Urinary amylase monitoring for early diagnosis of pancreas allograft rejection in dogs

The diagnosis of pancreas allograft rejection is usually made on the basis of blood glucose concentration, a late indicator of rejection. We performed segmental pancreas transplants in totally pancreatectomized dogs with the exocrine secretions drained into the bladder (ductocystostomy). We directly measured exocrine pancreatic secretions (urinary amylase), in an attempt to find a sensitive indicator for early rejection. Five groups were studied: (I) autografts; (II) autografts immunosuppressed with cyclosporine (CsA), azathioprine and prednisone; (III) allografts without immunosuppression; (IV) allografts immunosuppressed with CsA alone; (V) allografts immunosuppressed with CsA, azathioprine, and prednisone. The control groups (I, II) maintained high urine amylase concentrations indefinitely (mean +/- SE of 125,544 +/- 36,931 u/liter). Rejection, as diagnosed by rise of serum glucose to greater than 150 mg/dl, occurred at a mean (+/- SE) of 9.0 +/- 0.2 days in nonimmunosuppressed recipients of Group III, at 9.3 +/- 0.7 days in cyclosporine-treated dogs of Group IV, and at 28.0 +/- 8.3 days after transplantation in dogs immunosuppressed with triple therapy of Group V. In all allograft recipients, urine amylase declined precipitously (less than 1000 u/liter) before the onset of hyperglycemia, by 1.3 +/- 0.2 days in Group III, 3.3 +/- 1.0 days in Group IV, and 9.4 +/- 2.8 days in Group V. In a further experiment, nine dogs with pancreas allografts received cyclosporine for prophylactic immunosuppression; further antirejection therapy with azathioprine and antilymphocyte globulin was given for 5 days beginning the first day that rejection was diagnosed. In five dogs (Group A) rejection was diagnosed when serum glucose rose to greater than 150 mg/dl.(ABSTRACT TRUNCATED AT 250 WORDS)     

猪全胰十二指肠移植排斥反应的早期诊断

目的 探讨移植胰腺分泌的胰液中肿瘤坏死因子（ＴＮＦ－α）水平、淀粉酶流量和受者的血糖水平在排斥反应早期诊断中的意义。方法 采用全胰切除的猪行全胰十二指肠移植，第１组受者不用免疫抑制剂；第２组受者应用甲泼尼龙＋雷公藤多甙片；第３组受者应用环孢素Ａ＋雷公藤多甙＋甲泼尼龙。观察受者的空腹血糖、胰液淀粉酶流量和ＮＴＦ－α水平。结果 第１组受者移植后第４ｄ胰液和淀粉酶流量下降，第８ｄ停止；第２组受者的胰液和     

Duplex-Doppler ultrasonography in monitoring clinical pancreas transplantation

Abstract. The findings are reported that were obtained with duplex-Doppler ultrasonography (US) in seven diabetic patients who underwent pancreatic grafting with pancreaticocystostomy. Five normal functioning grafts showed homogenous echostructure and pulsed Doppler spectrum characteristics of low impedance vascular beds. Four of these patients developed graft rejection (five episodes). The remaining two grafts had pulsed Doppler evidence of venous thrombosis. It was not possible to differentiate graft rejection from venous thrombosis using real-time US. In both circumstances a heterogeneous pancreatic echostructure with a small amount of peripancreatic fluid and an increase in pancreas size were observed. Pulsed Doppler, however, showed absence of venous flow in both cases of venous thrombosis whereas all rejection episodes were characterized by an increase in arterial impedance. We conclude that duplex-Doppler US is a promising noninvasive method of detecting surgical complications and graft rejection in pancreatic transplant recipients.     

Duplex-Doppler ultrasonography in monitoring clinical pancreas transplantation

The findings are reported that were obtained with duplex-Doppler ultrasonography (US) in seven diabetic patients who underwent pancreatic grafting with pancreaticocystostomy. Five normal functioning grafts showed homogenous echostructure and pulsed Doppler spectrum characteristics of low impedance vascular beds. Four of these patients developed graft rejection (five episodes). The remaining two grafts had pulsed Doppler evidence of venous thrombosis. It was not possible to differentiate graft rejection from venous thrombosis using real-time US. In both circumstances a heterogeneous pancreatic echostructure with a small amount of peripancreatic fluid and an increase in pancreas size were observed. Pulsed Doppler, however, showed absence of venous flow in both cases of venous thrombosis whereas all rejection episodes were characterized by an increase in arterial impedance. We conclude that duplex-Doppler US is a promising noninvasive method of detecting surgical complications and graft rejection in pancreatic transplant recipients.     

Single-center experience with pancreas transplantation

Background

Recently improved patient and graft survivals, as well as decreased of postoperative morbidity have ushered in pancreas transplantation (PT) due to technical refinements as well as better immunosuppression and postoperative management. Herein we analyzed the outcomes of PT over a 19-year experiences at a single center.

