Impacto das complicações pós-transplante simultâneo pâncreas-rim sobre o custo da internação hospitalar / Simultaneous pancreas-kidney transplantation and the impact of postoperative complications on hospitalization cost

RESUMO Objetivo: avaliar o impacto financeiro das complicações pós-operatórias no transplante simultâneo pâncreas-rim durante a internação hospitalar. Métodos: estudo retrospectivo dos dados da internação hospitalar dos pacientes submetidos consecutivamente ao transplante simultâneo pâncreas-rim no período de janeiro de 2008 a dezembro de 2014 no Hospital do Rim/Fundação Oswaldo Ramos. As principais variáveis estudadas foram a reoperação, pancreatectomia do enxerto, óbito, complicações pós-operatórias (cirúrgicas, infecciosas, clínicas e imunológicas) e os dados financeiros da internação para o transplante. Resultados: a amostra foi composta de 179 pacientes transplantados. As características dos doadores e receptores foram semelhantes nos pacientes com e sem complicações. Na análise dos dados, 58,7% dos pacientes apresentaram alguma complicação pós-operatória, 21,8% necessitaram de reoperação, 12,3%, de pancreatectomia do enxerto e 8,4% evoluíram para o óbito. A necessidade de reoperação ou pancreatectomia do enxerto aumentou o custo da internação em 53,3% e 78,57%, respectivamente. A presença de complicação pós-operatória aumentou significativamente o custo. Entretanto, a presença de óbito, hérnia interna, infarto agudo do miocárdio, acidente vascular cerebral e disfunção do enxerto pancreático não apresentaram significância estatística no custo, cuja média foi de US$ 18,516.02. Conclusão: complicações pós-operatórias, reoperação e pancreatectomia do enxerto aumentaram significativamente o custo médio da internação hospitalar do SPK, assim como as complicações cirúrgicas, infecciosas, clínicas e imunológicas. No entanto, o óbito durante a internação, a hérnia interna, o infarto agudo do miocárdio, o acidente vascular cerebral e a disfunção do enxerto pancreático não interferiram estatisticamente neste custo.

ABSTRACT Objective: considering simultaneous pancreas-kidney transplantation cases, to evaluate the financial impact of postoperative complications on hospitalization cost. Methods: a retrospective study of hospitalization data from patients consecutively submitted to simultaneous pancreas-kidney transplantation (SPKT), from January 2008 to December 2014, at Kidney Hospital/Oswaldo Ramos Foundation (Sao Paulo, Brazil). The main studied variables were reoperation, graft pancreatectomy, death, postoperative complications (surgical, infectious, clinical, and immunological ones), and hospitalization financial data for transplantation. Results: the sample was composed of 179 transplanted patients. The characteristics of donors and recipients were similar in patients with and without complications. In data analysis, 58.7% of the patients presented some postoperative complication, 21.8% required reoperation, 12.3% demanded graft pancreatectomy, and 8.4% died. The need for reoperation or graft pancreatectomy increased hospitalization cost by 53.3% and 78.57%, respectively. The presence of postoperative complications significantly increased hospitalization cost. However, the presence of death, internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not present statistical significance in hospitalization cost (in average US$ 18,516.02). Conclusion: considering patients who underwent SPKT, postoperative complications, reoperation, and graft pancreatectomy, as well as surgical, infectious, clinical, and immunological complications, significantly increased the mean cost of hospitalization. However, death, internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not statistically interfere in hospitalization cost.

Ensayo pictórico: Imágenes en trasplante de páncreas: ¿qué debemos buscar? / Pictorial essay: Imaging in pancreas transplants: what should we look for?

El trasplante de páncreas es una alternativa terapéutica para pacientes diabéticos con complicaciones metabólicas severas y/o enfermedad renal crónica terminal. En el 80% de los casos, se realiza trasplante simultáneo de páncreas y riñón. El ultrasonido (US) es la técnica de elección para una primera evaluación del injerto, principalmente el modo Doppler espectral. Este último permite la evaluación de la vasculatura y perfusión de injerto. La tomografía computada (TC) y resonancia magnética (RM) se reservan para la evaluación de complicaciones (Tabla 1). Se realizó una revisión retrospectiva de una serie casos de trasplante páncreas-riñón realizada en nuestra institución entre los años 2014 y 2017, con un total de 12 casos.

