Experience with 100 consecutive simultaneous kidney-pancreas transplants with bladder drainage.

From December 1985 to December 1989, 100 consecutive simultaneous pancreas-kidney (SPK) transplants were performed at the University of Wisconsin Hospital and Clinics. Bladder drainage technique was used for all grafts. One- and three-year patient survival was 93% and 90%; kidney survival, 90% and 85%; and pancreas survival, 86% and 84%. Quadruple immunosuppressive therapy was used in all patients and consisted of either MALG or OKT3 induction, and cyclosporine, prednisone, and azathioprine maintenance therapy. OKT3 induction therapy was used in 42 patients and Minnesota antilymphocyte globule in 58 patients, with equivalent results except for more opportunistic infection with OKT3. The duodenal button technique was used in the first 17 patients with systemic anticoagulation and was associated with significantly more postoperative bleeding and infection compared with the duodenal segment technique. The most common surgical complication of the duodenal segment technique was urine leak (13%), which usually occurred from the distal duodenal segment. The most common urologic complication of bladder drainage was hematuria (13%), which was usually self-limited. Within 6 months of transplantation, 84% of patients developed urinary tract infections, and 25% of patients had opportunistic infections. The surgical techniques and immunosuppressive methods used in this series are reviewed, and strategies for preventing medical and surgical complications are outlined.     

Gross hematuria following combined kidney-pancreas transplantation with pancreaticocystostomy.

We report on a 46-year-old man who presented with gross hematuria 3 months after combined kidney and pancreas transplantation with pancreaticocystostomy. There are few reported urological complications from this procedure and this operative technique adds to the differential diagnosis of hematuria in the post-transplant patient.     

Massive splenomegaly. Superior results with a combined endovascular and operative approach

Splenectomy for massive splenomegaly (drained splenic weight, greater than 1000 g) has an uncommonly high morbidity and mortality because of technical challenges and problems of hemostasis. In a group of 10 patients with massive splenomegaly due to myeloproliferative disorders (average splenic weight, 4193 g), we developed a management algorithm based on preoperative angiographic embolization of the splenic artery. Average operating time was 1.7 hours (range, 1 to 2.5 hours). Average blood loss was 528 mL; six of the 10 patients had blood loss less than 250 mL. There were four minor complications and one major complication (gastric ulcer requiring reoperation). There were no deaths in the perioperative period, and no patients required reoperation for hemorrhage.     

Successful long-term kidney-pancreas transplants regardless of C-peptide status or race

BACKGROUND: We have previously shown that our patient population of 60% minority races has end-stage renal disease primarily as a result of diabetes mellitus and hypertension. It therefore was logical to explore the restoration of normal insulin production and renal function by simultaneous pancreas-kidney (SPK) transplantation, without regard to race. This study represents new analyses integrating race with C-peptide status and reports the outcome of 136 SPK transplantations performed over the last 10 years. RESULTS: Of the 49 African-Americans with diabetes mellitus and end-stage renal disease, 60% were type I and 40% were type II, based on C-peptide levels. In comparison, only 16% of Caucasians were type II. The average age at onset of diabetes mellitus was 15.7 years for type I compared with 20.7 years for type II (P>0.05). The actuarial 10-year survival rates for the 136 SPKs were 91.79% (patient), 85.07% (pancreas), and 83.58% (kidney). The type I and type II survival rates were similar in the two diabetic groups. CONCLUSIONS: The data strongly suggest that pretransplant C-peptide status does not influence the outcome of SPK transplantation in patients with renal failure from diabetes mellitus. SPK transplants should be offered to all suitable diabetic patients with renal failure regardless of C-peptide status or race.     

