RESUMO
OBJECTIVE: The racial impact on graft outcome is not well defined in diabetic recipients. The purpose of this study is to analyze our experience with kidney-alone (A) and kidney-pancreas (KP) transplantation in type 1 diabetic recipients and evaluate the impact of racial disparity on outcome. RESEARCH DESIGN AND METHODS: The records of 217 kidney transplants (118 KA, 99 KP) performed on type 1 diabetic patients between 1985 and 1995 at the Medical University of South Carolina and the University of Texas Medical Branch were reviewed. RESULTS: A total of 53 (31%) white patients and 15 (33%) black patients experienced at least one episode of biopsy-proven acute rejection of the renal graft (NS). Patient survival at 1, 2, and 5 years was similar in white (92, 87, 69%) and black (91, 91, 69%) patients (NS). Kidney graft survival at 1, 2, and 5 years in the KA group was 72, 62, and 42% in blacks, compared with 79, 76, and 53% in whites (NS). Kidney graft survival at 1, 2, and 5 years in the KP group was 92, 92, and 74% in blacks, compared with 83, 77, and 58% in whites (NS). Pancreas graft survival at 1, 2, and 5 years was 81, 81, and 81% in blacks, compared with 81, 75, and 62% in whites (NS). Cox regression analysis revealed that donor age > or = 40 years increased the risk of renal graft failure 6.2-fold (P = 0.0001), whereas the addition of a pancreas transplant to a kidney and a living-related transplant decreased the risk of failure of the kidney graft 0.2 (P = 0.005) and 0.1 times (P = 0.005). CONCLUSIONS: Our results suggest that when compared with whites, there may be a trend toward an improved kidney and pancreas graft outcome in blacks undergoing KP transplants. These findings suggest that diabetes may override the risk factors that account for the pronounced disparity in outcome observed between nondiabetic white and black recipients.
Assuntos
População Negra , Diabetes Mellitus Tipo 1/cirurgia , Rejeição de Enxerto/genética , Sobrevivência de Enxerto/genética , Transplante de Rim , Transplante de Pâncreas , População Branca , Adulto , Diabetes Mellitus Tipo 1/genética , Diabetes Mellitus Tipo 1/mortalidade , Feminino , Seguimentos , Sobrevivência de Enxerto/imunologia , Humanos , Transplante de Rim/mortalidade , Masculino , Transplante de Pâncreas/mortalidade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Doadores de Tecidos , Resultado do TratamentoRESUMO
BACKGROUND: Post-transplant lymphoproliferative disease is a serious complication of renal transplantation. Major risk factors include Epstein-Barr virus (EBV) seronegativity and induction immunosuppression with lymphocyte-depleting agents. RESULTS: We present a case of a 50-year year-old woman with very early onset PTLD confined to the donor ureter. Phenotypic studies on the tumor material reveal that the lymphoma was most likely of donor origin. A complete staging workup including the kidney allograft was negative for any other sites of involvement. CONCLUSIONS: This case, which had a fatal outcome, emphasizes the risk of renal transplantation in BV-negative individuals when given induction with lymphocyte-depleting drugs.
Assuntos
Transplante de Rim , Transtornos Linfoproliferativos/etiologia , Doadores de Tecidos , Ureter/patologia , Doenças Ureterais/etiologia , Feminino , Humanos , Transtornos Linfoproliferativos/diagnóstico , Pessoa de Meia-Idade , Fatores de Tempo , Doenças Ureterais/diagnósticoRESUMO
Clinical decision analysis has become an important tool for evaluating specific clinical scenarios and exploring public health policy issues. A decision analysis model that incorporates patient preferences regarding various outcomes, as well as cost, may be particularly informative in patients with type I diabetes and end-stage renal disease (ESRD). Such a model that includes pancreas transplantation as a treatment choice has not been performed and is presented in this study. The decision tree consisted of a choice between four possible treatment strategies: dialysis, kidney-alone transplant from a cadaver (KA-CAD) or living donor (KA-LD), and simultaneous pancreas-kidney (SPK) transplant. The analysis was based on a 5-year model, and the measures of outcome used in the model were cost and cost adjusted for quality of life. The measure of preference for quality of life was obtained using the "Standard Reference Gamble" method in 17 SPK transplant recipients who underwent transplantation between January, 1992 and June, 1996 at our center. The measures for various outcome states (mean +/- 1 SD) were dialysis-free/insulin-free = 1, dialysis-free/insulin-dependent = 0.6 (0.4 to 0.8), dialysis-dependent/insulin-free = 0.5 (0.36 to 0.64), dialysis-dependent/insulin-dependent = 0.4 (0.21 to 0.59), and death = 0. The expected 5-year costs for each of the treatment strategies in the model were dialysis, $216,068; KA-CAD transplant, $214,678; KA-LD transplant, $210,872; and SPK transplant, $241,207. The expected cost per quality-adjusted year for each of the treatment strategies in the model were dialysis, $317,746; KA-CAD transplant, $156,042; KA-LD transplant, $123,923; and SPK transplant, $102,422. SPK transplantation remained the optimal strategy after varying survival probabilities, costs, and utilities over plausible ranges by means of one-way sensitivity analysis. In conclusion, according to the 5-year cost-utility model presented in this study, SPK transplantation is the most cost-effective treatment strategy for a patient with type I diabetes and ESRD. From a policy standpoint, looking at the cost alone of pancreas transplantation is deceiving. In these patients, who may view various outcome states differently, it would be important to take into account cost adjusted for quality of life when evaluating this procedure.
