Progress in pancreas transplantation and combined pancreas-kidney transplantation

BACKGROUND: Pancreas transplantation (PT) has proved effective but it is associated with a high risk of surgical complications and technical failure. Duct management and venous drainage are identified as major issues. Improvements in immunosuppression and prophylaxis greatly have contributed to surgical progress. DATA SOURCES: A literature search of the PubMed database (1996-2005) was conducted and research articles on PT reviewed. RESULTS: More than 23 000 PTs have been performed throughout the world. The majority (83%) were performed in combination with kidney transplantation [simultaneous pancreas-kidney transplantation (SPK)]. Pancreas graft survival rates at one year were 85% for 2001-2003 SPK cases, 79% for pancreas after kidney transplantation (PAK) cases, and 76% for pancreas transplantation alone (PTA) cases. For the 1999-2003 cases, enteric drainage was done in 79% of the SPK cases and bladder drainage in 21%. Patient survival rates, pancreas and kidney graft survival rates, and pancreas graft immunological failure rates did not differ significantly in enteric versus bladder drainage cases. All the available data fail to demonstrate a definitive advantage of portal drainage over systemic drainage. From 1993 to 2002, the use of rabbit antithymocyte globulin increased from 0 to 37%; the use of daclizumab increased from 0 to 16%; and the use of basiliximab increased from 0 to 25%. In 1993, 98% of SPK recipients received cyclosporine; but this was decreased to 9% in 2002. Tacrolimus (FK506) usage has increased from 0 (1993) to 87% (2002) of SPK recipients. Sirolimus (SIR) usage has increased from 0 (1993) to 18% (2002) of SPK recipients. CONCLUSIONS: PT remains an effective therapy for treatment of type I diabetes mellitus. Enteric drainage is currently predominant in SPK, but bladder drainage is still largely used. Portal drainage is as safe as systemic drainage, but there is still no convincing evidence about whether it is immunologically or metabolically convenient. The combined of FK506 and mycophenolate mophetil (MMF) is the preferred maintenance immunosuppression in PT. Sirolimus may be a good alternative as a second agent in recipients of PT under FK506 therapy.

Simultaneous pancreas-kidney transplantation with enteric drainage of exocrine secretions

s To simplify the enteric drainage (ED) procedure and to decrease surgical and metabolic complications in simultaneous pancreas-kidney transplantation (SPK) patients Methods Between June 2000 and June 2002, nine patients with insulin-dependent diabetes mellitus (IDDM) and uremia underwent simultaneous pancreas-kidney transplantati on The arterial inflow of the pancreas was based upon the right external iliac artery, while venous drainage was systemic via the external iliac vein The allografts’ exocrine secretions were drained into the proximal jejunum via a two-layer hand sewn, side-to-side donor duodenum to proximal small bowel anastomosis after reperfusion No Roux-en-Y an astomosis of the jejunum was performed The kidney graft was placed in the left iliac fossa Quadruple immunosuppressive therapy with antilymphocyte globulin or anti-CD25 monoclonal antibody (Zenapax ), tacrolimus, mycophenolate mofetil and steroids was standard treatment in all patients Results This procedure was successfully applied in all 9 patients without complication referable to the technique All patients had achieved euglycemia and excellent renal function, and stopped being dependent on an external insulin source Fasting serum glucose fell from 9 5 preoperatively to 4 8 mmol/L and remained stable thereafter At the time this paper was written, the grafts from eight patients were functioning well Conclusions Our primary experience suggests that SPK with ED without Roux-en-Y anastomosis represents a more physiologic milieu, and a viable alternation to replace the bladder (BD) as the primary route of drainage for exocrine secretions of the pancreas It is a feasible and safer procedure