Pancreas transplantation is a therapeutic alternative for diabetic patients with severe metabolic complications and/or terminal chronic kidney disease. In 80% of cases, a simultaneous transplant of pancreas and kidney is performed. Ultrasound (US) is the technique of choice for a first evaluation of the implant, mainly the spectral Doppler mode, which allows evaluation of the graft vasculature and perfusion. Computed tomography (CT) and magnetic resonance imaging (MRI) are reserved for the evaluation of complications (Table). A retrospective review of a series of cases of pancreas-kidney transplantation performed at our institution between 2014 and 2017 was carried out, with a total of 12 cases.

Diarrea aguda en trasplantes renales y reno-pancreáticos

La diarrea es una complicación frecuente y potencialmente grave del trasplante renal. Se describen aquí, en un estudio de corte transversal, las características epidemiológicas y microbiológicas de la diarrea aguda y persistente en pacientes internados con trasplante renal o reno-páncreas. Se incluyeron 52 pacientes internados en un hospital de la Ciudad de Buenos Aires, 42 (80.8%) habían recibido un trasplante renal y 10 (19.2%) reno-páncreas. La diarrea fue el motivo de ingreso en 34 casos (65.4%). La etiología de la diarrea pudo estudiarse en 50 pacientes: en 25 (50%) no se arribó a un diagnóstico etiológico y en 18 (36%) se constató diarrea con causa microbiológica específica: 3 (6%) enfermedad por citomegalovirus, 6 (12%) diarrea atribuida a citomegalovirus, 5 (10%) a rotavirus y 4 (8%) a Clostridium difficile. En 7 (14%) la diarrea fue atribuida a fármacos (mofetil micofenolato y sirolimus). Aquellos con diarrea con causa microbiológica habían recibido recientemente inmunosupresores a altas dosis con mayor frecuencia que el resto (p = 0.048). Los pacientes con diarrea atribuida a fármacos recibían más frecuentemente mofetil micofenolato (p = 0.039). En 16 (30.8%) se realizaron modificaciones de los inmunosupresores como medida terapéutica, y a 47 (90.4%) se les indicó antibioticoterapia empírica. La mediana de duración de internación fue de 6 días y 7 pacientes (14.6%) persistieron con diarrea al quinto día. Todos tuvieron resolución de la diarrea al alta y un tercio persistió con insuficiencia renal. La información de este estudio puede servir para mejorar las medidas preventivas, diagnósticas y terapéuticas en estos pacientes.

Diarrhea is a frequent and potentially severe complication of kidney transplantation. We describe here, in a cross-sectional study, the epidemiological and microbiological characteristics of acute and persistent diarrhea in 52 inpatients with kidney and kidney-pancreas transplant in a hospital in Buenos Aires, 42 (80.8%) of whom had received a kidney and 10 (19.2%) a kidney-pancreas transplant. Diarrhea was the reason of admission of 34 cases (65.4%). The etiology could be studied in 50 patients: 25 (50%) had no etiological diagnosis of diarrhea and 18 (36%) had a specific infectious etiology: 3 (6%) cytomegalovirus disease, 6 (12%) diarrhea attributed to cytomegalovirus, 5 (10%) to rotavirus and 4 (8%) to Clostridium difficile. In 7 (14%) diarrhea was attributed to drugs (mycophenolate mofetil and sirolimus). Patients with infectious diarrhea had recently received high doses of immunosuppressive therapy more frequently than the rest (p = 0.048). Those with diarrhea attributed to drugs were more frequently on mycophenolate mofetil than the rest (p = 0.039). Empirical modification of the immunosuppressive treatment was done in 16 (30.8%) and empirical antibiotic therapy was given to 47 patients (90.4%). Median length of hospital stay was 6 days. Seven patients (14.6%) persisted with diarrhea at the fifth day of admission. At hospital discharge all cases had complete resolution of symptoms and one third persisted with kidney failure. Information provided in this study can be useful as a starting point for improving preventive, diagnostic and therapeutic measures in these patients.

