medigraphic.com
ISSN 0326-3428 (Print)
Órgano de difusión científica de la Asociación Nefrológica de Buenos Aires

2021, Number 1

<< Back Next >>

Rev Nefrol Dial Traspl 2021; 41 (1)

Current Status of the Kidney-Pancreas Transplant

Uva PD, Quevedo A, Rosés J, Toniolo MF, Pilotti R, Chuluyan E, Re L

Language: Spanish
References: 26
Page: 55-61
PDF size: 235.35 Kb.


ABSTRACT

Pancreas transplantation is an alternative treatment for diabetes. Its modalities and indications are the following: 1) simultaneous pancreas and kidney transplantation: type 1 diabetes mellitus patients with end-stage diabetic nephropathy (in replacement treatment or close to it); 2) pancreas transplantation after kidney: type 1 diabetes mellitus patients with a functioning kidney transplant; 3) isolated pancreas transplantation: type 1 diabetes mellitus patients with unperceived hypoglycemia requiring hospitalization or rescue by third parties. Some of the screened type 2 diabetes mellitus patients may be pancreas transplantation candidates. Choosing a donor is very important: the ideal donor should be a deceased one who died due to intracranial injury, under 45 years of age, weighing between 30 and 90 kg, with a BMI below 30kg/m2, hemodynamically stable and having no history of cardiopulmonary arrest or sustained hypotension. There exist various strategies to divert the endocrine function (systemic and portal) and the exocrine function (vesical or enteric), systemic and enteric diversion being the most commonly used. Among the techniques which stand out during perioperative management, we could mention maintaining a good tissue perfusion, a strict glycemic control, an antiaggregation/anticoagulation plan to prevent graft thrombosis and antibiotic, antifungal and antiviral prophylactic treatment. Classic immunosuppression schemes consist of induction with T cell depleting steroids and antibodies and keeping a three-drug treatment including steroids, tacrolimus and mycophenolate. Banff classification draws a distinction between cellular and humoral rejection. The basis for cellular rejection treatment includes steroid-pulse therapy and T-cell depleting antibodies, while humoral rejection requires plasmapheresis and endovenous immunoglobulin. The main postoperative complications are bleeding, pancreatitis, graft thrombosis and anastomosis fistula. As for the results, the survival rate 5 years after pancreas transplantation is 90% for patients and 77% for pancreatic grafts. Isolated transplantation presents a lower long-term survival of the graft. In Argentina, between 60 and 80 pancreas transplants are performed every year. INCUCAI regulations provide for early registration on the waiting list for patients suffering from end-stage nephropathy with a creatinine clearance lower than 30 mL/min.


REFERENCES

  1. IDF Diabetes Atlas [Internet]. 9th ed. Brussels:International Diabetes Federation, 2019. Disponible en:(consulta: 18/03/2020).

  2. Diabetes Control and Complications Trial ResearchGroup, Nathan DM, Genuth S, Lachin J, Cleary P,Crofford O, et al. The effect of intensive treatment ofdiabetes on the development and progression of longtermcomplications in insulin-dependent diabetesmellitus. N Engl J Med. 1993;329(14):977-86. doi:10.1056/NEJM199309303291401.

  3. Gruessner RW, Gruessner AC. The current stateof pancreas transplantation. Nat Rev Endocrinol.2013;9(9):555-62. doi: 10.1038/nrendo.2013.138.

  4. Orlando G, Stratta RJ, Light J. Pancreastransplantation for type 2 diabetes mellitus. Curr OpinOrgan Transplant. 2011;16(1):110-5. doi: 10.1097/MOT.0b013e3283424d1f.

  5. Axelrod DA, Sung RS, Meyer KH, Wolfe RA, KaufmanDB. Systematic evaluation of pancreas allograft quality,outcomes and geographic variation in utilization. AmJ Transplant. 2010;10(4):837-45. doi: 10.1111/j.1600-6143.2009.02996.x.

  6. Vinkers MT, Rahmel AO, Slot MC, Smits JM, SchareckWD. How to recognize a suitable pancreas donor:a Eurotransplant study of preprocurement factors.Transplant Proc. 2008;40(5):1275-8. doi: 10.1016/j.transproceed.2008.03.142.

  7. Odorico JS, Heisey DM, Voss BJ, Steiner DS,Knechtle SJ, D’Alessandro AM, et al. Donor factorsaffecting outcome after pancreas transplantation.Transplant Proc. 1998;30(2):276-7. doi: 10.1016/s0041-1345(97)01263-3.

  8. Kirchner VA, Finger EB, Bellin MD, Dunn TB,Gruessner RW, Hering BJ, et al. Long-term outcomesfor living pancreas donors in the modern era.Transplantation. 2016;100(6):1322-8. doi: 10.1097/TP.0000000000001250.

  9. Bazerbachi F, Selzner M, Marquez MA, Norgate A,Aslani N, McGilvray ID, et al. Portal venous versussystemic venous drainage of pancreas grafts: impact onlong-term results. Am J Transplant. 2012;12(1):226-32.doi: 10.1111/j.1600-6143.2011.03756.x.

