Pancreas transplantation using compatible but non‐identical ABO blood group donors

Methods A review of all pancreas transplants from a single institution from 01/2003 to 07/2016 (n=606) revealed 41 recipients of a NIC donor pancreas which were matched for age, race, gender, year and type of transplant with 41 ABO identical cases. Groups were compared for allograft survival, incidence of acute cellular rejection (ACR), length of hospital stay, 3‐month readmissions and transfusion requirements. Serum haptoglobin and Lactate dehydrogenase were used to identify hemolysis in patients requiring repeated transfusions without overt blood loss. Results The 1‐year graft survival was 100% and 88% in the study and control groups. In the study group, 6/41(14%) developed hemolysis, all of which were ABO O into A. All responded to donor blood type specific transfusions. Discussion There are limited data on outcomes of solid organ transplant using NIC donors with almost none specifically addressing pancreas transplantation. In this study, graft survival was similar but 14% developed hemolysis, which was transient and treated with transfusion of donor blood type specific blood. Conclusion NIC pancreas transplants have similar graft survival compared to ABO identical. Hemolysis may occur so some caution is required

One Year Incidence of Infection in Pediatric Intestine Transplantation

Background: This study reports the infection rate, location of infection, and pathogen causing bacterial, fungal, or viral infections in intestine transplant recipients at a pediatric transplant center. Methods: Records from a pediatric center were reviewed for patients receiving an intestine transplant. Positive cultures and pathology reports were used to diagnose bacterial, fungal, and viral infections and also to determine location and infectious agent. Risk for infection was assessed based on liver or colon inclusion, and immunosuppression induction, as part of the intestine transplant. Results: During the study period 52 intestine transplants were performed on 46 patients. Bacterial, fungal, and viral infection rates were 90%, 25%, and 75%, respectively. Enterococcus (non-vancomycin resistant enterococci (VRE)) species were the most common pathogens and were isolated from 52% of patients. VRE was present in 12% of transplant recipients. Candida species were the most common fungal pathogens (23% of patients). Respiratory viral infections were common (44%) and cytomegalovirus infection rate was 17%. Common sites of infection were bloodstream, urinary, and upper respiratory tract. Colon and liver inclusion in the transplant graft was not associated with increased risk of infection, nor was addition of rituximab to the immunosuppression induction protocol. Conclusion: Post-intestine transplant infections are ubiquitious in the pediatric population, including high rates of infection from bacterial, viral and fungal sources. Inclusion of the liver and/or colon as a component of the transplant graft did not appear to greatly impact the infectious risk. Adding rituximab to the immunosuppression induction protocol did not impact on infectious risk

Impact of Donor Pre-Procurement Cardiac Arrest (PPCA) on Clinical Outcomes in Liver Transplantation

BACKGROUND Transplantation of liver grafts from deceased donors who experienced cardiac arrest prior to liver procurement is now common. This single-center study analyzed the impact of pre-donation arrest time on clinical outcomes in liver transplantation. MATERIAL AND METHODS Records of all orthotopic liver transplants performed at a single center over a 15-year period were reviewed. Donor records were reviewed and total arrest time was calculated as cumulative minutes. Post-transplant liver graft function was assessed using laboratory values. Graft survival was assessed with Cox regression analysis. RESULTS Records for 1830 deceased donor transplants were reviewed, and 521 donors experienced pre-procurement cardiac arrest (28%). Median arrest time was 21 min (mean 25 min, range 1-120 min). After transplant, the peak alanine aminotransferase and bilirubin levels for liver grafts from donors with arrest were lower compared to those for donors without arrest (p40 min arrest) demonstrated no statistically significant difference in survival at 10 years. Subgroup analysis of 93 donation after cardiac death grafts showed no significant difference for these same outcomes. CONCLUSIONS These results support the use of select deceased liver donors who experience pre-donation cardiac arrest. Pre-donation arrest may be associated with less early allograft dysfunction, but had no impact on long-term clinical outcomes. The results for donation after cardiac death donors were similar

The survival advantage of pancreas after kidney transplant

Patient survival after pancreas after kidney transplant (PAK) has been reported to be inferior to patient survival after simultaneous pancreas–kidney transplant (SPK). The authors examine national data to further explore allograft (kidney and pancreas) and patient survival after PAK. Kaplan–Meier and Cox proportional hazard models were used to analyze Organ Procurement and Transplantation Network data from 1995 to 2010. The analysis compared PAK and SPK candidates and recipients. Kaplan–Meier analysis results showed that PAK after either a living or a deceased donor kidney transplant is associated with increased kidney graft survival compared with recipients with type 1 diabetes who received only a kidney. The best kidney allograft survival was for patients who received a living donor kidney followed by PAK. Receiving a living donor kidney was associated with increased pancreas allograft survival compared with receiving a deceased donor kidney. PAK transplant recipients who receive both organs have a survival advantage compared with uremic candidates who receive neither (SPK waitlist). Compared with uremic diabetic waitlist patients, SPK and PAK recipients showed similar overall patient survival. Successful PAK offers a survival advantage compared with receiving neither a kidney nor a pancreas transplant. These data also suggest that receiving a pancreas (after kidney) transplant may have a protective effect on the kidney allograft

Pain interventions for organ transplant patients undergoing incisional hernia repair: Is epidural or transversus abdominus plane block a better option?

