单中心胰肾联合移植的远期疗效观察

目的 回顾性分析单中心58例胰肾联合移植的远期疗效及相关影响因素。方法 回顾性分析中国人民解放军联勤保障部队第九二三医院器官移植科2010年5月至2019年12月完成的58例胰肾联合移植手术受者和移植器官的存活率,并分析移植器官功能丢失和受者死亡原因。结果 1、3、5、8年受者生存率分别为98.28%、98.28%、92.24%、89.99%,移植胰腺存活率分别为86.21%、84.48%、78.40%、76.16%,移植肾存活率分别为98.28%、98.28%、82.83%、80.60%,胰液膀胱引流（bladder drainage,BD）术式1、3、5、8年生存率为96.15%、96.15%、86.73%、86.73%,胰液空肠引流（enteric drainage,ED）术式1、3、5、8年生存率为100%、100%、96.67%、93.33%(P=0.187)。结论 胰肾联合移植对于终末期糖尿病肾病的远期疗效较好,ED术式可能会有更好的长期预后,外科并发症是影响胰肾联合移植远期疗效的主要因素,器官排斥反应、感染和受者带功死亡也是移植器官功能丢失的重要因素。     

实施胰肾联合移植的体会

实施胰肾联合移植的体会浙江医科大学附属第一医院肝胆外科（３１０００３）郑树森胰肾联合移植（ＳＰＫ）是治疗胰岛素依赖型（Ｉ型）糖尿病（ＩＤＤＭ）并发尿毒症的有效方法，胰腺移植之后可获得正常的糖代谢，不需要外源性胰岛素并可逆转糖尿病的并发症和提高生活质量...     

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     

胰肾联合移植治疗Ⅰ型糖尿病合并终末期肾病

目的 探讨胰肾联合移植治疗Ⅰ型糖尿病合并终末期肾病的临床效果。方法 ８例Ⅰ型糖尿病合并终末期肾病的患者接受胰肾联合移植,平均年龄４３．４６岁,２例合并视网膜病变,双目失明,病史２～２２年。胰腺移植于右髂窝,胰腺外分泌经膀胱引流,肾脏移植于左髂窝。免疫抑制方案开始四联用药,以后三联用药继续治疗。结果 ８例虱其中７例术后即不需要应用胰岛素,空腹血糖可维持在正常范围,１例术后应用胰岛素４０ｄ后停用。１例     

胰肾联合移植治疗糖尿病终末期肾病11例临床分析

目的：探讨胰肾联合移植（SPK）治疗糖尿病合并终末期肾病的临床效果。方法：回顾性分析2016年11月至2019年3月11例糖尿病合并终末期肾病患者行SPK的临床资料,总结手术疗效以及并发症情况。结果：所有患者均接受随访,资料统计截至2019年12月1日,随访观察9～37月,人、肾、胰腺存活率分别为100%、100%、91%。11例患者术后1月血肌酐（101±28）μmol/L;末次复查血肌酐（96±24）μmol/L,糖化血红蛋白为（5.6±0.5）%。至资料统计截止时间,10例患者移植肾功能正常,1例患者新发移植肾肾病（血肌酐71～202μmol/L）。术后并发胰腺血栓形成2例,其中1例经肠系膜下静脉自脾静脉中取出血栓,胰腺功能恢复;另1例行移植胰腺切除。胰腺门静脉扭转1例,胰腺排斥反应1例,胰周脓肿1例,消化道出血1例,切口愈合不良5例。9例患者术后空腹、餐后血糖均正常,1例患者午餐后血糖稍高,口服二甲双胍血糖控制可。结论：SPK治疗糖尿病合并终末期肾病疗效确切,但围手术期并发症发生率较高,积极防治围手术期并发症可有效提高手术成功率。     

肾胰联合移植的疗效评价

肾胰联合移植的疗效评价周佩军唐孝达作者单位：２０００８０上海市第一人民医院泌尿科研究室对患终末期肾病（ＥＳＲＤ）的糖尿病患者，肾移植疗效优于慢性透析，能显著延长病人生命，但移植效果仍较非糖尿病差。胰腺移植能防止糖尿病全身性并发症的发生和发展。对胰岛素...     

