[Pancreas transplantation--indication, technique and results].
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Pancreas transplantation is the only therapeutic measure currently available to achieve long term normoglycemia and normal HbA1 levels in diabetic patients. A live long immunosuppression with it's side effects is the price payed for that treatment. Like in renal transplantation an alternative treatment is available for potential pancreas transplant recipients so that most transplant centers are willing to perform pancreas transplantation as a combined kidney pancreas transplantation in patients with diabetic nephropathy only. This article reviews indications, technique, results and complications of simultaneous kidney pancreas transplantation and pancreas after kidney transplantation.Keywords:
Pancreas transplantation
Immunosuppression
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▪ Abstract Vascularized pancreas transplantation has assumed an increasing role in the treatment of diabetes mellitus. Through 1993, over 5500 pancreas transplants have been performed worldwide, with over 80% being combined pancreas-kidney transplants. Overall one-year patient survival exceeds 90% and graft survival (complete insulin independence) exceeds 70%. Although successful pancreas transplantation achieves euglycemia and complete insulin independence, this occurs at the expense of hyperinsulinemia and chronic immunosuppression. The net result of these changes on diabetic complications in the long term remains to be determined. In the short term, improvement in the quality of life and possible prevention of further morbidity associated with diabetes makes pancreas transplantation an important therapeutic option, particularly when combined with a kidney transplant, in appropriately selected diabetic patients.
Pancreas transplantation
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Objective To sum up the experience of simultaneous pancreas-kidney transplantation. Methods Simultaneous pancreaticoduodenal and kidney transplantation was performed on one uremic patient with insulin-dependent diabetes mellitus. Bladder drainage was used for management of pancreas exocrine secretions. After operation, quadruple drug immunosuppression with anti-lymphocyte induction with a monoclonal antibody was employed. Maintenance immunosuppression is triple therapy consisting of a calcineurin inhibitor (cyclosporine), corticosteroids and an anti-metabolite. Results The renal and pancreatic graft obtained normal function and became insulin-independent and the serum creatinine and BUN as well as fasting blood sugar was decreased to normal levels 4 days after operation. Twenty days after transplantation, insulin was completely stopped. Conclusion Combined pancreas-kidney transplantation was an effect treatment toⅠtype diabetes mellitus and nephropathy.
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This review of current foreign literature is focused on the analysis of different variants of pancreas and kidney transplantation in patients with terminalrenal insufficiency resulting from diabetic nephropathy. Most authors consider combined pancreas and kidney transplantation to be the method ofchoice for patients with this pathology. Given the adequately functioning pancreas implant, this operation ensures excellent engaftment of the kidneyimplant and survival of the recipient. An alternative method is isolated transplantation of a kidney from a live donor with subsequent transplantationof the pancreas. Isolated transplantation of a cadaveric kidney results in transplant and recipient.
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Portal-enteric (PE) transplantation of the pancreas allograft provides maintained physiologic drainage, and theoretically the portal delivery of transplantation antigens may have beneficial effects on the graft acceptance leading to improved graft survival. To determine whether the technique of pancreas placement affects the incidence of acute rejection we reviewed our experience in technically successful PE and systemic-bladder (SB) drained simultaneous pancreas and kidney (SPK) transplants performed between 1989 and 1994. Forty-seven recipients were included (SB = 30, PE = 17). All patients received cyclosporine based quadruple immunosuppression and survived at least 1 month. The two groups were comparable in HLA mismatches, cold ischemia time and level of immunosuppression at time of rejection. In the SB group the incidence of rejection was 1.04 kidney rejection/patient and 0.90 pancreas rejection/patient whereas the PE group experienced 0.53 kidney rejection/patient and 0.47 pancreas rejection/patient. The two groups were compared using incidence density statistics due to great variation in follow-up time. The SB group had a significant higher density of both kidney and pancreas rejections (p < or = 0.037 for kidney rejection and 0.058 for pancreas rejection). In addition, while 6 of 30 (20%) pancreas grafts and 4 of 30 (13%) kidney grafts were lost to irreversible rejection in the SB group, only 1 of 17 (6%) pancreas graft and 1 of 17 (6%) kidney graft were lost in the PE group. These data demonstrate, that the PE placement of pancreas allograft affects the rates of acute rejection and graft loss, and imply that there exist some important immunological advantages when the pancreas graft is drained into the portal circulation.
