Laparoscopic Biopsies in Pancreas Transplantation.

As there is no precise laboratory test or imaging study for detection of pancreas allograft rejection, there is increasing interest in obtaining pancreas tissue for diagnosis. Pancreas allograft biopsies are most commonly performed percutaneously, transcystoscopically, or endoscopically, yet pancreas transplant surgeons often lack the skills to perform these types of biopsies. We have performed 160 laparoscopic pancreas biopsies in 95 patients. There were 146 simultaneous kidney-pancreas biopsies and 14 pancreas-only biopsies due to pancreas alone, kidney loss, or extraperitoneal kidney. Biopsies were performed for graft dysfunction (89) or per protocol (71). In 13 cases, an additional laparoscopic procedure was performed at the same operation. The pancreas diagnostic tissue yield was 91.2%; however, the pancreas could not be visualized in eight cases (5%) and in 6 cases the tissue sample was nondiagnostic (3.8%). The kidney tissue yield was 98.6%. There were four patients with intraoperative complications requiring laparotomy (2.5%) with two additional postoperative complications. Half of all these complications were kidney related. There were no episodes of pancreatic enzyme leak and there were no graft losses related to the procedure. We conclude that laparoscopic kidney and pancreas allograft biopsies can be safely performed with very high tissue yields.

Case report: pancreas graft with a duodenal complication rescued using total duodenectomy.

Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice for type 1 diabetics with end-stage renal disease. Recently patients with type 2 diabetes have been considered for transplantation. Despite that the patient and graft survival rates have improved over the past years, it continues to be a procedure with high surgical complication rates. We herein report a case of a pancreatic graft with a duodenal complication rescued using a total duodenectomy, a procedure that is seldom used. A 57-year-old type 2 diabetic underwent a SPK transplantation with systemic-enteric drainage. He was converted to a Roux en Y at day 7 for a small duodenal fistula without peritonitis. At day 13, with good graft function, he presented with gastrointestinal and abdominal bleeding. At laparotomy he had a congestive duodenum with intraluminal bleeding and an anastomotic fistula. We performed a total duodenectomy with enteric drainage. The patient was discharged home on day 39 with a pancreatic fistula on intramuscular Octretotide that lasted for 3 months. He was never readmitted and has good pancreas and kidney function at 16 months of follow-up. We think this is an option to rescue a pancreas graft with duodenal complications in selected cases.

Use of small donors (<28 kg) for pancreas transplantation.

OBJECTIVE: Small donors have long been considered a potential source of organs for simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone (PTA). Our aim was to analyze our experience with SPK and PTA using small donors weighing <28 kg. PATIENTS AND METHODS: Between September 2006 and October 2008, we performed 68 SPK, 3 PTA, and 3 pancreas after kidney transplantations (PAK). All recipients were adults with type 1 diabetes mellitus, including 8 who received small donor organs (<28 kg): 6 SPK and 2 PTA. We used 3 graft combinations for SPK: pancreas and single kidney; pancreas and en bloc kidneys; and en bloc dual kidney-pancreas. In contrast, we used conventional grafts for PTA. Mean weight among donors was 20.82 kg (range, 9.6-27 kg). RESULTS: We observed neither delayed graft function nor mortality. At a follow-up of approximately 281 days, all patients were free of insulin and dialysis treatments. CONCLUSIONS: Kidneys and pancreas from donors weighing <28 kg can be used in adult type 1 diabetic patients with excellent results. These small pediatric donors enabled us to enlarge the number of transplantations by 10.81%.

Results of a calcineurin-inhibitor-free immunosuppressive protocol in renal transplant recipients of expanded criteria deceased donors.

The increasing number of patients on waiting lists and the relatively stable organ procurement rate provide the groundwork for the use of expanded criteria deceased donors. While calcineurin-inhibitors (CNI) are excellent immunosuppressive drugs, their nephrotoxicity is largely responsible for the lack of improvement in long-term graft survival. The objective of this study was to analyze the results obtained with the use of a calcineurin inhibitor-free immunosuppressive protocol (polyclonal antibody induction, plus sirolimus, mycophenolate mofetil, and low doses of steroids) in terms of graft and patient survival as well as posttransplant clinical complications over 2 years. Under this immunosuppressive protocol, 78.04% of the patients completed the follow-up. A protocol biopsy was performed on 17 patients (53.1%) within 2 years posttransplant of which 82.31% were diagnosed as chronic allograph nephropathy grade I. The incidence of clinical complications was low and not significantly different from that reported with other immunosuppressive schemes. Death-censored graft survival was 95.12%. In conclusion, the use of a calcineurin inhibitor-free protocol in renal-transplant recipients of expanded criteria deceased donors was associated with excellent graft and patient survival rates and a low incidence of adverse events.

Risk factors for Pneumocystis carinii pneumonia in kidney transplant recipients: a case-control study.