Assuntos
Diabetes Mellitus Tipo 1/economia , Diabetes Mellitus Tipo 1/terapia , Nefropatias Diabéticas/economia , Nefropatias Diabéticas/terapia , Falência Renal Crônica/economia , Falência Renal Crônica/terapia , Adulto , Cadáver , Análise Custo-Benefício , Custos e Análise de Custo , Sistemas de Apoio a Decisões Clínicas , Feminino , Humanos , Transplante de Rim/economia , Doadores Vivos , Masculino , Transplante de Pâncreas/economia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Diálise Renal/economiaRESUMO
BACKGROUND: Donor and recipient selection criteria for pancreas allograft are not standardized and may vary from center to center. METHODS: Simultaneous pancreas-kidney transplantations performed between April 1988 and June 1994 were reviewed (n = 61), and univariate and multivariate analyses of factors that affect pancreas graft survival were performed. Analysis of all cases and cases excluding early thrombosis were performed separately. RESULTS: Pancreas graft survival when early thrombosis was excluded and in the overall group was 76% and 70%, respectively, at 1 year. Although blood group and donor gender were weak predictors of graft survival by univariate analysis, neither affected graft survival in the multivariate model. Risk factors for graft failure as determined by Cox regression analysis and in descending order of significance were (1) duration of brain death before procurement, (2) length of donor admission, and (3) donor age of 40 years or older. The risk of graft failure for each of these factors was increased 2.2-, 3.2-, and 4-fold, respectively. Prolonged brain death was the only risk factor in the overall group, suggesting an association with early thrombosis. CONCLUSIONS: Center-specific donor risk factors for pancreas graft survival after simultaneous pancreas-kidney transplantation were identified in this study, the importance of which need to be better defined.
Assuntos
Sobrevivência de Enxerto , Transplante de Rim , Transplante de Pâncreas , Doadores de Tecidos , Adulto , Fatores Etários , Análise de Variância , Antígenos de Grupos Sanguíneos , Morte Encefálica , Feminino , Teste de Histocompatibilidade , Humanos , Transplante de Rim/imunologia , Transplante de Rim/mortalidade , Masculino , Análise Multivariada , Preservação de Órgãos , Transplante de Pâncreas/imunologia , Transplante de Pâncreas/mortalidade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Falha de TratamentoRESUMO
BACKGROUND: Historically, primary enteric drainage (ED) of exocrine secretions in pancreas allografts was associated with a poor outcome, mostly as a result of infectious complications. On the other hand, bladder drainage (BD), which is presently used in the majority of institutions, is associated with substantial urologic morbidity. The aim of this study is to reassess the role of primary ED by reviewing our experience with ED versus BD in simultaneous pancreas-kidney transplantations. STUDY DESIGN: The records of all pancreas-kidney transplantations performed between October 1990 and September 1996 were reviewed (n = 42). Enteric drainage was used in the last 16 (38%) and BD in the first 26 (62%). The BD and ED groups were comparable with respect to donor and recipient characteristics. RESULTS: Length of stay for the transplantation (mean +/- standard deviation) was significantly shorter with ED than with BD (12.9 +/- 5.6 versus 20.4 +/- 9.6 days, p = 0.007). The total number of readmissions (1.7 +/- 1.5 versus 1.2 +/- 1.2 days, p = 0.2) and the length of hospital stay in the first 6 months after discharge (13.7 +/- 16.2 versus 10 +/- 11.3 days, p = 0.4) were similar between BD and ED. Complications requiring admission were distributed as follows in BD and ED recipients: recurrent/persistent urinary complications (46% versus 6%, p = 0.01), dehydration (27% versus 6%, p = 0.05), symptomatic graft pancreatitis (8% versus 6%, p = 0.9), gastrointestinal disturbance (27% versus 12%, p = 0.1), and wound infection (12% versus 19%, p = 0.5). The duration of the operative procedure was shorter in ED than in BD (4.3 +/- 0.9 versus 5.4 +/- 0.8 hours, p = 0.01). Reoperation during the initial transplantation stay was necessary in 23% of the patients having BD, compared with none having ED (p = 0.04). Similarly, fewer ED patients underwent reoperations compared with BD patients in the first 6 months after discharge (38% versus 69%, p = 0.04). Hospital charges for ED were lower than for BD for the initial admission ($73,458 +/- 17,103 versus $107,193 +/- 32,965, p = 0.001). Actuarial patient (96% versus 94%, p = 0.6), kidney (85% versus 87%, p = 0.9), and technically successful pancreas (90% versus 85%, p = 0.6) survival rates at 1 year were similar for BD and ED. CONCLUSIONS: Our results indicate that, compared with BD, ED is associated with less morbidity and shorter hospitalization without compromising outcome. Primary ED is a viable alternative to BD in simultaneous pancreas-kidney transplantation. More clinical experience with careful cost-effectiveness analysis is needed to better assess the implications of primary ED.