Imaging Spectrum after Pancreas Transplantation with Enteric Drainage

Since the introduction of pancreas transplantation more than 40 years ago, surgical techniques and immunosuppressive regiments have improved and both have contributed to increase the number and success rate of this procedure. However, graft survival corresponds to early diagnosis of organ-related complications. Thus, knowledge of the transplantation procedure and postoperative image anatomy are basic requirements for radiologists. In this article, we demonstrate the imaging spectrum of pancreas transplantation with enteric exocrine drainage.

Trasplante simultáneo de páncreas y riñon en diabetes mellitus tipo 1: Experiencia de un centro en Chile / Simultaneous kidney and pancreas transplantation (SKPT) in patients with type 1 diabetes and chronic renal failure: Experience in 12 patients in Chile

Background: Simultaneous kidney and páncreas transplantation (SKPT) is the best alternative for end stage renal disease among patients with insulin dependent diabetes mellitus. Aim: To report our experience with SKPT. Material andMethods: Retrospective analysis ofl2 recipients of SKPT transplanted in one center starting in 1994, with a meanfollow-upperiod of6.8years (2-15). Results: Eleven ofl2 recipients were in chronic hemodialysis before SKPT. Mean A, B, DR and HLA mismatch was 4.3. Mean preformed anti HLA antibodies was 3.3 percent. Mean cold ischemia times for páncreas and kidney were 6 and 10 hours, respectively. In the first eight cases, the páncreas was drained to the bladder, and in the last four, an enteric drainage was performed. Eleven recipients were induced with antibodies, and maintenance immunosuppression consisted ofCyclosporine or Tacrolimusplus an antiproliferative agent. Ten year patient survival was 70 percent. Páncreas and kidney survival, defined by insulin and dialysis independence, were 72 and 73 percent respectively. Fifty percent of recipients experienced acute graft rejection (cellular or humoral), with good response to treatment except in one case. Conclusions: This experience shows that SKPT is associated with an excellent patient survival associated to insulin and dialysis independence in 70 percent of patients at 10 years.

Trasplante páncreas y riñón en Clínica Las Condes / Simultaneous kidney pancreas transplant, Clínica Las Condes experience

El trasplante combinado páncreas-riñón (TPR) para pacientes portadores de Diabetes Mellitus 1 con insuficiencia renal crónica terminal, ha demostrado ser la única terapia que permite alcanzar el estado de normoglicemia de manera estable, situación que lleva a una disminución de las complicaciones crónicas de la DM y mejora la expectativa y calidad de vida. En nuestro país la tasa de realización de este trasplante es aún muy baja, lo que se debe a factores asociados a la donación y a una insuficiente divulgación de los resultados nacionales. Objetivo: Describir los resultados obtenidos por el equipo de trasplante de Clínica Las Condes en TPR desde el inicio del programa, en marzo 1994 a marzo 2009. Método: Se recopiló la información de los 12 pacientes sometidos a TPR en nuestro centro entre 1994 y marzo 2009, analizando las variables con estadística descriptiva y la sobrevida con curvas de Kaplan-Meier. Resultados: La sobrevida actuarial de pacientes a 5 y 10 años fue de 75 por ciento. La sobrevida actuarial de páncreas fue 83 por ciento a los 5 y 10 años, y la de riñón 74 por ciento en los mismos periodos. Nueve pacientes presentan injertos funcionantes a marzo 2009, todos los cuales realizan una vida normal. Discusión: Estos resultados son comparables a los presentados por centros extranjeros de prestigio internacional y se deben principalmente a avances en las técnicas quirúrgicas y de inmunosupresión. La baja tasa de complicaciones y alta sobrevida presentada refuerzan la necesidad de potenciar esta terapia en nuestro país.

Combined kidney-pancreas transplant (KPT) for patients with type 1 Diabetes Mellitus complicated with end stage renal disease has shown to be the best treatment to achieve a stable metabolic condition, which may lead to a decrease in chronic diabetes complications and improves quality of life and patient survival. In our country, the rate of this transplant is still very low, associated with donation issues and little knowledge of the results achieved by Chilean experience. Objective: describe the results obtained by Clínica Las Condes transplant team in KPT, from the beginning of the program in March 1994 to March 2009. Methods: Information of 12 patients undergoing KPT in our center from 1994 to march 2009, was collected and analyzed through descriptive statistics. Actuarial survival was calculated with Kaplan Meier formula. Results: Patient survival was 75 percent at 5 and 10 years. Kidney transplant survival was 74 percent and pancreas survival was 83 percent in the same periods. Nine patients have functioning grafts, all of them living a normal life. Discussion: These results are similar to those reported by foreign centers of international status and are due to advances in surgical techniques and immunosuppressive treatment. The low rate of complications and excellent survival presented in this article enforces the need to potentates this therapy in our country.

