Search

The decision for simultaneous pancreas-kidney (SPK) versus kidney transplant alone (KTA) in diabetic patients with renal failure depends on the potential risks and benefits for each procedure. The purpose of this study was to compare the morbidity, mortality, and renal allograft survival in diabetic patients who underwent SPK versus KTA, and to discern the added risks associated with pancreas transplantation. Between 7/1/86 and 9/30/90, 69 primary cadaver SPK and 59 primary cadaver KTA were performed in type I diabetic patients with chronic renal failure. Antilymphocyte globulin or OKT3 was used for induction therapy, followed by standard triple therapy (prednisone, azathioprine, and cyclosporine). Patient and graft survivals were retrospectively analyzed. In addition, a detailed comparison of morbidity in those patients treated after 7/1/87 was performed (53 SPK, 49 KTA). For those less than 45 years of age (65 SPK, 42 KTA), there were no significant differences (P greater than 0.6) in the actuarial patient survival at one year (SPK 92%, KTA 95%), or two years (SPK 89%, KTA 92%), or actuarial renal allograft survival at one year (SPK 82%, KTA 83%) or two years (SPK 77%, KTA 83%). However, for those greater than 45 years old, actuarial renal allograft survival was significantly higher (P less than 0.03) in the KTA group. The mean serum creatinine levels were similar at one year (SPK 1.8, KTA 1.9 mg/d).(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of multiple donor and recipient variables on functional survival of 307 cadaveric pancreas allografts transplanted in 253 recipients at the authors' institution between July 25, 1978 and September 4, 1990 was determined using the Cox proportional hazards regression model. Relative risk of graft loss was calculated for all cases as well as for technically successful (TS) ones. Factors with an impact in descending order of significance for TS cases were immunosuppression (RR = 3.9 for double-drug versus triple-drug maintenance, p less than 0.0001); recipient category (RR = 2.4 for pancreas alone versus simultaneous pancreas/kidney, p = 0.009); retransplantation (RR = 1.8 for retransplants versus primary grafts, p = 0.007); donor hyperglycemia (RR = 1.7 for blood glucose greater than or equal to 200 versus less than 200 mg/dL, p = 0.02); human leukocyte antigen (HLA) matching (RR = 2.1 for poor versus a good match, p = 0.04). A logistic regression analysis also was performed to determine which factors predisposed to technical failure; none were identified. To make the model as relevant as possible to their current program, the authors analyzed only the bladder-drained cases (n = 221; 1984 to 1990). All patients received triple therapy. Recipient category, retransplantation, donor hyperglycemia, and degree of HLA matching remained as significant risk factors. Construction of estimated survival curves showed that the results of retransplantation were significantly improved, and the penalty incurred by using hyperglycemic donors was partially ameliorated by using well-matched donors. Because preservation times up to 30 hours did not exert an adverse effect on outcome, an argument is made to share pancreata between centers to achieve good matches.

An outcome analysis was performed on pancreas transplants in the United States reported to the United Network for Organ Sharing (UNOS) Registry from its inception on 1 October 1987 to 21 October 1990 (n=1021). These cases comprise nearly one-third of the 3082 pancreas transplants reported to the International Pancreas Transplant Registry (1819 U.S., 1263 non-U.S.) from 1 December 1966 to 31 December 1990, including 619 in 1990 (528 U.S., 91 non-U.S.). Nearly all pancreas transplants in the U.S. during the 1987-90 period were by the bladder-drainage (BD) technique (92%). The overall patient and pancreas graft actuarial survival rates were 92% and 72% at 1 year. Patient survival rates were similar in all recipient categories, but pancreas graft survival rates were significantly higher (p less than 0.001) in recipients of a simultaneous pancreas and kidney (SPK) transplant (n=883) than in recipients of a pancreas after a kidney (PAK, n=112) or a pancreas transplant alone (PTA, n=71), being 77%, 52%, and 54%, respectively, at 1 yr. Kidney graft survival at 1 yr in U.S. SPK recipients was 86%. Most grafts (81%) were preserved in University of Wisconsin (UW) solution, and more than half were stored greater than 12 hours, with no difference in outcome with increasing duration of storage. At 1 yr, functional survival rates were 72% for U.S. pancreas grafts stored for either less than 12 (n=439), 12-24 (n=422), or 24-30 h (n=42). For grafts stored greater than 30 h (n=8), the 1-yr functional survival rate was 50% (p=ns versus the other storage times). On univariate analysis, no effect of HLA antigen mismatching on outcome for 1987-90 U.S. cases could be discerned. The results in the UNOS Registry were compared to the results for U.S. cases in the International Pancreas Transplant Registry performed between 1 January 1984 and 30 September 1987. In all recipient categories the pancreas graft functional survival rates were significantly higher in the 1987-90 (UNOS) than in the 1984-87 (pre-UNOS) era. A Cox multivariate analysis of 1984-90 cases showed the relative risk for pancreas graft loss to be significantly less (p less than 0.05) with bladder-drainage, with simultaneous transplantation of the kidney, with use of UW solution for preservation, and with 0-1 HLA-A, B, DR or 0 HLA-DR mismatches.(ABSTRACT TRUNCATED AT 400 WORDS)