胰,十二指肠及肾Ⅰ期联合移植的麻醉处理二例报告

Ⅰ型糖尿病并发糖尿病性尿毒症需长期应用胰岛素和血液透析。近年,国内外采用胰肾Ⅰ期联合移植治疗Ⅰ型糖尿病并发尿毒症。我院分别于1994年4月及1995年5月在硬膜外-静吸复合全麻下施行了2例胰、十二指肠及肾Ⅰ期联合移植,术后恢复良好,现将麻醉处理报告如下。 病例介绍 例1 男49岁,糖尿病史25年,长期联合应用降糖药及胰岛素。4年前因出现肾功能衰竭尿毒症开始行血液透析治疗直至术前24h。术前血钾3.45mmol/L、血钠140mmol/L、血氯106mmol/L、血肌酐4.1mg/dl、血     

胰肾联合移植麻醉处理分析(附6例临床报告)

对于胰岛素依赖型糖尿病伴终末期肾病有效治疗方法为胰肾联合移植［１］。但在此期间病人均有糖尿病伴尿毒症、高血压和酸碱平衡失调。此类病人的状况较为复杂，对麻醉期间的管理提出了挑战。我院１９９９年９月至２０００年４月进行６例一期胰肾联合移植，临床效果满意，本文就麻醉处理的有关问题进行讨论。资料与方法一般资料 男５例，女１例。年龄2６～４８岁，体重５６～７０ｋｇ。Ⅰ型糖尿病4例，Ⅱ型糖尿病 ２例。病史 １０～２０年。6例均合并高血压（血压为 １５０－１８５／９５～１２０ｍｍ Ｈｇ），肾功能不全和尿毒症。２例出现…     

1型糖尿病肾病尿毒症期患者胰肾联合移植与单独肾移植远期疗效观察

目的研究1型糖尿病肾病尿毒症期患者胰肾联合移植（simultaneouspancreas—kidneytransplantation,SPK）与单独肾移植（kidneytransplantationalone,KTA）的长期临床效果。方法选取2001年10月至2004年7月在南方医科大学南方医院接受SPK和KTA的1型糖尿病肾病尿毒症期患者共16例,其中SPK组6例,KTA组10例。回顾性分析和比较两组5年人／移植物存活率、急性排斥反应和蛋白尿的发生率及空腹血糖、血肌酐、血脂（甘油三酯、胆固醇）、血压水平。结果16例受者至今存活。SPK组移植胰腺功能正常,1例于移植后第5年血肌酐升至450μmol／L左右,尿蛋白阳性,其余受者血肌酐均不超过130μmol／L,尿蛋白阴性,5年人／移植物存活率均为100％。KTA组3例血肌酐浓度为150～180μmol／L,尿蛋白阳性,1例于移植后第4年因血肌酐升至700μmol／L以上开始规律血液透析治疗,5年人／移植物存活率为100％和90％。两组急性排斥反应的发生率差异无统计学意义（P〉0．05）。移植后5年SPK组和KTA组血肌酐平均浓度为（166．3±139．3）μmol／L和（209．8±188．6）μmoL／L,蛋白尿、高血脂、高血压的发生率分别为16．7％、33．3％、50％和40％、60％、80％,SPK组均低于KTA组,但差别无统计学意义（均P〉0．05）;而血糖水平、胆固醇浓度、收缩压水平SPK组均低于KTA组,差别有统计学意义（均P〈0．05）。结论SPK是1型糖尿病肾病尿毒症期患者的有效治疗方法,与KTA比较,其移植后5年的移植肾功能较好,高血脂、高血压的发生率较低。     

