Partial venous thrombosis of the pancreatic allografts after simultaneous pancreas-kidney transplantation

Despite new advances in transplantation, complete venous thrombosis (VT) of the pancreas after simultaneous pancreas kidney (SPK) transplantation usually results in graft loss. Data are limited regarding the outcome and treatment of partial VT of the pancreas allograft. From July 1994 to December 1999, 126 patients with IDDM/end-stage renal disease underwent SPK with systemic bladder drainage at the University of Miami. We retrospectively reviewed our experience regarding the outcome and treatment options of partial VT of the pancreas allografts. From July 1994 to April 1997, partial VT was not seen in the first 66 SPK patients induced with anti-CD3 rnAb and oral or intravenous (i.v.) tacrolimus (TAC) in the operating room. From May 1997 to June 1999, 14 (29%) out of 48 patients had VT. These cases were identified following the i.v. use of TAC with anti-IL-2R antibody-induction therapy (7/15) or without (7/33). Partial thrombosis of the splenic vein (PTSV) was documented in 10 patients, 2 had complete thrombosis of the splenic vein (CTSV), 1 had partial thrombosis of the superior mesenteric vein (PTSMV), and 1 patient had PTSV and PTSMV. These were identified incidentally during routine color Doppler ultrasonography (CDU). None of these SPK recipients demonstrates a change in clinical parameters. The first 8 patients were systemically heparinized, followed by oral anticoagulation, except 1 patient with CTSV. He progressed to complete thrombosis of the pancreas allograft and was treated with percutaneous thrombectomy and urokinase infusion, followed by heparinization and oral anticoagulation. One patient required exploration for bleeding. In an attempt to reduce the morbidity of heparinization, we treated the next 6 patients with PTSV with aspirin followed by serial CDU. All 14 patients had preservation of the endocrine and exocrine pancreatic functions. CDU showed resolution with recanalization of the thrombosed vein(s). From July 1999 to December 1999, 12 SPK recipients were administered TAC orally with or without induction therapy with anti-IL-2R antibody. So far, in this group, VT has not been identified. In summary, a total of 14 out of 126 patients (11%) had isolated VT with a mean follow-up of 36.4 months. Based on our experience, we suggest that extensive VT after pancreas transplantation, including splenic and superior mesenteric VT, be treated with heparin and subsequent oral anticoagulation for 3 months. For more limited, partial splenic VT, aspirin may be sufficient. Follow-up CDU is critical for a successful outcome. The i.v. use of TAC appears to be a risk factor for the increased incidence of VT. Currently, using IL-2rmAb as induction, TAC is started orally on postoperative days 3 or 4 and aspirin on postoperative day 2.     

Outcomes of simultaneous kidney-pancreas transplantation in African-American recipients: a case-control study

INTRODUCTION: Previous studies have suggested that African-American (AA) ethnicity is a risk factor for rejection and graft loss after kidney transplantation. However, little data is available regarding outcomes after simultaneous kidney pancreas transplantation (SKPT) in AA recipients. The objective of this study was to compare the outcomes of SKPT in AA patients to matched Caucasian patients as controls. METHODS: From January 1996 to September 1999, we performed 79 SKPTs, including 10 in AA recipients. Ten Caucasian controls were selected and matched for age, gender, weight, timing and technique of transplantation, and immunosuppressive regimen. Clinical outcomes were collected and compared between the two groups. RESULTS: The two groups were well matched for donor and recipient demographic, immunologic and transplant characteristics, including 2 patients in each group with type 2 diabetes. All patients received tacrolimus (TAC), mycophenolate mofetil (MMF) and steroids, and about half in each group received antibody induction therapy. Patient survival was 100% in both groups with a mean follow-up of 18 months (range 6 47). Kidney and pancreas graft survival rates were both 80% in the AA and 100% in the Caucasian groups, respectively (p = 0.14). All but one kidney (in the AA group) and all pancreas grafts experienced immediate function. There were two immunologic kidney and two immunologic pancreas graft losses in the AA group. No grafts were lost due to technical problems. The mean length of initial hospital stay was 16 d in the AA group compared to 10 d in the Caucasian group (p = 0.07). The AA group had a slight increase in the number of readmissions (mean 2.2 AA vs. 1.6 Caucasian, p = 0.08). The incidence of biopsy-proven pancreas acute rejection was significantly higher in the AA group (50%) compared to the Caucasian group (10%) (p = 0.05). The incidence of either kidney or pancreas acute rejection was also higher in the AA group (60% AA vs. 20% Caucasian, p = 0.06). TAC levels were comparable at specific times after transplantation, al-though there was a trend toward higher doses of TAC in the AA group to achieve therapeutic levels. The incidences of relaparotomy (30% AA vs. 20% Caucasian) and major infection (40% AA vs. 60% Caucasian) were similar between groups. Renal and pancreas allograft functions were comparable between groups at specific times after transplantation. CONCLUSIONS: These results suggest that SKPT in AA recipients may be associated with a higher incidence of rejection and immunologic graft loss compared to matched Caucasian controls.     

