Improving results in solitary pancreas transplantation with portal-enteric drainage, thymoglobin induction, and tacrolimus/mycophenolate mofetil-based immunosuppression

Abstract

Advances in surgical techniques and clinical immunosuppression have led to steadily improving results in pancreas transplantation (PTX). The purpose of this study was to analyze retrospectively the outcomes in patients undergoing solitary PTX with portal-enteric (P-E) drainage and contemporary immunosuppression. From June 1998 through December 2000, we performed 28 solitary PTXs with antibody induction and tacrolimus/mycophenolate mofetil maintenance therapy. The first 13 patients received daclizumab (DAC) induction, while the next 15 received thymoglobulin (rabbit anti-human thymocyte gamma globulin; Thymo) induction. The study group included 13 pancreas alone (PA) and 15 sequential pancreas-after-kidneytransplantations (PAKT). Solitary PTX was performed with P-E drainage in 18 patients and systemicenteric (S-E) drainage in ten. Patient and pancreas graft survival rates were 96% and 79%, respectively, with a mean follow-up of 22 (range 1-39) months. The 1-year actual death-censored pancreas graft survival rate was 89%. One PAKT patient died with a functioning graft at 1 month; three patients (1 1 YO) experienced early graft loss due to thrombosis and were excluded from the immunological analysis, leaving 24 evaluable patients. The incidence of acute rejection was 54%, including 50% in PA and 58% in PAKT recipients (P= NS). In patients receiving Thymo induction, the rate of acute rejection was slightly lower (43% Thymo vs 70% DAC). Moreover, P-E drainage was associated with a slightly lower rate of acute rejection (44% P-E vs 75% S-E; P = N S ) . In patients with both Thymo induction and P-E drainage (n = 1 1), there was a tendency toward less rejection (the incidence of acute rejection was 36%). Two immunological graft losses occurred (one due to non-compliance), both in patients with P-E drainage. Only one patient had a cytomegalovirus (CMV) infection. Event-free survival (no rejection, graft loss, or death) was slightly higher in patients receiving Thymo (47%) than in those on DAC (23%) induction ( P = NS). We can conclude that solitary PTX with P-E drainage and Thymo induction may be associated with improved intermediate-term outcomes and a possible immunological advantage.

Technical Failures after Pancreas Transplants: Why Grafts Fail and the Risk Factors—A Multivariate Analysis

“…The multiple reasons include superior immunosuppression, better posttransplant management, and improved surgical techniques (1,2). While the surgical procedure has undergone significant refinements, technical complications continue to be a major problem in these recipients.…”

Immediate Retransplantation for Pancreas Allograft Thrombosis

“…Improvements in immunosuppression, surgical technique and posttransplant management have all contributed to better graft survival (3,4). Despite (5) and is responsible for more than 50% of all pancreas grafts lost in the first 6 months following transplantation (6)…”

Kidney-Pancreas Transplantation

“…This improvement also is seen in PTA patients that traditionally have the worst outcome, as shows in many studies. For example in a report Stratta et al by 1 year patient and graft survival has increased to 96% and 86%, respectively (Stratta RJ, et al, 2003). In one the largest recently published studies, the 5-year, 10-year, and 20-year patient survival for SPK recipients was 89, 80, and 58%, respectively (Wai PY & Sollinger HW, 2011).…”