Eight-year results of cyclosporine-treated patients with cardiac transplants

To elucidate the long-term effects of cyclosporine, we retrospectively studied 310 consecutive patients who have undergone cardiac transplantation at our institution since December 1980 and in whom immunosuppression has been maintained with cyclosporine. The ages of recipients ranged from 1 month to 64 years and of donors from 1 month to 48 years. The actuarial survival rates for cyclosporine-treated patients were 80.7% at 1 year and 59.7% at 5 years and were significantly greater than those for previous patients not treated with cyclosporine (p less than 0.005). Their actuarial prevalence of rejection was 60.0% at 1 month and 86.9% at 1 year; 206 patients are living. The actuarial prevalence of lymphoma development was 4.6% at 5 years but has been significantly lower with the current immunosuppression protocol of lower doses of cyclosporine, and OKT3 in place of rabbit anti-thymocyte globulin (p less than 0.005). Infection remains the most common cause of death. Recipients less than 50 years of age had a significantly higher actuarial survival than older recipients (p less than 0.01). Male and female recipients had similar overall prevalence of survival and rejection, but men died of graft atherosclerosis significantly more frequently (p less than 0.005). Rehabilitation has been successful in 85% of patients surviving 1 year after transplantation. Of those surviving 1 year, 96.5% were in New York Heart Association class I. Thus the results of orthotopic cardiac transplantation have improved since the introduction of cyclosporine and have allowed measured liberalization of the criteria for recipient selection.     

Lipoprotein profile after combined kidney-pancreas transplantation in insulin-dependent diabetes mellitus

In order to evaluate the effect of a combined kidney-pancreas (KP) transplantation in insulin-dependent diabetes mellitus (IDDM) patients on the lipid and lipoprotein profile, 15 KP patients were compared with 11 kidney (K)-transplanted IDDM patients, 19 IDDM patients on hemodialysis (HD), and 15 nondiabetic control subjects. Cholesterol, triglycerides, apo AI, and apo B were measured in total plasma and in VLDL, LDL, and HDL of all participants. VLDL-cholesterol, VLDL-triglycerides, and VLDL-apo B were significantly lower in KP patients, but not in K patients, than in HD patients. In addition, patients in the K, but not in the KP, group showed high levels of apo B in LDL and an increased triglyceride/apo B ratio in VLDL, compared with patients in the HD group. The percentage of apo AI associated with HDL was significantly higher in both transplanted groups than in the HD group. However, compared with a nondiabetic control population, an increase in VLDL particles and in triglyceride content in LDL and HDL still persisted following combined KP transplantation. Insulin resistance (probably due to steroid therapy) associated with high peripheral and potentially low hepatic insulin levels (due to the systemic drainage of the transplanted pancreas) could be the main causes of the remaining lipoprotein abnormalities.This paper is dedicated to the memory of our esteemed colleague and friend, Mariella Parlavecchia, who died on April 2, 1994     

Acute torsion of the renal transplant after combined kidney-pancreas transplant

BACKGROUND: Surgical complications after combined kidney and pancreas transplantation are a major source of morbidity and mortality. Complications related to the pancreas occur with greater frequency as compared to renal complications. The occurrence in our practice of two cases of renal infarction resulting from torsion about the vascular pedicle led to our retrospective review of similar vascular complications after combined kidney and pancreas transplantation. METHODS: Charts were reviewed retrospectively, and two patients were identified who experienced torsion about the vascular pedicle of an intra-abdominally placed renal allograft. RESULTS: Two patients who had received combined intraperitoneal kidney and pancreas transplantation presented at 16 and 11 months after transplant, respectively, with abdominal pain and decreased urine output. One patient had radiological documentation of abnormal rotation before the graft loss; unfortunately, the significance of this finding was missed. Diagnosis was made in both patients at laparotomy, where the kidneys were infarcted secondary to torsion of the vascular pedicle. Both patients underwent transplant nephrectomy and subsequently received a successful second cadaveric renal transplant. CONCLUSIONS: The mechanism of this complication is a result of the intra-abdominal placement of the kidney, length of the vascular pedicle, excess ureteral length, and paucity of adhesions secondary to steroid administration. These factors contribute to abnormal mobility of the kidney. Technical modifications such as minimizing excess ureteral length and nephropexy may help to avoid this complication.     

