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Malik AK, Tingle SJ, Chung N, Owen R, Mahendran B, Counter C, Sinha S, Muthasamy A, Sutherland A, Casey J, Drage M, van Dellen D, Callaghan CJ, Elker D, Manas DM, Pettigrew GJ, Wilson CH, White SA. The impact of time to death in donors after circulatory death on recipient outcome in simultaneous pancreas-kidney transplantation. Am J Transplant 2024:S1600-6135(24)00134-5. [PMID: 38360185 DOI: 10.1016/j.ajt.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/27/2024] [Accepted: 02/07/2024] [Indexed: 02/17/2024]
Abstract
The time to arrest donors after circulatory death is unpredictable and can vary. This leads to variable periods of warm ischemic damage prior to pancreas transplantation. There is little evidence supporting procurement team stand-down times based on donor time to death (TTD). We examined what impact TTD had on pancreas graft outcomes following donors after circulatory death (DCD) simultaneous pancreas-kidney transplantation. Data were extracted from the UK transplant registry from 2014 to 2022. Predictors of graft loss were evaluated using a Cox proportional hazards model. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. Three-hundred-and-seventy-five DCD simultaneous kidney-pancreas transplant recipients were included. Increasing TTD was not associated with graft survival (adjusted hazard ratio HR 0.98, 95% confidence interval 0.68-1.41, P = .901). Increasing asystolic time worsened graft survival (adjusted hazard ratio 2.51, 95% confidence interval 1.16-5.43, P = .020). Restricted cubic spline modeling revealed a nonlinear relationship between asystolic time and graft survival and no relationship between TTD and graft survival. We found no evidence that TTD impacts pancreas graft survival after DCD simultaneous pancreas-kidney transplantation; however, increasing asystolic time was a significant predictor of graft loss. Procurement teams should attempt to minimize asystolic time to optimize pancreas graft survival rather than focus on the duration of TTD.
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Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK.
| | - Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | - Nicholas Chung
- Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Ruth Owen
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Balaji Mahendran
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | | | - Sanjay Sinha
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - John Casey
- Edinburgh Royal Infirmary, Edinburgh, UK
| | - Martin Drage
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Chris J Callaghan
- NHS Blood and Transplant, Bristol, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Doruk Elker
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Derek M Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; NHS Blood and Transplant, Bristol, UK
| | - Gavin J Pettigrew
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Colin H Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | - Steven A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; NHS Blood and Transplant, Bristol, UK
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2
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Gopal JP, McLean A, Muthusamy A. Metabolic Outcomes After Pancreas Transplant Alone From Donation After Circulatory Death Donors-The UK Transplant Registry Analysis. Transpl Int 2023; 36:11205. [PMID: 37266028 PMCID: PMC10229791 DOI: 10.3389/ti.2023.11205] [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: 01/18/2023] [Accepted: 05/04/2023] [Indexed: 06/03/2023]
Abstract
Extrapolating data from early DCD (donation after circulatory death) kidney transplantation, pancreas transplants from DCD grafts were feared to have worse metabolic outcomes. Hence, we aimed to address the question of pancreas transplant alone (PTA) from DCD donors-are our concerns justified? A UK transplant registry analysis of 185 PTA performed between 2005 and 2018 was done. All early graft losses (<3 months) were excluded to allow focus on the metabolic outcomes (HbA1c, weight gain and incidence of secondary diabetic macrovascular complications). The aim was to compare the metabolic outcomes, rejection rates (including the need for steroids), patient and graft survival between DBD (Donation after brainstem death) and DCD groups. After excluding early graft losses, data from 162 PTA (DBD = 114 and DCD = 48) were analyzed. Body mass index of the donor was less in DCD group (DBD = 23.40 vs. DCD = 22.25, p = 0.006) and the rest of the baseline transplant characteristics were comparable. There were no significant differences in the HbA1c, weight gain, rejection rate, and incidence of secondary diabetic macrovascular complications post-transplant between DBD and DCD recipients. The 1-, 5-, and 10-year patient and graft survival were similar in both the groups. PTA from DCD donors have equivalent metabolic outcomes and survival (patient/graft) as that of DBD donors.
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Affiliation(s)
- Jeevan Prakash Gopal
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Adam McLean
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Anand Muthusamy
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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3
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Cappucci SP, Smith WS, Schwartzstein R, White DB, Mitchell SL, Fehnel CR. End-Of-Life Care in the Potential Donor after Circulatory Death: A Systematic Review. Neurohospitalist 2023; 13:61-68. [PMID: 36531837 PMCID: PMC9755608 DOI: 10.1177/19418744221123194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Donation after circulatory death (DCD) is becoming increasingly common, yet little is known about the way potential donors receive end-of-life care. Purpose The aims of this systematic review are to describe the current practice in end-of-life care for potential donors and identify metrics that are being used to assess discomfort among these patients. Research design and Study Sample This review encompasses published literature between June 1, 2000 and June 31, 2020 of end-of-life care received by potential DCD patients. The population of interest was defined as patients eligible for Maastracht classification III donation after circulatory death for a solid organ transplantation. Outcomes examined included: analgesic or palliative protocols, and surrogates of discomfort (eg dyspnea, agitation). Results Among 141 unique articles, 27 studies were included for full review. The primary reason for exclusion was lack of protocol description, or lack of reporting on analgesic medications. No primary research studies specifically examined distress in the DCD eligible population. Numerous professional guidelines were identified. Surveys of critical care practitioners identified concerns regarding the impact of symptom management on hastening the dying process in the DCD population as a potential barrier to end-of-life palliative treatment. Conclusions There is a paucity of empirical evidence for end-of-life symptom assessment and management for DCD patients. Key evidence gaps identified for DCD include the need for: i) a multidisciplinary structure of treatment teams and preferred environment for DCD, ii) objective tools for monitoring of distress in this patient population, and iii) evidence guiding the administration of analgesic medications following withdrawal of life sustaining therapy.
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Affiliation(s)
- Stefanie P Cappucci
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wade S Smith
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas B White
- Department of Critical Care, University of PittsburghSchool of Medicine, Pittsburgh, PA, USA
| | - Susan L Mitchell
- Harvard Medical School, Boston, MA, USA
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
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4
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Campsen J, Zimmerman MA. Pancreas transplantation following donation after circulatory death. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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5
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Pancreas Transplantation from Donors after Cardiac Death – The US Experience. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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6
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Honarmand K, Alshamsi F, Foroutan F, Rochwerg B, Belley-Cote E, Mclure G, D'Aragon F, Ball IM, Sener A, Selzner M, Guyatt G, Meade MO. Antemortem Heparin in Organ Donation After Circulatory Death Determination: A Systematic Review of the Literature. Transplantation 2021; 105:e337-e346. [PMID: 33901108 DOI: 10.1097/tp.0000000000003793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Donation after circulatory death determination frequently involves antemortem heparin administration to mitigate peri-arrest microvascular thrombosis. We systematically reviewed the literature to: (1) describe heparin administration practices and (2) explore the effects on transplant outcomes. We searched MEDLINE and EMBASE for studies reporting donation after circulatory death determination heparin practices including use, dosage, and timing (objective 1). To explore associations between antemortem heparin and transplant outcomes (objective 2), we (1) summarized within-study comparisons and (2) used meta-regression analyses to examine associations between proportions of donors that received heparin and transplant outcomes. We assessed risk of bias using the Newcastle Ottawa Scale and applied the GRADE methodology to determine certainty in the evidence. For objective 1, among 55 eligible studies, 48 reported heparin administration to at least some donors (range: 15.8%-100%) at variable doses (up to 1000 units/kg) and times relative to withdrawal of life-sustaining therapy. For objective 2, 7 studies that directly compared liver transplants with and without antemortem heparin reported lower rates of primary nonfunction, hepatic artery thrombosis, graft failure at 5 y, or recipient mortality (low certainty of evidence). In contrast, meta-regression analysis of 32 liver transplant studies detected no associations between the proportion of donors that received heparin and rates of early allograft dysfunction, primary nonfunction, hepatic artery thrombosis, biliary ischemia, graft failure, retransplantation, or patient survival (very low certainty of evidence). In conclusion, antemortem heparin practices vary substantially with an uncertain effect on transplant outcomes. Given the controversies surrounding antemortem heparin, clinical trials may be warranted.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Graham Mclure
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Frederick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Alp Sener
- Department of Surgery and Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Markus Selzner
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Maureen O Meade
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
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7
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Callaghan CJ, Ibrahim M, Counter C, Casey J, Friend PJ, Watson CJE, Karydis N. Outcomes after simultaneous pancreas-kidney transplantation from donation after circulatory death donors: A UK registry analysis. Am J Transplant 2021; 21:3673-3683. [PMID: 33870619 DOI: 10.1111/ajt.16604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 01/25/2023]
Abstract
There are concerns that simultaneous pancreas-kidney (SPK) transplants from donation after circulatory death (DCD) donors have a higher risk of graft failure than those from donation after brain death (DBD) donors. A UK registry analysis of SPK transplants between 2005 and 2018 was performed. Pancreas survivals of those receiving organs from DCD or DBD donors were compared. Multivariable analyses were used to adjust for baseline differences between the two groups and to identify factors associated with pancreas graft loss. A total of 2228 SPK transplants were implanted; 403 (18.1%) were from DCD donors. DCD donors were generally younger, slimmer, less likely to have stroke as a cause of death, with lower terminal creatinines and shorter pancreas cold ischemic times than DBD donors. Median (IQR) follow-up was 4.2 (1.6-8.1) years. On univariable analysis, there were no statistically significant differences in 5-year death-censored pancreas graft survival between the two donor types (79.5% versus 80.4%; p = .86). Multivariable analysis showed no statistically significant differences in 5-year pancreas graft loss between transplants from DCD (n = 343) and DBD (n = 1492) donors (hazard ratio 1.26, 95% CI 0.76-1.23; p = .12). The findings from this study support the increased use of SPK transplants from DCD donors.
