RESUMEN
BACKGROUND: Pancreas transplant is an effective treatment for insulin-dependent diabetic individuals with end-stage renal disease, yet immunosuppression-associated adverse events may adversely affect patient and graft survival. The aim of the study was to document whether mammalian target of rapamycin inhibitors (mTORi) are safe and effective as a second-line drug after pancreas transplant. METHODOLOGY: An observational single-center study was performed in a cohort of 490 simultaneous pancreas-kidney transplant and 45 pancreas-after-kidney transplant individuals after conversion to mTORi (n = 13) owing to adverse events of either tacrolimus or mycophenolate. RESULTS: mTORi conversion was performed 11.5 ± 10.1 (range, 1-28) months after pancreas transplant, mainly owing to cytomegalovirus infection and gastrointestinal intolerance. We frequently observed clinical complications after mTORi conversion, yet creatinine, eGFR, proteinuria, fasting plasma glucose, HbA1c, and C-peptide remained stable throughout the study (mean follow-up 8.2 ± 5, range 1-17) years, as did the lipid profile (P > .05). However, graft loss occurred in almost 20% of patients owing to chronic alterations. LIMITATIONS: The small number of patients and a single-center cohort were limitations of the study. CONCLUSIONS: Late mTORi conversion is a safe and effective approach when tacrolimus or mycophenolate-mediated adverse events occur after pancreas transplant.
Asunto(s)
Everolimus/uso terapéutico , Inmunosupresores/uso terapéutico , Trasplante de Páncreas/métodos , Sirolimus/uso terapéutico , Adulto , Sustitución de Medicamentos/métodos , Femenino , Rechazo de Injerto/prevención & control , Supervivencia de Injerto/efectos de los fármacos , Humanos , Terapia de Inmunosupresión/métodos , Trasplante de Riñón , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Immunosuppressive regimen is associated with several metabolic adverse effects. Bone loss and fractures are frequent after transplantation and involve multifactorial mechanisms. METHODS: A retrospective analysis of 130 patients submitted to simultaneous pancreas-kidney transplantation (SPKT) and an identification of risk factors involved in de novo Charcot neuroarthropathy by multivariate analysis were used; P<0.05 was considered significant. RESULTS: Charcot neuroarthropathy was diagnosed in 4.6% of SPKT recipients during the first year. Cumulative glucocorticoid doses (daily dose plus methylprednisolone pulse) during the first 6 months both adjusted to body weight (>78 mg/kg) and not adjusted to body weight were associated with Charcot neuroarthropathy (P=0.001 and P<0.0001, respectively). Age, gender, race, time on dialysis, time of diabetes history, and posttransplantation hyperparathyroidism were not related to Charcot neuroarthropathy after SPKT. CONCLUSIONS: Glucocorticoids are the main risk factors for de novo Charcot neuroarthropathy after SPKT. Protocols including glucocorticoid avoidance or minimization should be considered.
Asunto(s)
Artropatía Neurógena/etiología , Diabetes Mellitus Tipo 1/cirugía , Glucocorticoides/efectos adversos , Inmunosupresores/efectos adversos , Trasplante de Riñón/efectos adversos , Trasplante de Páncreas/efectos adversos , Artropatía Neurógena/diagnóstico , Relación Dosis-Respuesta a Droga , Femenino , Articulaciones del Pie/diagnóstico por imagen , Articulaciones del Pie/patología , Rechazo de Injerto/inmunología , Rechazo de Injerto/prevención & control , Humanos , Imagen por Resonancia Magnética , Masculino , Radiografía , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: We used homeostasis model assessment to investigate insulin sensitivity and secretion after a simultaneous pancreas-kidney transplant or kidney transplant alone. In that model, fasting plasma glucose and C-peptide levels are used to evaluate insulin sensitivity and beta-cell function. MATERIALS AND METHODS: Factors (eg, age, sex, race, delayed kidney allograft function) were correlated with homeostasis model assessment of beta-cell function and homeostasis model assessment of insulin sensitivity values after simultaneous pancreas-kidney transplant (n=89) or kidney transplant alone (n=68), and the results were compared with those in healthy subjects (n=49). RESULTS: Homeostasis model assessment of beta-cell function values were similar in patients who underwent kidney transplant alone or a simultaneous pancreas-kidney transplant, and were higher than homeostasis model assessment of beta cell function values in healthy subjects. The homeostasis model assessment of insulin sensitivity showed intermediate values for patients who underwent a simultaneous pancreas-kidney transplant and correlated with prednisone dosages (in those who underwent kidney transplant alone) and tacrolimus levels (in patients who underwent a simultaneous pancreas-kidney transplant). Homeostasis model assessment of beta-cell function values correlated with prednisone dosages in both groups and with tacrolimus levels in only those who underwent a simultaneous pancreas-kidney transplant. The body mass index of subjects who underwent kidney transplant alone correlated with both homeostasis model assessment of beta-cell function results and homeostasis model assessment of insulin sensitivity results. A family history of diabetes in subjects who underwent a simultaneous pancreas-kidney transplant correlated with homeostasis model assessment of beta-cell function results and homeostasis model assessment of insulin sensitivity results. CONCLUSIONS: Immunosuppressive regimen and body mass index were linked with reduced insulin sensitivity after kidney transplant. A family history of diabetes was linked with higher values of insulin secretion and lower insulin sensitivity in patients who underwent a simultaneous pancreas-kidney transplant.
