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Ai Li E, Farrokhi K, Zhang MY, Offerni J, Luke PP, Sener A. Heparin Thromboprophylaxis in Simultaneous Pancreas-Kidney Transplantation: A Systematic Review and Meta-Analysis of Observational Studies. Transpl Int 2023; 36:10442. [PMID: 36819126 PMCID: PMC9928749 DOI: 10.3389/ti.2023.10442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 01/18/2023] [Indexed: 02/04/2023]
Abstract
Thrombosis is a leading causes of pancreas graft loss after simultaneous pancreas kidney (SPK), pancreas after kidney (PAK), and pancreas transplant alone (PTA). There remains no standardized thromboprophylaxis protocol. The aim of this systematic review and meta-analysis is to evaluate the impact of heparin thromboprophylaxis on the incidence of pancreas thrombosis, pancreas graft loss, bleeding, and secondary outcomes in SPK, PAK, and PTA. Following PRISMA guidelines, we systematically searched BIOSIS®, PubMed®, Cochrane Library®, EMBASE®, MEDLINE®, and Web of Science® on April 21, 2021. Primary peer-reviewed studies that met inclusion criteria were included. Two methods of quantitative synthesis were performed to account for comparative and non-comparative studies. We included 11 studies, comprising of 1,122 patients in the heparin group and 236 patients in the no-heparin group. When compared to the no-heparin control, prophylactic heparinization significantly decreased the risk of early pancreas thrombosis and pancreas loss for SPK, PAK and PTA without increasing the incidence of bleeding or acute return to the operating room. Heparin thromboprophylaxis yields an approximate two-fold reduction in both pancreas thrombosis and pancreas loss for SPK, PAK and PTA. We report the dosage, frequency, and duration of heparin administration to consolidate the available evidence.
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Affiliation(s)
- Erica Ai Li
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kaveh Farrokhi
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Max Y Zhang
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada
| | - Juliano Offerni
- Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada.,Department of Surgery, Division of Urology, London Health Sciences Center, London, ON, Canada
| | - Patrick P Luke
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada.,Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada.,Department of Surgery, Division of Urology, London Health Sciences Center, London, ON, Canada
| | - Alp Sener
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada.,Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada.,Department of Surgery, Division of Urology, London Health Sciences Center, London, ON, Canada
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2
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Serrano OK, Kandaswamy R, Finger EB. Survival benefit of the homologous kidney allograft in simultaneous pancreas-kidney transplants and its potential protective role. Clin Transplant 2021; 35:e14462. [PMID: 34403158 DOI: 10.1111/ctr.14462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 07/27/2021] [Accepted: 08/06/2021] [Indexed: 11/30/2022]
Abstract
The superior death-censored graft survival of the pancreas allograft in simultaneous pancreas kidney transplants (SPK) over pancreas alone transplants (PTA) has long been recognized. Using data from the Scientific Registry of Transplant Recipients (SRTR) and a high-volume pancreas transplant program, we investigated the possible protective role of the kidney allograft in SPK transplants. We analyzed 19,043 primary pancreas transplants between 2000 and 2020, including 735 transplants performed at the University of Minnesota. SPK transplants demonstrated a superior death-censored graft survival over pancreas after kidney (PAK) and simultaneous pancreas and living donor kidney (SPLK) transplants, which both demonstrated better survival than PTA transplants. This effect was not affected by mode or duration of renal replacement therapy prior to transplant. Furthermore, we found that HLA match at the B-locus between the prior kidney and current pancreas allografts demonstrated a protective effect (HR 0.54; 95% confidence interval 0.29-1.00), with a 2-antigen match demonstrating superior death-censored graft survival to a 1- or 0-antigen match. We propose that a homologous kidney allograft in SPK transplants affords protection to the pancreas allograft - likely through a combination of better surveillance for rejection and direct immunoprotection offered by the same-donor kidney. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Oscar K Serrano
- Hartford Hospital Transplant Program, Hartford, CT, USA.,Department of Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Raja Kandaswamy
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Erik B Finger
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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3
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Parajuli S, Arunachalam A, Swanson KJ, Aziz F, Garg N, Redfield RR, Kaufman D, Djamali A, Odorico J, Mandelbrot DA. Outcomes after simultaneous kidney‐pancreas versus pancreas after kidney transplantation in the current era. Clin Transplant 2019; 33:e13732. [PMID: 31628870 DOI: 10.1111/ctr.13732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/28/2019] [Accepted: 10/14/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Annamalai Arunachalam
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Kurtis J. Swanson
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Fahad Aziz
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Neetika Garg
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Robert R. Redfield
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Dixon Kaufman
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Arjang Djamali
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Jon Odorico
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Didier A. Mandelbrot
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
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4
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Zhou J, Dong Y, Mei S, Gu Y, Li Z, Xiang J, Zheng H, Chen Z, Huang Z, Hu Z. Influence of duration of type 1 diabetes on long‐term pancreatic transplant outcomes. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:583-592. [PMID: 31566900 DOI: 10.1002/jhbp.677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Jie Zhou
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Yinlei Dong
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Shengmin Mei
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Yangjun Gu
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Zhiwei Li
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Jie Xiang
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Huilin Zheng
- Zhejiang Provincial Collaborative Innovation Center of Agricultural Biological Resource Biochemical Manufacturing School of Biological and Chemical Engineering Zhejiang University of Science and Technology Hangzhou Zhejiang China
| | - Zheng Chen
