Early Pancreas Retransplantation for Vascular Thrombosis in Simultaneous Pancreas–Kidney Transplants

Sansalone, C. V.; Aseni, Paolo; Follini, M.L.; Rossetti, O.; Slim, A. O.; Colella, G.; Benedetto, Fabrizio Di; Rombolà, Giuseppe; Rondinara, G. F.; Carlis, Luciano De; Brunati, C; Meroni, A.; Confalonieri, R.; Civati, G; Forti, D

doi:10.1016/s0041-1345(97)01248-7

Cited by 12 publications

(3 citation statements)

References 2 publications

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“…195 The introduction of an immediate retransplant 196 for a primary technical failure (e.g., thrombosis) has been adopted by other groups. 197,198 Even our use of enteric drainage pancreas grafts to correct exocrine deficiency 90 has been duplicated. 199 Regarding surgical techniques, segmental pancreas transplantation has largely disappeared except with living donors, as has the use of duct management techniques other than bladder or enteric drainage.…”

Section: Discussionmentioning

confidence: 99%

Lessons Learned From More Than 1,000 Pancreas Transplants at a Single Institution

Sutherland¹,

Gruessner²,

Dünn³

et al. 2001

Annals of Surgery

605

434

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ObjectiveTo determine outcome in diabetic pancreas transplant recipients according to risk factors and the surgical techniques and immunosuppressive protocols that evolved during a 33-year period at a single institution. Summary Background DataInsulin-dependent diabetes mellitus is associated with a high incidence of management problems and secondary complications. Clinical pancreas transplantation began at the University of Minnesota in 1966, initially with a high failure rate, but outcome improved in parallel with other organ transplants. The authors retrospectively analyzed the factors associated with the increased success rate of pancreas transplants. MethodsFrom December 16, 1966, to March 31, 2000, the authors performed 1,194 pancreas transplants (111 from living donors; 191 retransplants): 498 simultaneous pancreas-kidney (SPK) and 1 simultaneous pancreas-liver transplant; 404 pancreas after kidney (PAK) transplants; and 291 pancreas transplants alone (PTA). The analyses were divided into five eras: era 0, 1966 to 1973 (n ϭ 14), historical; era 1, 1978 to 1986 (n ϭ 148), transition to cyclosporine for immunosuppression, multiple duct management techniques, and only solitary (PAK and PTA) transplants; era 2, 1986 to 1994 (n ϭ 461), all categories (SPK, PAK, and PTA), predominately bladder drainage for graft duct management, and primarily triple therapy (cyclosporine, azathioprine, and prednisone) for maintenance immunosuppression; era 3, 1994 to 1998 (n ϭ 286), tacrolimus and mycophenolate mofetil used; and era 4, 1998 to 2000 (n ϭ 275), use of daclizumab for induction immunosuppression, primarily enteric drainage for SPK transplants, pretransplant immunosuppression in candidates awaiting PTA. ResultsPatient and primary cadaver pancreas graft functional (insulinindependence) survival rates at 1 year by category and era were as follows: SPK, era 2 (n ϭ 214) versus eras 3 and 4 combined (n ϭ 212), 85% and 64% versus 92% and 79%, respectively; PAK, era 1 (n ϭ 36) versus 2 (n ϭ 61) versus 3 (n ϭ 84) versus 4 (n ϭ 92), 86% and 17%, 98% and 59%, 98% and 76%, and 98% and 81%, respectively; in PTA, era 1 (n ϭ 36) versus 2 (n ϭ 72) versus 3 (n ϭ 30) versus 4 (n ϭ 40), 77% and 31%, 99% and 50%, 90% and 67%, and 100% and 88%, respectively. In eras 3 and 4 combined for primary cadaver SPK transplants, pancreas graft survival rates were significantly higher with bladder drainage (n ϭ 136) than enteric drainage (n ϭ 70), 82% versus 74% at 1 year (P ϭ .03). Increasing recipient age had an adverse effect on outcome only in SPK recipients. Vascular disease was common (in eras 3 and 4, 27% of SPK recipients had a pretransplant myocardial infarction and 40% had a coronary artery bypass); those with no vascular disease had significantly higher patient and graft survival rates in the SPK and PAK categories. Living donor segmental pancreas transplants were associated with higher technically successful graft survival rates in each era, predominately solitary (PAK and PTA) in eras 1 and 2 and SPK in eras 3 and 4. Diabetic seconda...