Assuntos
Drenagem/métodos , Exsudatos e Transudatos , Transplante de Pâncreas/métodos , Adulto , Antibioticoprofilaxia , Drenagem/economia , Feminino , Humanos , Terapia de Imunossupressão , Intestinos , Transplante de Rim , Tempo de Internação , Masculino , Transplante de Pâncreas/economia , Estudos Retrospectivos , Bexiga UrináriaRESUMO
The use of polytetrafluoroethylene (PTFE) for hemodialysis requires a maturation period to allow for tissue ingrowth around the graft. If hemodialysis is necessary during this waiting period, then temporary access is used. Unfortunately, temporary access is difficult, if not impossible, to establish in many patients undergoing chronic hemodialysis. We describe a technique for the construction of a prosthetic arteriovenous fistula that eliminates the waiting period and the need for temporary access in selected patients who require PTFE fistulas for hemodialysis.
Assuntos
Derivação Arteriovenosa Cirúrgica/métodos , Politetrafluoretileno , Diálise Renal , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Trombose/etiologiaRESUMO
Changes in donor liver allotment will not generate more organs. At this time, diverse training and experience are all that guide donor organ selection. Donor variables are now recognized to influence patient and graft survival at 1 year and beyond. Little is known about the molecular biology of hepatic ischemia/reperfusion that might enable informed donor preparation and selection. This study of South-Eastern Organ Procurement Foundation liver transplant centers identifies differences among liver transplant surgeons in donor assessment as issues for further consideration. Sixteen of 25 centers responded. A 170 mEq/L donor serum sodium was the upper limit for acceptance. Selection based on donor vasopressor use lacked uniformity. Preimplantation donor liver biopsy was used selectively, and the maximum acceptable fat content was 30 per cent for most centers. Donor hospitalization for more than 7 days was considered a negative factor by all groups. Surprisingly, five centers were not using donor livers testing positive for hepatitis C. This study points to the great variability in the assessment of organ donors. Greater consensus in this area could lead to increased organ use and/or less retransplantation, a net gain in organ economy.
Assuntos
Transplante de Fígado , Doadores de Tecidos , Obtenção de Tecidos e Órgãos , Instalações de Saúde , Humanos , Inquéritos e QuestionáriosRESUMO
Alterations in magnesium (Mg) homeostasis during and after orthotopic liver transplantation are common. The purpose of this study is to compare total Mg (TMg), calculated ionized Mg (cMg++) and measured ionized Mg (mMg++) during and immediately following liver transplantation. The newly developed first generation ion selective electrode analyzer, AVL 988-4, was used to measure mMg++ in 63 serum samples from 3 transplant recipients and 48 serum samples from 48 healthy volunteers. Analysis was divided into intraoperative (stages 1 to 3) and postoperative periods. Decreased TMg, cMg++ and mMg++ levels were observed intraoperatively and > 2 weeks postoperatively. The cMg++ levels were consistently higher than mMg++, presumably owing to the fact that the equation used for the calculation does not take complex-Mg++ into account. A better correlation was observed between mMg++ and cMg++ in the transplant group (r = 0.87 to 0.99) compared to controls (r = 0.74). The usefulness of direct measurement of Mg++ in liver transplantation remains to be determined.