Pancreas transplantation: review / Transplante de pâncreas: revisão

ABSTRACT Vascularized pancreas transplantation is the only treatment that establishes normal glucose levels and normalizes glycosylated hemoglobin levels in type 1 diabetic patients. The first vascularized pancreas transplant was performed by William Kelly and Richard Lillehei, to treat a type 1 diabetes patient, in December 1966. In Brazil, Edison Teixeira performed the first isolated segmental pancreas transplant in 1968. Until the 1980s, pancreas transplants were restricted to a few centers of the United States and Europe. The introduction of tacrolimus and mycophenolate mofetil in 1994, led to a significant outcome improvement and consequently, an increase in pancreas transplants in several countries. According to the International Pancreas Transplant Registry, until December 31st, 2010, more than 35 thousand pancreas transplants had been performed. The one-year survival of patients and pancreatic grafts exceeds 95 and 83%, respectively. The better survival of pancreatic (86%) and renal (93%) grafts in the first year after transplantation is in the simultaneous pancreas-kidney transplant group of patients. Immunological loss in the first year after transplant for simultaneous pancreas-kidney, pancreas after kidney, and pancreas alone are 1.8, 3.7, and 6%, respectively. Pancreas transplant has 10 to 20% surgical complications requiring laparotomy. Besides enhancing quality of life, pancreatic transplant increases survival of uremic diabetic patient as compared to uremic diabetic patients on dialysis or with kidney transplantation alone.

RESUMO O transplante vascularizado de pâncreas é o único tratamento que estabelece normoglicemia e normaliza os níveis séricos de hemoglobina glicosilada em pacientes diabéticos tipo 1. O primeiro transplante de pâncreas vascularizado foi realizado para tratar um paciente diabético tipo 1 em dezembro de 1966, por William Kelly e Richard Lillehei. No Brasil, Edison Teixeira realizou o primeiro transplante de pâncreas segmentar isolado em 1968. Até a década de 1980, os transplantes de pâncreas ficaram restritos a poucos centros dos Estados Unidos e da Europa. A introdução dos imunossupressores tacrolimo e micofenolato mofetila, a partir de 1994, propiciou a melhora significativa dos resultados e a consequente realização de transplantes em escala crescente em vários países. Segundo o Registro Internacional de Transplante de Pâncreas, foram realizados, até 31 de dezembro de 2010, mais de 35 mil transplantes de pâncreas. Sobrevida no primeiro ano dos pacientes e dos enxertos pancreáticos excede, respectivamente, 95 e 83%. A melhor sobrevida dos enxertos pancreático (86%) e renal (93%), no primeiro ano pós-transplante, está na categoria de transplante simultâneo de pâncreas e rim. As perdas imunológicas no primeiro ano pós-transplante para transplante simultâneo de pâncreas e rim, transplante de pâncreas após rim e transplante de pâncreas isolado foram, respectivamente, 1,8, 3,7, e 6%. O transplante de pâncreas apresenta de 10 a 20% de complicações cirúrgicas, necessitando laparotomia. O transplante de pâncreas, além de melhorar a qualidade de vida, proporciona o aumento da sobrevida em diabéticos urêmicos, comparados aos diabéticos em diálise ou transplantados renais.

Financial cost of the admissions for simultaneous pancreas-kidney transplant in a Brazilian Hospital

PURPOSE: To perform a cost analysis of simultaneous pancreas-kidney transplantation (SPKT) in a Brazilian hospital. METHODS: Between January 2008 and December 2011, 105 consecutive SPKTs at the Hospital of Kidney and Hypertension in Sao Paulo were evaluated. We evaluated the patient demographics, payment source (public health system or supplementary system), and the impact of each hospital cost component. The evaluated costs were corrected to December 2011 values and converted to US dollars. RESULTS: Of the 105 SPKT patients, 61.9% were men, and 38.1% were women. Eight patients died, and 97 were discharged (92.4%). Eighty-nine procedures were funded by the public health system. The cost for the patients who were discharged was $18.352.27; the cost for the deceased patients was $18.449.96 (p = 0.79). The FOR for SPKT during this period was positive at $5,620.65. The costs were distributed as follows: supplies, 36%; administrative costs, 20%; physician fees, 15%; intensive care unit, 10%; surgical center, 10%; ward, 9%. CONCLUSION: Mortality did not affect costs, and supplies were the largest cost component. .

