Regional procurement team for abdominal organs Signori, S; Boggi, U; Vistoli, F ...
Transplantation proceedings,
04/2004, Letnik:
36, Številka:
3
Journal Article, Conference Proceeding
Recenzirano
The graft shortages make multiorgan procurements mandatory. We describe the results of a regional procurement team policy that has been employed over a 5-year period.
Three hundred forty-three ...multiorgan procurements were performed by a regional team using an en bloc harvesting method.
Among 1374 grafts procured, none was discarded because of iatrogenic injuries. In three instances the liver, the pancreas, and the small bowel were procured simultaneously and transplanted to different recipients. In 42 instances the liver was not allocated to our center. Forty liver teams (95%) from 11 institutions agreed to allow the regional procurement team to run the donor procedure.
Our experience confirms that a regional team can successfully manage most multiorgan procurements including complex donor procedures, such as simultaneous procurement of liver, pancreas, and intestine from the same donor for transplantation to different recipients.
No experimental study has clearly demonstrated how liver necrosis worsens the evolution of fulminant hepatic failure. Considering that several types of liver injury are associated with oxidative ...stress, we decided to measure plasma oxidative markers in two pig models of fulminant hepatic failure without and with liver necrosis.
Fulminant hepatic failure was produced in two groups of six pigs each by either total hepatectomy or complete hepatic devascularization. The following parameters were recorded before and during the course of hepatic failure: electrocerebral activity, plasma vitamin E, malondialdehyde and fluorescent protein-aldehyde adducts, total cholesterol, lactate-dehydrogenase, creatine phosphokinase, and ammonium.
Despite comparable survival periods, hepatic necrosis was associated with earlier electrocerebral deterioration. Plasma concentration of malondialdehyde and fluorescent protein-aldehyde adducts rose and vitamin E content decreased in both groups. However, while in the group without liver necrosis the rates of cholesterol and vitamin E decay were identical, in the group with liver necrosis cholesterol concentration decreased less than vitamin E concentration, strongly indicating a true intravascular oxidation of vitamin E. Interestingly, in both models the rise of oxidative parameters preceded the development of cell injury.
Oxidative stress, although present in both models, was significantly higher in the group with liver necrosis.
Our work was aimed to evaluate the precocious reduction of proteinuria in patients suffering from diabetes mellitus type 1 with incipient and evident nephropathy after isolated pancreas ...transplantation (PTA).
From December 2000 to March 2003, we followed 24 PTA grafts in 24 patients with diabetes mellitus type 1 (mean age 37.8 years; mean duration of diabetes 24.8 years). The pancreas was transplanted with portal-enteric drainage in 23 patients and systemic-enteric in 1 patient. The immunosuppressive therapy used basilixmab induction and tacrolimus, mycophenolate mophetil (MMF), and low dose steroid maintenance therapy. The renal function, proteinuria, and the glucose metabolic parameters were evaluated before and during the following months after transplant.
All patients are alive and twenty-one have a well-functioning pancreas with three grafts lost. All patients had persistence of normal renal function. Before transplantation 12 patients displayed proteinuria that was clearly reduced in 11 and gone in three patients, all of whom were insulin-independent.
TPA seems to reduce, and in some cases to regress, the proteinuria associated with early diabetic nephropathy.
Background: A large animal model of total hepatectomy is suitable to test the efficacy of any system designed to support patients in hepatic coma. The models previously described in the pig entail a ...significant degree of surgical trauma, which might alter the evolution of the ensuing hepatic failure and compromise the reproducibility of the model.
Methods: Twenty-eight pigs underwent a total hepatectomy according to a new technique. A model was considered satisfactory when it required no blood transfusions and when hematologic and hemodynamic parameters determined before, during, and until 4 hours after hepatectomy showed no significant variations. Moreover, to revive the pattern of hepatic coma produced in the anhepatic model, 7 pigs were monitored until brain death occurred.
Results: Twenty-five pigs (89%) underwent a smooth total hepatectomy with minimal variations of the selected parameters. They constituted a highly homogeneous group. Survival of the 7 pigs, followed up until brain death occurred, ranged from 625 to 1595 minutes (mean 1013.57 minutes). The animals remained stable until a few hours before brain death, an event heralded by a final sharp increase of the serum ammonia level and by a well-evident decline of both arterial pressure and liver-dependent clotting factors.
Conclusions: This technique of total hepatectomy allows the construction of a reproducible model of anhepaty suitable to test the efficacy of any system conceived to temporarily replace hepatic functions. (Surgery 1999;125:448-55.)
Although tacrolimus (Prograf) is the calcineurin inhibitor usually employed in simultaneous pancreas-kidney transplantation (SPKTx), no prospective randomized studies have compared its efficacy to ...cyclosporine (Neoral), when either drug is used in combination with mycophenolate mofetil (MMF) and the pancreas is drained into the portal vein.
Between May 2001 and June 2003, 16 SPKTx recipients were randomized to be prescribed Neoral and 17 Prograf in addition to basiliximab, steroids, and MMF. All pancreata were drained into the portal vein.
After a median follow-up of 15.6 months, six kidney acute rejection episodes were observed with Prograf (36.5%; one steroid-resistant) and one Neoral (
n = 1, 6.2%;
P = .04). No pancreas rejection episode was recorded. Two infections occurred in two recipients from each group. No major adverse events were noted other than a severe hematological toxicity (Prograf). Metabolic parameters were equivalent in the two groups, save for higher total cholesterol (212 ± 39 mg/dL vs 173 ± 23 mg/dL;
P = .008), LDL (129 ± 33 mg/dL vs 101 ± 21 mg/dL;
P = .029), and triglyceride (191 ± 86 mg/dL vs 126 ± 40 mg/dL;
P = .028), values with Neoral, although the same differences were already present at baseline. One recipient (Neoral) died with functioning grafts. Patient, pancreas, and kidney survival rates were all 94% for Neoral versus 100% for Prograf.