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Affiliation(s)
- Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Statistics and Clinical Studies, National Health Service Blood and Transplant, Bristol, UK
| | - Claire Counter
- Statistics and Clinical Studies, National Health Service Blood and Transplant, Bristol, UK
| | - John Casey
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, The NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Cambridge, UK
| | - Nikolaos Karydis
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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8
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Outcomes From Brain Death Donors With Previous Cardiac Arrest Accepted for Pancreas Transplantation: A Single-center Retrospective Analysis. Ann Surg 2021; 273:e230-e238. [PMID: 30829695 DOI: 10.1097/sla.0000000000003218] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the effect of cardiac arrest time (CAT) in donors after brain death (DBD) donors on pancreas transplant outcome. SUMMARY OF BACKGROUND DATA Results from donors after circulatory death report good outcomes despite warm ischemia times up to 57 minutes. Previous cardiac arrest in DBD has been addressed as a potential risk factor, but duration of the CAT has never been evaluated. METHODS We conducted a retrospective analysis including 342 pancreas transplants performed at our center from 2000 to 2016, and evaluated the effect of previous cardiac arrest in DBD (caDBD) on pancreas transplant outcomes. RESULTS A total of 49 (14.3%) caDBD were accepted for transplantation [median CAT of 5.0 min (IQR 2.5-15.0)]. Anoxic encephalopathy was most frequent and P-PASS higher (16.9 vs 15.6) in caDBD group when compared with other DBD. No differences were found in all other characteristics evaluated.Graft survival was similar between both groups, as was the incidence of early graft failure (EGF). CAT increased the risk for EGF [OR 1.09 (95% CI, 1.01-1.17)], and the duration of CPR discriminated for EGF [AUC of 0.86 (95% CI, 0.74-0.98)], with a sensitivity and specificity of 100% and 75% at a cutoff of 15 minutes. When evaluated separately, caDBD >15 min increased over 5 times the risk for EGF [HR 5.80 (95% CI, 1.82-18.56); P = 0.003], and these presented fewer days on the ICU (1.0 vs 3.0 d). CONCLUSION CaDBD donors are suitable for routine pancreas transplantation without increasing EGF risk, and in those with longer CAT it may be prudent to postpone donation a few days to allow a thorough evaluation of organ damage following cardiac arrest.
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9
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Casanova D, Gutierrez G, Noriega MG, Castillo F. Complications during multiorgan retrieval and pancreas preservation. World J Transplant 2020; 10:381-391. [PMID: 33437671 PMCID: PMC7769728 DOI: 10.5500/wjt.v10.i12.381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/04/2020] [Accepted: 10/05/2020] [Indexed: 02/05/2023] Open
Abstract
In pancreas transplantation, complications can arise at each step of the process, from the initial selection of donors and recipients through the surgical technique itself and the post-operative period, when lifelong immunosuppression is required. In the early steps, careful retrieval and preservation of the pancreas are crucial for the viability of the organ and ultimate success of the transplant. The pancreas is a low-flow gland, making it highly sensitive to transplantation conditions and presenting risk of pancreatitis due to periods of ischemia. The two groups of donors - after brain death (DBD) or after cardiac arrest (DCD) - require different strategies of retrieval and preservation to avoid or reduce the risk of complications developing during and after the transplantation. For DBD donor transplantation, multiorgan retrieval and cold preservation is the conventional technique. Asystole donor (DCD) transplantation, in contrast, can benefit from the newest technologies, such as hypothermic and especially normothermic preservation machines (referred to as NECMO), to optimize organ preservation. The latter has led to an increase in the pool of donors by facilitating recuperation of organs for transplantation that would have been discarded otherwise.
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Affiliation(s)
- Daniel Casanova
- Department of Surgery, University Hospital Marques de Valdecilla, University Cantabria, Santander 39008, Cantabria, Spain
| | - Gonzalo Gutierrez
- Department of Surgery, University Hospital Marques de Valdecilla, Santander 39008, Cantabria, Spain
| | - Monica Gonzalez Noriega
- Department of Surgery, University Hospital Marques de Valdecilla, Santander 39008, Cantabria, Spain
| | - Federico Castillo
- Department of Surgery, University Hospital Marques de Valdecilla, Santander 39008, Cantabria, Spain
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10
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Parajuli S, Muth BL, Astor BC, Redfield RR, Mandelbrot DA, Odorico JS, Djamali A, Kaufman DB. Delayed kidney graft function in simultaneous pancreas-kidney transplant recipients is associated with early pancreas allograft failure. Am J Transplant 2020; 20:2822-2831. [PMID: 32306520 DOI: 10.1111/ajt.15923] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/13/2020] [Accepted: 04/02/2020] [Indexed: 01/25/2023]
Abstract
Delayed graft function (DGF) is a common complication associated with significant untoward effects in kidney-alone transplantation. The incidence and outcomes following kidney delayed graft function (K-DGF) among patients undergoing simultaneous pancreas-kidney (SPK) transplantation are less certain. We analyzed SPK recipients transplanted at our center between January 1994 and December 2017. A total of 632 recipients fulfilled the selection criteria, including 69 (11%) with K-DGF and 563 without. The incidence of K-DGF was significantly higher in recipients of organs from older donors and donation after circulatory death (DCD). The presence of K-DGF was significantly associated with an increased risk of pancreas graft failure during the first 90 days (n = 9, incidence rate [IR] 2.45/100 person-months), but not with late pancreas failure (n = 32, IR 0.84/100 person-months), kidney graft failure, or patient death. Although DCD was associated with K-DGF, it was not associated with either pancreas (hazard ratio [HR] 0.91, 95% CI 0.58-1.44, P = .69) or kidney (HR 1.09, 95% CI 0.66-1.82, P = .74) graft failure after adjustment for potential confounders. We found K-DGF to be a significant risk factor for pancreas graft failure but not kidney graft failure, with the major risk period being early (<90 days) posttransplant, and the major donor risk factor being older donor age.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brenda L Muth
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Department of Population Health Sciences, 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
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jon S Odorico
- 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
| | - Dixon B Kaufman
- Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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11
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Shingde R, Calisa V, Craig JC, Chapman JR, Webster AC, Pleass H, O’Connell PJ, Allen R, Robertson P, Yuen L, Kable K, Nankivell B, Rogers NM, Wong G. Relative survival and quality of life benefits of pancreas–kidney transplantation, deceased kidney transplantation and dialysis in type 1 diabetes mellitus—a probabilistic simulation model. Transpl Int 2020; 33:1393-1404. [DOI: 10.1111/tri.13679] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/27/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Rashmi Shingde
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
| | - Vaishnavi Calisa
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health Flinders University Adelaide SA Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Angela C. Webster
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
- Sydney School of Public Health University of Sydney Sydney NSW Australia
| | - Henry Pleass
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Philip J. O’Connell
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Richard Allen
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Paul Robertson
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Lawrence Yuen
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Kathy Kable
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Brian Nankivell
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Natasha M. Rogers
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Germaine Wong
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
- College of Medicine and Public Health Flinders University Adelaide SA Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Sydney School of Public Health University of Sydney Sydney NSW Australia
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12
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Shahrestani S, Chen S, Hitos K, Hameed A, Davies S, Goire N, Pleass HC, Hawthorne WJ. Culture of Transplant Perfusate Using BACTEC Technology and Antibiotic Prophylaxis Influences Wound Complications Within a Kidney Transplant and SPK Transplant Cohort. Transplant Proc 2020; 52:2909-2915. [PMID: 32580872 DOI: 10.1016/j.transproceed.2020.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/25/2020] [Accepted: 03/12/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Routine screening for microbial contamination in organ recovery perfusion transport solution (ORPTS) is by microbiological culture without broth enrichment. Our aim was to examine the clinical utility of broth enrichment of perfusion solution, through use of BACTEC (Becton Dickinson) blood culture media, in preventing wound complications for transplant recipients in comparison with culture without enrichment. METHODS We prospectively collected samples of ORPTS of 395 kidney (n = 250) or simultaneous pancreas-kidney (SPK, n = 145) donors over a 7-year period. Results of culture with and without broth enrichment (n = 285) using BACTEC blood culture media were examined to compare the sensitivity of BACTEC with non-BACTEC methods. We then conducted a paired analysis of 110 recipients with both BACTEC and non-BACTEC culture organ perfusion media. We examined the rates of wound infection and whether the use of targeted antimicrobials reduced infections in the BACTEC group and recipients with both types of cultures. RESULTS Of 395 patients with cultures of ORPTS, first, the results of 79 cultures performed using BACTEC media only were compared with 206 non-BACTEC cultures (n = 285). Second, 110 cultures were performed using both methods. For the first part of the study, BACTEC media detected significantly greater microbial growth than non-BACTEC methods (n = 79, 64.6% vs n = 206, 14.6%; P < .001). In the 110 patients with both BACTEC (52.3%) and non-BACTEC cultures (9.9%), there was significantly higher sensitivity of the BACTEC method (P < .001); 68.2% of these patients had antimicrobial cover in the days immediately following transplant sufficient to cover the cultured organism. In the patients with appropriate antimicrobial cover, the rate of recipient wound infection was significantly reduced (P = .003). CONCLUSIONS Routine screening of ORPTS with BACTEC broth enrichment should always be employed. When paired with antimicrobial prophylaxis, it has the potential to significantly reduce the risk of recipient wound infection.
