, 1982, 18 from related donors. Currently (June 1982), 13 patients have functioning grafts and are insulin independent between 1 and 46 months after transplantation, 5 for more than 1 year. Nineteen patients lost graft function between 1 and 7 months. Sixteen grafts failed for technical reasons. Eight patients died between 1 and 21 months from infections or preexisting complications or for unknown reasons, three with functioning grafts. Actuarial 1-year graft survival is 24% and patient survival is 84%. A variety of techniques were used to handle exocrine secretions of 41 hemipancreas segmental grafts, 4 extended segmental grafts, and 4 whole pancreas grafts. Currently, 3 of 14 duct-open, 0 of 2 duct-ligated, 0 of 4 prolamine-injected, 6 of 19 silicone rubber-injected, and 4 of 10 jejunal anastomosed pancreatic grafts are functioning. Of 33 technically successful allografts, 5 in 12 conventionally immunosuppressed and 8 in 21 cyclosporin A (Cy A)-immunosuppressed recipients are functioning. Most technically successful grafts that failed were not biopsied or removed. In those that were biopsied, fibrosis was a dominant feature in all but one patient. In this patient endocrine and exocrine tissue was normal except for the absence of insulin-positive (beta) cells in the islets and an increase in glucagon-positive (alpha) cells, in contrast to the normal appearance of alpha and beta cells in islets at the time of the pancreas transplant. Currently, we perform pancreas transplants in diabetic patients who have previously received kidney transplants and therefore already require immunosuppression. For nonuremic patients, we perform pancreas transplant only if it is judged that their complications of diabetes exceed, or predictably will exceed, the potential side effects of chronic immunosuppression.