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

Comparison of methods of providing analgesia after pancreas transplant: IV opioid analgesia versus transversus abdominis plane block with liposomal bupivacaine or continuous catheter infusion

Background Current practices emphasize a multimodal approach to perioperative analgesia due to higher efficacy and decreased opioid usage. Analgesia for pancreas transplant (PT) has traditionally been managed with intravenous (IV) opioids, and reports of transversus abdominis plane (TAP) blocks are limited in this population. Methods Three interventions were compared in adult PT patients, including IV opioids, TAP catheter, and TAP block with liposomal bupivacaine. Time to return of intestinal function and oral diet, postoperative pain scores, opioid usage, and length of stay were recorded. Results Study included 197 PT patients: 62 (32%) standard care, 90 (45%) TAP catheters with continuous 0.2% ropivacaine, and 45 (23%) single liposomal bupivacaine TAP block. Pain scores were lowest for the IV opioid group (P < 0.001). The liposomal bupivacaine group had lower pain scores on postoperative days (POD) 1‐5 than the TAP catheter group. Opioid use during POD 1‐5 was lower for both TAP block groups (P = 0.03). Time to bowel function was faster for the TAP block groups (P < 0.05). Conclusions Compared with IV opioid analgesia, TAP block interventions were associated with lower overall use of opioids and a faster time to intestinal function following pancreas transplant

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

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

Steroid Free Three Drug Maintenance Regimen for Pancreas Transplant Alone: Comparison of Induction with Rabbit Antithymocyte Globulin +/- Rituximab

Graft survival following pancreas transplant alone (PTA) is inferior to other pancreas transplants. Steroid elimination is appealing, but a two drug maintenance strategy may be inadequate. Additionally, recipients tend to have diabetic nephropathy and do not tolerate nephrotoxic medications. A three‐drug maintenance strategy permits immunosuppression through different mechanisms as well as an opportunity to use lower doses of the individual medications. Induction consisted of five doses of rabbit antithymocyte globulin (1 mg/kg/dose). As of October 2007, a single dose of rituximab (150 mg/m2) was added. Maintenance consisted of tacrolimus, sirolimus and mycophenolate mofetil. From 2004 to 2017, 166 PTA were performed. Graft loss at 7‐ and 90‐ days were 4% and 5%, and one year patient and graft survival were 97% and 91%. Comparing induction without and with rituximab, there was no significant difference in 7 or 90 day graft loss, 1 year patient or graft survival or in the rate of rejection or infection. Rabbit antithymocyte globulin induction and steroid withdrawal followed by a three drug immunosuppression regimen is an excellent strategy for PTA recipients

Repeat coronary angioplasty: Correlates of a second restenosis

AbstractTo identify the correlates of a second restenosis after repeat percutaneous coronary angioplasty, the records of 384 patients with single vessel disease who underwent repeat angioplasty for restenosis complicating a first elective angioplasty were examined. A second restenosis occurred in 47 (31%) of 151 patients having angiographic follow-up. Univariate correlates of a second restenosis were an interval between the first and the second angioplasty <5 months (41 versus 20% of patients had restenosis, p < 0.01), male gender (35 versus 12%, p < 0.05), lesion length ≥15 mm before the second angioplasty (62 versus 28%, p < 0.05), diameter stenosis >90% before the second angioplasty (67 versus 29%, p < 0.05), final gradient >20 mm Hg after the second angioplasty (52 versus 28%, p < 0.05) and an additional site requiring dilation at the time of the second angioplasty (50 versus 29%, p = 0.10).Multivarlate predictors of a second restenosis were an interval of <5 months between the first and the second angioplasty (p = 0.001), male gender (p = 0.001), lesion length ≥15 mm before the second angioplasty (p = 0.001) and the need to have an additional site dilated at the time of the second angioplasty (p = 0.002). Patients at increased risk of restenosis after the second angioplasty can be identified and may serve as a useful population for intervention studies

Radiologic Assessment of Muscle and Fat Stores in Long-Term Type I Diabetics Referred for Pancreas Transplant Compared to Healthy Controls

Type 1 diabetes (DM1) is associated with loss of skeletal muscle and bone mass and may affect body fat stores. This study employs computed tomography (CT) scans to assess the body composition of DM1 patients referred for pancreas transplant compared to healthy controls. A 1:1 case–control design matched study patients with otherwise healthy patients from the trauma database. Matching criteria included age ± 5 years, gender, and body mass index (BMI) ± 2kg/m2. Nutrition variables included serum albumin and protein levels, BMI, and CT measures of muscle mass and fat stores. There were 22 subjects and 22 controls (median DM1 duration 24 years). DM1 patients had less muscle mass and less subcutaneous fat but no difference in visceral fat. Patients with the greatest muscle deficit were those with DM1 greater than 20 years and those younger than age 40. DM1 patients maintain similar BMI and protein levels compared to healthy controls but have marked deficits of muscle and subcutaneous fat. These results inform the nutritional management of DM1 patients and quantify the muscle and fat deficits present in these patients. At highest risk are young patients and those with duration of DM1 over 20 years

Rabbit anti‐thymocyte globulin administration to treat rejection in simultaneous pancreas and kidney transplant recipients with recent COVID‐19 infection

Transplant recipients may be more susceptible to COVID‐19 and itsrelated complications.1‐3Despite most patients being managed with reduction of immunosuppression, the risk of rejection or graft loss does not seem to be increased during COVID‐19