Dual-kidney transplants: long-term results

BACKGROUND: Dual-kidney transplantation, where two usually aged adult kidneys are placed into an adult recipient, is one way to help alleviate the continuing disparity between the number of patients on the kidney transplant waiting list and those who receive kidney transplants each year. The Dual Kidney Registry was developed to analyze donor and recipient data and outcomes at several centers. METHODS: Two hundred eighty-seven patients who have undergone transplantation since 1994 have been entered into the relational database. The patients were followed yearly after initial entry into the database. RESULTS: The mean donor age was 58+/-13 years and the mean terminal creatinine clearance was 77+/-40 mL/min. The mean glomerular sclerosis on procurement biopsy was 16+/-13%. Delayed graft function (DGF), defined as dialysis in the first 7 days after transplantation, was a predictor of poor outcome, and increased cold storage time was a predictor of DGF. The overall incidence of DGF was 27%. In recipients with prompt graft function (PGF), the mean cold storage time was 22+/-9 hr versus 29+/-10 hr in recipients with DGF (P<0.001). The overall 1- and 5-year graft survival was 86% and 69%, respectively. The 1- and 5-year graft survival rates were significantly better in recipients with PGF (90% and 74%) versus DGF (79% and 54%) (P<0.002). CONCLUSIONS: Cold storage time and DGF have a significant impact on the 1- and 5-year graft survival in recipients of dual-kidney transplants. The 5-year graft survival in recipients of dual-kidney transplants is excellent.     

Urologic aspects of kidney-pancreas transplantation.

The population of pancreas transplant recipients is growing steadily, and urologists most likely will be confronted with their unique anatomy and metabolic complications. The principles of diagnosis and management of these patients can be applied to other transplant recipients (e.g., heart, lung, and liver) who also are maintained on life-long immunosuppression and in whom urologic pathology develops commensurate with the incidence in the general population.     

他克莫司联合霉酚酸酯应用于胰肾联合移植的初步经验

目的 总结他克莫司(FK506)联合霉酚酸酯(MMF)应用于胰液膀胱引流式胰肾联合移植受者的初步经验. 方法 胰肾联合移植患者14例,术后应用FK506 0.07～0.15mg·kg-1·d-1加MMF 1.0～1.5 g/d加泼尼松25 mg/d三联免疫抑制治疗方案.采用微粒子酶免疫分析法每周测定口服FK506后全血峰谷浓度,依此调整剂量维持最初3个月内FK506全血浓度峰值10～20 μg/L,谷值5～15μg/L.并观察排斥反应的发生及药物的肝肾毒性. 结果 9例患者术后胰肾功能恢复良好,早期无排斥反应发生,血糖及肌酐水平恢复正常.随访18～70个月,平均34个月.存活1～3年者3例,3年～者1例,4年～者1例,>5年者4例,胰肾功能良好,血糖正常,均未使用降糖药.1例因超急性排斥反应术后第2天切除移植胰腺,随访2年肾功能良好.4例死亡,死因分别为术后急性右心功能衰竭、呼吸骤停、急性排斥反应及十二指肠瘘.胰肾联合移植术后各时期FK506全血峰、谷浓度差异均有统计学意义(P<0.05).术后共发生肾脏急性排斥反应4例次,肾毒性2例次,肝毒性1例次. 结论 FK506与MMF在药效上有协同作用,联合应用于胰肾联合移植具有良好的免疫抑制效果,能有效降低排斥反应发生率和提高移植物长期存活率.     

Fixation of skin transplants in burns with SurfaSoft and staples. An analysis of the results

The use of SurfaSoft and staples enables a rapid and adequate fixation of (meshed) skin grafts, even when large wounds and anatomically difficult areas are involved. The smooth, porous and transparent structure of SurfaSoft makes frequent inspection of the transplanted skin possible and allows dressing changes to be carried out from the first day after operation onwards. Analysis of 232 skin transplantations shows that on a surgical wound bed the mean take rate is 71% when full sheet or meshed transplants are used. A mean take rate of 96% can be achieved when expanded autograft and specially prepared allografts are used together for covering large wound areas. Transplantation of meshed skin on a granulating wound surface results in a mean take rate of 82%.