Long-Term Outcomes of Pancreas After Kidney Transplantation in Small Centers: Is It Justified?

Background

Currently, the long-term advantages of having a pancreas transplantation (PT) are debated, particularly in patients receiving pancreas after kidney (PAK) allografts. The United Network for Organ Sharing (UNOS) requires that a transplant center perform a minimum number of PT per year to remain an active PT center. The long-term outcomes and challenges of PAK in small pancreas transplant centers are not well studied.

Methods

In this retrospective analysis, we report short- and long-term outcomes in a small center performing 2–9 PT annually.

Results

Forty-eight PT (25 simultaneous pancreas and kidney transplantation [SPK], 23 PAK) were performed in our center. Donor and recipient demographics were similar in both groups. All suitable local donors were used for SPK. All organs for PAK transplantation were imported from other UNOS regions. Mean follow-up was 61 ± 46 and 74 ± 46 months for SPK and PAK, respectively. Patient and graft survival rates were similar in SPK and PAK groups and better than the reported national average. Four patients (11%) died (1 due to trauma, 1 brain lymphoma, 1 ruptured aneurysm; and 1 unknown cause). Two patients (4%; 1 SPK, 1 PAK) lost their grafts because of thrombosis on postoperative days 3 and 5 in 2002. No graft thrombosis occurred since 2002. Seven patients (15%) required reoperation (4 for bleeding, 2 anastomotic leaks, 1 small bowel perforation). Two patients (4%) developed post-transplantation lymphoproliferative disease. Five patients (11%) experienced cytomegalovirus antigenemia which responded well to antiviral therapy.

Conclusions

Compared with outcomes for diabetic patients on dialysis, current SPK and PAK short- and long-term results are favorable even in a small PT center. Therefore, unless there is a contraindication, PT should be offered to all type 1 diabetic patients with end-stage renal disease at the time of kidney transplantation or afterward.     

Control of the vertebral artery from a posterior approach: a technical report

Background contextVertebral artery (VA) injury is a rare but potentially devastating complication of cervical spinal fusion. The Magerl and Harms techniques are associated with a rate between 0% to 8% and 0% to 5%, respectively. Most of reported VA injuries are related to surgical exposure or screw placement, which in turn is likely due to variability in VA anatomy.PurposeThe purpose of this report was to present the case of a 77-year-old woman, with a history of right VA occlusion, who sustained an intraoperative left VA injury during posterior cervical spine fusion and the subsequent intraoperative and postoperative management strategies.Study designThis is a single-patient case report.MethodsThe patient was placed prone and into Mayfield tongs. A midline incision was made, and dissection was carried down to the lamina and facet joints from occiput to T2. During dissection, she sustained a left-sided VA injury, which was subsequently controlled.ResultsThe patient was doing well at her 1-year postoperative visit without any residual neurologic deficits. Her severe neck pain had resolved.ConclusionA detailed understanding of VA anatomy of each individual patient is paramount. There are four types of anomalies: intraforaminal; extraforaminal; arterial; and anomalies of the surrounding bony and soft-tissue architecture. In the event of a posterior intraoperative VA injury, we outlined an algorithm to deal with this complication: control bleeding temporarily to gain visualization of the arterial injury; remove lateral masses and tissue to adequately visualize the arterial injury; once visualized, control the bleeding and see if there are any neuromonitoring changes as a result of the VA occlusion; and proceed with definitive control of the artery by either repair or ligation.     

Timing of CMV‐specific effector memory T cells predicts viral replication and survival after allogeneic hematopoietic stem cell transplantation

The aim of this study was to characterize timing, kinetic, and magnitude of CMV‐specific immune response after hematopoietic stem cell transplantation (HSCT) and its ability to predict CMV replication and clinical outcomes. Using cell surface and intracellular cytokine staining by flow cytometry, CMV‐specific T‐cell response was measured in blood, while CMV viral load and chimerism were determined by real‐time PCR. Patients that reconstituted CMV‐specific T‐cell response within 6 weeks after Allo‐SCT showed a more robust immune response (CD8⁺: 0.7 cells/μl vs. 0.3/μl; P‐value = 0.01), less incidence of CMV replication (33% vs. 89.5%; P‐value = 0.007), reduced viral loads (1.81 log copies/ml vs. 0 copies/ml; P‐value = 0.04), and better overall survival (72%; CI: 0.53–0.96 vs. 42% CI: 0.24–0.71; P‐value = 0.07) than patients with a delayed immune reconstitution. Viremic patients had significantly higher transplant‐related mortality than nonviremic patients after 1 year (33% CI: 0.15–0.52 vs. 0% CI: 0.05–0.34; P‐value = 0.01). Risk factors independently associated with viral replication were receptor pretransplant CMV‐positive serostatus (P‐value = 0.02) and acquiring CMV‐specific T‐cell response after 6 weeks post‐transplantation (P‐value = 0.009). In conclusion, timing of acquiring a positive CMV‐specific T‐cell immune response after transplantation may identify patients with different risk for viral replication and different clinical outcomes, including survival.     