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Affiliation(s)
- Sara Shahrestani
- Sydney Medical School, University of Sydney, NSW, 2145, Australia; The Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Westmead, NSW, 2145, Australia; The Department of Surgery, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Sharon Chen
- Sydney Medical School, University of Sydney, NSW, 2145, Australia; Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia; The Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney
| | - Kerry Hitos
- Sydney Medical School, University of Sydney, NSW, 2145, Australia; Westmead Research Centre for Evaluation of Surgical Outcomes, Department of Surgery, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Ahmer Hameed
- Sydney Medical School, University of Sydney, NSW, 2145, Australia; The Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Westmead, NSW, 2145, Australia; The Department of Surgery, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Sussan Davies
- The Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Westmead, NSW, 2145, Australia
| | - Namraj Goire
- Sydney Medical School, University of Sydney, NSW, 2145, Australia
| | - Henry C Pleass
- Sydney Medical School, University of Sydney, NSW, 2145, Australia; The Department of Surgery, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Wayne J Hawthorne
- Sydney Medical School, University of Sydney, NSW, 2145, Australia; The Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Westmead, NSW, 2145, Australia; The Department of Surgery, Westmead Hospital, Westmead, NSW, 2145, Australia.
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Abstract
PURPOSE OF REVIEW Beta-cell replacement is the best therapeutic option for patients with type 1 diabetes. Because of donor scarcity, more extended criteria donors are used for transplantation. Donation after circulatory death donors (DCD) are not commonly used for pancreas transplantation, because of the supposed higher risk of complications. This review gives an overview on the pathophysiology, risk factors, and outcome in DCD transplantation and discusses different preservation methods. RECENT FINDINGS Studies on outcomes of DCD pancreata show similar results compared with those of donation after brain death (DBD), when accumulation of other risk factors is avoided. Hypothermic machine perfusion is shown to be a safe method to improve graft viability in experimental settings. DCD should not be the sole reason to decline a pancreas for transplantation. Adequate donor selection and improved preservation techniques can lead to enhanced pancreas utilization and outcome.
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Affiliation(s)
- M. Leemkuil
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
| | - H. G. D. Leuvenink
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
| | - R. A. Pol
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
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14
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Chen J, Mikhail DM, Sharma H, Jevnikar J, Cooper M, Luke PP, Sener A. Donor age is the most important predictor of long term graft function in donation after cardiac death simultaneous pancreas-kidney transplantation: A retrospective study. Am J Surg 2019. [DOI: 10.1016/j.amjsurg.2019.02.024 and 21=21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Chen J, Mikhail DM, Sharma H, Jevnikar J, Cooper M, Luke PP, Sener A. Donor age is the most important predictor of long term graft function in donation after cardiac death simultaneous pancreas-kidney transplantation: A retrospective study. Am J Surg 2019; 218:978-987. [DOI: 10.1016/j.amjsurg.2019.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 02/05/2019] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
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16
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Donor age is the most important predictor of long term graft function in donation after cardiac death simultaneous pancreas-kidney transplantation: A retrospective study. Am J Surg 2019. [DOI: 10.1016/j.amjsurg.2019.02.024 and 67=89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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17
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Romano A, Alsabeah K, Wilczek H, Söderdahl G, Nordström J, Sandberg J, Ericzon BG, Nowak G. Simultaneous Pancreas-Kidney Transplant From Donors After Brain Death vs Donors After Circulatory Death: A Single-Center Follow-up Study Over 3 Decades. Transplant Proc 2019; 51:845-851. [DOI: 10.1016/j.transproceed.2019.01.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/17/2019] [Indexed: 02/08/2023]
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18
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Giorgakis E, Mathur AK, Chakkera HA, Reddy KS, Moss AA, Singer AL. Solid pancreas transplant: Pushing forward. World J Transplant 2018; 8:237-251. [PMID: 30596031 PMCID: PMC6304337 DOI: 10.5500/wjt.v8.i7.237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 11/10/2018] [Accepted: 11/15/2018] [Indexed: 02/05/2023] Open
Abstract
Pancreas transplant has evolved significantly in recent years. It has now become a viable treatment option on type 1 diabetic patients with poorly controlled diabetes on conventional treatment, insulin intolerance, hypoglycaemia unawareness, brittle diabetes and/ or end-stage kidney disease. The purpose of this review is to provide an overview of pancreas transplant historical origins and current barriers to broader utilization of pancreata for transplant, with a focus on areas for future improvement to better pancreas transplant care. Donor pancreata remain underutilized; pancreatic allograft discard rates remain close to 30% in the United States. Donations after cardiac death (DCD) pancreata are seldom procured. Study groups from Europe and the United Kingdom showed that procurement professionalization and standardization of technique, as well as development of independent regional procurement teams might increase organ procurement efficiency, decrease discards and increase pancreatic allograft utilization. Pancreas transplant programs should consider exploring pancreas procurement opportunities on DCD and obese donors. Selected type 2 diabetics should be considered for pancreas transplant. Longer follow-up studies need to be performed in order to ascertain the long-term cardiovascular and quality of life benefits following pancreas transplant; the outcomes of which might eventually spearhead advocacy towards broader application of pancreas transplant among diabetics.
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Affiliation(s)
- Emmanouil Giorgakis
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
- Department of Transplant, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Amit K Mathur
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Harini A Chakkera
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Kunam S Reddy
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Adyr A Moss
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Andrew L Singer
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
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19
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Abstract
PURPOSE OF REVIEW The use of organs from donors after circulatory death (DCD) has become standard practice in solid organ transplantation of most abdominal organs and has been used successfully in some centres for pancreas transplantation. Nevertheless, concerns regarding poor graft outcomes and complications remain. This review aims to discuss the current state of DCD pancreas transplantation and the associated outcomes. RECENT FINDINGS In many countries, whereas the number of donors after brainstem death (DBD) remains stable, the mean age and BMI have increased making these donors, previously considered to be low risk, now more marginal. Recent meta-analyses have confirmed previous single-centre and registry reports that graft and patient survival after DCD pancreas transplantation are comparable with outcomes using pancreases from DBD donors; DCD pancreas transplantation is now common practice in several countries in Europe, particularly the United Kingdom. Although there have been reports of higher thrombosis rates after DCD pancreas transplantation, the significance of this is difficult to judge as the impact has not been seen in overall graft survival. SUMMARY Pancreas transplantation using DCD organs is well tolerated and feasible when other risk factors are minimized. Although there has been some evidence of an increased risk of thrombosis, this has not translated into a significant difference in graft survival.