Qualidade de vida dos pacientes diabéticos tipo 1 submetidos a transplante / Quality of life of type 1 diabetic patients following transplantation

A qualidade de vida é um desfecho importante quando analisamos os resultados de qualquer tipo de tratamento. No que tange ao diabetes tipo 1, este desfecho torna-se de especial relevância. Os tratamentos mais eficazes para controlar esta enfermidade podem modificar ignificativamente a qualidade de vida dos pacientes. Nos casos de diabetes com complicações crônicas em estágios avançados, o transplante de órgãos passou a ser indicado de forma mais liberal, visando a melhorar a qualidade de vida deste subgrupo de enfermos. Este artigo tem como objetivo revisar as publicações que avaliaram as modificações na qualidade de vida dos pacientes diabéticos tipo 1 submetidos às diferentes modalidades de transplante de órgãos (transplante isolado de rim, transplante simultâneo de pâncreas e rim e transplante isolado de pâncreas).

Quality of life is an important outcome when the results of any type of treatment are analyzed. Concerning diabetes type 1, this outcome becomes especially relevant. The most effective treatments to control this disease may significantly affect the quality of life of the patients. In the cases of diabetes with chronic complications at advanced stages, organ transplantation came to be indicated more frequently, as a measure to improve the quality of life of this subgroup of patients. This article aimed at reviewing the published studies evaluating changes to the quality of life of type 1 diabetic patients following different types of organ transplantation (kidney transplant, simultaneous pancreas-kidney transplant, and pancreas transplant.).

Transplante de pâncreas e ilhotas em portadores de diabetes melito: [revisão] / Pancreas and islet transplantation in patients with diabetes mellitus: [review]

O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.

Transmissão do glioma de um doador de múltiplos órgãos para o enxerto pancreático / Transmission of glioma from multiple organ donor do pancreas recipient

Introdução: A disparidade entre a oferta e a demanda de órgãos para transplante impulsiona a inclusão de doadores com tumores primários do sistema nervoso central (SNC) no programa de transplantes. Objetivo: reportar um caso de um paciente que desenvolveu um glioma no enxerto pancreático proveniente de um doador de múltiplos órgãos cuja causa mortis foi um glioma maligno / Introduction: the disparity between the suplly of and the demand for transplant organs has led to an acceptance of donors with primary central nervous system (CNS) tumors. Purpose: face the rarity, the authors report the case of a patient who developed a glioma on a pancreatic grafft received from a donor with a malignant glioma as cause of brain death...

Vanishing Pancreatic Grafts

Comparison of pancreaticoduodenal transplants (PDT) and duct-ligated pancreas transplant (DLPT) were performed using syngeneic and allogeneic studies in rats. Both DLPT and PDT allogeneic grafts showed mild rejection. DLPT groups showed disorganized pathology and acini replaced by fat. Eventually, massive fibrosis was seen in the Islets of Langerhans, as well as rejection cellular infiltrates. In both PDT groups, normal histology was observed in the same period. Thus the effect of duct occlusion is highly detrimental for the grafts.

Allograft biopsies in management of pancreas transplant recipients.

Pancreatic transplantation is becoming increasingly accepted as a treatment modality for Type 1 diabetes mellitus. When allograft dysfunction is noted during follow up of patients, a biopsy is an extremely useful tool to diagnose various forms of rejection, and to rule out non-immunologic causes of graft malfunction, such as donor disease, ischaemic/preservation injury, vascular thrombosis, pancreatitis, post-transplant lymphoproliferative disease, technical complications and recurrence of diabetes mellitus. In addition to its role in establishing the primary diagnosis, a biopsy can grade the severity of pathology present, help determine the most appropriate therapy, and provide information relevant to graft prognosis.