We compared outcome after pancreas and liver transplantation when both organs were retrieved from the same donor to outcome when only one or the other organ was retrieved. A total of 166 cadaver pancreata were transplanted at our institution between November 1984 and August 1989; 64 were obtained from donors in whom the liver was also donated (LD), and 102 were retrieved from non-liver donors (non-LD). Of the 64 LD pancreata, 53 were the entire organ with a segment of duodenum and 11 were segmental. Both the superior mesenteric artery (SMA) and celiac axis (CA) were retained with the pancreas in 13, while in 40 pancreata the CA was retrieved with the liver and the blood supply to the pancreas was reconstructed [end-to-side anastomosis of splenic artery (SA) to SMA in 11 and a Y-graft of donor iliac bifurcation to SA and SMA in 29]; a graft of common iliac vein was used to extend the portal vein in 10. The technical failure rate was 8/64 (12%) in LD pancreata, and 13/102 (13%) in non-LD pancreata (P greater than 0.1). The overall pancreas allograft survival rate at 1 year was 76% for pancreata obtained from LD (n = 64) and 64% for technically successful transplanted pancreata obtained from non-LD (n = 102, P greater than 0.1). One-year actuarial patient survival was 95% in the LD group and 90% in the non-LD group (P greater than 0.1). Among the 64 livers from pancreas donors (PD), 20 were transplanted at our hospital, 42 were transported to other institutions, and 2 were not transplanted. Follow-up information regarding 47 primary orthotopic adult, whole liver PD recipients (18 at our hospital, 29 at other institutions) was available for analysis and was compared with information concerning 62 adult recipients of primary orthotopic whole livers from non-PD transplanted during the same period at our institution. The total PNF rate among 47 PD liver allografts was 2/47 (4%), compared with 1/62 (1%) for the livers from non-PD (P greater than 0.1). The technical failure rate for the PD group was 1/47 (2%) versus 5/62 (8%) in the non-PD group (P greater than 0.1). The overall liver allograft survival rate at 1 year was 75% for livers obtained from PD (n = 47) and 81% for livers obtained from non-PD (n = 62, P greater than 0.1). One-year actuarial patient survival was 88% in the PD group and 81% in the non-PD group (P greater than 0.1). We concluded that simultaneous procurement of liver and pancreas grafts had no significant detrimental effect on the rate of technical failure, or on allograft or patient survival after either pancreas or liver transplantation.

This report contains information on analysis of 2,292 pancreas transplants worldwide reported to the International Pancreas Transplant Registry from 1966 through 1989, with 1-year recipient survival rates improving from 39% to 71% to 80% to 87% and 1-year graft survival rates from 5% to 26% to 40% to 56% for 1966 to 1977 (n = 64), 1977 to 1983 (n = 336), 1984 to 1985 (n = 364), and 1986 to 1989 (n = 1,220) cases, respectively. The last 2 eras were combined for analyses of multiple variables. In the analyses of all world cases for the 1984 to 1989 period (n = 1,604), the most important finding was the influence of HLA-DR matching or mismatching on pancreas graft survival rates; 1-year function rates for grafts in recipients matched for 2, 1, or 0 DR antigens with the donor were 73% (n = 52), 53%, (n = 468), and 48% (n = 67) (p less than 0.005 for all comparisons). Likewise, in an analysis of 1984 to 1989 cases according to DR mismatching, the 1-year graft survival rates with 0, 1, or 2 DR mismatches were 63% (n = 128), 50% (n = 583), and 49% (496) (p less than 0.02). An analysis of the 1986 to 1989 era cases worldwide confirms the trend in the period analysis for bladder drainage (BD) to be associated with significantly higher graft survival rates than intestinal drainage or duct injection, at 1-year being 59% (n = 656), 47% (n = 97), and 54% (n = 210). Likewise, for the 1986 to 1989 era, worldwide 1-year pancreas graft functional survival rates were significantly higher in recipients of simultaneous-pancreas/kidney transplants (SPK) than in recipients of pancreas-after-kidney (PAK) or a pancreas-transplant-alone (PTA); 63% (n = 865), 45% (n = 186), and 37% (n = 165). In a new analysis of the United States cases reported to the UNOS Registry from October 1, 1987 through June 30, 1989, 1-year patient and graft survival rates were 91% and 69%. Almost all United States cases reported to the UNOS Registry during 1987 to 1989 were with BD (n = 324).(ABSTRACT TRUNCATED AT 400 WORDS)