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20
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Donation After Circulatory Arrest in Pancreas Transplantation: A Report of 10 Cases. Transplant Proc 2017; 49:2310-2314. [DOI: 10.1016/j.transproceed.2017.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Anderson PT, Aquil S, McLean K, McAlister VC, Sener A, Luke PP. First Canadian experience with donation after cardiac death simultaneous pancreas and kidney transplants. Can J Surg 2017; 60:323-328. [PMID: 28742013 DOI: 10.1503/cjs.011315] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Compared with neurologic determination of death (NDD) donor organs, donation after cardiac death (DCD) donor organs have traditionally been considered of inferior quality owing to warm ischemia experienced during procurement. We present, to our knowledge, the first analysis of simultaneous pancreas and kidney (SPK) transplants using DCD donor organs in Canada. METHODS We carried out a retrospective cohort study of SPK transplants from 13 DCD and 68 NDD donors performed between October 2008 and July 2016. In all patients immunosuppression was induced with thymoglobulin and continued with tacrolimus, mycophenolate mofetil and prednisone maintenance therapy. RESULTS Donor and recipient characteristics of DCD and NDD groups were similar with respect to age, sex, body mass index, kidney and pancreas cold ischemia times, and donor terminal creatinine. Mean DCD graft warm ischemia time was 0.5 (range 0.4-0.7) hours. Median follow-up was 2.2 (range 0.1-6.7) years and 2.7 (range 0.3-6.3) years for the DCD and NDD groups, respectively. The DCD and NDD groups were similar with regards to recipient percent panel reactive antibody and presence of human leukocyte antigen antibodies. The groups also received similar total doses of thymoglobulin. In total 38% of patients in the DCD group experienced renal delayed graft function (DGF) compared with 10% in the NDD group (p = 0.027). There were 7 cases of pancreas graft thrombosis requiring relaparotomy in the NDD group compared with none in the DCD group. No patients from either group required insulin at any time after transplant. Although the estimated glomerular filtration rate (eGFR) was lower in the DCD than the NDD group on postoperative days 7 and 14 (p = 0.025), no difference was noted on day 30 or through 4 years after transplant. No differences were seen between the groups with respect to amylase, lipase, or glycosated hemoglobin (HbA1c) up to 4 years after transplant, or in kidney, pancreas, or patient survival at any time after transplant. CONCLUSION Our results show that, apart from a higher renal DGF rate, SPK transplants with DCD donor organs have comparable outcomes to standard transplants with NDD donor organs.
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Affiliation(s)
- Patrick T Anderson
- From the Department of Surgery, Division of Urology, The Ottawa Hospital, University of Ottawa, Ottawa, Ont. (Anderson); the Western University Schulich School of Medicine and Dentistry, London, Ont. (McAlister, Sener, Luke); the Department of Surgery, Western University, London, Ont. (Aquil, McLean, McAlister, Sener, Luke); and the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Aquil, McLean, McAlister, Sener, Luke)
| | - Shahid Aquil
- From the Department of Surgery, Division of Urology, The Ottawa Hospital, University of Ottawa, Ottawa, Ont. (Anderson); the Western University Schulich School of Medicine and Dentistry, London, Ont. (McAlister, Sener, Luke); the Department of Surgery, Western University, London, Ont. (Aquil, McLean, McAlister, Sener, Luke); and the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Aquil, McLean, McAlister, Sener, Luke)
| | - Kelly McLean
- From the Department of Surgery, Division of Urology, The Ottawa Hospital, University of Ottawa, Ottawa, Ont. (Anderson); the Western University Schulich School of Medicine and Dentistry, London, Ont. (McAlister, Sener, Luke); the Department of Surgery, Western University, London, Ont. (Aquil, McLean, McAlister, Sener, Luke); and the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Aquil, McLean, McAlister, Sener, Luke)
| | - Vivian C McAlister
- From the Department of Surgery, Division of Urology, The Ottawa Hospital, University of Ottawa, Ottawa, Ont. (Anderson); the Western University Schulich School of Medicine and Dentistry, London, Ont. (McAlister, Sener, Luke); the Department of Surgery, Western University, London, Ont. (Aquil, McLean, McAlister, Sener, Luke); and the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Aquil, McLean, McAlister, Sener, Luke)
| | - Alp Sener
- From the Department of Surgery, Division of Urology, The Ottawa Hospital, University of Ottawa, Ottawa, Ont. (Anderson); the Western University Schulich School of Medicine and Dentistry, London, Ont. (McAlister, Sener, Luke); the Department of Surgery, Western University, London, Ont. (Aquil, McLean, McAlister, Sener, Luke); and the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Aquil, McLean, McAlister, Sener, Luke)
| | - Patrick P Luke
- From the Department of Surgery, Division of Urology, The Ottawa Hospital, University of Ottawa, Ottawa, Ont. (Anderson); the Western University Schulich School of Medicine and Dentistry, London, Ont. (McAlister, Sener, Luke); the Department of Surgery, Western University, London, Ont. (Aquil, McLean, McAlister, Sener, Luke); and the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Aquil, McLean, McAlister, Sener, Luke)
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22
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Abstract
PURPOSE OF REVIEW Donor issues have a direct impact on the pancreas transplant surgical procedure and play a critical role in the success of the procedure. The purpose of this review is to examine several key donor issues that are likely to have a significant impact on outcomes after pancreas transplant. This review will focus on recent publications dealing specifically with issues related to the pancreas donor. RECENT FINDINGS Overall pancreas donors remain underutilized, in the US and in Europe. Only about half of potential pancreas grafts are utilized at present. Concern over the quality of the organ, and the potential risk for surgical complications with extended criteria donor grafts is a major concern. Pancreas grafts from donation after cardiac death donors, for example, provide acceptable results in the long term, but may be associated with a higher incidence of early surgical problems. Risk factors for poor outcome can be identified with the donor that can help in better defining selection criteria, and may help to properly allocate pancreas grafts between whole organ versus islet cell transplantation. SUMMARY Proper donor selection and defining donor risk factors plays a critical role in pancreas graft allocation and ultimately the success of the operative procedure.
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23
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Outcomes From Pancreatic Transplantation in Donation After Cardiac Death: A Systematic Review and Meta-Analysis. Transplantation 2017; 101:122-130. [PMID: 26950713 DOI: 10.1097/tp.0000000000001084] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreas transplantation remains the gold standard for treatment for type I diabetes providing an insulin-independent, normoglycemic state. Increasingly, donation after cardiac death (DCD) donors are used in view of the organ donor shortage. We aimed to systematically review recipient outcomes from DCD donors and where possible compared these with donor after brain death (DBD) donors. METHODS We searched the databases MEDLINE via PubMed, EMBASE, and The Cochrane Library from inception to March 2015, for studies reporting the outcome of DCD pancreas transplants. We appraised studies using the Newcastle-Ottawa scale and meta-analyzed using a random effects model. RESULTS We identified 18 studies, 4 retrospective and 6 prospective cohort studies and 8 case reports. Our bias assessment revealed that although studies were well conducted, some studies had potential confounding factors and absence of comparator groups. Eight of the 18 studies included a DBD comparison group comprising 23 609 transplant recipients. Importantly, there was no significant difference in allograft survival up to 10 years (hazard ratio, 0.98; 95% confidence interval [95% CI], 0.74-1.31; P = 0.92), or patient survival (hazard ratio, 1.31; 95% CI, 0.62-2.78; P = 0.47) between DCD and DBD pancreas transplants. We estimated that the odds of graft thrombosis was 1.67 times higher in DCD organs (95% CI, 1.04-2.67; P = 0.006). However, subgroup analysis found thrombosis was not higher in recipients whose DCD donors were given antemortem heparin (P = 0.62). CONCLUSIONS Using current DCD criteria, pancreas transplantation is a viable alternative to DBD transplantation, and antemortem interventions including heparinization may be beneficial. This potential benefit of DCD pancreas donation warrants further study.