Methods

All recipients who underwent deceased donor or living donor PT from July 1992 to July 2011 were enrolled in this study. We reviewed their medical records, including operative records, as well as clinical and laboratory findings. We analyzed graft and patient survival rates using the Kaplan-Meier method.

Results

One hundred fifty-three cases were performed between July 1992 and July 2011. The indication for PT was type I diabetes in 125 (81.7%), and type II diabetes in 28 (18.3%) patients. The pancreas donor was deceased in 139 (90.8%) and living in 14 cases (9.2%). The type of PT was simultaneous pancreas-kidney transplantation (n = 91, 59.5%), pancreas alone (n = 49; 32.0%), or pancreas after kidney (n = 13, 8.5%). Median follow-up was 43.0 months (range 0-228). At 1, 5, and 10 years overall patient survivals were 93.8%, 88.1%, and 85.1%, and graft survivals, 82.3%, 70.6%, and 64.6%, respectively. When we divided the deceased donor PT recipients into two groups according to when they underwent PT (up to 2005 [n = 54]) vs 2006 and later [n = 85]), the recent group showed significantly improved patient and graft survival rates (P < .001). With no difference between type I (n = 65) and type II (n = 20) patients (P = .159).

Conclusion

Considering the improved quality of life and long-term patient survival, PT can be an effective treatment strategy in diabetic patients requiring insulin regardless of type of disorder.     

肾移植术后抗体监测和移植肾病理学检查有助于早期诊断抗体介导的排斥反应

目的 分析肾移植术后抗人类白细胞抗原(HLA)抗体监测和移植肾穿刺病理学检查早期诊断抗体介导的排斥反应(AMR)的必要性。 方法 筛选51例术后产生新生供体特异性抗体(dnDSA)的受者,检测供体特异性抗体(DSA)及其结合C1q的能力,同时进行移植肾穿刺病理诊断。对于符合AMR诊断的受者,比较分析移植肾功能不稳定组和稳定组受者的DSA类别、补体结合能力和移植肾病理组织Banff评分。对无排斥反应组、移植肾功能不稳定组和稳定组受者的移植物进行Kalan-Meier生存分析。 结果 在移植肾功能不稳定组和稳定组受者中,HLA抗体的不同类别、DSA的平均荧光强度(MFI)值、补体相关检测C1q结合力和C4d管周毛细血管沉积情况差异均无统计学意义(均为P＞0.05)。在组织形态学损伤方面,两组在微血管炎、动脉内膜炎、肾小管-间质炎、移植肾小球病、肾小管萎缩-间质纤维化等表现的Banff评分差异均无统计学意义(均为P＞0.05)。移植肾功能不稳定组受者移植物累积存活率显著低于稳定组,稳定组明显低于不符合排斥病理诊断的受者(P=0.002)。 结论 肾移植术后定期监测抗HLA抗体和做移植肾病理穿刺检查非常必要,有助于早期发现和诊断AMR。      

Initial experience using histidine-tryptophan-ketoglutarate solution in clinical pancreas transplantation

BACKGROUND: The colloid-based University of Wisconsin (UW) preservation solution has been used extensively in clinical pancreas transplantation. Experimental studies support the use of the crystalloid-based histidine-tryptophan-ketoglutarate (HTK) preservation solution for this purpose. AIM: We report our initial experience with HTK for pancreas allograft preservation and compare this to a contemporary experience with UW solution in conventional multiorgan deceased donors (<50 yr). MATERIALS AND METHODS: Retrospectively collected information on 33 pancreas transplants between September 2001 and October 2002 were analyzed for early graft function and complications up to 30 d after procurement and storage in either HTK or UW solutions. During multi-organ recovery, either UW solution (4-5 L) or HTK solution (8-10 L) was used for aortic perfusion and subsequent back-table flush and storage. Exocrine drainage of 31 pancreas allografts was enteric, while the bladder was used for drainage in two cases. Patient outcomes were analyzed according to the preservation solution used. Sixteen pancreata were used in combination with a kidney allograft (SPK), seven were used in patients after prior kidney transplantation (PAK), while 10 were used in patients who were not in renal failure (PTA). RESULTS: The UW group consisted of 17 patients (10 SPK, three PAK, four PTA) with a mean donor age of 29.5 +/- 10.7, and a mean cold ischemia time of 15.1 +/- 2.1 h. The mean post-transplant pancreas and kidney function on days 1 and 10 were amylase (315 and 99 IU/L), lipase (1727 and 346 IU/L), glucose (121 and 100 mg/dL) and creatinine (5.01 and 1.77 mg/dL). Patient and graft survival was 100% at 1-month post transplant. In the HTK group there were 16 patients (six SPK, four PAK, six PTA) with a mean donor age 21.9 +/- 5.7 and a mean cold ischemia time 14.0 +/- 1.3 h. The mean post-transplant pancreas and kidney function on days 1 and 10 were amylase (588 and 126 IU/L), lipase (4711 and 441 IU/L), glucose (97 and 109 mg/dL) and creatinine (5.28 and 2.42 mg/dL). Patient survival was 100% while graft survival was 94% at 1-month post-transplant. CONCLUSIONS: Early graft function and complications are comparable with HTK and UW solutions for pancreas allograft preservation.     