Is SAPS 3 better than APACHE II at predicting mortality in critically ill transplant patients?

OBJECTIVES: This study compared the accuracy of the Simplified Acute Physiology Score 3 with that of Acute Physiology and Chronic Health Evaluation II at predicting hospital mortality in patients from a transplant intensive care unit. METHOD: A total of 501 patients were enrolled in the study (152 liver transplants, 271 kidney transplants, 54 lung transplants, 24 kidney-pancreas transplants) between May 2006 and January 2007. The Simplified Acute Physiology Score 3 was calculated using the global equation (customized for South America) and the Acute Physiology and Chronic Health Evaluation II score; the scores were calculated within 24 hours of admission. A receiver-operating characteristic curve was generated, and the area under the receiver-operating characteristic curve was calculated to identify the patients at the greatest risk of death according to Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores. The Hosmer-Lemeshow goodness-of-fit test was used for statistically significant results and indicated a difference in performance over deciles. The standardized mortality ratio was used to estimate the overall model performance. RESULTS: The ability of both scores to predict hospital mortality was poor in the liver and renal transplant groups and average in the lung transplant group (area under the receiver-operating characteristic curve = 0.696 for Simplified Acute Physiology Score 3 and 0.670 for Acute Physiology and Chronic Health Evaluation II). The calibration of both scores was poor, even after customizing the Simplified Acute Physiology Score 3 score for South America. CONCLUSIONS: The low predictive accuracy of the Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores does not warrant the use of these scores in critically ill transplant patients.

Trasplante simultáneo de páncreas y riñon en diabetes mellitus tipo 1: Experiencia de un centro en Chile / Simultaneous kidney and pancreas transplantation (SKPT) in patients with type 1 diabetes and chronic renal failure: Experience in 12 patients in Chile

Background: Simultaneous kidney and páncreas transplantation (SKPT) is the best alternative for end stage renal disease among patients with insulin dependent diabetes mellitus. Aim: To report our experience with SKPT. Material andMethods: Retrospective analysis ofl2 recipients of SKPT transplanted in one center starting in 1994, with a meanfollow-upperiod of6.8years (2-15). Results: Eleven ofl2 recipients were in chronic hemodialysis before SKPT. Mean A, B, DR and HLA mismatch was 4.3. Mean preformed anti HLA antibodies was 3.3 percent. Mean cold ischemia times for páncreas and kidney were 6 and 10 hours, respectively. In the first eight cases, the páncreas was drained to the bladder, and in the last four, an enteric drainage was performed. Eleven recipients were induced with antibodies, and maintenance immunosuppression consisted ofCyclosporine or Tacrolimusplus an antiproliferative agent. Ten year patient survival was 70 percent. Páncreas and kidney survival, defined by insulin and dialysis independence, were 72 and 73 percent respectively. Fifty percent of recipients experienced acute graft rejection (cellular or humoral), with good response to treatment except in one case. Conclusions: This experience shows that SKPT is associated with an excellent patient survival associated to insulin and dialysis independence in 70 percent of patients at 10 years.

O impacto da função do enxerto renal e da ocorrência de infecção intra-abdominal na sobrevida em 1 ano do paciente após o transplante simultâneo de pâncreas-rim (TSPR) / The impact of kidney function and intra-abdominal infection on patient 1-yr survival after simultaneous pancreas-kidney transplantation (SPKT)