Although a larger series and a longer follow-up are needed, Neoral and Prograf used in combination with MMF seem to achieve equivalent success rates among primary SPKTx when the pancreas is drained into the portal vein.
Most solitary pancreas transplants (SPTx) fail due to unrecognized rejection episodes. Consequently, SPTx are monitored by draineage into the bladder or by surveillance biopsies.
Between April 2001 ...and June 2003, a consecutive series of 48 SPTx were performed using portal enteric drainage (PED). Rejection episodes were diagnosed empirically, based on the elevated pancreatic enzymes without a surveillance biopsy. Immunosuppression consisted of basiliximab (
n = 42) or ATG (
n = 6), low-dose steroids, MMF, and tacrolimus. Donors (mean age 28.9 year; range 9 to 54 year) were selected according to standard criteria irrespective of HLA match, although the best HLA matching was considered at the time of graft allocation.
After a mean cold ischemia time of 676 minutes (range 475 to 900 minutes), all but two pancreata (95.8%) functioned immediately. Relaparotomy was required in seven cases (14.6%). Three grafts were lost in the early posttransplant period due to hyperacute rejection. Two additional grafts were lost later due to arterial thrombosis or to chronic rejection. After a median follow-up period of 12.2 months (range 0.2 to 27 months) three further recipients were diagnosed with rejection episodes that were reversed with steroid boluses. Actuarial 1-year patient and graft survival rates were 100% and 93.1% and 2-year figures 100% and 88.7%, respectively. At the longest follow-up no recipient was diagnosed with a malignancy.
With current immunosuppression protocols SPTx achieves high rates of insulin independence even without surveillance biopsy or routine use of T-cell–depleting therapies.
Although the use of Celsior has been recently described for heart, lung, liver, and kidney transplantation, no data are available on its use for clinical pancreas preservation.
We herein describe the ...results of 112 pancreas transplants preserved with either University of Wisconsin (UW; (n = 56) or Celsior (n = 56) solution at two Italian transplant centers. The groups were comparable with regard to all donor and recipient characteristics.
Mean cold and warm ischemia times were 10.1 ± 2.2 hours and 37.2 ± 8.2 minutes for UW compared to 10.8 ± 2.4 hours and 38.3 ± 6.7 minutes for Celsior (P = NS). Delayed endocrine pancreas function was recorded in two UW-preserved grafts (3.6%). Actuarial 1-year patient survival was 94.6% for UW as compared with 100% for Celsior (P = NS). Equivalent graft survival figures were 91.0% for UW as compared with 96.4% for Celsior (P = NS).
Within the range of cold ischemia times reported in this study, UW and Celsior solutions have similar safety profiles for pancreas transplantation.
In case of cystectomy, some forms of urinary diversion can impair the graft function of renal transplant patients. Here we present the case of a 70-year-old male with carcinoma of the bladder 12 ...years after renal transplantation. Immunosuppression was achieved with Cyclosporin A (200 mg/day) and Prednisone (5 mg/day). The patient's serum creatinine level was 1.4 mg/dl. Following cystectomy, an orthotopic ileal neobladder was constructed by means of Studer technique, and the afferent ileal loop was anastomosed to the graft ureter. Pathology revealed pT1 G3 N+ transitional cell carcinoma. Ten months later, periaortic nodal recurrences necessitated four cycles of chemotherapy with Epidoxorubicyn and Gemcytabine. To date, 20 months after cystectomy, the patient is stable, with day and night-time urinary continence. His serum creatinine level is 1.3 mg/dl, and there is no evidence of hydronephrosis or acidosis. We conclude that the orthotopic ileal neobladder is an effective form of urinary diversion in renal transplant patients requiring cystectomy, allowing good preservation of the renal function.
Shortage of suitable donors and current graft allocation priorities reduce the number of cadaveric kidneys available to diabetic recipients. The concurrent excess of solitary cadaveric pancreata and ...the excellent results of living kidney transplantation make simultaneous cadaveric pancreas-living kidney transplantation (SPLKTx) an attractive alternative to simultaneous pancreas-kidney transplantation (SPKTx).
Between June 2001 and June 2003, 80 recipients were enrolled in the SPKTx waiting list. Each recipient's family was counseled about living kidney donation (LKD). Twenty-nine (36.2%) candidates were evaluated for LKD and 8 (27.6%) were disqualified. The remaining 21 candidates were scheduled for LKD and 18 actually donated.
Thanks to LKD 18 additional recipients were transplanted, thus expanding the donor pool from 33 to 51 (
P = .004). The median waiting time for SPLKTx was 14 days as compared with 95 days for SPKTx (
P = .006). Without LKD the median waiting time for SPKTx would have been 198 days (
P = .02). Similarly, 1 year after the enrollment on the waiting list 60% of recipients had been transplanted, while without LKD only 42% would had been grafted (
P = .01). Two-year recipient survival rate was 100% for SPLKTx compared with 96.9% for SPKTx. Equivalent figures for kidney and pancreas were 80.0% and 84.0% for SPLKTx compared with 96.9% and 96.9% for SPKTx.
LKD expanded the kidney donor pool, reduced the waiting time of recipients listed for a totally cadaveric procedure, and increased their chance to get a timely graft. One-year outcome of SPLKTx equaled that of SPKTx.