Follow-up experience using histidine-tryptophan ketoglutarate solution in clinical pancreas transplantation

In May 2003, at Indiana University, the standard cold preservation solution University of Wisconsin (UW) solution was replaced by histidine-tryptophan ketogluatarate (HTK) solution. Earlier, we presented our initial experience with HTK in pancreas preservation with an analysis of the first 10 pancreas transplants. Here we report updated results with HTK in pancreas transplantation over the past 18 months. Between May 2003 and March 2005, a total of 87 pancreas transplants were performed with 78 of these organs utilizing HTK. Seventy five patients received 78 organ transplants. Surgical procedures performed were: simultaneous kidney pancreas transplantation (n = 50, 64%), pancreas after kidney transplantation (n = 19, 24%), solitary pancreas transplantation (n = 9, 12%). Donor and recipient data were collected with primary outcomes as primary nonfunction and 30-day graft and patient survivals, and compared to the UW cohort from our original report. Donor and recipient demographics were similar. Mean follow-up time is 12 +/- 6 months. The mean cold ischemia time was 9 +/- 3 hours. There were no cases of primary graft nonfunction. Thirty-day and 1-year patient survivals were 99% and 93%. The 30-day and 1-year graft survivals were 96% and 93%. There were five grafts lost, including three within the first month (two venous and one arterial thrombosis). There was one case of chronic rejection and one noncompliance. All other patients were insulin-independent by discharge. Serum fasting blood glucose and serial amylase remained comparable at all intervals posttransplantation. Within this range of cold ischemia time, HTK appears to provide effective pancreas preservation.     

实验性小肠移植早期排斥标志物研究

为寻找小肠移植（ＳＢＴ）早期排斥标志物，本实验采用逆转录聚合酶链式反应技术，对小鼠ＳＢＴ术后１２小时受体Ｔ细胞表面白细胞介素－２受体α链（ＩＬ－２Ｒα）编码基因进行定性检测，并对移植小肠行同期病理学检查。结果发现：同种异体移植小鼠体内ＩＬ－２α ｃＤＮＡ阳性例数均明显高于非手术、同系移植及加环孢素Ａ（ＣｓＡ）治疗的同种异体移植小鼠；移植小肠病理学检查无异常变化。提示：Ｔ细胞表面ＩＬ－２Ｒα基因的活     

Clinical experience in continuous graft monitoring with microdialysis early after liver transplantation

BACKGROUND: Early detection of impaired graft function after transplantation is essential. Microdialysis permits continuous monitoring of metabolic changes by mimicking the passive function of a capillary blood vessel by perfusion of a tubular semipermeable membrane introduced into the tissue. Based on the results of animal experiments, a clinical pilot study was undertaken. METHODS: Ten consecutive patients undergoing whole-organ orthotopic liver transplantation were studied. Intrahepatic implantation of a microdialysis catheter was performed at the end of the operation. A reference catheter was placed in the subcutaneous tissue over the right pectoral area immediately after abdominal closure. Consecutive serial samples were collected at 1-h intervals for 3 days after the operation. Glucose, lactate, pyruvate and glycerol concentrations were measured. RESULTS: During the first 24 h, the glucose level was higher in the liver than in reference tissue. Initially, increased mean(s.e.m.) levels of lactate (7.0(1.9) mmol/l) were observed in the liver, with a rapid decrease (to 2.7(0.3) mmol/l) over 24 h. A decrease in, and later stabilization of, the lactate : pyruvate ratio in the liver, from 18.7(4.2) to 10.0(1.1), was observed within 24 h after transplantation. Liver glycerol levels decreased from 62.3(7.4) to 24.3(7.5) micro mol/l within the first 16 h after reperfusion and remained stable thereafter. CONCLUSION: Microdialysis allows continuous monitoring of tissue metabolism in the transplanted liver. The procedure is easy to perform and safe. The specific detection and monitoring of pathological changes in the liver graft (e.g. arterial and portal vein thrombosis, or early rejection) with microdialysis should be addressed in further studies.     