The prevalence of anxiety and depression among end-stage renal disease patients on hemodialysis in Saudi Arabia

Depression commonly overlaps with uremic symptoms, but anxiety is less commonly studied among renal patients. The symptoms of medical illness, along with the psychological and social stresses that often accompany a debilitating chronic disease, are thought to produce deleterious psychological consequences. We sought to determine the prevalence and predictors of anxiety and depression among Saudi dialysis patients in Makkah. A cross-sectional study of anxiety and depression among end-stage renal disease (ESRD) patients in Makkah was conducted in November 2011. The Hospital Anxiety and Depression Scale (HADS) was used to screen for anxiety and depression. Participants’ demographic data, possible stressors and past psychiatric history were obtained. All participants were Saudi ESRD patients on maintenance hemodialysis. According to HADS, 57 (21.1%) patients were probable cases of anxiety and 63 (23.3%) were probable cases of depression. Only 32 (11.3%) were diagnosed with depression or anxiety before ESRD onset. Age was a significant predictor of anxiety and depression diagnoses. Major family problems (p?=?0.001) were also a significant predictor of anxiety. Anxiety and depressive symptoms are prevalent among ESRD patients in Makkah, and anxiety can be predicted by family factors. Early detection, management and family support might improve clinical outcomes.     

Outcomes of metastatic breast cancer patients in relationship to disease‐free interval following primary treatment of localized disease; a pooled analysis of two clinical trials

The aim of the current study is to assess the impact of disease‐free interval (DFI) following treatment of primary localized breast cancer on the outcomes of patients with subsequent metastatic breast cancer treated with first‐line docetaxel chemotherapy. This study is a combined analysis of patient‐level raw data of 604 metastatic breast cancer patients referred for docetaxel first‐line chemotherapy in two clinical trials. Overall survival and time to progression were evaluated according to DFI through Kaplan‐Meier analysis. Multivariate analysis of factors affecting overall survival and time to progression was then conducted through Cox regression analysis. For the overall cohort, shorter DFI is associated with worse overall survival (P < 0.0001). When classified by the hormone receptor status, the shorter interval was associated with worse overall survival in both hormone receptor positive and negative patients (P = 0.009; P = 0.018; respectively). Likewise, shorter DFI is associated with shorter time to progression (P < 0.0001) in the overall cohort. When classified by the hormone receptor status, the shorter interval was associated with shorter time to progression for hormone receptor negative but not positive patients (P = 0.001; P = 0.070; respectively). In multivariate Cox regression analysis, the following factors were associated with worse overall survival: shorter DFI (P < 0.0001), poorer ECOG performance score (P = 0.008) and lower body mass index (P = 0.018). Likewise, in multivariate Cox regression analysis, the following factors were associated with shorter time to progression: shorter DFI (P < 0.0001) and hormone receptor negative status (P = 0.025). Shorter DFI was associated with worse overall survival and shorter time to progression among patients receiving first‐line docetaxel chemotherapy.     

The use of diffusion‐weighted MR imaging in the functional assessment of the testes of patients with clinical varicocele

We aimed to evaluate the use of diffusion‐weighted imaging (DWI) in the assessment of the varicocele effect on testicular parenchyma and spermatogenesis, with estimation of apparent diffusion coefficient (ADC) value changes in the testicular parenchyma. We prospectively evaluated 30 consecutive patients (18 patients with bilateral varicocele and 12 patients with unilateral varicocele) and 10 healthy controls. US and DWI were performed to all patients. A total of 80 testes were included, which divided into three groups: group A: testes ipsilateral to the varicocele (n = 48, 60%); group B: testes contralateral to the varicocele (n = 12, 15%); and group C: normal testes of the control (n = 20, 25%). There was a statistically significant difference in mean ADC value between all groups (p‐value < 0.001). In groups A and B, there was a negative correlation between mean ADC values and varicocele grade as well as pampiniformis venous diameter. In group A, there was a significant positive correlation between mean ADC value and sperm count (p‐value = 0.01, r‐value = 0.48) as well as sperm motility (p‐value = 0.04, r‐value = 0.33). DWI sequence can be used to evaluate the sequel of varicocele, with decreased ADC values that are significantly correlated with abnormal semen parameters. Thus, ADC values may be considered as an ancillary indicator of testicular parenchyma changes.     

