1
|
Raveh Y, Ciancio G, Burke GW, Figueiro J, Chen L, Morsi M, Namias N, Singh BP, Lindsay M, Alfahel W, Sleem MS, Nicolau-Raducu R. Susceptibility-directed anticoagulation after pancreas transplantation: A single-center retrospective study. Clin Transplant 2019; 33:e13619. [PMID: 31152563 DOI: 10.1111/ctr.13619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 02/06/2023]
Abstract
Pancreas transplant achieves consistent long-term euglycemia in type 1 diabetes. Allograft thrombosis (AT) causes the majority of early graft failure. We compared outcomes of four anticoagulation regimens administered to 95 simultaneous kidney-pancreas or isolated pancreas transplanted between 1/1/2015 and 11/20/2018. Early postoperative anticoagulation regimens included the following: none, subcutaneous heparin/aspirin, with or without dextran, and heparin infusion. The regimens were empirically selected based on each surgeon's assessment of hemostasis of the operative field and personal preference. A sonographic-based global scoring system of AT is presented. The 47-month recipients and graft survival were 95% and 86%, respectively. Recipients with or without AT had similar survival. Five and four grafts were lost due to death and AT, respectively. Outcomes of prophylaxis regimens correlated with intensity of anticoagulation. Compared with no anticoagulation, an increase in hemorrhagic complications occurred exclusively with iv heparin. The higher arterial AT score found in regimens lacking antiplatelet therapy highlights the importance of early antiaggregants therapy. Abnormal fibrinolysis was associated with an increase in AT score. Platelet dysfunction, warm ischemia time, and enteric drainage were predictive of AT and, along with other known risk factors, were incorporated into an algorithm that matches intensity of early postoperative anticoagulation to the thrombotic risk.
Collapse
Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Gaetano Ciancio
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - George W Burke
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Jose Figueiro
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Linda Chen
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Mahmoud Morsi
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Nicholas Namias
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Bhavna P Singh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Martine Lindsay
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Waseem Alfahel
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Mahmoud S Sleem
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Ramona Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| |
Collapse
|
2
|
Patel SR, Hakim N. Prevention and management of graft thrombosis in pancreatic transplant. EXP CLIN TRANSPLANT 2013; 10:282-9. [PMID: 22631067 DOI: 10.6002/ect.2012.0003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pancreatic transplant effectively cures type 1 diabetes mellitus and maintains consistent long-term euglycemia. However, technical failure, and in particular graft thrombosis, accounts for the vast majority of transplants lost in the early postoperative period. The pancreas' inherently low microvascular flow state makes it vulnerable to vascular complications, as does the hypercoagulable blood of diabetic patients. Ultimately, the phenomenon is most definitely multifactorial. Prevention, as opposed to treatment, is key and should focus on reducing these multiple risk factors. This will involve tactical donor selection, optimal surgical technique and some form of anticoagulation. Close monitoring and early intervention will be crucial when treating thrombosis once preventative methods have failed. This may be achieved by further anticoagulation, graft salvage, or pancreatectomy with retransplant. This article will explore the multiple factors contributing to graft thrombus formation and the ways in which they may be addressed to firstly prevent, or more likely, reduce thrombosis. Secondly, we will consider the management strategies which can be implemented once thrombosis has occurred.
Collapse
Affiliation(s)
- Shaneel R Patel
- The West London Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | |
Collapse
|
3
|
Adamec M, Janouŝek L, Lipár K, Tosenovský P, Hampl F, Saudek F, Koznarová R, Boucek P, Havrdová T. A prospective comparison of bladder versus enteric drainage in vascularized pancreas transplantation. Transplant Proc 2005; 36:1524-5. [PMID: 15251375 DOI: 10.1016/j.transproceed.2004.04.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In previous years, the number of pancreas transplants has increased significantly. Debate continues over the optimum technique for exocrine drainage. Enteric drainage (ED) has recently been increasingly popular owing to the long-term complications of bladder drainage (BD). We prospectively evaluated 40 consecutive pancreas transplant recipients undergoing either bladder (n = 20) or enteric (n = 20) drainage. After simultaneous kidney-pancreas transplantation 1-year patient, kidney, and pancreas graft survival rates were 95%, 95%, 85% for the BD group, and 90%, 85%, 85%, for the ED group. Surgical complications were not significantly different between the two groups. The incidence of acute rejection, major infections and cytomegalovirus disease were also similar. The length of the initial hospital stay was likewise comparable. However, the BD group was characterized by a slight increase in the number of urologic complications, metabolic acidosis, and dehydration. Our results suggest excellent patient and graft survival irrespective of the drainage technique.
Collapse
Affiliation(s)
- M Adamec
- Transplant Surgery Department, IKEM, Prague, Czech Republic
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Gonzalez AM, Lopes Filho GDJ, Triviño T, Messetti F, Rangel ÉB, Melaragno C. Opções técnicas utilizadas no transplante pancreático em centros brasileiros. Rev Col Bras Cir 2005. [DOI: 10.1590/s0100-69912005000100006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Analisar o perfil dos principais centros de transplantes do Brasil, quanto às opções técnicas no transplante de pâncreas. MÉTODO: Foi encaminhado um questionário por correio eletrônico (email) para um membro de cada equipe de 12 centros de transplante do Brasil, com casuística mínima de um transplante de pâncreas. O questionário continha 10 perguntas, abordando aspectos controversos e não padronizados. RESULTADOS: A maioria dos centros (90,9%) utiliza incisão mediana. O órgão de escolha a ser implantado primeiro foi principalmente o rim, em 63% dos centros. Em relação à drenagem venosa, 90,9% utilizam a drenagem sistêmica. A ligadura da veia ilíaca interna é realizada em 54,5% dos centros. A maioria dos centros (90,9%) utiliza a drenagem entérica para transplante combinado pâncreas-rim. Para o transplante de pâncreas isolado, apenas cinco centros responderam, sendo que dois utilizam a drenagem entérica e três a vesical. A utilização de dreno na cavidade abdominal ocorre em 63% dos centros. Em 72,7% dos centros é realizada algum tipo de indução na imunossupressão para o transplante combinado pâncreas-rim, sendo a imunossupressão básica a associação de tacrolimus (FK506), micofenolato mofetil (MMF) e corticóide. A antibioticoprofilaxia é realizada por todos os centros e profilaxia para fungos é realizada por seis centros (54,5%). Oito centros (72,7%) utilizam algum tipo de profilaxia para trombose vascular, em esquemas diversos. CONCLUSÃO: Existem diversos caminhos técnicos na condução do transplante pancreático. A falta de padronização dificulta a análise e a comparação dos resultados. Apesar dessa heterogeneidade das equipes, observamos uma tendência para a realização de incisão mediana, drenagem venosa sistêmica e exócrina entérica, com a utilização de algum tipo de profilaxia para trombose vascular nos transplantes combinados pâncreas-rim.
Collapse
|