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van Loo ES, Krikke C, Hofker HS, Berger SP, Leuvenink HGD, Pol RA. Outcome of pancreas transplantation from donation after circulatory death compared to donation after brain death. Pancreatology 2016; 17:13-18. [PMID: 27838258 DOI: 10.1016/j.pan.2016.11.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/01/2016] [Accepted: 11/05/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To overcome the gap of organ shortage grafts from donation after circulatory death (DCD) can be used. This review evaluates the outcomes after DCD pancreas donation compared to donation after brain death (DBD). MATERIALS AND METHODS A literature search was performed using Medline, Embase, and PubMed databases. All comparative cohort studies reporting the outcome after DCD and DBD pancreas transplantation were included. All data were assessed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. To evaluate the event rates, pooled odds ratios (ORs) as well as the 95% confidence intervals (CI) were calculated. Since the number of studies is small we used the random-effects model only to overcome heterogeneity. RESULTS There is no difference in 1-year pancreas graft survival (OR 1.092, CI 95% 0.649-1.837, P = 0.741) or patient survival (OR 0.699, CI 95% 0.246-1.985, P = 0.502). Simultaneous pancreas-kidney (SPK) transplantation showed significantly higher graft survival rates compared to pancreas transplantation alone (87.2% vs. 76.6%, P < 0.001 in DBD and 86.5% vs. 74.9%, P < 0.001 in DCD). DCD SPK grafts show a higher delayed kidney graft function rate compared to DBD SPK-grafts (OR 0.209, CI 95% 0.104-0.421, P < 0.001). There is significantly less pancreas graft thrombosis after DBD-donation (OR 0.567, CI 95% 0.340-0.946, P = 0.030). We found no difference in the HbA1c level at 1-year follow-up with a median of 5.4% in both groups and a mean of 5.63% (DCD) vs 5.43% (DBD). DISCUSSION DCD pancreas transplantation has comparable patient and 1-year graft survival rates and should be considered a safe alternative for DBD pancreas transplantation.
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Affiliation(s)
- Ellen S van Loo
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Christina Krikke
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Hendrik S Hofker
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Stefan P Berger
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Henri G D Leuvenink
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Robert A Pol
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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25
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Redfield RR, Rickels MR, Naji A, Odorico JS. Pancreas Transplantation in the Modern Era. Gastroenterol Clin North Am 2016; 45:145-66. [PMID: 26895686 DOI: 10.1016/j.gtc.2015.10.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The field of pancreas transplantation has evolved from an experimental procedure in the 1980s to become a routine transplant in the modern era. With short- and long-term outcomes continuing to improve and the significant mortality, quality-of-life, and end-organ disease benefits, pancreas transplantation should be offered to more patients. In this article, we review current indications, patient selection, surgical considerations, complications, and outcomes in the modern era of pancreas transplantation.
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Affiliation(s)
- Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Clinical Science Cntr-H4/772, Madison, WI 53792, USA.
| | - Michael R Rickels
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, 2-134 Smilow Center for Translational Research, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Ali Naji
- Division of Transplantation, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Clinical Science Cntr-H4/772, Madison, WI 53792, USA
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26
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Chiari D, Bissolati M, Gazzetta P, Guarneri G, Tomanin D, Maffi P, Secchi A, Rosati R, Socci C. Pancreas Transplantation From Very Small Pediatric Donor Using the “Cephalic Placement” Technique: A Case Report. Transplant Proc 2016; 48:435-7. [DOI: 10.1016/j.transproceed.2016.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/03/2016] [Accepted: 01/12/2016] [Indexed: 01/04/2023]
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27
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Kuan KG, Wee MN, Chung WY, Kumar R, Mees ST, Dennison A, Maddern G, Trochsler M. Extracorporeal machine perfusion of the pancreas: technical aspects and its clinical implications – a systematic review of experimental models. Transplant Rev (Orlando) 2016; 30:31-47. [DOI: 10.1016/j.trre.2015.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/11/2015] [Accepted: 06/14/2015] [Indexed: 12/25/2022]
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Andres A, Kin T, O'Gorman D, Livingstone S, Bigam D, Kneteman N, Senior P, Shapiro AMJ. Clinical islet isolation and transplantation outcomes with deceased cardiac death donors are similar to neurological determination of death donors. Transpl Int 2016; 29:34-40. [PMID: 26264982 DOI: 10.1111/tri.12650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 06/12/2015] [Accepted: 08/02/2015] [Indexed: 02/05/2023]
Abstract
In islet transplantation, deceased cardiac death (DCD) donation has been identified as a potential extended source. There are currently no studies comparing outcomes between these categories, and our goal was to compare islet isolation success rates and transplantation outcomes between DCD and neurological determination of death (NDD) donors. Islet isolations from 15 DCD and 418 NDD were performed in our centre between September 2008 and September 2014. Donor variables, islet yields, metabolic function of isolated isled and insulin requirements at 1-month post-transplant were compared. Compared to NDD, pancreata from DCD were more often procured locally and donors required less vasopressive support (P < 0.001 and P = 0.023, respectively), but the other variables were similar between groups. Pre- and postpurification islet yields were similar between NDD and DCD (576 vs. 608 × 10(3) islet equivalent, P = 0.628 and 386 vs. 379, P = 0.881, respectively). The metabolic function was similar between NDD and DCD, as well as the mean decrease in insulin requirement at 1-month post-transplantation (NDD: 64.82%; DCD: 60.17% reduction, P = 0.517). These results support the broader use of DCD pancreata for islet isolation. A much larger DCD islet experience will be required to truly determine noninferiority of both short- and long-term outcomes.
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Affiliation(s)
- Axel Andres
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Tatsuya Kin
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Doug O'Gorman
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Scott Livingstone
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Norman Kneteman
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Peter Senior
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
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Oberhuber R, Ritschl P, Fabritius C, Nguyen AV, Hermann M, Obrist P, Werner ER, Maglione M, Flörchinger B, Ebner S, Resch T, Pratschke J, Kotsch K. Treatment with tetrahydrobiopterin overcomes brain death-associated injury in a murine model of pancreas transplantation. Am J Transplant 2015; 15:2865-76. [PMID: 26104062 PMCID: PMC4744967 DOI: 10.1111/ajt.13364] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 04/05/2015] [Accepted: 04/23/2015] [Indexed: 02/06/2023]
Abstract
Brain death (BD) has been associated with an immunological priming of donor organs and is thought to exacerbate ischemia reperfusion injury (IRI). Recently, we showed that the essential nitric oxide synthase co-factor tetrahydrobiopterin (BH4) abrogates IRI following experimental pancreas transplantation. We therefore studied the effects of BD in a murine model of syngeneic pancreas transplantation and tested the therapeutic potential of BH4 treatment. Compared with sham-operated controls, donor BD resulted in intragraft inflammation reflected by induced IL-1ß, IL-6, VCAM-1, and P-selectin mRNA expression levels and impaired microcirculation after reperfusion (p < 0.05), whereas pretreatment of the BD donor with BH4 significantly improved microcirculation after reperfusion (p < 0.05). Moreover, BD had a devastating impact on cell viability, whereas BH4-treated grafts showed a significantly higher percentage of viable cells (p < 0.001). Early parenchymal damage in pancreatic grafts was significantly more pronounced in organs from BD donors than from sham or non-BD donors (p < 0.05), but BH4 pretreatment significantly ameliorated necrotic lesions in BD organs (p < 0.05). Pretreatment of the BD donor with BH4 resulted in significant recipient survival (p < 0.05). Our data provide novel insights into the impact of BD on pancreatic isografts, further demonstrating the potential of donor pretreatment strategies including BH4 for preventing BD-associated injury after transplantation.
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Affiliation(s)
- R Oberhuber
- Center for Operative Medicine, Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - P Ritschl
- Center for Operative Medicine, Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - C Fabritius
- Center for Operative Medicine, Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - A-V Nguyen
- Center for Operative Medicine, Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - M Hermann
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - P Obrist
- Department of Pathology, St. Vincent's Hospital, Zams, Innsbruck, Austria
| | - E R Werner
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - M Maglione
- Center for Operative Medicine, Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - B Flörchinger
- Department of Cardiothoracic Surgery, Regensburg University Hospital, Regensburg, Germany
| | - S Ebner
- Center for Operative Medicine, Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - T Resch
- Center for Operative Medicine, Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - J Pratschke
- Department of Visceral, Abdominal and Transplantation Surgery, Charité-Universitätsmedizin, Berlin, Germany
| | - K Kotsch
- Center for Operative Medicine, Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
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Berney T, Boffa C, Augustine T, Badet L, de Koning E, Pratschke J, Socci C, Friend P. Utilization of organs from donors after circulatory death for vascularized pancreas and islet of Langerhans transplantation: recommendations from an expert group. Transpl Int 2015; 29:798-806. [PMID: 26340064 DOI: 10.1111/tri.12681] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/15/2015] [Accepted: 08/26/2015] [Indexed: 12/26/2022]
Abstract
Donation after circulatory death (DCD) donors are increasingly being used as a source of pancreas allografts for vascularized organ and islet transplantation. We provide practice guidelines aiming to increase DCD pancreas utilization. We review risk assessment and donor selection criteria. We report suggested factors in donor and recipient clinical management and provide an overview of the activities and outcomes of vascularized pancreas and islet transplantation.