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Zhichao Huang
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
| | - Zhenhua Hu
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital School of Medicine Zhejiang University Hangzhou Zhejiang China
- Division of Hepatobiliary and Pancreatic Surgery Department of Surgery Fourth Affiliated Hospital School of Medicine Zhejiang University Yiwu Zhejiang China
- Division of Hepatobiliary and Pancreatic Surgery Yiwu Central Hospital Yiwu Zhejiang China
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Fridell JA, Niederhaus S, Curry M, Urban R, Fox A, Odorico J. The survival advantage of pancreas after kidney transplant. Am J Transplant 2019; 19:823-830. [PMID: 30188614 DOI: 10.1111/ajt.15106] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/07/2018] [Accepted: 08/12/2018] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Silke Niederhaus
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Read Urban
- United Network for Organ Sharing, Richmond, VA, USA
| | - Abigail Fox
- United Network for Organ Sharing, Richmond, VA, USA
| | - Jon Odorico
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
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6
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Hu ZH, Gu YJ, Qiu WQ, Xiang J, Li ZW, Zhou J, Zheng SS. Pancreas grafts for transplantation from donors with hypertension: an analysis of the scientific registry of transplant recipients database. BMC Gastroenterol 2018; 18:141. [PMID: 30231859 PMCID: PMC6146664 DOI: 10.1186/s12876-018-0865-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/24/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND With the rising demands for pancreas transplantation, surgeons are trying to extend the donors pool and set up a more appropriate assessment system. We aim to evaluate the effect of donor hypertension on recipient overall and graft survival rates. METHODS Twenty-four thousand one hundred ninety-two pancreas transplantation patients from the Scientific Registry of Transplant Recipients database were subdivided into hypertension group (HTN, n = 1531) and non-hypertension group (non-HTN, n = 22,661) according to the hypertension status of donors. Recipient overall and graft survival were analyzed and compared by log rank test, and hazard ratios of predictors were estimated using Cox proportional hazard models. RESULTS Patient overall and graft survival of non-HTN group were higher than that of the HTN group (both p < 0.001). The duration of hypertension negatively influenced both overall and graft survival rates (both p < 0.001). Multivariate analyses demonstrated that hypertension was an independent factor for reduced survival (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.01-1.18; p < 0.001). Other independent factors included recipient body mass index (HR, 1.02; 95% CI, 1.01-1.05; p < 0.001) and transplant type (pancreas after kidney transplants / pancreas transplant alone vs. simultaneous pancreas-kidney transplants; HR, 1.41; 95% CI, 134-1.55; p < 0.001). CONCLUSIONS Donor hypertension is an independent factor for recipient survival after pancreas transplantation and could be considered in donor selection as well as post-transplant surveillance in clinical practice.
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Affiliation(s)
- Zhen-Hua Hu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, 79N, Qingchun RD, Hangzhou, China.,Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yang-Jun Gu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, 79N, Qingchun RD, Hangzhou, China.,Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wen-Qi Qiu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, 79N, Qingchun RD, Hangzhou, China.,Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jie Xiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, 79N, Qingchun RD, Hangzhou, China.,Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhi-Wei Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, 79N, Qingchun RD, Hangzhou, China.,Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jie Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, 79N, Qingchun RD, Hangzhou, China.,Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shu-Sen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, 79N, Qingchun RD, Hangzhou, China. .,Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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7
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Zaman F, Abreo KD, Levine S, Maley W, Zibari GB. Pancreatic Transplantation: Evaluation and Management. J Intensive Care Med 2016; 19:127-39. [PMID: 15154994 DOI: 10.1177/0885066604263916] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
More than 2 million people in the United States have type 1 diabetes mellitus. Pancreatic transplantation has emerged as the single most effective means of achieving normal glucose homeostasis in this patient population. Newer immunosuppressive agents and surgical techniques continue to evolve, resulting in improved long-term graft and patient survival. Herein, an understanding of the evaluation, technical aspects, and perioperative management of pancreas transplantation is outlined.
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Affiliation(s)
- Fahim Zaman
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana71130, USA.
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8
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Kobayashi T, Gruessner AC, Wakai T, Sutherland DER. Three types of simultaneous pancreas and kidney transplantation. Transplant Proc 2015; 46:948-53. [PMID: 24767388 DOI: 10.1016/j.transproceed.2013.11.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 11/22/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE The purposes of this study were to study and compare clinical and functional outcomes after simultaneous deceased donor pancreas and kidney transplantation (SPK DD), simultaneous deceased donor pancreas and living donor kidney transplantation (SPK DL), and simultaneous living donor pancreas and kidney transplantation (SPK LL). METHODS From January 1, 1996 to September 1, 2005, 8918 primary, simultaneous pancreas and kidney transplantation (SPK) procedures were reported to the International Pancreas Transplant Registry. Of these, 8764 (98.3%) were SPK DD, 115 (1.3%) were SPK DL, and 39 (0.4%) were SPK LL. We compared these 3 groups with regard to several endpoints including patient and pancreas and kidney graft survival rates. RESULTS The 1-year and 3-year patient survival rates for SPK DD were 95% and 90%, 97% and 95% for SPK DL, and 100% and 100% for SPK LL recipients, respectively (P ≥ .07). The 1-year and 3-year pancreas graft survival rates for SPK DD were 84% and 77%, 83% and 71% for SPK DL, and 90% and 84% for SPK LL recipients, respectively (P ≥ .16). The 1-year and 3-year kidney graft survival rates for SPK DD were 92% and 84%, 94% and 86% for SPK DL, and 100% and 89% for SPK LL recipients, respectively (P ≥ .37). CONCLUSIONS Patient survival rates and graft survival rates for pancreas and kidney were similar among the 3 groups evaluated in this study.