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Diabetes Mellitus/genética , Resistencia a la Insulina/fisiología , Insulina/metabolismo , Trasplante de Riñón/fisiología , Trasplante de Páncreas/fisiología , Linaje , Adulto , Glucemia/metabolismo , Índice de Masa Corporal , Péptido C/sangre , Estudios de Casos y Controles , Diabetes Mellitus/metabolismo , Diabetes Mellitus/fisiopatología , Femenino , Homeostasis/fisiología , Humanos , Inmunosupresores/uso terapéutico , Secreción de Insulina , Células Secretoras de Insulina/fisiología , Trasplante de Riñón/inmunología , Masculino , Modelos Biológicos , Prednisona/uso terapéutico , Tacrolimus/uso terapéuticoRESUMEN
Pancreas transplantation is an invasive procedure that can restore and maintain normoglycemic level very successfully and for a prolonged period in DM1 patients. The procedure elevates the morbimortality rates in the first few months following the surgery if compared to kidney transplants with living donors, but it offers a better quality of life to patients.Although controversial, several studies have shown the stabilization or the improvement of some of the chronic complications related to diabetes, as well as the extra number of years of life that patients submitted to a double pancreas-kidney transplantation may gain.Recent studies have demonstrated clashing outcomes regarding isolated pancreas transplantations, a fact which reinforces the need for a more discerning selection of patients for this procedure.
RESUMEN
BACKGROUND: Diabetes is a disease of increasing worldwide prevalence and is the main cause of chronic renal failure. Type 1 diabetic patients with chronic renal failure have the following therapy options: kidney transplant from a living donor, pancreas after kidney transplant, simultaneous pancreas-kidney transplant, or awaiting a deceased donor kidney transplant. For type 2 diabetic patients, only kidney transplant from deceased or living donors are recommended. Patient survival after kidney transplant has been improving for all age ranges in comparison to the dialysis therapy. The main causes of mortality after transplant are cardiovascular and cerebrovascular events, infections and neoplasias. Five-year patient survival for type 2 diabetic patients is lower than the non-diabetics' because they are older and have higher body mass index on the occasion of the transplant and both pre- and posttransplant cardiovascular diseases prevalences. The increased postransplant cardiovascular mortality in these patients is attributed to the presence of well-known risk factors, such as insulin resistance, higher triglycerides values, lower HDL-cholesterol values, abnormalities in fibrinolysis and coagulation and endothelial dysfunction. In type 1 diabetic patients, simultaneous pancreas-kidney transplant is associated with lower prevalence of vascular diseases, including acute myocardial infarction, stroke and amputation in comparison to isolated kidney transplant and dialysis therapy. CONCLUSION: Type 1 and 2 diabetic patients present higher survival rates after transplant in comparison to the dialysis therapy, although the prevalence of cardiovascular events and infectious complications remain higher than in the general population.
RESUMEN
OBJECTIVES: Simultaneous pancreatic-renal transplant is an effective treatment for insulin-dependent patients with chronic renal failure. We sought to identify the main influences on pancreatic and patient survival rates after simultaneous pancreas-kidney transplants. PATIENTS AND METHODS: The 1-year patient and pancreas survival rates of 150 patients who had undergone simultaneous pancreas-kidney transplant were analyzed by the Cox proportional hazards regression model and the Kaplan-Meier method. Uni and multivariate analyses were performed in terms of transplant-, recipient-, and donor-related risk factors. RESULTS: At 1 year, patient and pancreatic allograft survival rates were 82% and 76.7%, respectively. Delayed graft function in the kidney (P = .001, HR 5.41), acute kidney rejection (P = .016, HR 3.36), and intra-abdominal infection (P < .0001, HR 4.15) were the main factors related to 1-year patient survival. Pancreatic allograft survival at 1 year was related to intra-abdominal infection (P < .0001, OR 12.83), vascular thrombosis (P = .002, OR 40.55), acute kidney rejection (P = .027, OR 3.06), donor sodium greater than 155 mEq/L (P = .02, OR 3.27), and dopamine administration exceeding 7.6 microg/kg/min (P = .046, OR 2.85). CONCLUSIONS: Delayed kidney allograft function and intra-abdominal infection had an important effect on both patient and pancreatic allograft survival rates.