胰肾联合移植的外科并发症分析

目的：总结分析胰肾一期联合移植(SPK)外科并发症的发生情况、原因和处理方式。方法：12例Ⅰ型糖尿病合并尿毒症患者施行了SPK，最初2例应用胰液膀胱引流(BD)术式，另10例为改进的胰液空肠引流（ED）术式。术后早期采用他克莫司(FK506)／环孢素A(CsA)加霉酚酸酯(MMF)、皮质激素、抗淋巴细胞球蛋白(ALG)或抗CD25单抗四联诱导治疗，以后改为三联维持。抗凝治疗使用肝素和低分子右旋糖酐。结果：12例手术均获成功，术后移植胰、移植肾功能恢复良好，停用了外源性胰岛素。外科近期并发症；腹腔感染3例，切口感染2例，分别经引流、换药后二期愈合；肾周血肿2例，经手术探查、清理后好转，多与抗凝剂短期应用过量有关。远期并发症：2例BD术式患者长期存在化学性膀胱炎，其中1例发生2次反流性移植物胰腺炎，经保守治疗后好转。所有病例术后均未发生吻合口漏和移植物血管血栓形成等严重并发症。结论：外科并发症的综合防治是SPK成功的关键之一。     

Pregnancy outcomes in simultaneous pancreas and kidney transplant recipients: a national French survey study

Simultaneous pancreas and kidney transplantation (SPK) is currently the best therapeutic option for patients with type 1 diabetes and terminal renal failure. Renal transplantation restores fertility enabling women to pursue pregnancies. However, scarcity of available data on pregnancy outcomes in SPK impedes fair medical counseling. Medical files of all pregnancies that lasted ≥3 months among recipients of functional SPK performed between 1990 and 2015 in France were retrospectively analyzed. Twenty‐six pregnancies in 22 SPK recipients were identified. Main maternal complications included gestational hypertension (53.8%) and infections (50%). Cesarean section was performed in 73% of cases. Overall fetal survival was 92.6% with a mean gestational age of 34.2 ± 3 weeks. Four children (16.7% of live births) had a birth weight <10th percentile. Endocrine pancreas graft function remained stable during pregnancy. An acute kidney rejection occurred in two patients, one of which resulting in graft loss. Kidney and pancreas graft survival was, respectively, 96% and 100% at 1 year postconception and did not differ from controls. Pregnancy in SPK is feasible, but patients should be informed of the risks for the fetus, the mother, and the grafts. Planning of pregnancy in SPK women is key to allow a personalized multidisciplinary monitoring, which represents the most straightforward approach to optimize outcomes.     

Diabetic muscle infarction after simultaneous pancreas-kidney transplant

Diabetic muscle infarction (DMI) is a rare entity that occurs in patients with long-standing type 1 insulin dependent diabetes mellitus (IDDM). We describe DMI occurring on an average of 5 months after SPK in four patients with IDDM and end stage renal disease (ESRD). These patients had evidence of other long-term diabetic complications including retinopathy and neuropathy, as well as microangiopathy and hypercoagulability, both of which are pre-disposing factors for DMI. The etiology of DMI is not well understood. Despite establishment of normoglycemia after kidney-pancreas transplantation, DMI may occur as a result of tissue damage/fragility secondary to the pre-existing long-term labile glycemic control and hypertension. This may be exacerbated by the pro-coagulant effects of the calcineurin-inhibitors and the use of steroids as part of the immunosuppressive regimen.     

Outcomes after simultaneous kidney‐pancreas versus pancreas after kidney transplantation in the current era

Simultaneous pancreas and kidney (SPK) and pancreas after kidney (PAK) transplant are both potential options for diabetic ESRD patients. Historically, PAK pancreas graft outcomes were felt to be inferior to SPK pancreas graft outcomes. Little is known about outcomes in the modern era of transplantation. We analyzed our SPK and PAK recipients transplanted between 01/2000 and 12/2016. There were a total of 635 pancreas and kidney transplant recipients during the study period, 611 SPK and 24 PAK. Twelve of the PAK patients received a living donor kidney. There were no significant differences between the two groups in kidney or pancreas graft rejection at 1 year. Similarly, 1‐year graft survival for both organs was not different. At last follow‐up, uncensored and death‐censored graft survival was not statistically different for kidney or pancreas grafts. In addition, in Cox regression analysis SPK and PAK were associated with similar graft survival. Although the majority of pancreas transplants are in the form of SPK, PAK is an acceptable alternative. Simultaneous pancreas and kidney avoids donor risks associated with live donation, so may be preferable in regions with short wait times, but PAK with a living donor kidney may be the best alternative in regions with long SPK wait times.     