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Affiliation(s)
- T Kobayashi
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - A C Gruessner
- College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - T Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - D E R Sutherland
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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10
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Martins LS, Outerelo C, Malheiro J, Fonseca IM, Henriques AC, Dias LS, Rodrigues AS, Cabrita AM, Noronha IL. Health-related quality of life may improve after transplantation in pancreas-kidney recipients. Clin Transplant 2015; 29:242-51. [PMID: 25581297 DOI: 10.1111/ctr.12511] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2015] [Indexed: 11/29/2022]
Abstract
Pancreas-kidney transplantation (PKT) may significantly improve quality of life (HRQOL) in patients with type 1 diabetes. We have assessed the changes felt by PKT patients, using the Gastrointestinal Quality of Life Index (GIQLI) and EuroQol-5D questionnaires. Patients were asked to compare how their HRQOL had changed from pre-transplantation to the last visit. The 60 men and 66 women enrolled had a mean follow-up of five yr; 84.1% with both grafts, 15.9% with one graft functioning. In all domains of EuroQol-5D scores improved after PKT, as well as the visual analogue scale health state (from 38% to 84%, p < 0.001; effect size 3.34). In GIQLI, physical function was felt better after PKT than before (14.83 ± 3.86 vs. 7.86 ± 4.43, p < 0.001; effect size 1.68); the same was observed for psychological status, social function, and GI complaints. Concerning the burden of medical treatment, the score significantly improved (from 1.31 to 3.63, p < 0.001, effect size 2.02). The rate of unemployed patients decreased after PKT (from 50.8% to 36.5%, p < 0.001). Multivariate analysis showed that having only one functioning graft was associated with worse HRQOL scores (B = -5.157, p = 0.015). In conclusion, for all assessed domains, patients reported a significant improvement in HRQOL after PKT. Maintenance of the two grafts functioning predicted higher improvement of HRQOL scores.
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Affiliation(s)
- La Salete Martins
- Nephrology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal; Transplantation Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, Institute of Biomedical Sciences Abel Salazar, University Hospital de Santo António, University of Porto, Porto, Portugal
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11
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Abstract
Pancreatic transplantation, performed alone or in conjunction with kidney transplantation, is an effective treatment for advanced type I diabetes mellitus and select patients with type II diabetes mellitus. Following advancements in surgical technique, postoperative management, and immunosuppression, pancreatic transplantation has significantly improved the length and quality of life for patients suffering from pancreatic dysfunction. While computed tomography (CT) and magnetic resonance imaging (MRI) have more limited utility, ultrasound is the preferred initial imaging modality to evaluate the transplanted pancreas; gray-scale assesses the parenchyma and fluid collections, while Doppler interrogation assesses vascular flow and viability. Ultrasound is also useful to guide percutaneous interventions for the transplanted pancreas. With knowledge of the surgical anatomy and common complications, the abdominal radiologist plays a central role in the perioperative and postoperative evaluation of the transplanted pancreas.
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Affiliation(s)
- Matthew T Heller
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Puneet Bhargava
- Department of Radiology, University of Washington Harborview Medical Center, Seattle, Washington, USA
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14
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Stanekzai J, Isenovic ER, Mousa SA. Treatment options for diabetes: potential role of stem cells. Diabetes Res Clin Pract 2012; 98:361-8. [PMID: 23020931 DOI: 10.1016/j.diabres.2012.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 06/27/2012] [Accepted: 09/04/2012] [Indexed: 01/09/2023]
Abstract
There are diseases and injuries in which a patient's cells or tissues are destroyed that can only be adequately corrected by tissue or organ transplants. Stem cells may be able to generate new tissue and even cure diseases for which there is no adequate therapy. Type 1 diabetes (T1DM), an insulin-dependent diabetes, is a chronic disease affecting genetically predisposed individuals, in which insulin-secreting beta (β)-cells within pancreatic islets of Langerhans are selectively and irreversibly destroyed by autoimmune assault. Type 2 diabetes (T2DM) is characterized by a gradual decrease in insulin sensitivity in peripheral tissues and the liver (insulin resistance), followed by a gradual decline in β-cell function and insulin secretion. Successful replacing of damaged β-cells has shown considerable potential in treating T1DM, but lack of adequate donors is a barrier. The literature suggests that embryonic and adult stem cells are promising alternatives in long-term treatment of diabetes. However, any successful strategy should address both the need for β-cell replacement and controlling the autoimmune response to cells that express insulin. This review summarizes the current knowledge of options and the potential of stem cell transplantation in diabetes treatment.
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Affiliation(s)
- Jamil Stanekzai
- Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive, Rensselaer, NY 12144, USA
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15
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Zhang SH, Wu HY, Zhu L. Current status of pancreas transplantation. Shijie Huaren Xiaohua Zazhi 2011; 19:1651-1658. [DOI: 10.11569/wcjd.v19.i16.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pancreas transplantation has emerged as the treatment of choice for patients with end-stage diabetes mellitus. Over the last four decades, many improvements have been made in the surgical techniques and immunosuppressive regimens, which contributed to increased number of indications and improved allograft survival. Pancreas transplantation can be justified on the basis that patients replace daily injections of insulin with an improved quality of life but at the expense of a major surgical procedure with a relatively higher complication rate, and lifelong immunosuppression. Therefore, efforts to develop more minimally invasive techniques for endocrine replacement therapy such as islet transplantation have been in progress. This article summarizes the current understanding of pancreas transplantation-associated indications, donor selection, surgical techniques, immunosuppression, and rejection.
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16
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Jahansouz C, Kumer SC, Ellenbogen M, Brayman KL. Evolution of β-Cell Replacement Therapy in Diabetes Mellitus: Pancreas Transplantation. Diabetes Technol Ther 2011; 13:395-418. [PMID: 21299398 DOI: 10.1089/dia.2010.0133] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus remains one of the leading causes of morbidity and mortality worldwide. According to the Centers for Disease Control and Prevention, approximately 23.6 million people in the United States are affected. Of these individuals, 5-10% have been diagnosed with type 1 diabetes mellitus (TIDM), an autoimmune disease. Although it often appears in childhood, T1DM may manifest at any age. The effects of T1DM can be devastating, as the disease often leads to significant secondary complications, morbidity, and decreased quality of life. Since the late 1960s, surgical treatment for diabetes mellitus has continued to evolve and has become a viable alternative to chronic insulin administration. In this review, the historical evolution, current status, graft efficacy, benefits, and complications of pancreas transplantation are explored.