From December 1966 to December 1988, 1,830 pancreas transplants were reported to the International Pancreas Transplant Registry. Of these, 1,549 were reported as of June 30, 1988 and analyzed on July 13, 1988. One-year actuarial graft function (insulin-independent) and recipient survival rates for all cases were 42% and 80%, respectively. In an analysis by era of 1966 to 1977 (n = 64), 1978 to 1983 (n = 336), 1984 to 1985 (n = 387), and 1986 to 1988 (n = 762) cases, 1-year graft function rates were 5%, 25%, 41%, and 55% and recipient survival rates were 44%, 72%, 81%, and 88%, respectively (p less than or equal to 0.01 all comparisons). In an analysis of 1984 to 1988 cases only (n = 1,149), the overall 1-year graft function and patient survival rates were 49% and 85%, respectively. During this period, graft functional survival rates for the most common duct management methods were 53% for duct injection (n = 313), 45% for intestinal drainage (n = 257), and 51% for bladder drainage (n = 535) at 1 year (p less than 0.04 for intestinal vs bladder drainage). Graft function rates were similar for whole (n = 552) and segmental (n = 595) pancreas transplants (48% vs 50% at 1 year). Functional survival rates according to duration of preservation for grafts stored less than 6 hours (n = 706), 6-12 hours (n = 243), 12-24 hours (n = 95), and 12-24 hours (n = 9) were 50%, 47%, 43%, and 78% at 1 year, and none of the differences were significant. Graft functional survival rates for 1984 to 1988 cases were significantly higher (p less than 0.05) in recipients who received AZA and CsA in combination (n = 895) than in those who received CsA without AZA (n = 218) or AZA without CsA, (n = 27), with 1-year graft functional survival rates of 52%, 41%, and 33%, respectively. For technically successful grafts, the function survival rates were also significantly higher (p less than 0.05) in recipients treated with CsA + AZA (n = 708) than in those who received CsA without AZA (n = 156) or AZA without CsA (n = 19), with 1-year function rates of 66%, 56%, and 47%, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Since our report at the 1984 American Surgical Association meeting of 100 pancreas transplants from 1966 through 1983, another 190 have been performed. The current series, begun in 1978, now numbers 276 cases, and includes 133 nonuremic recipients of pancreas transplants alone (PTA), 46 simultaneous pancreas/kidney transplants (SPK), and 97 pancreas tranplants after a kidney transplant (PAK). Duct management techniques used were free intraperitoneal drainage in 44 cases, duct occlusion in 44, enteric drainage in 89, and bladder drainage in 128. The 1-year patient and graft survival rates in the entire cohort of 276 were 91% and 42%. One-year patient survival rates were 88% in the first 100, 91% in the second 100, and 92% in the last 76 cases; corresponding 1-year graft survival rates were 28%, 47%, and 56% (p less than 0.05). A prospective comparison of bladder drainage (n = 82) versus enteric drainage (n = 46) in PAK/PTA cases since November 1, 1984 favored bladder drainage (1-year graft survival rates of 52% vs. 41%) because of urinary amylase monitoring. The best results were in recipients of primary SPK bladder-drained transplants (n = 39), with a 1-year pancreas graft survival rate of 75%, kidney graft survival rate of 80%, and patient survival rate of 95%. Logistic regression analysis, with 1-year graft function as the independent variable, showed significant (p less than 0.05) predictors of success (odds ratio) to be technique: bladder drainage (5.8) versus enteric drainage (2.5) versus duct injection (1.0); category: SPK (6.0) versus PAK from same donor (3.2) versus PAK from different donor (1.2) versus PTA (1.0); and donor HLA DR mismatch: 0 (5.0) versus 1 (2.5) versus 2 (1.0) antigens. On April 1, 1989, 90 patients had functioning grafts (60 euglycemic and insulin-free for more than 1 year, 10 for 5 to 10 years); these, along with 24 others whose grafts functioned for 1 to 6 years before failing, are part of an expanding cohort in whom the influence of inducing a euglycemic state on pre-existing secondary complications of diabetes is being studied. Only preliminary data is available. In regard to neuropathy, at more than 1 year after transplant in patients with functioning grafts, conduction velocities in some nerves were increased over baseline. In regard to retinopathy, deterioration in grade occurred in approximately 30% of the recipients by 3 years, whether the graft functioned continuously or failed early, but thereafter retinopathy in the patients with functioning grafts remained stable.(ABSTRACT TRUNCATED AT 400 WORDS)