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Affiliation(s)
- Thierry Berney
- Department of Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Catherine Boffa
- Nuffield Department of Surgery, Oxford Transplant Centre, University of Oxford, Oxford, UK
| | - Titus Augustine
- Department of Transplantation, Central Manchester University Hospitals, Manchester, UK
| | - Lionel Badet
- Division of Urology and Transplant Surgery, Hospices Civils de Lyon, Lyons, France
| | - Eelco de Koning
- Department of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johann Pratschke
- Department of General, Visceral and Transplant Surgery, Charité-University Hospital, Berlin, Germany
| | - Carlo Socci
- Department of Surgery, Scientific Institute San Raffaele, Milan, Italy
| | - Peter Friend
- Nuffield Department of Surgery, Oxford Transplant Centre, University of Oxford, Oxford, UK
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Donation after circulatory death: the current state and technical approaches to organ procurement. Curr Opin Organ Transplant 2015; 20:127-32. [PMID: 25719900 DOI: 10.1097/mot.0000000000000179] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In this review, we discuss the current state of donation after circulatory death (DCD). We define the DCD donor and describe the current protocols in management of the DCD patient. We then discuss current techniques in organ procurement of the lung and abdominal organs. RECENT FINDINGS Although donation after brain death is preferable to DCD, recent data have demonstrated acceptable early outcomes in both thoracic and abdominal organ transplant. In spite of advancements in surgical techniques and organ preservation, much has yet to be learned to minimize warm ischemia time and reperfusion injury in the DCD population. SUMMARY In light of the continually growing disparity between organ supply and demand, DCD has regained traction as a means to increase the donor pool.
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Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med 2015; 43:1291-325. [PMID: 25978154 DOI: 10.1097/ccm.0000000000000958] [Citation(s) in RCA: 200] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.
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Fridell JA, Powelson JA, Kubal CA, Burke GW, Sageshima J, Rogers J, Stratta RJ. Retrieval of the pancreas allograft for whole-organ transplantation. Clin Transplant 2014; 28:1313-30. [PMID: 25203627 DOI: 10.1111/ctr.12459] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2014] [Indexed: 01/15/2023]
Abstract
Proper pancreas retrieval during multi-organ recovery is one of the cornerstones of technically successful whole-organ pancreas transplantation. With evolving surgical approaches for organ retrieval and implantation, it has become standard to procure the pancreas in conjunction with other abdominal organs without compromising either vasculature, graft quality, or transplant outcomes. This review summarizes the major steps required for proper whole-organ retrieval of the pancreas allograft with suggestions and tips whenever alternative approaches are available.
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Affiliation(s)
- Jonathan A Fridell
- The Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
OBJECTIVE There is reluctance to use donation after cardiac death (DCD) organs for fear of worse outcomes due to increased warm ischemia time. Extensive evidence to confirm the quality of DCD pancreas transplants is not manifest. METHODS A united network for organ sharing database review of pancreas transplants performed between 1996 and 2012 was conducted. We compared outcomes and all demographic variables between donors after cardiac death and donors after brain death in pancreas transplantation. RESULTS There were 320 DCD pancreas transplants and 20,448 donation after brain death pancreas transplants performed in the United States between 1996 and 2012. There was no statistically significant difference in graft survival or patient survival in pancreas transplantation in DCD versus donation after brain death donors measured at 1-year, 3-year, 5-year, 10-year, and 15-year intervals. There was no significant difference between donor and recipient age, race, sex, and body mass index (BMI) between the groups. There was no significant difference between the recipient ethnicity or time on wait list between the groups. CONCLUSIONS Pancreata procured by DCD have comparable outcomes to those procured after brain death. Donation after cardiac death pancreas transplant is a viable method of increasing the donor pool, decreasing wait list mortality, and improving the quality of life for type 1 diabetic patients.
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Current state of pancreas preservation and implications for DCD pancreas transplantation. Transplantation 2013; 95:1419-24. [PMID: 23579769 DOI: 10.1097/tp.0b013e318285558f] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
One of the main factors limiting potential uptake of pancreas transplantation, particularly in the United Kingdom, is the shortage of grafts. There has therefore been a recent expansion, particularly in the United Kingdom, in the utilization of grafts from donation after cardiac death (DCD) donors. These grafts are subjected to a greater ischemic insult and are arguably at higher risk of poor functional outcome. Although conventional preservation techniques may be adequate for donation after brain death (DBD) and low-risk DCD pancreases, as the number of DCD pancreas transplants increase and the threshold for rejecting organs decreases, the importance of optimal preservation techniques is going to increase. Over recent years, there have been significant advances in preservation techniques for DCD kidneys, improving the outcome of these marginal grafts. However, the use of such techniques for pancreas preservation is extremely limited and mainly historical. This overview describes the background and results of the established method of pancreas preservation for DBD, namely, cold static storage, and describes the use of the two-layer method. It also reviews pulsatile machine perfusion and normothermic perfusion for pancreas preservation techniques, which have shown promise in the preservation of DCD kidney grafts. The use of these techniques in pancreas preservation is predominantly historical but warrants reevaluation as to the feasibility of applying these techniques to DCD pancreas grafts not only for preservation but also for viability assessment. Further areas for development of pancreas preservation are discussed.
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Clinically significant peripancreatic fluid collections after simultaneous pancreas-kidney transplantation. Transplantation 2013; 95:1263-9. [PMID: 23507700 DOI: 10.1097/tp.0b013e318289c978] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Peripancreatic fluid collections (PPFC) are a serious complication after simultaneous pancreas-kidney transplantation (SPKTx). METHODS Retrospective study for all 223 SPKTx performed from December 8, 1996, to October 10, 2011, to evaluate the risk factors (RF) and impact of PPFCs on outcomes was conducted. RESULTS Clinically significant PPFCs were seen in 36 (16%) cases, all within 3 months after transplantation. Radiologic drainage resolved 2 (6%) cases, and 34 required laparotomy (mean [SD], 4 [7]). Compared with the non-PPFC group (n=186), the PPFC group had similar patient and total kidney graft survivals but significantly lower total pancreas survival (68% vs. 85%) and greater incidence of infections (75% vs. 46%, all P<0.05) at 5 years. PPFCs were associated with early graft pancreatitis in 18 (50%), pancreatic fistula in 20 (56%, 9 with obvious duodenal stump leak) and infection in the collection in 20 (56%) cases. Comparison of PPFCs with pancreas graft loss to the PPFCs with surviving grafts showed that the incidence of pancreatic fistula was greater in the former (90% pancreas graft loss vs. 42% pancreas graft survival, P<0.01). Binary logistic regression analysis of RF for developing PPFC showed a donor age >30 years to be significant (P=0.03; odds ratio, 3.4; confidence interval, 1.1-10.5) and a trend of association with donor body mass index >30 and pancreas cold ischemia time greater than 12 hr. CONCLUSIONS PPFCs are associated with significant reduction in pancreas allograft survival and impact resource use. Donor age >30 years is a significant RF for their development. PPFCs associated with pancreatic fistula carry a greater risk for pancreas graft loss.