Background Postoperative pain management in transplant recipients undergoing incisional herniorraphy is challenging. Historically limited to intravenous or oral opioids, alternatives including transversus abdominus plane (TAP) block catheters and thoracic epidural catheters have been introduced. The aim of this study was to determine whether TAP catheters and thoracic epidural analgesia significantly impacted on postoperative pain and opioid usage in transplant recipients undergoing incisional hernia repair. Methods This single‐center retrospective study included 154 patients undergoing incisional hernia repair from January 2011 to June 2015. Of these, 56 received epidurals, 51 received TAP catheters, and 47 received no intervention. Results Demographic profiles were comparable among the three groups including type of previous transplant and type of hernia surgery. Thoracic epidural analgesia was associated with lower median, mean, and maximum pain scores (P < 0.001) and less opioid requirement (P < 0.001). There was no difference in pain scores and opioid usage among the TAP catheter and no intervention groups. There was no difference in time to first flatus or first bowel movement, length of hospital stay, individual opioid‐related side effects, and adverse reactions among the three groups. Conclusion This study supports the use of thoracic epidural analgesia in patients undergoing hernia repair after transplant surgery

Donation After Circulatory Arrest in Pancreas Transplantation: A Report of 10 Cases

Introduction Transplantation of pancreas allografts procured from donation after circulatory death (DCD) remains uncommon. This study reviews a series of pancreas transplants at a single center to assess the donor and recipient characteristics for DCD pancreas transplant and to compare clinical outcomes. Methods DCD procurement was performed with a 5-minute wait time from pronouncement of death to first incision. In 2 patients, tissue plasminogen activator was infused as a thrombolytic during the donor flush. All kidney grafts were placed on pulsatile perfusion. Results There were 606 deceased donor pancreas transplants, 596 standard donors and 10 DCD donors. Of the 10 DCD transplants, 6 were simultaneous pancreas-kidney and 4 were pancreas transplant alone. The average time from incision to aortic cannulation was less than 3 minutes. The median total ischemia time for the DCD grafts was 5.4 hours, compared with 8.0 hours for standard donors (P = .15). Median length of hospital stay was 7 days for both groups, and there were no episode of acute cellular rejection in the first year post-transplant for the DCD group (4.2 % for standard group, P = .65). There was no difference in early or late graft survival, with 100% graft survival in the DCD group up to 1 year post-transplant. Ten-year Kaplan-Meier analysis shows similar graft survival for the 2 groups (P = .92). Conclusions These results support the routine use of carefully selected DCD pancreas donors. There were no differences in graft function, postoperative complications, and early and late graft survival

Post‐intestine transplant graft‐versus‐host disease: Associated with inclusion of a liver graft and with a high mortality risk

Introduction This study reports the incidence, anatomic location, and outcomes of graft‐versus‐host disease (GVHD) at a single active intestine transplant center. Methods Records were reviewed for all patients receiving an intestine transplant from 2003 to 2015. Pathology reports and pharmacy records were reviewed to establish the diagnosis, location, and therapeutic interventions for GVHD. Results A total of 236 intestine transplants were performed during the study period, with 37 patients (16%) developing GVHD. The median time to onset of disease was 83 days, with 89% of affected patients diagnosed in the first year post‐transplant. Mortality for affected patients was 54% in the one‐year after GVHD diagnosis. Skin lesions were the most common manifestation of GVHD. Other sites of disease included lungs, bone marrow, oral mucosa, large intestine, and brain. The incidence of GVHD was 16% in adult patients, and slightly lower in pediatric recipients (13%). In adults, increasing graft volume (isolated versus multi‐organ) and liver inclusion were associated with increasing risk of GVHD, though this was not seen in pediatric patients. Conclusion Overall, 16% of intestine transplant recipients developed GVHD. GVHD is associated with high mortality, and disease in the lungs, brain, and bone marrow was universally fatal

Excellent outcomes in combined liver-kidney transplantation: Impact of KDPI and delayed kidney transplantation

The positive impact of delayed kidney transplantation (KT) on patient survival for combined liver-KT (CLKT) has already been demonstrated by our group. The purpose of this study is to identify whether the quality of the kidneys (based on KDPI) or the delayed approach KT contributes to improved patient survival. 130 CLKT were performed between 2002-2015; 69 with simultaneous KT (Group S) and 61 with delayed KT (Group D) (performed as a second operation with a mean cold ischemia time [CIT] of 50±15h). All patients were categorized according to the KDPI score; 1-33%, 34-66%, and 67-99%. Recipient and donor characteristics were comparable within Groups S and D. Transplant outcomes were comparable within Groups S and D, including liver and kidney CIT, warm ischemia time, and delayed graft function. Lower KDPI kidneys (<34%) were associated with increased patient survival in both groups. Combination of delayed KT and KDPI 1-33% resulted in 100% patient survival at 3-years. These results support that delayed KT in CLKT improves patient survival. The combination of delayed KT and low KDPI offers excellent patient survival up to 3-years. Improved outcomes in the delayed KT group including high KDPI kidneys supports expansion of the donor pool with the use of more ECD and DCD kidneys

Life threatening nontraumatic tension gastrothorax

Tension gastrothorax is a rare condition, which poses a diagnostic dilemma and can be mistaken for a tension pneumothorax. Awareness of the risk factors, clinical presentation, and radiology findings of tension gastrothorax can help with the prompt identification and successful management of this life-threatening condition