Evaluation of neurodevelopmental outcome in highrisk infants in Australia

An understanding of the neurodevelopmental outcome of long-term survivors of neonatal intensive care is essential for the informed management of preterm or high risk infants. This annotation looks at the current status of neonatal follow-up services in Australasia and highlights problems in the collection and interpretation of data. It suggests that we should work towards achieving a consensus on standard definitions and test regimes and on national data collection.     

A national study of risk factors associated with mortality in very low birthweight infants in the Malaysian neonatal intensive care units

To determine the risk factors associated with mortality in very low birthweight (VLBW) infants admitted to the neonatal intensive care units (NIUC) in Malaysia.

Method:

A prospective observational study of outcome of all VLBW infants born between 1 January 1993 and 30 June 1993 and admitted to the NICU.

Results:

Data of 868 VLBW neonates from 18 centres in Malaysia were collected. Their mean birthweight was 1223 g (95% confidence intervals: 1208–1238 g). Thirty-seven point four per cent (325/868) of these infants died before discharge. After exclusion of all infants with congenital anomalies ( n =66, and nine of them also had incomplete records) and incomplete records ( n =82), stepwise logistic regression analysis of the remaining 720 infants showed that the risk factors that were significantly associated with increased mortality before discharge were: delivery in district hospitals, Chinese race, lower birthweight, lower gestation age, persistent pulmonary hypertension of the newborn, pulmonary airleak, necrotizing enterocolitis of stage 2 or 3, confirmed sepsis, hypotension, hypothermia, acute renal failure, intermittent positive pressure ventilation, and umbilical arterial catheterization. Factors that were significantly associated with lower risk of mortality were: use of antenatal steroid, oxygen therapy, surfactant therapy and blood transfusion.

Conclusion:

The mortality of VLBW infants admitted to the Malaysian NICU was high and was also associated with a number of preventable risk factors.     

CYTOMEGALY OF PANCREATIC D CELLS IN TRIPLOIDY

Triploidy is a common chromosomal aberration seen in 1 of clinically recognized human pregnancies. Development beyond 10 weeks is unusual. Occasionally fetuses survive past 20 weeks; however, they usually present as a stillbirth with only a few managing some hours of independent life. The clinical features of these infants cover a wide spectrum, but a consistent feature is organ hypoplasia and hypotonia. We observed marked enlargement of somatostatin-producing cells (D cells) in the pancreata of triploid fetuses. Somatostatin-producing cells are widely distributed in normal mammals although concentrated in the pancreas and gastrointestinal tract, generally being antiproliferative and having an inhibitory effect on various functions. The control of fetal growth is not well understood. There is, however, some evidence that somatostatin does play a significant part and our consistent observation of cytomegaly of the pancreatic D cells in growth-retarded triploid fetuses provides more support for this contention.     