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Affiliation(s)
- Cyrus Jahansouz
- University of Virginia School of Medicine, Charlottesville, Virginia, USA.
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17
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Speight J, Reaney MD, Woodcock AJ, Smith RM, Shaw JAM. Patient-reported outcomes following islet cell or pancreas transplantation (alone or after kidney) in Type 1 diabetes: a systematic review. Diabet Med 2010; 27:812-22. [PMID: 20636963 DOI: 10.1111/j.1464-5491.2010.03029.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS For selected individuals with complex Type 1 diabetes, pancreatic islet transplantation (IT) offers the potential of excellent glycaemic control without significant hypoglycaemia, balanced by the need for ongoing systemic immunosuppression. Increasingly, patient-reported outcomes (PROs) are considered alongside biomedical outcomes as a measure of transplant success. PROs in IT have not previously been compared directly with the closest alternate treatment option, pancreas transplant alone (PTA) or pancreas after kidney (PAK). METHODS We used a Population, Intervention, Comparisons, Outcomes (PICO) strategy to search Scopus and screened 314 references for inclusion. RESULTS Twelve studies [including PRO assessment of PAK, PTA, islet-after kidney (IAK) and islet transplant alone (ITA); n = 7-205] used a total of nine specified and two unspecified PRO measures. Results were mixed but identified some benefits which remained apparent up to 36 months post-transplant, including improvements in fear of hypoglycaemia, as well as some aspects of diabetes-specific quality of life (QoL) and general health status. Negative outcomes included short-term pain associated with the procedure, immunosuppressant side effects and depressed mood associated with loss of graft function. CONCLUSIONS The mixed results may be attributable to limited sample sizes. Also, some PRO measures may lack sensitivity to detect actual changes, as they exclude issues and domains of life likely to be important for QoL post-transplantation and when patients may no longer perceive themselves to have diabetes. Thus, the full impact of islet/pancreas transplantation (alone or after kidney) on QoL is unknown. Furthermore, no studies have assessed patient satisfaction, which may highlight further advantages and disadvantages of transplantation.
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Affiliation(s)
- J Speight
- AHP Research, Brunel Science Park, Kingston Lane, Uxbridge, UK.
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18
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Pancreas After Living Donor Kidney Versus Simultaneous Pancreas-Kidney Transplant: An Analysis of the Organ Procurement Transplant Network/United Network of Organ Sharing Database. Transplantation 2010; 89:1496-503. [DOI: 10.1097/tp.0b013e3181dd3587] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fridell JA, Mangus RS, Hollinger EF, Taber TE, Goble ML, Mohler E, Milgrom ML, Powelson JA. The case for pancreas after kidney transplantation. Clin Transplant 2009; 23:447-53. [DOI: 10.1111/j.1399-0012.2009.00996.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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20
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Kleinclauss F, Fauda M, Sutherland DER, Kleinclauss C, Gruessner RW, Matas AJ, Kasiske BL, Humar A, Kandaswamy R, Kaul S, Gruessner AC. Pancreas after living donor kidney transplants in diabetic patients: impact on long-term kidney graft function. Clin Transplant 2009; 23:437-46. [PMID: 19496790 DOI: 10.1111/j.1399-0012.2009.00998.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this single-institution study, we compared outcomes in diabetic recipients of living donor (LD) kidney transplants that did vs. did not undergo a subsequent pancreas transplant. Of 307 diabetic recipients who underwent LD kidney transplants from January 1, 1995, through December 31, 2003, a total of 175 underwent a subsequent pancreas after kidney (PAK) transplant; 75 were deemed eligible (E) for, but did not receive (for personal or financial reasons), a PAK, and thus had a kidney transplant alone (KTA); and 57 deemed ineligible (I) for a PAK because of comorbidity also had just a KTA. We analyzed the three groups (PAK, KTA-E, KTA-I) for differences in patient characteristics, glycemic control, renal function, patient and kidney graft survival rates, and causes of death. Kidney graft survival rates (actuarial) were similar in the PAK vs. KTA-E groups at one, five, and 10 yr post-transplant: 98%, 82%, and 67% (PAK) vs. 100%, 84%, and 62% (KTA-E) (p = 0.9). The long-term (greater than four yr post-transplant) estimated glomerular filtration rate (GFR) was higher in the PAK than in the KTA-E group: 53 +/- 20 mL/min (PAK) vs. 43 +/- 16 mL/min (KTA-E) (p = 0.016). The patient survival rates were also similar for the PAK and KTA-E groups. We conclude that the subsequent transplant of a pancreas after an LD kidney transplant does not adversely affect patient or kidney graft survival rates; in fact, it is associated with better long-term kidney graft function.
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Affiliation(s)
- Francois Kleinclauss
- Department of Surgery, Division of Renal Disease and Hypertension, University of Minnesota, Minneapolis, MN, USA.
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21
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Abstract
Since the introduction of pancreas transplantation more than 40 years ago, efforts to develop more minimally invasive techniques for endocrine replacement therapy have been in progress, yet this surgical procedure still remains the treatment of choice for diabetic patients with end-stage renal failure. Many improvements have been made in the surgical techniques and immunosuppressive regimens, both of which have contributed to an increasing number of indications for pancreas transplantation. This operation can be justified on the basis that patients replace daily injections of insulin with an improved quality of life but at the expense of a major surgical procedure and lifelong immunosuppression. The various indications, categories, and outcomes of patients having a pancreas transplant are discussed, particularly with reference to the effect on long-term diabetic complications.