OBJECTIVE: To analyze risk factors for Pneumocystis carinii pneumonia (PCP) in kidney transplant recipients. STUDY DESIGN: In a case-control study, 17 PCP cases diagnosed between July 1994 and July 2000 were matched with two controls each (previous and subsequent kidney transplant recipients who did not develop PCP during the same follow-up period). Demographics, organ origin, human leukocyte antigen (HLA) mismatches, use of poly- or monoclonal anti-CD3 antibodies (Po/MoAb) for induction or rejection treatment, rejection episodes, cumulative steroid dose for rejection treatment, immunosuppressive regimens, and other infections were analyzed. RESULTS: No significant differences were seen in gender (male 10 vs. 15), mean age (39.7 vs. 35.4 years), organ origin (cadaver donor 13 vs. 19), HLA mismatches, or Po/MoAb use in induction treatment. Significant differences were observed in PCP cases for rejection history (P=0.02), and median and total number of rejection episodes (P=0.0018). The relative risks for PCP for 1, 2, and > or =3 rejection treatments vs. no such treatment were 1, 1.05, and 6.30, respectively (P=0.021). The relative risk for PCP for steroid-resistant rejection was 4.34 (95% confidence interval [CI], 1.04-18.89) (P=0.019), and that for the use of Po/MoAb for rejection treatment was 7.23 (95% CI, 1.28-49.34) (P=0.006). The relative risk for PCP for 0, 1, and > or =2 previous or concomitant cytomegalovirus (CMV) infection vs. no such infections were 1.0, 2.32, and 13.0, respectively (P=0.012). The relative risks for PCP for tuberculosis (TB) was 18 (95% CI, 1.76-852.03), that for bacterial pneumonia was 14.22 (95% CI, 2.16-150.23), and that for hepatitis C virus infection was 5.25 (95% CI, 1.03-28.91). Immunosuppressive regimens with tacrolimus, mycophenolate mofetil (MMF), steroids (P=0.06), and MMF as a single variable (P=0.05) were more frequently used in cases. Primary trimethoprim-sulfamethoxazole prophylaxis failure was observed in 12 patients in association with heavy immunosuppression and concomitant infections. CONCLUSIONS: The risk of PCP in kidney transplant recipients is related to the number and type of rejection treatments. It is also related to the occurrence of CMV infection, and to other immunomodulating infections such as TB and hepatitis C, and might also be increased with the use of newer and more potent immunosuppressive agents. Primary prophylaxis failure may occur in association with some of these risk factors.

A randomized and prospective study comparing treatment with high-dose intravenous immunoglobulin with monoclonal antibodies for rescue of kidney grafts with steroid-resistant rejection.

BACKGROUND: The aim of this study was to compare the effectiveness of intravenous immunoglobulin (IVIg) versus monoclonal anti-CD3 as a treatment for steroid-resistant rejections. From January 1995 to June 1997, 30 patients were analyzed. They were randomized into two groups. Resistant rejections were diagnosed by core biopsy. Group A received 500 mg/ kg/day IVIg (Sandoglobulin) for 7 consecutive days, whereas group B received 5 mg/day of OKT3 for 14 consecutive days. Daily T cell CD3+ peripheral count was performed for 14 days for group B. The immunosuppression was similar for both groups. Cyclosporine was stopped during both treatments. METHODS: Demographic factors, HLA mismatch, creatinine levels before and after treatment, and the incidence of rejections after treatment (up to 1 month) were taken into account for this study. RESULTS: Data from different samples were compared using Fisher's exact test. Graft and patient survival were analyzed using the Kaplan-Meier method. The were no significant differences found in age, graft origin, HLA mismatch, or time of follow-up until the episode of rejection. Success was achieved for 11 (73.3%) of 15 of group A and 13 (86.6%) of 15 of group B (P=0.79). Creatinine levels before and after treatment were as follows: A, 2.99+/-1.30 mg/dl and 2.1+/-0.70 mg/dl versus B, 3.1+/-1.1 mg/dl and 2.5+/-0.8 mg/dl. Besides, we did not observe differences in the creatinine 1 month after treatment (A: 2.35+/-0.78 mg/dl; B: 2.51+/-1.10 mg/dl; P=0.66) nor in the third month (A: 1.83+/-0.58 mg/dl; B: 2.30+/-0.89 mg/dl; P=0.24). The incidence of rejections after treatment was 5 (46%) of 11 for group A and 9 (75%) of 12 for group B (P=0.4). The patient survival rates 2 years after treatment were 87 and 92% for A and B groups, respectively. Graft survival was identical (80% in both groups). CONCLUSION: Should the favorable result presented in this report be confirmed in larger number of patients, IVIg could become the preferable choice of rejection treatment for steroid-resistant rejection because of a complete absence of the unwanted side effects commonly associated with OKT3.