BK virus nephropathy in simultaneous pancreas kidney transplant: a potentially preventable cause of kidney allograft loss

More than half of the simultaneous pancreas kidney transplant (SPK) patients afflicted with BK virus nephropathy (BKVN) lose their kidney allograft. Fear of pancreatic rejection limits the ability to reduce immunosuppression; this may result in inadequate treatment of BKVN. This single-center retrospective review included 138 SPK patients who underwent periodic BKV screening and were managed with IS reduction alone as a treatment of choice for BKVN. All patients underwent rabbit anti-thymocyte globulin (rATG) induction and were maintained on tacrolimus/sirolimus or mycophenolate. The incidence of BKVN was 4.4%. BKVN was diagnosed at a median of 11 months; mean serum creatinine 2.1 mg/dL and the geometric mean BK serum viral load at diagnosis 1,758,000 DNA copies/mL. Median time to BKV clearance was 5.6 months; there was 96% reduction in the mycophenolate dose, 100% reduction in sirolimus, and 40% reduction in the tacrolimus blood level at BKVN clearance. No BKVN-related kidney failure was noted, and patients retained excellent kidney and pancreatic allograft function till last follow-up (43 months). BKVN in SPK is a potentially preventable cause of end-stage kidney disease, and IS reduction alone is an acceptable treatment modality in SPK without a higher risk of kidney/pancreas allograft loss as long as close monitoring can be ensured.     

Simultaneous pancreas and kidney transplantation from organ donation after cardiac death

Background: The concept of organ donation after cardiac death (DCD) historically precedes the current practice of organ procurement from heartbeating donors meeting the brainstem death criteria. DCD has not gained widespread interest, however, due partly to initial fears that transplantation of such organs leads to suboptimal outcome. Methods: Available data on long‐term outcomes following simultaneous pancreas and kidney transplant (SPK) from DCD donors were reviewed, and it was found that the long‐term outcome is comparable to SPK from heartbeating donors. Australia’s first SPK from a DCD donor was performed. Results: The patient received a kidney and a pancreas from a young healthy donor after cardiac death, and at the time of writing was well with functioning grafts. Conclusion: SPK from donation after cardiac death is safe and should continue to be available for patients in need.     

Management of leukopenia in kidney and pancreas transplant recipients

Abstract: Leukopenia is frequently observed in the setting of solid organ transplantation. The risk factors, natural history, and outcomes associated with leukopenia post‐transplantation have not been well defined. We retrospectively studied 102 adult kidney and/or pancreas transplant recipients over a one‐yr period of time. By defining leukopenia as a white blood cell count ≤3000 cells/mm³ and neutropenia as an absolute neutrophil count ≤2000/mm³, the combined incidence of either leukopenia or neutropenia was 58% (59/102); the first episode occurred at a mean of 91 d post‐transplant. A significant increase in the incidence of leukopenia was found in patients who either received alemtuzumab induction (42% with alemtuzumab vs. 9% with rabbit anti‐thymocyte globulin induction, p < 0.05) and/or had rapid steroid withdrawal in the early post‐transplant period (44% with vs. 16% without steroid withdrawal, p < 0.05). The most common intervention performed for leukopenia was reducing the dose of mycophenolate mofetil and/or valganciclovir. When granulocyte stimulating factors were used, a mean of 3.1 doses were needed to successfully manage the leukopenia. Although leukopenia was a common finding in our study of kidney and/or pancreas transplant recipients, there was no difference in the rates of infection or acute rejection in patients with and without leukopenia.     