O transplante de pâncreas-rim (TSPR) é um dos tratamentos mais efetivos para o paciente com diabetes melito e insuficiência renal crônica. Métodos: Foram realizadas análises retrospectivas da sobrevida de 150 pacientes submetidos ao TSPR pela regressão de COX e determinação das curvas de Kaplan-Meier, além das análises uni - e multivariadas para identificação dos fatores de risco tradicionais e aqueles relacionados ao transplante. Resultados: As taxas de sobrevidas em um ano dos pacientes, dos enxertos renais e pancreáticos foram de 82,0%, 80,0% e 76,7%, respectivamente. Função retardada do enxerto renal (FRR) (P = 0,001, RR 5,41), rejeição aguda renal (P = 0,016, RR 3,36) e infecção intra-abdominal (IIA) (P < 0,0001, RR 4,15) foram os principais fatores de risco que influenciaram a sobrevida do paciente em um ano. A sobrevida do paciente em um ano esteve relacionada à ocorrência de FRR (P = 0,013, RC 3,39), à rejeição aguda renal (P = 0,001, RC 4,74) e à IIA (P = 0,003, RC 6,29). A sobrevida do enxerto pancreático em um ano esteve relacionada à IIA (P < 0,0001, RC 12,83), à trombose vascular (P = 0,002, RC 40,55), à rejeição aguda renal (P = 0,027, RC 3,06), ao sódio do doador > 155 mEq/L (P = 0,02, RC 3,27) e ao uso de dopamina > 7,6 µcg/kg/min (P = 0,046, RC 2,85). Discussão: A ocorrência de função retardada do enxerto renal e infecção intraabdominal teve impacto na sobrevida em um ano tanto do paciente quanto dos enxertos renal e pancreático

Simultaneous pancreas-kidney transplantation (SPKT) is one of the treatments for insulin-dependent patients with chronic renal failure. Methods: One-year patient and kidney allograft survival rates of 150 patients submitted to SPKT analyzed by COX regression and Kaplan-Meier. Uni- and multivariate analysis identified the risk factors involved with either allograft or patient survival. Results: One-year patient and kidney allograft survival rates were 82% and 80%, respectively. Delayed graft function from kidney (DGF) (P = 0.001, HR 5.41), acute kidney rejection (P = 0.016, HR 3.36) and intra-abdominal infection (IAI) (P < 0.0001, HR 4.15) were related to the 1-yr patient survival. One-year kidney allograft survival was also related to DGF (P = 0.013, OR 3.39), acute rejection (P = 0.001, OR 4.74) and IAI (P = 0.003, OR 6.29). Main risk factors for DGF: time on dialysis > 27 months (P = 0.046, OR 2.59), kidney cold ischemia time > 14 hours (P = 0.027, OR 2.94), donor age > 25 years (P = 0.03, OR 2.82) and donor serum sodium > 155 mEq/l (P < 0.0001, OR 1.09). Conclusions: Delayed kidney allograft function and IAI had an important impact on either patient or kidney allograft survival rates. Improving deceased donor care may reduce DGF occurrence.

Transplante de pâncreas e ilhotas em portadores de diabetes melito: [revisão] / Pancreas and islet transplantation in patients with diabetes mellitus: [review]

O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.

Trasplante de islotes pancreáticos: estado actual / Transplantation of Pancreatic Islets of Lagerhans: present status

El trasplante clínico de islotes luego del protocolo de Edmonton, presenta en centros de excelencia una reversión de l enfermedad del 80 por ciento de los pacientes al año del implante. Sin embargo la necesidad de utilizar dos o más páncreas pra curar a un solo paciente y la inmunosupresión crónica limitan el proceso a pacientes diabéticos lábiles exclusivamente. En esta revisión se analizan las distintas estrategias para superar estos inconvenientes y extender el procedimiento a todos los pacientes diabéticos tipo I

Trasplante de páncreas en 132 pacientes diabéticos insulino-dependientes / Pancreas transplantation in 132 insulin-dependent diabetic patients

A total of 140 pancreatic transplants have been performed in 132 insulin-dependent diabetic patients at lyon (France). Most cases received a double pancreatic and renal transplant. The duct obstruction technique was utilized in 113 segmental transplants. A total pancreatic transplant was performed in 27 patients, with duct obstruction in 27, Gl tract derivation in 14, urinary tract derivation in 11 and intraductal obstruction in 2 patients. Utilizing quadruple immunosuppression, the one year survival rate was 90% and the transplant survival was 60%