HLA监测在肝移植排斥反应诊断和鉴别诊断标准规范化制定中的应用

20世纪以来,由于器官移植技术、移植免疫基础研究以及各种新的免疫抑制剂不断问世,器官移植已成为临床治疗器官功能哀竭的有效治疗手段,成为21世纪医学最令人瞩目的进展.     

Monitoring urinary amylase and pH in pancreas transplantation with urinary drainage in rats

Whole pancreas isografts or allografts (ACI donors, RT1a) with bladder drainage of exocrine secretions were performed in Lewis rats (RR1(1] with streptozotocin-induced diabetes. Urinary amylase, pH, and volume and serum glucose were measured daily. They were analyzed alone, or in combination, to determine patterns in deviations from normal values, from isograft control values, or from a posttransplant baseline in relation to rejection (defined as reversion of plasma glucose of greater than 200 mg/dl) in nonimmunosuppressed recipients. Also studied were the sensitivity and specificity by which such deviations predicted rejection. Functioning grafts were associated with increased urinary amylase and pH compared with normal or diabetic controls; urinary volume was less than that of diabetic rats, but greater than that of normal rats. In nonimmunosuppressed allograft recipients (n = 9), rejection occurred at a mean (+/- SD) of 7.78 +/- 0.44 days. Serum glucose rose to above normal (greater than 134 mg/dl) 1 day before rejection in 3 animals (sensitivity 33%, false negative rate 66%; false positive rate in 9 isograft recipients, 44%). Urinary volume dropped below 3 ml at a mean of 3.17 +/- 0.98 days (range 2-5 days) before rejection in 6 animals (sensitivity 66%, false negative rate 33%; false positive rate 0%). Urinary pH fell below 7.25 at a mean of 3.13 +/- 1.81 days (range 1-5 days) before rejection in 8 rats (sensitivity of 89%, false negative rate 11%; false positive rate 29%). Urinary amylase dropped from a posttransplant peak at a mean of 3.56 +/- 1.42 days (range 1-6 days) before rejection in 9 animals (sensitivity 100%, false negative rate 0%; false positive rate 43%), and dropped below 1500 units per 24 hr at a mean of 2.00 +/- 1.32 days (range 1-5 days) before rejection in 8 animals (sensitivity 89%, false negative rate 11%; false positive rate 0%). A drop in urinary amylase combined with a drop in urinary volume or pH occurred at a mean of 3.22 +/- 1.48 days (range 1-5 days) before rejection in 9 rats (sensitivity 100%, false negative rate 0%; false positive rate 0%). In a separate group of 10 allograft recipients, immunosuppression with prednisone and cyclosporine was begun concomitant with, or within 2 days of, the drop in urinary amylase from the peak value; rejection did not occur in 3 animals and was delayed to a mean of 12.0 +/- 5.0 days posttransplant in 7 animals (P less than .05 compared with the nonimmunosuppressed group).(ABSTRACT TRUNCATED AT 400 WORDS)     

Careful clinical monitoring in comparison to sequential Doppler sonography for the detection of acute rejection in the early phase after renal transplantation

Abstract Acute rejection is the most frequent cause of early graft failure. There is unanimity that Doppler sonography is a helpful method for the detection of complications after kidney transplantation. In the past, the indication for renal biopsy relied mainly on clinical assessment, although this assessment has not been standardised. Therefore, we conducted this prospective study to compare the value of sequential Doppler measurements with a standardised clinical rejection score, based on renal function, weight gain, graft swelling and tenderness. Fifty‐eight patients (37 males, 21 females, mean age 46 ± 12 years) after kidney transplantation were consecutively enrolled into the study. Doppler investigations were obtained within the first 24 h after transplantation, followed by an interval of 48‐72 h. At the same time, a clinical examination was scored by a transplant physician blinded to the Doppler results. Clinical score and Doppler results, both were referred to the histological results of renal biopsy. In 24 out of 58 patients 25 acute rejections occurred. In seven patients, acute rejection was superimposed on primary graft failure. The cut‐off levels for rejection were set at RI ≥ 0.80 and PI ≥ 1.70 based on receiver‐operator curves using data from 663 Doppler examinations. Sensitivity and specificity was 72 % for RI, and 72 % and 74 % for PI, respectively. The calculation of the intraindividual increase (ΔRI ≥ 3 %, ΔPI ≥ 10 %) did not improve these values. The clinical score revealed a sensitivity and specificity of 82% and 87 %, respectively. The combined analysis of Doppler indices and clinical score showed a sensitivity of 96 % with a specificity of 66%. Careful clinical monitoring alone using a clinical score is an appropriate procedure with which to decide about renal biopsy. Our data show that Doppler sonography should be performed within the first 24 h after transplantation to evaluate graft perfusion and baseline values. Afterwards, it should be used when clinical signs of rejection occur to underline the decision for renal biopsy even in borderline cases.