Screening for vesicoureteral reflux and renal scars in siblings of children with known reflux

The incidence of vesicoureteral reflux (VUR) in the general population is less than 1%, but it is high in families with reflux. The reported prevalence of VUR among siblings of index patients with reflux has ranged from 4.7% to 51%. Reflux carries an increased risk of pyelonephritis and long-term renal impairment. The purpose of this study was to identify the age-related incidence and severity of reflux, and the frequency of associated renal parenchymal damage in siblings of children with reflux in order to assess the use of screening at different ages. Between October 1994 and February 2003, 40 siblings of 34 index patients were screened with direct voiding cystography. 99( m ) technetium (Tc)-dimercaptosuccinic acid (DMSA) nuclear renal scans were performed in siblings with VUR to detect renal scarring. The cystograms were interpreted as showing the presence or absence of VUR and the DMSA scan as symmetrical or asymmetrical differential function, with or without renal scarring. Of 40 siblings, 17 had VUR, representing an incidence of 42.5%. The mean age at study entry of the 15 boys and 25 girls was 63 months (range 6 months to 12 years). The majority of siblings with abnormal DMSA scans were asymptomatic. Reflux was unilateral in 12 siblings and bilateral in 5. Of the 17 refluxing siblings (22 refluxing ureters), 7 (41.17%) had a history of symptomatic urinary tract infection (UTI). The frequency of VUR was nearly equal in siblings over 6 years and those younger than 6 years. Of the 17 siblings with VUR, 16 had DMSA scintigraphy. Of these, 5 were normal and 11 (68.75%) showed abnormalities (7 asymmetrical differential function and 4 parenchymal defect), which was bilateral in 7 and unilateral in 4. In conclusion, this study confirms a significant overall incidence of VUR and renal parenchymal damage in the siblings of patients with known reflux. The prevalence of reflux in older siblings is similar to that in younger siblings. Our review suggests that all siblings over 6 years should undergo a screening cystogram, even in the absence of urinary tract infection. DMSA scintigraphy of asymptomatic siblings appears to be beneficial in preventing renal injury.     

Biliary ascariasis as a cause of post-cholecystectomy syndrome in an endemic area

BACKGROUND: Post-cholecystectomy syndrome encompasses numerous biliary, pancreatic and other entities. Biliary ascariasis is a common cause of adult biliary disease in an endemic area. Post-cholecystectomy biliary ascariasis, a cause of post- cholecystectomy syndrome although not yet defined is frequently seen in this part of the world. METHOD: Between Jan. 1990 and Jan. 2001, 104 cases of post-cholecystectomy biliary ascariasis were seen. Ultrasonography was found to be an excellent tool for diagnosing and monitoring of the worms inside the biliary tract. Endoscopic retrograde cholangiopancreatography had both diagnostic and therapeutic value. RESULTS: The majority (68.2%) of patients responded to conservative treatment. Surgical treatment was advocated in 18.2%, which included 2 patients with liver abscesses. Endoscopic extraction of worms was successful in 48.2%. CONCLUSION: Post-cholecystectomy biliary ascariasis as a cause of post-cholecystectomy syndrome needs to be included in the list of causes for post-cholecystectomy syndrome. Although the majority of patients respond to conservative treatment but endoscopic extraction or surgical intervention may be needed. Routine deworming of patients undergoing cholecystectomy both preoperatively and postoperatively should be done in all patients in endemic areas of ascariasis. Although this entity is rare in Europe and United States, due to population migration and increased travel, it is necessary for surgeons in these countries to be aware of this condition.     

Versatile use of the muscle and nerve sparing latissimus dorsi flap

In this report, we describe the technique of muscle and nerve sparing latissimus dorsi (LD) flap and evaluate the outcomes of reconstruction of various defects with 12 free and 2 pedicled muscle and nerve sparing LD flaps in 14 patients. The LD muscle functions at operated and nonoperated muscles were evaluated clinically and with electroneuromyography. All flaps survived completely but one which had a partial necrosis. The mean follow-up time was 12.3 months. Adduction and extention ranges of the shoulders were the same bilaterally in all patients. In electroneuromyography, no significant difference was available statistically between the sides. This muscle and nerve sparing latissimus dorsi flap has advantages of thinness, muscle preservation and reliability, and thus can be a good option to other fasciocutaneous flaps in reconstruction surgery.