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Section: Discussionmentioning

confidence: 99%

Lessons Learned From More Than 1,000 Pancreas Transplants at a Single Institution

Sutherland¹,

Gruessner²,

Dünn³

et al. 2001

Annals of Surgery

605

434

View full text Add to dashboard Cite

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“…Among these, venous thrombosis (VT) is a serious complication, usually leading to allograft loss [2]. Ischemia/reperfusion injury, hypoperfusion at the time of organ procurement [3], technical problems [4,5], and hemoconcentration [6] are some of the factors considered to play a role in the loss of pancreatic microperfusion, with subsequent allograft loss due to vascular thrombosis. The literature reports a VT rate of 1–19% [7,8]; nevertheless, the incidence of VT has decreased progressively, likely due to the cumulative effect of the use of Belzer's solution for perfusion and preservation, whole pancreas versus segmental graft [9], shortening of cold ischemia time (CIT) [10], identification of segmental VT thrombosis by Doppler ultrasonography [11], identification of recipients who need anticoagulation [12], development of surgical technique in donor and recipient [2,13], and multivariate risk‐factor analysis after pancreatic transplantation [14,15].…”

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confidence: 99%

Partial venous thrombosis of the pancreatic allografts after simultaneous pancreas–kidney transplantation

Ciancio¹,

Cespedes

Olson

et al. 2000

Clinical Transplantation

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Despite new advances in transplantation, complete venous thrombosis (VT) of the pancreas after simultaneous pancreas kidney (SPK) transplantation usually results in graft loss. Data are limited regarding the outcome and treatment of partial VT of the pancreas allograft. From July 1994 to December 1999, 126 patients with IDDM/end-stage renal disease underwent SPK with systemic bladder drainage at the University of Miami. We retrospectively reviewed our experience regarding the outcome and treatment options of partial VT of the pancreas allografts. From July 1994 to April 1997, partial VT was not seen in the first 66 SPK patients induced with anti-CD3 rnAb and oral or intravenous (i.v.) tacrolimus (TAC) in the operating room. From May 1997 to June 1999, 14 (29%) out of 48 patients had VT. These cases were identified following the i.v. use of TAC with anti-IL-2R antibody-induction therapy (7/15) or without (7/33). Partial thrombosis of the splenic vein (PTSV) was documented in 10 patients, 2 had complete thrombosis of the splenic vein (CTSV), 1 had partial thrombosis of the superior mesenteric vein (PTSMV), and 1 patient had PTSV and PTSMV. These were identified incidentally during routine color Doppler ultrasonography (CDU). None of these SPK recipients demonstrates a change in clinical parameters. The first 8 patients were systemically heparinized, followed by oral anticoagulation, except 1 patient with CTSV. He progressed to complete thrombosis of the pancreas allograft and was treated with percutaneous thrombectomy and urokinase infusion, followed by heparinization and oral anticoagulation. One patient required exploration for bleeding. In an attempt to reduce the morbidity of heparinization, we treated the next 6 patients with PTSV with aspirin followed by serial CDU. All 14 patients had preservation of the endocrine and exocrine pancreatic functions. CDU showed resolution with recanalization of the thrombosed vein(s). From July 1999 to December 1999, 12 SPK recipients were administered TAC orally with or without induction therapy with anti-IL-2R antibody. So far, in this group, VT has not been identified. In summary, a total of 14 out of 126 patients (11%) had isolated VT with a mean follow-up of 36.4 months. Based on our experience, we suggest that extensive VT after pancreas transplantation, including splenic and superior mesenteric VT, be treated with heparin and subsequent oral anticoagulation for 3 months. For more limited, partial splenic VT, aspirin may be sufficient. Follow-up CDU is critical for a successful outcome. The i.v. use of TAC appears to be a risk factor for the increased incidence of VT. Currently, using IL-2rmAb as induction, TAC is started orally on postoperative days 3 or 4 and aspirin on postoperative day 2.

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“…Contraindications for retransplantation are likewise similar to primary transplant (cardiovascular, active infection, cancer, obesity/ insulin resistance). A special category of pancreas retransplant is when the primary graft is lost early after transplant from thrombosis and explanted, with either simultaneous retransplantation or retransplant within days or a few weeks (pancreas exchange, pancreas switch) [15,16]. In this situation, cultures should be taken of the operative field during explant and a hypercoagulable workup done.…”

Section: Recipient Selectionmentioning

confidence: 99%

Repeat Pancreas Transplant Procedures: Recipient Selection and Surgical Techniques

Dunn

Sutherland

2014

Curr Transpl Rep

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Pancreas retransplantation is not a common procedure but has been offered at experienced centers, and its application goes back to the late 1970s. In recent times, graft survival outcomes have become similar to that of primary transplants. Pancreas retransplantation can be challenging and is offered at a decreasing number of transplant centers. Success can hinge on recipient selection as well as technical aspects of the operation. We review the body of literature with attention to improved outcomes over time. This article highlights the existing literature on pancreas retransplant, and outlines key points regarding recipient selection and technical considerations that may be useful when offering pancreas retransplantation.

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Early Pancreas Retransplantation for Vascular Thrombosis in Simultaneous Pancreas–Kidney Transplants

Cited by 12 publications

References 2 publications

Lessons Learned From More Than 1,000 Pancreas Transplants at a Single Institution

Lessons Learned From More Than 1,000 Pancreas Transplants at a Single Institution

Partial venous thrombosis of the pancreatic allografts after simultaneous pancreas–kidney transplantation

Repeat Pancreas Transplant Procedures: Recipient Selection and Surgical Techniques

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