Asunto(s)
Supervivencia de Injerto , Trasplante de Riñón/mortalidad , Riñón/fisiopatología , Riñón/cirugía , Trasplante de Páncreas/mortalidad , Páncreas/fisiopatología , Páncreas/cirugía , Adolescente , Adulto , Brasil/epidemiología , Enfermedades Transmisibles/mortalidad , Enfermedades Transmisibles/fisiopatología , Funcionamiento Retardado del Injerto/mortalidad , Funcionamiento Retardado del Injerto/fisiopatología , Dopamina/efectos adversos , Femenino , Rechazo de Injerto/mortalidad , Rechazo de Injerto/fisiopatología , Humanos , Estimación de Kaplan-Meier , Trasplante de Riñón/efectos adversos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Trasplante de Páncreas/efectos adversos , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Sodio/sangre , Análisis de Supervivencia , Trombosis/mortalidad , Trombosis/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
Thrombotic microangiopathy (TMA) is rare after transplantation and is associated with a high incidence of kidney graft dysfunction. Between December 2000 and March 2006, 136 simultaneous pancreas-kidney transplantations were performed with an incidence of TMA of 5.1% (71.4% localized to kidney allograft). All cases were diagnosed during the first three months and were attributed to tacrolimus; 74% were women. Systemic TMA presented higher values of lactate dehydrogenase (2658 +/- 659 U/L vs. 1331 +/- 473 U/L, p = 0.04) and a greater decrease in hematocrit (45.8 +/- 17.7% vs. 19.2 +/- 6%, p = 0.02) than in localized TMA. Acute kidney rejection complicated almost 90% of the cases with 43% of kidney graft lost. Tacrolimus was switched to sirolimus and fresh-frozen plasma was administered. Creatinine clearance after a mean follow-up of two yr was 100.7 mL/min/1.73 m(2) and 57.9 mL/min/1.73 m(2) in patients with systemic and localized TMA, respectively. In conclusion, sirolimus is an alternative to TMA associated with tacrolimus.
Asunto(s)
Inmunosupresores/efectos adversos , Trasplante de Riñón , Riñón/irrigación sanguínea , Trasplante de Páncreas , Complicaciones Posoperatorias/inducido químicamente , Tacrolimus/efectos adversos , Trombosis/inducido químicamente , Adolescente , Adulto , Capilares/patología , Humanos , Glomérulos Renales/irrigación sanguínea , Glomérulos Renales/patología , Persona de Mediana Edad , Estudios Retrospectivos , Tacrolimus/uso terapéuticoRESUMEN
Foram estudados 17 indivíduos de ambos os sexos, internados para doaçäo de rim dois dias pré e cinco dias após a uninefrectomia (grupo I), nos quais foram medidos clearance de creatinina, proteinúria de 24 horas, excreçäo renal diária de sódio e potássio, assim como avaliado o tamanho renal pelo ultra-som. Esses doadores, após cinco dias de uninefrectomia, apresentaram aumento significante da filtraçäo glomerular (de 52,4 para 81,6ml/min), da proteinúria de 24 horas (de 30,5 para 109,2 mg), da excreçäo diária urinária de sódio (de 93,6 para 147,0 *Eq/min), assim como significante aumento do rim remanescente (de 9,9 para 10,9cm diâmetro longitudinal e 4,3 para 5,1 diâmetro transversal). Foram também estudados em 36 doadores de rim de ambos os sexos, após intervalos variáveis de um a nove anos de doaçäo, os mesmos parâmetros de funçäo e morfologia observados no grupo I, assim como avaliada a reserva funcional renal através de sobrecarga proteíca aguda (grupo II). Nesses pacientes observou-se uma tendência decrescente da reserva funcional renal, que se mostrou mais acentuada quanto maior tenha sido o tempo de doaçäo. O incremento da filtraçäo glomerular com a sobrecarga protéica foi de 56% em pacientes até 40 meses de doaçäo e decresceu a 14% quando a doaçäo se processou após nove anos de doaçäo. Esses pacientes também apresentaram proteinúria acima dos níveis normais, mais elevada nos pacientes com intervalo maior pós-doaçäo