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Affiliation(s)
- Steve A White
- Department of Hepatopancreatobiliary and Transplantation Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.
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22
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Abstract
Over the last 5 years, there has been a resumed interest in treating diabetes by transplantation, particularly islet transplantation. However, despite advances being reported in Canada and the US, replication in the UK has been much more difficult. At present there is still only one treatment that can consistently reverse insulin independence in the long-term and that is whole pancreas transplantation. Long-term normoglycaemia has beneficial effects on preventing and ameliorating the secondary complications of diabetes and will be discussed.
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Affiliation(s)
- S A White
- Department of Hepatobiliary and Transplant Surgery, The Freeman Hospital, Newcastle Upon Tyne, UK.
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23
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Lerner SM. Kidney and pancreas transplantation in type 1 diabetes mellitus. ACTA ACUST UNITED AC 2008; 75:372-84. [DOI: 10.1002/msj.20056] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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24
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Abstract
Preserving kidney function in patients after solitary pancreas transplantation (SPTx) is an important consideration, yet various factors may negatively impact long-term function of the native kidneys or kidney allograft. To determine changes in kidney function over time in a series of patients receiving SPTx, we conducted a retrospective analysis and tracked changes in serum creatinine (SCr) and calculated glomerular filtration rate (GFR) from baseline to 6 months, 1 year, or 3 years after SPTx in a series of pancreas after kidney transplants PAK; (n = 61) and pancreas transplants alone PTA; (n = 27) performed at our institution. The mean follow-up for the PAK and PTA groups was 3.4 and 2.7 years, respectively. In this series, 8% of patients after SPTx developed significant kidney failure, defined by either initiation of dialysis or receiving a kidney transplant (PAK-6, PTA-1). Twenty seven percent of SPTx patients with a baseline GFR < 60 suffered either an elevated SCr > 2.2, dialysis, or kidney transplant, whereas no patients with a baseline GFR > 60 developed significant kidney dysfunction. In the PAK group, the GFR did not show significant deterioration over time. In contrast to relatively stable kidney function in PAK patients, PTA patients experienced overall significantly greater rates of decline over time. GFR in PTA patients decreased from 78 +/- 19 (40 to 114) mL/min/1.73 m2 at baseline to 65 +/- 20 at 1 year (P = .006), while SCr increased from 1.03 +/- 0.25 mg/dL to 1.28 +/- 0.43 over the same time period (P = .012). These data show that kidney function may deteriorate after SPTx and proper patient selection may reduce the frequency of this complication.
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25
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Szakály P, Kalmár Nagy K, Wittmann I. The first case of single pancreas transplantation in Hungary. Orv Hetil 2008; 149:387-91. [DOI: 10.1556/oh.2008.28254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Az 1-es típusú inzulindependens cukorbetegség veseelégtelenséggel szövődött esetében a kombinált hasnyálmirigy- és veseátültetés az egyetlen olyan rutineljárás, mely inzulin nélkül normoglycaemiássá teszi a beteget jó vesefunkció mellett. A cukorbetegek egy részénél megtartott vesefunkció mellett is kialakulhat számos szövődmény. Ilyen esetben lehet választandó eljárás a hasnyálmirigy önmagában történő átültetése. 6 évvel hasnyálmirigy-transzplantációs programunk elindítását követően elvégeztük az első szóló hasnyálmirigy-átültetést. A beteg egy 40 éves férfi volt. Enterális drenázst alkalmaztunk portális vénás drenázs mellett. Időben kiterjesztett indukciós kezelésre IL-2-receptor-gátlót használtunk. A műtétből eredő technikai és immunológiai nehézségek ellenére szövődményünk nem volt, illetőleg kilökődést nem észleltünk. 3 évvel a műtét után betegünk életminősége jó, vesefunkciója megtartott, és nem szorul inzulinkezelésre. Összefoglalva megállapíthatjuk, hogy a szoliter hasnyálmirigy-átültetés rutinszerűen jó eredményekkel használható terápiás lehetőség az I-es típusú cukorbetegség veseelégtelenséggel nem komplikált eseteiben.
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Affiliation(s)
- Péter Szakály
- 1 Pécsi Tudományegyetem, Orvostudományi és Egészségtudományi Koordinációs Központ, Általános Orvostudományi Kar Sebészeti Klinika Pécs Ifjúság u. 13. 7624
| | - Károly Kalmár Nagy
- 1 Pécsi Tudományegyetem, Orvostudományi és Egészségtudományi Koordinációs Központ, Általános Orvostudományi Kar Sebészeti Klinika Pécs Ifjúság u. 13. 7624
| | - István Wittmann
- 2 Pécsi Tudományegyetem, Orvostudományi és Egészségtudományi Koordinációs Központ, Általános Orvostudományi Kar II. Belgyógyászati Klinika Pécs
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26
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Salvalaggio PR, Schnitzler MA, Abbott KC, Brennan DC, Irish W, Takemoto SK, Axelrod D, Santos LS, Kocak B, Willoughby L, Lentine KL. Patient and graft survival implications of simultaneous pancreas kidney transplantation from old donors. Am J Transplant 2007; 7:1561-71. [PMID: 17511681 DOI: 10.1111/j.1600-6143.2007.01818.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We investigated graft and patient survival implications of simultaneous pancreas kidney (SPK) transplant from old donors. Data describing patients with type 1 diabetes mellitus listed for an SPK transplant from 1994 to 2005 were drawn from Organ Procurement and Transplant Network registries. Allograft survival, patient survival and long-term survival expectations among SPK recipients from young (age <45 years) and old (age >/=45 years) donors were modeled by multivariate regression. We also examined predictors of reduced early access to young donor transplants. Of 16 496 eligible SPK candidates, 8850 patients (53.6%) received an SPK transplant and 776 (8.8%) of these transplants were from old donors. Reasonable 5-year, death-censored kidney (77.8 %) and pancreas (71.3%) survivals were achieved with old donors. SPK transplantation from both young and old donors predicted lower mortality compared to continued waiting. An additional expected wait of 1.5 years for a young donor equalized long-term survival expectations to that achieved with use of old donors. Early allocation of young donor transplants declined in the more recent era and varied by region, candidate age, blood type and sensitization. We conclude that old SPK donors should be considered for patients with decreased access to young donor transplants. Prospective evaluation of this practice is needed.