Hypoglycémie hyperinsulinémique persistante du nouveau-né et du nourrisson

Persistent hyperinsulinemic hypoglycaemia of infancy (PHHI) is the most frequent cause of hypoglycaemia in infancy. Clinical presentation is heterogeneous, with variable onset of hypoglycaemia and response to diazoxide, and presence of sporadic or familial forms. Underlying histopathological lesions can be focal or diffuse. Focal lesions are characterised by focal hyperplasia of pancreatic islet-like cells, whereas diffuse lesions implicate the whole pancreas. The distinction between the two forms is important because surgical treatment and genetic counselling are radically different. Focal lesions correspond to somatic defects which are totally cured by limited pancreatic resection, whereas diffuse lesions require a subtotal pancreatectomy exposing to high risk of diabetes mellitus. Diffuse lesions are due to functional abnormalities involving several genes and different transmission forms. Recessively inherited PHHI have been attributed to homozygote mutations for the beta-cell sulfonylurea receptor (SUR1) or the inward-rectifying potassium-channel (Kir6.2) genes. Dominantly inherited PHHI can implicate the glucokinase gene, particularly when PHHI is associated with diabetes, the glutamate dehydrogenase gene when hyperammonaemia is associated, or another locus.     

Neonatal Hemochromatosis, Renal Tubular Dysgenesis, and Hypocalvaria in a Neonate

We report a neonate with neonatal hemochromatosis (NH), renal tubular dysgenesis (RTD), and hypocalvaria. NH is a fatal condition of the newborn, characterized by severe idiopathic liver failure of intrauterine onset and siderosis, intra- and extrahepatic, with sparing of the reticuloendothelial system. RTD is characterized by short, abnormally developed cortical tubules that lack proximal tubule differentiation. Although both NH and RTD have been reported as entities with a genetic component, similar findings can be secondary to in utero insults. Hypocalvaria has been reported in association with fetal hypoxia including that secondary to angiotensin converting enzyme inhibitors. This 38-week-old infant died at 8.5 h. The small nodular liver weighed 44 g. Grossly, the kidneys were normal. Hypocalvaria was present. Microscopically, the hepatic parenchyma was distorted by fibrous tracts, proliferation of bile ducts, and abundant iron deposition in hepatocytes. Extrahepatic siderosis in the pancreas, myocardium, and other organs was consistent with NH. Proximal convoluted tubules were not seen on routine stains and markers for proximal tubules were negative. Previous reports have linked NH with RTD and RTD with hypocalvaria. This infant had all three of these rare conditions, which have been hypothesized or shown to be due to genetic factors, hypoxia, or drugs. The etiology in this case is unknown. Received May 20, 1997; accepted August 15, 1997.     

男性胰腺实性-假乳头状瘤2例临床病理观察

目的探讨胰腺实性-假乳头状瘤(SPT)的临床病理特征及了解分子病理学研究进展。方法2例SPT分别作HE、PAS、免疫组织化学(S—P法)染色观察。结果2例SPT男性患者均有腹部包块及腹痛症状。术后均无复发。肿块体积较大，囊实性相间。镜下瘤细胞围绕纤维血管形成特征性的假乳头结构，并可见退行性变、出血和泡沫细胞。免疫组化结果：2例AACT、ACT、Cga和Syn均为阳性，PR、ER、Ck和Ins均为阴性，1例Vim为阳性。结论胰腺SPT为具有独特临床病理特征的低度恶性肿瘤。     

瞬态诱发耳声发射用于黄疸新生儿的听力筛查

目的 探讨瞬态诱发耳声发射（TEOAE）应用于新生儿黄疸听力筛查的临床意义。方法 采用前瞻性队列研究方法对277例黄疸新生儿及50例健康新生儿进行TEOAE检测，出院前和出生后3个月复查。结果 初查时黄疸新生儿TEOAE通过率为64．23％，健康新生儿TEOAE通过率为96％，两组检出率比较，差异有非常显著意义（P〈0．01）。第1次复查黄疸新生儿TEOAE通过率为88％，第2次复查通过率为100％。结论 TEOAE是快速可行的高危新生儿听力筛查方法，新生儿测试耳TEOAE的通过率与黄疸严重程度有关，黄疸对耳蜗的影响是可逆的。     

人胎胰岛细胞单层培养方法的进一步探讨

目的：改良消化培养人胎胰岛细胞培养方法。方法：用V型胶原酶2g／L和Dispace110．3g／L在32℃水浴消化分离胰腺组织，通过转皿和碘乙酸结合的方法消除成纤维细胞，将先消化好的胰岛细胞及时转皿保护，适度调整培养液pH和控制CO2气体量。结果：成功地培养了人胎胰岛细胞。结论：掌握好以上环节可大幅度提高胰岛细胞获得率。