  10. Wai PY, Sollinger HW. Long-term outcomes aftersimultaneous pancreas-kidney transplant. Curr OpinOrgan Transplant. 2011;16(1):128-34. doi: 10.1097/MOT.0b013e328341b0b5.

  11. Parajuli S, Muth BL, Astor BC, Redfield RR,Mandelbrot DA, Odorico JS, et al. Delayed kidneygraft function in simultaneous pancreas-kidneytransplant recipients is associated with early pancreasallograft failure. Am J Transplant. 2020;20(10):2822-31. doi: 10.1111/ajt.15923.

  12. Farney AC, Rogers J, Stratta RJ. Pancreas graftthrombosis: causes, prevention, diagnosis, andintervention. Curr Opin Organ Transplant. 2012;17(1):87-92. doi: 10.1097/MOT.0b013e32834ee717.

  13. Aboalsamh G, Anderson P, Al-Abbassi A, McAlisterV, Luke PP, Sener A. Heparin infusion in simultaneouspancreas and kidney transplantation reduces graftthrombosis and improves graft survival. Clin Transplant.2016;30(9):1002-9. doi: 10.1111/ctr.12780.

  14. Marks WH, Borgström A, Sollinger H, MarksC. Serum immunoreactive anodal trypsinogenand urinary amylase as biochemical markersfor rejection of clinical whole-organ pancreasallografts having exocrine drainage into the urinarybladder. Transplantation. 1990;49(1):112-5. doi:10.1097/00007890-199001000-00025.

  15. Cantarovich D, De Amicis S, Akl A, Devys A, Vistoli F,Karam G, et al. Posttransplant donor-specific anti-HLAantibodies negatively impact pancreas transplantationoutcome. Am J Transplant. 2011;11(12):2737-46. doi:10.1111/j.1600-6143.2011.03729.x.

  16. Uva PD, Quevedo A, Roses J, Toniolo MF, Pilotti R,Chuluyan E, et al. Anti‐Hla donor‐specific antibodymonitoring in pancreas transplantation: role of protocolbiopsies. Clin Transplant. 2020;34(8):e13998. doi:10.1111/ctr.13998.

  17. Uva PD, Papadimitriou JC, Drachenberg CB, TonioloMF, Quevedo A, Dotta AC, et al. Graft dysfunction insimultaneous pancreas kidney transplantation (SPK):Results of concurrent kidney and pancreas allograftbiopsies. Am J Transplant. 2019;19(2):466-74. doi:10.1111/ajt.15012.

  18. Loupy A, Haas M, Solez K, Racusen L, Glotz D,Seron D, et al. The Banff 2015 Kidney MeetingReport: current challenges in rejection classificationand prospects for adopting molecular pathology. Am JTransplant. 2017;17(1):28-41. doi: 10.1111/ajt.14107.

  19. Papadimitriou JC, Drachenberg CB. Distinctivemorphological features of antibody-mediated andT-cell-mediated acute rejection in pancreas allograftbiopsies. Curr Opin Organ Transplant. 2012;17(1):93-9.doi: 10.1097/MOT.0b013e32834ee754.

  20. Hampson FA, Freeman SJ, Ertner J, Drage M, ButlerA, Watson CJ, et al. Pancreatic transplantation: surgicaltechnique, normal radiological appearances andcomplications. Insights Imaging. 2010;1(5-6):339-47.doi: 10.1007/s13244-010-0046-3.

  21. Stratta RJ, Gruessner AC, Gruessner RWG. Thepast, present, and future of pancreas transplantationfor diabetes mellitus. Endocrinol Diabetes Metab J.2018;2(3):1-9.

  22. Gruessner AC, Gruessner RW. Long-term outcomeafter pancreas transplantation: a registry analysis.Curr Opin Organ Transplant. 2016;21(4):377-85. doi:10.1097/MOT.0000000000000331.

  23. Wiseman AC, Huang E, Kamgar M, Bunnapradist S.The impact of pre-transplant dialysis on simultaneouspancreas-kidney versus living donor kidney transplantoutcomes. Nephrol Dial Transplant. 2013;28(4):1047-58. doi: 10.1093/ndt/gfs582.

  24. Argentina. Instituto Nacional Único Coordinador deAblación e Implante. Resolución N° 59 (3/12/2010).[Establécense pautas relacionadas con los datos quedeberán remitirse a los Organismos Jurisdiccionalesde Ablación e Implante para la correcta y eficienteorganización de los registros de lista de espera ytrasplante]. Boletín Oficial (20/12/2010).

  25. Argentina. Central de Reportes y Estadísticas delSINTRA (CRESI) [Internet]. Disponible en: (consulta: 18/03/2020).

  26. Argentina. Sistema Nacional de Información deProcuración y Trasplante. Registro Nacional deProcuración y Trasplante. Reporte de trasplante renal yrenopancreático [Internet]. Buenos Aires: INCUCAI,2019. Disponible en: (consulta: 18/03/2020).




2020     |     www.medigraphic.com