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Affiliation(s)
- P R Salvalaggio
- Center for Outcomes Research, and Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO, USA
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Bloom RD, Goldberg LR, Wang AY, Faust TW, Kotloff RM. An Overview of Solid Organ Transplantation. Clin Chest Med 2005; 26:529-43, v. [PMID: 16263394 DOI: 10.1016/j.ccm.2005.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Once a medical curiosity, solid organ transplantation is now a commonplace occurrence, with more than 27,000 procedures performed in the United States in 2004 alone. This article offers an overview of the various solid organ transplant procedures to provide a context within which subsequent articles on pulmonary complications can be viewed.
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Affiliation(s)
- Roy D Bloom
- Renal, Electrolyte, and Hypertension Division, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
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28
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Marroquin CE, Edwards EB, Collins BH, Desai DM, Tuttle-Newhall JE, Kuo PC. Half-Life Analysis of Pancreas and Kidney Transplants. Transplantation 2005; 80:272-5. [PMID: 16041274 DOI: 10.1097/01.tp.0000165094.94020.03] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although graft and patient survival data are available for pancreas and kidney transplants, they are rarely reported in terms of half-life. Our aim was to determine whether a more relevant measure of outcome is patient and allograft half-life. Using the data from the Organ Procurement and Transplantation Network Registry on kidney and pancreas transplants from January 1988 to December 1996, patient and graft half-life and 95% confidence intervals were calculated and demographic variables compared. No significant differences were found between demographic variables. Kidneys transplanted in diabetics as a simultaneous kidney-pancreas (SPK) fared better than diabetics receiving a kidney alone (9.6 vs. 6.3 years). Pancreatic graft survival in an SPK pair was better than pancreas after kidney transplant or pancreas transplant alone (11.2 vs. 2.5 years). Because kidney and pancreatic grafts have a longer half-life when transplanted with their mate grafts, we should consider the relative benefits of SPKs over pancreas after kidney transplant or pancreas transplant alone to limit the loss of precious resources.
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Affiliation(s)
- Carlos E Marroquin
- Duke University Medical Center, Department of Surgery, Durham, NC 27710, USA.
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29
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Abstract
Pancreas transplantation continues to evolve as a strategy in the management of diabetes mellitus. The first combined pancreas-kidney transplant was reported in 1967, but pancreas transplant now represents a number of procedures, each with different indications, risks, benefits, and outcomes. This review will summarize these procedures, including their risks and outcomes in comparison to kidney transplantation alone, and how or if they affect the consequences of diabetes: hyperglycemia, hypoglycemia, and microvascular and macrovascular complications. In addition, the new risks introduced by immunosuppression will be reviewed, including infections, cancer, osteoporosis, reproductive function, and the impact of immunosuppression medications on blood pressure, lipids, and glucose tolerance. It is imperative that an endocrinologist remain involved in the care of the pancreas transplant recipient, even when glucose is normal, because of the myriad of issues encountered post transplant, including ongoing management of diabetic complications, prevention of bone loss, and screening for failure of the pancreas graft with reinstitution of treatment when indicated. Although long-term patient and graft survival have improved greatly after pancreas transplant, a multidisciplinary team is needed to maximize long-term quality, as well as quantity, of life for the pancreas transplant recipient.
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Affiliation(s)
- Jennifer L Larsen
- Section of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, 983020 Nebraska Medical Center, Omaha, Nebraska 69198-3020, USA.
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30
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Abstract
Diabetes is a leading cause of morbidity and mortality worldwide. Complications of diabetes including renal failure, retinopathy, neuropathy, and cardiovascular disease limit both survival and quality of life. Pancreatic transplantation can restore euglycemia thereby stabilizing or even reversing secondary complications of diabetes as well as improving quality of life particularly in patients with labile diabetes. Recent evidence also shows an improved survival in diabetic patients that undergo pancreatic transplantation when combined with a kidney transplant. Pancreatic transplantation should more properly be referred to as beta cell replacement as the field today encompasses both whole organ and islet cell transplantation. We have outlined herein the indications and contraindications to islet or whole organ pancreas transplantation and we have described periprocedure care and short- and long-term prognosis.
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Affiliation(s)
- David L. Bigam
- University of Alberta Hospital, 8440-112 Street NW, Edmonton, Alberta, T6G 2B7, Canada
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31
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Abstract
In the face of a rising incidence of diabetes, pancreatic transplantation seems to be the only treatment capable of normalizing glycosylated hemoglobin and stabilizing or improving the complications of diabetes. To date, more than 19,000 pancreatic transplantations have been done worldwide. Surgical indications must take into account the constraints and risks specific to the diabetic illness, the risks of a complex surgical procedure, and the absolute necessity for long term immunosuppression. Combined kidney/pancreas transplantation is the most common procedure (90% of cases) and is the most effective treatment for renal insufficiency due to diabetes. Results have improved significantly over the last ten Years due to improvements in the surgical technique and to improvement of immunosuppressive regimens. Results are at least as good and perhaps better than those achieved in the transplantation of other solid organs; patient survival, renal graft survival, and pancreatic graft survival are respectively 95%, 92%, and 85% at one Year. Results of pancreatic transplantation alone have improved and now seem equal to those of combined organ transplantation. Transplantation seems to be cost-effective in the overall care of advanced diabetes, particularly in those patients on chronic dialysis or having degenerative complications.