Trasplante de páncreas y fructosa 1.6 disfosfato: un reporte preliminar / Transplantation pancreas and fructose 1.6 diphosphate: an report preliminary

Evaluar el efecto de la Fructuosa 1,6 difosfato (FDP) sobre el injerto pancreático, durante el período de isquemia, entre la pancreatectomía y el implante. Se trasplantaron un total de 10 perros los cuales fueron sometidos a autotransplante con 110 min de isquemia para el órgano una vez realizada la pancreatectomía. En el grupo control (n=5) se realizó pancreatectomía, perfusión del órgano con solución fisiológica durante 65 min. Inmerso en la misma solución a 4 grados centígrados, y autotrasplante; en el grupo experimental se realizó pancreatectomía, perfusión del órgano, inmerso en solución fisiológica a 4 grados centígrados, con solución 0,9 por ciento contenido mmol de FDP durante 65 min, y autotrasplante. El tiempo total de isquemia en ambos grupos fue de 110 min. En todos los animales el autotrasplante se realizó en la región inguinal izquierda, con anastomosis a la vena y arteria femorales en ese orden

Transplante simultâneo de rim e pâncreas: experiência com nove casos na Irmandade Santa Casa de Misericórdia de Porto Alegre / Simultaneous kidney and pancreas transplantation: experience with 9 cases in Irmandade Santa Casa de Misericórdia de Porto Alegre

É apresentada a experiência do Serviço de Nefrologia da Santa Casa de Porto Alegre com o Transplante Simultâneo de Rim e Pâncreas (TxSRP) em diabéticos insulino-dependentes urêmicos. Entre agosto de 1987 e fevereiro de 1996 foram realizados nove TxSRP. A sobrevida do paciente do rim e do pâncreas foi de 88,9 por cento, 77,8 por cento e 76,2 por cento no primeiro ano e de 63,4 por cento, 51,8 por cento e 50,7 por cento no terceiro ano. Ocorreram quatro óbitos. Foram perdidos um enxerto renal e um pancreático. Ao final da observaçäo, cinco pacientes estavam vivos com enxerto renal funcionante e quatro com funçäo pancreática normal. O TxSRP pode, em determinadas situaçöes, ser uma alternativa para o tratamento de diabéticos insulino-dependentes urêmicos necessitando de transplante renal.

Complicaciones urológicas del transplante riñon-pancreas / Urologic complications of the kidney-pancreas transplantation

Se analizan las complicaciones precoces ocurridas en los primeros 3 transplantes efectuados y que coinciden con las habitualmente publicadas I.T.U. hamaturia, uretritis, etc. Se presentan estas complicaciones y se analiza su manejo en cada caso. Se presentan estudios urodinámicos de los casos ya que vejigas de alta presión pueden ocacionar desde I.T.U. a pancreatitis del injerto. Se concluye que la mayoría de las complicaciones son precoces y con el transcurso del tiempo disminuye en frecuencia e intensidad

Trasplante de páncreas: resultados experimentales y clínicos con la técnica de derivación urinaria de las secreciones exocrinas / Pancreas transplantation: experimental and clinical results with exocrine diversion into the urinary system technique

Se presenta la experiencia experimental y clínica en los últimos años con la derivación urinaria de las secreciones exócrinas en el trasplante de páncreas. Experimentalmente la técnica descripta presentó ventajas en supervivencia del injerto y de los animales sobre las anteriormente desarrollladas por el grupo. En el aspecto clínico se describen modificaciones a la técnica original de Corry que redundaron en menores complicaciones. La supervivencia actual de pacientes fue del 96.5// con una supervivencia del implante del 93//. Todos los enfermos con páncres funcionante se encuentran actualmente en normoglucemia, con hemoglobina glicosilada normal y en insulinoindependencia

Trasplante de páncreas en 132 pacientes diabéticos insulino-dependientes / Pancreas transplantation in 132 insulin-dependent diabetic patients

A total of 140 pancreatic transplants have been performed in 132 insulin-dependent diabetic patients at lyon (France). Most cases received a double pancreatic and renal transplant. The duct obstruction technique was utilized in 113 segmental transplants. A total pancreatic transplant was performed in 27 patients, with duct obstruction in 27, Gl tract derivation in 14, urinary tract derivation in 11 and intraductal obstruction in 2 patients. Utilizing quadruple immunosuppression, the one year survival rate was 90% and the transplant survival was 60%