Kidney retransplantation following graft loss to polyoma virus-associated nephropathy: an effective treatment option in simultaneous pancreas and kidney transplant recipients.

Polyomavirus-associated nephropathy (PVAN) has emerged as an important cause of graft loss following kidney transplantation. Experience with kidney retransplantation (reKT) in PVAN is very limited, especially in the setting of uninterrupted immunosuppression protecting the still functioning pancreatic graft after simultaneous pancreas/kidney transplantation (SPK). We present a review of five cases of reKT in four SPK recipients with Type 1 diabetes mellitus from a single centre (a second reKT was performed in one patient following first reKT failure due PVAN recurrence). Pre-emptive nephrectomy of the failed graft was performed in three of the cases and all kidney grafts for reKT were harvested from cadaveric donors. All patients are dialysis- and insulin-independent at 30 (9-55), median (range), months following last reKT with maintenance immunosuppression consisting of tacrolimus/sirolimus in three and cyclosporine A/mycophenolate mofetil in one patient. In conclusion, reKT represents an effective treatment option in SPK patients with kidney failure on account of PVAN. Use of interventions designed to reduce active viral replication, including pre-emptive nephrectomy of the failed graft, should be considered before reKT.     

Changes in quality of life,health status and other patient-reported outcomes following simultaneous pancreas and kidney transplantation (SPKT): a quantitative and qualitative analysis within a UK-wide programme

We examined quality of life (QoL) and other patient-reported outcome measures (PROMs) in 95 simultaneous pancreas and kidney transplant (SPKT) recipients and 41 patients wait-listed for SPKT recruited to the UK Access to Transplantation and Transplant Outcome Measures (ATTOM) programme. Wait-listed patients transplanted within 12 months of recruitment (n = 22) were followed 12 months post-transplant and compared with those still wait-listed (n = 19) to examine pre- to post-transplant changes. Qualitative interviews with ten SPKT recipients 12 months post-transplant were analysed thematically. Cross-sectional analyses showed several better 12-month outcomes for SPKT recipients compared with those still wait-listed, a trend to better health utilities but no difference in diabetes-specific QoL or diabetes treatment satisfaction. Pre- to post-transplant, SPKT recipients showed improved treatment satisfaction, well-being, self-reported health, generic QoL and less negative impact on renal-specific QoL (ps < 0.05). Health utility values were better overall in transplant recipients and neither these nor diabetes-specific QoL changed significantly in either group. Pre-emptive transplant advantages seen in 12-month cross-sectional analyses disappeared when controlling for baseline values. Qualitative findings indicated diabetes complications, self-imposed blood glucose monitoring and dietary restrictions continued to impact QoL negatively post-transplant. Unrealistic expectations of SPKT caused some disappointment. Measuring condition-specific PROMs over time will help in demonstrating the benefits and limitations of SPKT.     

Comprehensive review: Frailty in pancreas transplant candidates and recipients

Well-selected patients with kidney disease and diabetes mellitus who undergo simultaneous kidney-pancreas transplantation often experience dramatic improvements in quality of life and long-term survival compared to those who remain on medical therapy. Over the past several years the importance of frailty in the pancreas transplant candidate and recipient populations has grown. More patients with advanced age have entered the waitlist, and complications from prolonged diabetes, even in younger patients, have created increased evidence of risk for frailty. Given these concerns, and the broad challenges facing pancreas transplantation volumes overall, we generated this review to help establish the impact and implications. We summarize the interplay of immunological factors, aging, environmental factors, diabetes mellitus, and chronic kidney disease that put these patients at risk for frailty. We discuss its measurement and recommend a combination of two instruments (both well-validated and one entirely objective). We describe the outcomes for patients before and after pancreas transplantation who may have frailty, and what interventions can be taken to mitigate its effects. Broader investigation into frailty in the pancreas transplant population is needed to better understand how to select patients for pancreas transplantation and to how manage its consequences thereafter.