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Affiliation(s)
- J P Duffas
- Service de Chirurgie Générale et Digestive, Hôpital Rangueil - Toulouse.
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32
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Abstract
Diabetic nephropathy affects both type 1 and type 2 diabetic patients with a frequency of 20-30%. The first sign is microalbuminuria within a range of 30-300 mg/24h, frequently evolving towards frank proteinuria and renal failure. Tight glucose control, control of arterial hypertension with the use of ACEi or ARB can retard progression. Once renal failure is established, kidney transplantation can be considered for type 1 and type 2 diabetic patients. Quality of life and survival are improved with this procedure. In type 1 diabetes, simultaneous grafting of a kidney and pancreas considerably improves quality of life and diabetic complications. Surgical and infectious complications are sporadic drawbacks of this procedure. Pancreas transplantation alone (PTA) remains controversial, since a retrospective study in 2003 by Venstrom concluded that survival for PTA patients is worse than for comparable patients remaining on the waiting list. PTA can be considered for type 1 diabetic patients without advanced renal failure with severe and frequent metabolic instability (hypoglycaemia, ketoacidosis). Islet transplantation is still an experimental but promising procedure in highly selected patients, avoiding major abdominal surgery.
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Affiliation(s)
- P Peeters
- Nephrology section, Dept of Internal Medicine, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium.
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33
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Bassetti M, Salvalaggio PRO, Topal J, Lorber MI, Friedman AL, Andriole VT, Basadonna GP. Incidence, timing and site of infections among pancreas transplant recipients. J Hosp Infect 2004; 56:184-90. [PMID: 15003665 DOI: 10.1016/j.jhin.2003.11.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2003] [Accepted: 11/10/2003] [Indexed: 12/22/2022]
Abstract
The incidence, timing and site of infections among the different categories of pancreas transplant recipients were investigated. Patients were divided into three groups: pancreas transplant alone (PTA), pancreas after kidney transplant (PAK), or simultaneous pancreas and kidney (SPK) transplants. Length of follow-up, time to death, pancreas graft survival, incidence, timing and site of bacterial infections were noted. Our study showed that at least 75% of pancreas transplant recipients experienced at least one infection (range from 77.8% in the PTA group to 86.7% in the PAK group). The SPK group presented the highest rate of infections with 35.1 infections per 1000/patient-days. Symptomatic urinary tract infections were the most common cause of infection in all patients. The incidence of infections was higher during the first month after transplantation, except for the SPK transplant group, where infections occurred over a longer time period.
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Affiliation(s)
- M Bassetti
- Department of Internal Medicine, Yale University School of Medicine and Yale New Haven Hospital, New Haven, CT 06510, USA.
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34
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Gaston RS, Alveranga DY, Becker BN, Distant DA, Held PJ, Bragg-Gresham JL, Humar A, Ting A, Wynn JJ, Leichtman AB. Kidney and pancreas transplantation. Am J Transplant 2004; 3 Suppl 4:64-77. [PMID: 12694051 DOI: 10.1034/j.1600-6143.3.s4.7.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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35
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Humar A, Khwaja K, Ramcharan T, Asolati M, Kandaswamy R, Gruessner RWG, Sutherland DER, Gruessner AC. Chronic rejection: the next major challenge for pancreas transplant recipients. Transplantation 2003; 76:918-23. [PMID: 14508354 DOI: 10.1097/01.tp.0000079457.43199.76] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE With newer immunosuppressive agents, acute rejection and graft loss resulting from acute rejection have become less common for pancreas transplant recipients. As long-term graft survival rates have improved, an increasing number of grafts are being lost to chronic rejection (CR). We studied the incidence of CR and identified risk factors. METHODS We retrospectively analyzed all cadaver pancreas transplants performed at the University of Minnesota between June 19, 1994, and December 31, 2002. We determined the causes of graft loss, the incidence of graft loss to CR and, using multivariate techniques, the major risk factors for CR. RESULTS A total of 914 cadaver pancreas transplants were performed in the following three categories: simultaneous pancreas-kidney (SPK) (n=321), pancreas after kidney (PAK) (n=389), and pancreas transplant alone (PTA) (n=204). The mean recipient age was 41.3 years and the mean donor age was 30.1 years. Of the 914 pancreas grafts, 643 (70.3%) continue to function (mean length of follow-up, 39 months). The most common cause of graft loss was technical failure, accounting for 118 (12.9%) of the failed grafts. The second most common cause was CR, accounting for 80 (8.8%) of the failed grafts. The incidence of graft loss to CR was highest for PTA (n=23 [11.3%]) and PAK (n=45 [11.6%]) recipients and lowest for SPK recipients (n=12 [3.7%]) (P=0.002). By multivariate analysis, the most significant risk factors for graft loss to CR were a previous episode of acute rejection (relative risk [RR]=4.41, P<0.0001), an isolated (vs. simultaneous) transplant (PAK or PTA [vs. SPK], RR=3.02, P=0.002), cytomegalovirus infection posttransplant (RR=2.41, P=0.001), a retransplant (versus primary transplant) (RR=2.27, P=0.004), and one or two (vs. zero) antigen mismatches at the B loci (RR=1.68, P=0.04). CONCLUSIONS As short-term pancreas transplant results improve and as isolated (PAK or PTA) pancreas transplants gain in popularity, CR will become increasingly common as a cause of pancreas graft loss.
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Affiliation(s)
- Abhinav Humar
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA.
