Long-term pancreatic allograft survival after renal retransplantation in prior simultaneous pancreas-kidney recipients

Analyzing outcomes following pancreas transplantation: Definition of a failure or failure of a definition

Pancreas transplantation has an identity crisis and is at a crossroads. Although outcomes continue to improve in each successive era, the number of pancreas transplants performed annually in the United States has been static for several years in spite of increasing numbers of deceased donors. For most practitioners who manage diabetes, pancreas transplantation is considered an extreme measure to control diabetes. With expanded recipient selection (primarily simultaneous pancreas-kidney transplantation) in patients who are older, have a higher BMI, are minorities, or who have a type 2 diabetes phenotype, the controversy regarding type of diabetes detracts from the success of intervention. The absence of a clear and precise definition of pancreas graft failure, particularly one that lacks a measure of glycemic control, inhibits wider application of pancreas transplantation with respect to reporting long-term outcomes, comparing this treatment to alternative therapies, developing listing and allocation policy, and having a better understanding of the patient perspective. It has been suggested that the definition of pancreas graft failure should differ depending on the type of pretransplant diabetes. In this commentary, we discuss current challenges regarding the development of a uniform definition of pancreas graft failure and propose a potential solution to this vexing problem.

Outcomes after pancreas retransplantation: is the juice worth the squeeze?

PURPOSE OF REVIEW

Pancreas retransplantations are rarely carried out, and their outcomes are still debatable because of a lack of studies and clinical series on this issue.

RECENT FINDINGS

In general, pancreas retransplantations achieve similar or even higher patient survival than primary transplantations; however, it should be noted that this finding may be biased, as only healthier patients are selected for retransplantation. Graft survival in retransplantations is usually lower than that in primary transplantation, but this comparison may also be biased, as most retransplantations are solitary pancreas transplantations (which are known to have lower graft survival), whereas primary transplantations are mostly simultaneous kidney-pancreas transplantations. Technical loss is similar between primary pancreas transplantations and pancreas retransplantations, but the occurrence of surgical complications is greater in the latter.

SUMMARY

This review summarizes the literature on pancreas retransplantations, comparing them with primary transplantations, and demonstrates that in selected patients in experienced centres, retransplantation can be a valid and effective option for returning the patient to an insulin-free state.

C-peptide levels do not correlate with pancreas allograft failure: Multicenter retrospective analysis and discussion of the new OPT definition of pancreas allograft failure

The OPTN Pancreas Transplantation Committee performed a multicenter retrospective study to determine if undetectable serum C-peptide levels correspond to center-reported pancreas graft failures. C-peptide data from seven participating centers (n = 415 graft failures for transplants performed from 2002 to 2012) were analyzed pretransplant, at graft failure, and at return to insulin. One hundred forty-nine C-peptide values were submitted at pretransplant, 94 at return to insulin, and 233 at graft failure. There were 77 transplants with two available values (at pretransplant and at graft failure). For recipients in the study with pretransplant C-peptide <0.75 ng/mL who had a posttransplant C-peptide value available (n = 61), graft failure was declared at varying levels of C-peptide. High C-peptide values at graft failure were not explained by nonfasting testing or by individual center bias. Transplant centers declare pancreas graft failure at varying levels of C-peptide and do not consistently report C-peptide data. Until February 28, 2018, OPTN did not require reporting of posttransplant C-peptide levels and it appears that C-peptide levels are not consistently used for evaluating graft function. C-peptide levels should not be used as the sole criterion for the definition of pancreas graft failure.