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Proneth A, Schnitzbauer AA, Zeman F, Foerster JR, Holub I, Arbogast H, Bechstein WO, Becker T, Dietz C, Guba M, Heise M, Jonas S, Kersting S, Klempnauer J, Manekeller S, Müller V, Nadalin S, Nashan B, Pascher A, Rauchfuss F, Ströhlein MA, Schemmer P, Schenker P, Thorban S, Vogel T, Rahmel AO, Viebahn R, Banas B, Geissler EK, Schlitt HJ, Farkas SA. Extended pancreas donor program - the EXPAND study rationale and study protocol. Transplant Res 2013; 2:12. [PMID: 23816330 PMCID: PMC3716891 DOI: 10.1186/2047-1440-2-12] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 06/20/2013] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Simultaneous pancreas kidney transplantation (SPK), pancreas transplantation alone (PTA) or pancreas transplantation after kidney (PAK) are the only curative treatment options for patients with type 1 (juvenile) diabetes mellitus with or without impaired renal function. Unfortunately, transplant waiting lists for this indication are increasing because the current organ acceptability criteria are restrictive; morbidity and mortality significantly increase with time on the waitlist. Currently, only pancreas organs from donors younger than 50 years of age and with a body mass index (BMI) less than 30 are allocated for transplantation in the Eurotransplant (ET) area. To address this issue we designed a study to increase the available donor pool for these patients. METHODS/DESIGN This study is a prospective, multicenter (20 German centers), single blinded, non-randomized, two armed trial comparing outcome after SPK, PTA or PAK between organs with the currently allowed donor criteria versus selected organs from donors with extended criteria. Extended donor criteria are defined as organs procured from donors with a BMI of 30 to 34 or a donor age between 50 and 60 years. Immunosuppression is generally standardized using induction therapy with Myfortic, tacrolimus and low dose steroids. In principle, all patients on the waitlist for primary SPK, PTA or PAK are eligible for the clinical trial when they consent to possibly receiving an extended donor criteria organ. Patients receiving an organ meeting the current standard criteria for pancreas allocation (control arm) are compared to those receiving extended criteria organ (study arm); patients are blinded for a follow-up period of one year. The combined primary endpoint is survival of the pancreas allograft and pancreas allograft function after three months, as an early relevant outcome parameter for pancreas transplantation. DISCUSSION The EXPAND Study has been initiated to investigate the hypothesis that locally allocated extended criteria organs can be transplanted with similar results compared to the currently allowed standard ET organ allocation. If our study shows a favorable comparison to standard organ allocation criteria, the morbidity and mortality for patients waiting for transplantation could be reduced in the future. TRIAL REGISTRATION Trial registered at: NCT01384006.
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Affiliation(s)
- Andrea Proneth
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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Blok JJ, Ringers J, Schaapherder AF, Dubbeld J, Baranski AG, de Fijter JW, van der Boog PJ, Verhagen MJ, Braat AE. Report of the first five DCDD pancreas transplants within the Eurotransplant region; excellent results with prolonged first warm ischemia times. Transpl Int 2013; 26:e31-3. [DOI: 10.1111/tri.12044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Joris J. Blok
- Department of Transplant Surgery; Leiden University Medical Center; Leiden; The Netherlands
| | - Jan Ringers
- Department of Transplant Surgery; Leiden University Medical Center; Leiden; The Netherlands
| | | | - Jeroen Dubbeld
- Department of Transplant Surgery; Leiden University Medical Center; Leiden; The Netherlands
| | - Andrzej G. Baranski
- Department of Transplant Surgery; Leiden University Medical Center; Leiden; The Netherlands
| | - Johan W. de Fijter
- Department of Nephrology; Leiden University Medical Center; Leiden; The Netherlands
| | - Paul J. van der Boog
- Department of Nephrology; Leiden University Medical Center; Leiden; The Netherlands
| | - Merel J. Verhagen
- Department of Transplant Surgery; Leiden University Medical Center; Leiden; The Netherlands
| | - Andries E. Braat
- Department of Transplant Surgery; Leiden University Medical Center; Leiden; The Netherlands
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40
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Dare AJ, Bartlett AS, Fraser JF. Critical care of the potential organ donor. Curr Neurol Neurosci Rep 2012; 12:456-65. [PMID: 22618126 DOI: 10.1007/s11910-012-0272-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Organ transplantation represents one of the great success stories of 20th century medicine. However, its continued success is greatly limited by the shortage of donor organs. This has led to an increased focus within the critical care community on optimal identification and management of the potential organ donor. The multi-organ donor can represent one of the most complex intensive care patients, with numerous competing physiological priorities. However, appropriate management of the donor not only increases the number of organs that can be successfully donated but has long-term implications for the outcomes of multiple recipients. This review outlines current understandings of the physiological derangements seen in the organ donor and evaluates the available evidence for management strategies designed to optimize donation potential and organ recovery. Finally, emerging management strategies for the potential donor are discussed within the current ethical and legal frameworks permitting donation after both brain and circulatory death.
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Affiliation(s)
- Anna J Dare
- Department of Surgery, Auckland City Hospital, University of Auckland & New Zealand Liver Transplant Unit, Park Road, Grafton, Auckland, New Zealand
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41
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Detry O, Le Dinh H, Noterdaeme T, De Roover A, Honoré P, Squifflet JP, Meurisse M. Categories of donation after cardiocirculatory death. Transplant Proc 2012; 44:1189-95. [PMID: 22663982 DOI: 10.1016/j.transproceed.2012.05.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The interest in donation after cardiocirculatory death (DCD) was renewed in the early 1990s, as a means to partially overcome the shortage of donations after brain death. In some European countries and in the United States, DCD has become an increasingly frequent procedure over the last decade. To improve the results of DCD transplantation, it is important to compare practices, experiences, and results of various teams involved in this field. It is therefore crucial to accurately define the different types of DCD. However, in the literature, various DCD terminologies and classifications have been used, rendering it difficult to compare reported experiences. The authors have presented herein an overview of the various DCD descriptions in the literature, and have proposed an adapted DCD classification to better define the DCD processes, seeking to provide a better tool to compare the results of published reports and to improve current practices. This modified classification may be modified in the future according to ongoing experiences in this field.
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Affiliation(s)
- O Detry
- Department of Abdominal Surgery and Transplantation, CHU Liège, University of Liège, Liège, Belgium.
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42
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Reich DJ, Guy SR. Donation After Cardiac Death in Abdominal Organ Transplantation. ACTA ACUST UNITED AC 2012; 79:365-75. [DOI: 10.1002/msj.21309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Qureshi MS, Callaghan CJ, Bradley JA, Watson CJE, Pettigrew GJ. Outcomes of simultaneous pancreas-kidney transplantation from brain-dead and controlled circulatory death donors. Br J Surg 2012; 99:831-8. [PMID: 22437616 DOI: 10.1002/bjs.8733] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Organ scarcity has prompted increased use of organs from donation after circulatory death (DCD) donors. An early single-centre experience of simultaneous pancreas-kidney (SPK) transplantation from controlled DCD donors is described here. METHODS Outcomes of SPK transplants from DCD and donation after brain death (DBD) donors between August 2008 and January 2011 were reviewed retrospectively. RESULTS SPK transplants from 20 DCD and 40 DBD donors were carried out. Donor and recipient characteristics were similar for both groups, although pancreas cold ischaemia times were shorter in DCD recipients: median (range) 8·2 (5·9-10·5) versus 9·5 (3·8-12·5) h respectively (P = 0·004). Median time from treatment withdrawal to cold perfusion was 24 (range 16-110) min for DCD donors. There were no episodes of delayed pancreatic graft function in either group; the graft thrombosis rates were both 5 per cent. Similarly, there were no differences in haemoglobin A1c level at 12 months: median (range) 5·4 (4·9-7·7) per cent in DCD group versus 5·4 (4·1-6·2) per cent in DBD group (P = 0·910). Pancreas graft survival rates were not significantly different, with Kaplan-Meier 1-year survival estimates of 84 and 95 per cent respectively (P = 0·181). CONCLUSION DCD SPK grafts had comparable short-term outcomes to DBD grafts, even when procured from selected donors with a prolonged agonal phase.
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Affiliation(s)
- M S Qureshi
- Cambridge Transplant Unit, Addenbrooke's Hospital, National Institute for Health Research and Cambridge Biomedical Research Centre, Cambridge, UK
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Maruyama M, Kenmochi T, Saigo K, Naotake A, Iwashita C, Otsuki K, Ito T. Results of Islet Isolation and their Relationship to the Clinical Outcome of Kidney Transplantation in Cases where Both Grafts are Harvested from the Same Non-Heart-Beating Donor. Cell Transplant 2012; 21:559-63. [DOI: 10.3727/096368911x605484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Grafts from non-heart-beating donors (NHBDs) are used because of the limited availability of heart-beating brain-dead donors. These grafts sustain ischemic damage, and the severity of this damage varies among different areas of an organ. This study determined whether the results of islet isolation were correlated with the clinical outcomes of kidney transplantations in cases where both grafts were harvested from the same NHBD. Islets we isolated from the pancreata of 23 NHBDs between February 2004 and March 2007. Forty-six kidneys were also harvested from these NHBDs. The recipients of kidney transplants were divided into the successful isolation ( n = 14) and failed isolation ( n = 32) groups depending on the results of islet isolation. The clinical outcomes of kidney transplantation were compared between the recipients in these two groups. The immediate graft function rate and the 1-year graft survival rate after kidney transplantation in both groups were similar. Hemodialysis after transplantation was required for 6.0 days (SD, 5.2 days) in the successful isolation group and for 12.7 days (13.1 days) in the failed isolation group ( p < 0.05). The serum creatinine concentrations at 1, 3, 6, and 12 months after transplantation were elevated in the failed isolation group ( p < 0.05). The islet yield was inversely correlated with the requirement of hemodialysis (days) and the serum creatinine level at 1 month after transplantation. However, hemodialysis was required for only 7 days in the recipients of six kidneys that were obtained from NHBDs from whom <40,000 IEQ were obtained (extreme failure of islet isolation). The results of islet isolation were found to correlate with the kidney function after transplantation when both grafts are harvested from the same NHBD. However, the marginal conditions of NHBDs affect the results of islet isolation more than they do the posttransplantation kidney function.