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Kidney graft biopsies were performed 2–3 yr after transplantation in eight type I (insulin-dependent) diabetic patients who had previously been subjected to kidney transplantation (six patients) or combined kidney and segmental pancreas transplantation (two patients). In five of the six patients that had undergone only kidney transplantation, light microscopic examination of the graft biopsy revealed changes compatible with diabetic nephropathy, and electron microscopic morphometry showed a thickening of the glomerular basement membrane (GBM). In the two patients who had been subjected to combined pancreas and kidney transplantation, the kidney graft biopsy showed no light microscopic changes suggestive of diabetic nephropathy, and electron microscopy showed no thickening of the GBM. Thus, it appears to be possible to prevent the recurrence of diabetic nephropathy in human kidney allografts by simultaneous pancreas transplantation.
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Pancreas transplantation
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Objective To suro up the experience of simultaneous pancreas-kidney transplantation.Methods Simultaneous pancreaticoduodenal and kidney transplantation was performed on one uremic patient with insulin-dependent diabetes mellitus.Bladder drainage was used for management of pancreas exocrine secretions.After operation,quadruple drug immunosuppmssion with anti-lymphocyte induction with a monoclonal antibody was employed.Maintenance immunosuppression is triple therapy consisting of a ealcineurin inhibitor(cyclosporine),corticosteroids and an anti-metabolite.Results The renal and pancreatic graft obtained normal function and became insulin-independent and the serum creatinine and BUN as well as fasting blood sugar was decreased to normal levels 4 days after operation.Twenty days after transplantation,insulin was completely stopped.Conclusion Combined pancreas-kidney transplantation was an effect treatment to Ⅰ type diabetes mellitus and nephropathy.
Key words:
Diabetes mellitus,insulin-dependent; Uremia; Pancreas; Kidney; Transplantation
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Evaluation of whole-organ pancreas transplantation in the therapy of IDDM has been difficult because of generally poor graft survival and significant complications in past experience. We report a technically successful simultaneous pancreas/kidney transplant program with patient and graft survival of 85% over 3 years of follow-up (mean 21 months) in 33 subjects with IDDM. Glucose metabolism was normalized without need for exogenous insulin immediately posttransplant in all but one recipient and remained normal in 85% of recipients. The outcome in pancreas/kidney recipients was compared with that in 18 insulin-dependent diabetic recipients of kidney transplant only performed in the same period. Quality of life was assessed with one general and one diabetes-specific questionnaire. General quality of life issues improved significantly in both pancreas/kidney and kidney recipients, but diabetes specific quality of life improved only in the pancreas/kidney recipients. Pancreas/kidney recipients required twice as long a period of hospitalization for the transplant and two times as many readmissions for a variety of complications. Only a minority of hospital admissions was strictly attributable to the pancreas graft. Of the five deaths in the pancreas/kidney recipients, two were attributable to the pancreas transplant. Pancreas transplantation in IDDM can now be accomplished with a high degree of success, resulting in normalized glucose metabolism and with overall mortality similar to kidney transplantation alone. Successful pancreas transplantation improves quality of life with respect to diabetes but this benefit is accomplished at a cost of increased hospital admissions and complications related to the transplanted pancreas. The effects of pancreas transplantation on the long-term complications of insulin-dependent diabetes remain unknown.
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Pancreas transplantation is the only therapeutic measure currently available to achieve long term normoglycemia and normal HbA1 levels in diabetic patients. A live long immunosuppression with it's side effects is the price payed for that treatment. Like in renal transplantation an alternative treatment is available for potential pancreas transplant recipients so that most transplant centers are willing to perform pancreas transplantation as a combined kidney pancreas transplantation in patients with diabetic nephropathy only. This article reviews indications, technique, results and complications of simultaneous kidney pancreas transplantation and pancreas after kidney transplantation.
Pancreas transplantation
Immunosuppression
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