Kidney retransplantation in the ipsilateral iliac fossa: a surgical challenge

The aim of this study is to review the surgical outcome of kidney retransplantation in the ipsilateral iliac fossa in comparison to first kidney transplants. The database was screened for retransplantations between 1995 and 2013. Each study patient was matched with 3 patients with a first kidney transplantation. Just for graft and patient survival analyses, we added an extra control group including all patients receiving a second transplantation in the contralateral iliac fossa. We identified 99 patients who received a retransplantation in the ipsilateral iliac fossa. There was significantly more blood loss and longer operative time in the retransplantation group. The rate of vascular complications and graft nephrectomies within 1 year was significantly higher in the study group. The graft survival rates at 1 year and 3, 5, and 10 years were 76%, 67%, 61%, and 47% in the study group versus 94%, 88%, 77%, and 67% (p < 0.001) in the first control group versus 91%, 86%, 78%, and 57% (p = 0.008) in the second control group. Patient survival did not differ significantly between the groups. Kidney retransplantation in ipsilateral iliac fossa is surgically challenging and associated with more vascular complications and graft loss within the first year after transplantation. Whenever feasible, the second renal transplant (first retransplant) should be performed contralateral to the prior failed one.

Early complications related to the transplanted kidney after simultaneous pancreas and kidney transplantation

OBJECTIVE

Simultaneous pancreas and kidney transplantation (SPKTx) is the most often performed multiorgan transplantation. The main source of complication is transplanted pancreas; as a result, early complications related to kidney transplant are rarely assessed. The aim of this study was to evaluate prevalence, types, and severity of postoperative complications due to kidney graft among the simultaneous pancreas and kidney recipients.

METHODS

Complications related to transplanted kidney among 112 SPKTx recipients were analyzed. The indication for SPKTx was end-stage diabetic nephropathy due to long-lasting diabetes type 1. The cumulative survival rates for kidney graft function and cumulative freedom from complication on days 60 and 90 after transplantation were assessed. Severity of complications was classified according to the modified Dindo-Clavien scale.

RESULTS

The 12-month cumulative survival rate for kidney graft was 0.91. Cumulative freedom from complication on the 60th day after transplantation was 0.84. The rates for II, IIIA, IIIB, IVA, and IVB severity grades were: 34.9%, 4.3%, 26.1%, 26.1%, and 8.6%, respectively. Acute tubular necrosis and rejection were the most frequent (43.4%) cause of complication. The most frequent reasons for graft nephrectomy were infections (2/7; 28.6%) and vascular thrombosis due to atherosclerosis of recipient iliac arteries (2/7; 28.6%). The most severe (IVB) complications were caused by fungal infection.

CONCLUSION

Rate and severity of complications due to renal graft after SPKTx was low; however, to prevent the most serious ones reduction of fungal infection was necessary.

Pancreatic retransplantation is associated with poor allograft survival: an update of the United Network for Organ Sharing database

The aim of the study was to assess outcomes of pancreas retransplantation versus primary pancreas transplantation.

METHODS

Data from the United Network for Organ Sharing database on all adult (age, ≥18 years) subjects who received pancreas and kidney-pancreas transplants between 1996 and 2012 were analyzed (n = 20,854). The subjects were analyzed in the following 2 groups: retransplant (n = 1149) and primary transplant (n = 19,705).

RESULTS

Kaplan-Meier analysis demonstrated significantly different patient survival (P < 0.0001) and death-censored graft survival (P < 0.0001) between the primary transplant versus retransplant subjects. Allograft survival was significantly poorer in the retransplantation group. Patient survival was greater in the retransplant group.

CONCLUSIONS

The results of our study differ from previous studies, which showed similar allograft survival in primary and secondary pancreas transplants. Further studies may elucidate specific patients who will benefit from retransplantation. At the present time, it would appear that pancreas retransplantation is associated with poor graft survival and that retransplantation should not be considered for all patients with primary pancreatic allograft failure.

Syndrome of rapid-onset end-stage renal disease in two consecutive renal transplant recipients

A syndrome of rapid-onset end-stage renal disease (SORO-ESRD) following acute kidney injury (AKI) in native kidneys was described recently. To what extent this syndrome of unanticipated and rapidly irreversible ESRD impacts renal allograft survival is unknown. Over 6 months, we managed two deceased donor renal transplant recipients (RTRs) with rapid acceleration of previously stable allograft chronic kidney disease to abruptly terminate in irreversible ESRD following AKI. These are the first reports of SORO-ESRD in RTRs. More research is needed to ascertain the contribution of SORO-ESRD to renal allograft loss.