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Affiliation(s)
| | - Takashi Kenmochi
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Kenichi Saigo
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Akutsu Naotake
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Chikara Iwashita
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Kazunori Otsuki
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Taihei Ito
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
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Bellingham JM, Santhanakrishnan C, Neidlinger N, Wai P, Kim J, Niederhaus S, Leverson GE, Fernandez LA, Foley DP, Mezrich JD, Odorico JS, Love RB, De Oliveira N, Sollinger HW, D'Alessandro AM. Donation after cardiac death: a 29-year experience. Surgery 2011; 150:692-702. [PMID: 22000181 DOI: 10.1016/j.surg.2011.07.057] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 07/11/2011] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To report the long-term outcomes of 1218 organs transplanted from donation after cardiac death (DCD) donors from January 1980 through December 2008. METHODS One-thousand two-hundred-eighteen organs were transplanted into 1137 recipients from 577 DCD donors. This includes 1038 kidneys (RTX), 87 livers (LTX), 72 pancreas (PTX), and 21 DCD lungs. The outcomes were compared with 3470 RTX, 1157 LTX, 903 PTX, and 409 lung transplants from donors after brain death (DBD). RESULTS Both patient and graft survival is comparable between DBD and DCD transplant recipients for kidney, pancreas, and lung after 1, 3, and 10 years. Our findings reveal a significant difference for patient and graft survival of DCD livers at each of these time points. In contrast to the overall kidney transplant experience, the most recent 16-year period (n = 396 DCD and 1,937 DBD) revealed no difference in patient and graft survival, rejection rates, or surgical complications but delayed graft function was higher (44.7% vs 22.0%; P < .001). In DCD LTX, biliary complications (51% vs 33.4%; P < .01) and retransplantation for ischemic cholangiopathy (13.9% vs 0.2%; P < .01) were increased. PTX recipients had no difference in surgical complications, rejection, and hemoglobin A1c levels. Surgical complications were equivalent between DCD and DBD lung recipients. CONCLUSION This series represents the largest single center experience with more than 1000 DCD transplants and given the critical demand for organs, demonstrates successful kidney, pancreas, liver, and lung allografts from DCD donors.
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Affiliation(s)
- Janet M Bellingham
- Division of Organ Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-7375, USA
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Chaib E, Ribeiro MAF, Santos VR, Meirelles RF, D'Albuquerque LAC, Massad E. A mathematical model for shortening waiting time in pancreas-kidney transplantation. World J Gastrointest Surg 2011; 3:119-22. [PMID: 22007279 PMCID: PMC3192217 DOI: 10.4240/wjgs.v3.i8.119] [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] [Received: 04/08/2011] [Revised: 05/26/2011] [Accepted: 06/05/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To simulate a hypothetical increase of 50% in the number of pancreas-kidney (PK) transplantations using less-than-ideal donors by a mathematical model.
METHODS: We projected the size of the waiting list by taking into account the incidence of new patients per year, the number of PK transplantations carried out in the year and the number of patients who died on the waiting list or were removed from the list for other reasons. These variables were treated using a model developed elsewhere.
RESULTS: We found that the waiting list demand will meet the number of PK transplantation by the year 2022.
CONCLUSION: In future years, it is perfectly possible to minimize the waiting list time for pancreas transplantation through expansion of the donor pool using less-than-ideal donors.
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Affiliation(s)
- Eleazar Chaib
- Eleazar Chaib, Marcelo Augusto F Ribeiro Jr, Vinicius Rocha Santos, Roberto Ferreira Meirelles Jr, Luiz Augusto Carneiro D'Albuquerque, Eduardo Massad, Liver and Pancreas Transplantation Surgery Unit, LIM 37 and LIM 01, Department of Gastroenterology, University of Sao Paulo School of Medicine, Av Dr Eneas de Carvalho Aguiar 255, Level 9, 05403-010, Sao Paulo, Brazil
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Rhee JY, Ruthazer R, O'Connor K, Delmonico FL, Luskin RS, Freeman RB. The impact of variation in donation after cardiac death policies among donor hospitals: a regional analysis. Am J Transplant 2011; 11:1719-26. [PMID: 21749645 DOI: 10.1111/j.1600-6143.2011.03634.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The Joint Commission requires all hospitals have a policy regarding donation after cardiac death. To this date however, a quantitative analysis of adult hospital donation after cardiac death (DCD) policies and its impact on transplantation outcomes has not been reported. Specific characteristics for DCD polices were identified from 90 of the 164 (54.9%) hospitals within the New England Organ Bank's donor service area. Forty-five policies (50.0%) allow family members to be present during withdrawal of life-sustaining therapy (WLST) whereas eight (8.9%) prohibit this. Seventeen policies (18.9%) require WLST to occur in the operating room (OR); 20 (22.2%) specify a location outside of the OR. Fifty-six (62.2%) policies fail to state the method of determining death; however, some require arterial line (15 policies, 16.6%) and/or EKG (10 policies, 11.1%). These variables were not associated with organ recovery, utilization or donor ischemia time. Our regional analysis highlights the high degree of variability of hospital DCD policies, which may contribute to misunderstanding and confusion among providers and patients that may influence acceptance of this mode of donation.
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Affiliation(s)
- J Y Rhee
- Transplantation, Tufts Medical Center, Boston, MA, USA
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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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Rogers J, Farney AC, Al-Geizawi S, Iskandar SS, Doares W, Gautreaux MD, Hart L, Kaczmorski S, Reeves-Daniel A, Winfrey S, Ghanta M, Adams PL, Stratta RJ. Pancreas transplantation: lessons learned from a decade of experience at Wake Forest Baptist Medical Center. Rev Diabet Stud 2011; 8:17-27. [PMID: 21720669 DOI: 10.1900/rds.2011.8.17] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This article reviews the outcome of pancreas transplantations in diabetic recipients according to risk factors, surgical techniques, and immunosuppression management that evolved over the course of a decade at Wake Forest Baptist Medical Center. A randomized trial of alemtuzumab versus rabbit anti-thymocyte globulin (rATG) induction in simultaneous kidney-pancreas transplantation (SKPT) at our institution demonstrated lower rates of acute rejection and infection in the alemtuzumab group. Consequently, alemtuzumab induction has been used exclusively in all pancreas transplantations since February 2009. Early steroid elimination has been feasible in the majority of patients. Extensive experience with surveillance pancreas biopsies in solitary pancreas transplantation (SPT) is described. Surveillance pancreas biopsy-directed immunosuppression has contributed to equivalent long-term pancreas graft survival rates in SKPT and SPT recipients at our center, in contrast to recent registry reports of persistently higher rates of immunologic pancreas graft loss in SPT. Furthermore, the impact of donor and recipient selection on outcomes is explored. Excellent results have been achieved with older (extended) donors and recipients, in recipients of organs from donation after cardiac death donors managed with extracorporeal support, and in African-American patients. Type 2 diabetics with detectable C-peptide levels have been transplanted successfully with outcomes comparable to those of insulinopenic diabetics. Our experiences are discussed in the light of findings reported in the literature.
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Affiliation(s)
- Jeffrey Rogers
- Department of General Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
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Fridell JA, Mangus RS, Taber TE, Goble ML, Milgrom ML, Good J, Vetor R, Powelson JA. Growth of a nation part I: impact of organ donor obesity on whole-organ pancreas transplantation. Clin Transplant 2011; 25:E225-32. [DOI: 10.1111/j.1399-0012.2011.01419.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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