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36
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Joseph JT, Baines LS, Morris MC, Jindal RM. Quality of life after kidney and pancreas transplantation: a review. Am J Kidney Dis 2003; 42:431-45. [PMID: 12955671 DOI: 10.1016/s0272-6386(03)00740-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
There is an increasing amount of data on quality of life (QOL) in most chronic illnesses; some of the instruments used are generic, but recently, there is a tendency to use disease-specific instruments. We propose that recipients of organ transplants be assessed routinely for QOL by means of the 36-Item Short-Form Health Survey or a disease-specific instrument; for compliance, by means of the Long-Term Medication Behavior Self-Efficacy Scale; and for psychological status, by means of the Beck Depression Inventory Brief Symptom Inventory or the Symptom Checklist. The widespread use of QOL data in recipients of organ transplants will increase accountability of service providers and eventually increase patient satisfaction because these instruments are patient reported.
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37
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Zieliński A, Nazarewski S, Bogetti D, Sileri P, Testa G, Sankary H, Benedetti E. Simultaneous pancreas-kidney transplant from living related donor: a single-center experience. Transplantation 2003; 76:547-52. [PMID: 12923442 DOI: 10.1097/01.tp.0000076624.79720.14] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Simultaneous pancreas and kidney transplantation (SPK) from cadaveric donors has become a widely accepted therapeutic option for insulin-dependent uremic patients. In 1996 the first SPK from a live donor was performed. This procedure offers the advantage of a better immunologic match, reduced cold ischemia injury, and decreased waiting time. As such, it is an attractive alternative treatment for diabetic patients with end-stage nephropathy with an available living donor. METHODS We performed six SPKs from living-related donors. There were four men and two women among the recipients; median age was 34 (range, 29-39) years. All donors were recipients' siblings with excellent HLA matching. Donors underwent standardized metabolic workup, anti-insulin and anti-islet antibody assays, and computed tomography of the abdomen. Both donors and recipients were treated with octreotide for 5 days perioperatively. After transplantation, the patients were maintained on tacrolimus-based immunosuppression, with the exception of one recipient of SPK from an identical twin, who received cyclosporine monotherapy. RESULTS All the donors are doing well and have normal renal function and blood glucose levels. One-year patient, renal, and pancreatic graft survival rates were 100%, 100%, and 83%, respectively. Acute kidney rejection was documented in two patients, and both recovered completely after OKT3 therapy. No rejection of pancreatic graft has been documented. Except for one patient who lost the graft because of hemorrhagic pancreatitis, all recipients maintained serum glucose levels at less than 130 mg/dL without insulin therapy. No major surgical complications such as graft thrombosis, intra-abdominal infection, or abscess were reported. CONCLUSIONS Living donor SPK can represent a successful alternative to cadaveric donor SPK. The procedure can be performed safely in the donor and with low morbidity in the recipient.
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Affiliation(s)
- Adam Zieliński
- Department of Surgery, University of Illinois at Chicago, Chicago, IL 60612, USA
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38
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Nikolaidis P, Amin RS, Hwang CM, Mc Carthy RM, Clark JH, Gruber SA, Chen PC. Role of sonography in pancreatic transplantation. Radiographics 2003; 23:939-49. [PMID: 12853668 DOI: 10.1148/rg.234025160] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite recent advancements in surgical technique and immunosuppressive therapy, postoperative complications of pancreatic transplantation are still common. A complex spectrum of such adverse events includes graft rejection, peripancreatic fluid collections, pancreatitis, exocrine leaks, vascular thrombosis, and hemorrhage. Sonography plays a key role in the initial evaluation of the transplanted pancreas. Gray-scale sonography, duplex Doppler imaging, and sonographic guidance for percutaneous biopsy all contribute to posttransplantation evaluation and detection of sequelae. Color and power Doppler imaging offer valuable information regarding the regional vasculature and potential vascular complications. Because gray-scale sonographic findings alone are often nonspecific, several clinical criteria, including those from biochemical analysis of the urine and serum, must be reviewed with the sonographic findings to provide a thorough evaluation of the transplanted pancreas. When used in conjunction with serologic and urinary markers, the findings from sonography can help direct management options or suggest the need for further examination. Therefore, an understanding of the spectrum of complications combined with knowledge concerning the limitations of this imaging modality are essential for proper diagnosis and effective treatment.
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Affiliation(s)
- Paul Nikolaidis
- Department of Radiology, Northwestern University Medical School, 676 N St Clair St, Suite 800, Chicago, IL 60611, USA.
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39
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Simultaneous cadaveric pancreas and living donor kidney transplant: a logistic nightmare or a reasonable solution compared with PAK? Curr Opin Organ Transplant 2003. [DOI: 10.1097/00075200-200306000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Hariharan S, Pirsch JD, Lu CY, Chan L, Pesavento TE, Alexander S, Bumgardner GL, Baasadona G, Hricik DE, Pescovitz MD, Rubin NT, Stratta RJ. Pancreas after kidney transplantation. J Am Soc Nephrol 2002; 13:1109-1118. [PMID: 11912273 DOI: 10.1681/asn.v1341109] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Sundaram Hariharan
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - John D Pirsch
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Christopher Y Lu
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Laurence Chan
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Todd E Pesavento
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Steven Alexander
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Ginny L Bumgardner
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Giacomo Baasadona
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Donald E Hricik
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Mark D Pescovitz
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Nina T Rubin
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Robert J Stratta
- *Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Transplant Surgery, University of Wisconsin, Madison, Wisconsin; Division of Nephrology, University of Texas, Dallas, Texas; Division of Nephrology, University of Colorado, Denver, Colorado; Division of Nephrology, Ohio State University, Columbus, Ohio; Division of Pediatric Nephrology, Stanford University, Stanford, California; #Department of Transplant Surgery, Yale University, New Haven, Connecticut; **Division of Nephrology, Case Western Reserve University, Cleveland, Ohio; Department of Transplant Surgery, Indiana University, Indianapolis, Indiana; Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and Department of Transplant Surgery, Wake Forest University, Winston-Salem, North Carolina
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