Outcome of simultaneous kidney pancreas transplantation: a single center analysis.

The aim of this study was to evaluate the outcome of simultaneous kidney pancreas transplantation (SKPT) by various surgical techniques. The 161 patients submitted to SKPT underwent the following: 36 pancreas with duct occlusion (from 1985 to 1989), 75 with whole pancreas with bladder diversion (from 1990 to 1998), and 50 whole pancreas with enteric diversion (40 with systemic and 10 with portal drainage) (from 1999 to September 2002). A positive effect on patient survival was evident using enteric diversion versus the duct occlusion group (P = .005), and versus the bladder diversion group (.035), and on pancreas graft survival in the enteric diversion versus the duct occlusion group (P < .028). These improvements may be due to refined donor and patient selection criteria, surgical technique, and immunosuppression.

Long-term survival after kidney and kidney-pancreas transplantation in diabetic patients.

PURPOSE: To investigate the influence of diabetes mellitus on patient and graft survival among renal versus renal-pancreatic recipients. METHODS: Among 270 renal transplants performed from 1985 to 2002, a total of 204 (75%) were in diabetic patients and 66 (25%) in nondiabetic patients. Among the 204 diabetic patients 161 (60%) kidneys were transplanted simultaneously with a pancreatic graft (SKPT group). The overall group of patient included 164 (61%) men and 106 (39%) women with mean time on dialysis of 31 +/- 21 months (range 0 to 126 months). The mean duration of diabetes was 24 +/- 7 years (range 5 to 51 years). Ninety-nine percent of the patients were on renal replacement therapy (79% hemodialysis and 20% peritoneal dialysis). RESULTS: The overall rejection rate was similar (NS). Both patient and kidney graft survival rates were worse in diabetics. Patient survival was 82% at 5 years among patients undergoing SKPT, 60% in diabetics receiving only a kidney, and 88% in nondiabetic transplanted patients. Kidney graft survival at 5 years was 77% in diabetics receiving SKPT, 68% in diabetics receiving a kidney alone, and 82% in nondiabetic patients. Overall patient survival was significantly greater among nondiabetics (P =.002) or in diabetics who received SKPT compared with diabetics who only had a kidney transplant (P =.001). CONCLUSIONS: This retrospective clinical evaluation confirms that combined pancreas and kidney transplantation should be the first choice to insulin-dependent diabetes mellitus (IDDM) patients with end-stage diabetic nephropathy.

Simultaneous pancreas-kidney transplantation: short- and long-term results.

Simultaneous kidney and pancreas transplantation (SKPT) is the treatment of choice for a majority of type I diabetic patients with end-stage renal disease. With continual refinements in surgical technique and an evolving immunosuppressive arsenal, graft and patient survival have continually improved. The purpose of this study was to evaluate the short- and long-term results of SKPTs performed in 174 recipients from June 1985 to March 2003 including 37 segmental grafts with duct occlusion, 73 whole pancreas transplants with bladder diversion, and 64 whole pancreas grafts with enteric diversion. The series includes 160 cases with systemic drainage and 14 with portal drainage. In the segmental pancreas group, patient survival was 85%, 76%, and 53% with pancreas survival of 67%, 36%, and 15%, and kidney survival of 82%, 63%, and 15%, respectively, at 1, 5, and 10 years. Among the bladder diversion group, patient survival was 94%, 83%, and 73% pancreas survival 72%, 67%, and 65%, and kidney survival 89%, 78%, and 58%, respectively, 1, 5, and 10 years. Among the enter diversion group patient survival was 90% and 90% at 12 and 108 months, pancreas survival 80% and 65%, and kidney survival 85% and 85%, respectively. There were significant differences between curves of survival distribution according to the surgical technique applied for patients (P =.04), pancreas (P =.007), and kidney (P =.005). Based on the results from our study, the short- and long-term prognosis after SKPT is satisfactory, especially compared to the outcomes of long-term dialysis among patients with end-stage renal disease caused by type I diabetes.

[Simultaneous pancreas-kidney transplantation: a single center experience on 148 cases]. / Risultati del trapianto simultaneo di rene e pancreas: esperienza su 148 casi.

AIM: To evaluate the outcome of simultaneous pancreas transplantation (SKPT) focusing on the surgical technique applied. PATIENTS AND METHODS: One hundred forty-eight patients were submitted to SKPT 33 with segmental pancreas with duct occlusion (from 1985 to 1990), 77 with whole pancreas with bladder diversion (from 1990 to 1998) and 38 whole pancreas with enteric diversion (29 with systemic and 9 with portal drainage) (from 1998 to December 2001). RESULTS: Patient survival was 92%, 82%, 63% at 1, 5, and 10 years respectively. Kidney survival was 87%, 75%, and 48% at 1, 5, 10 years. Pancreas graft survival was 71%, 58%, and 46% at 1, 5, 10 years. In the enteric diversion group patient, kidney, pancreas survival at one year was 93%, 92%, and 75%. A positive effect on patient survival was evident in enteric diversion versus duct occlusion group (p = 0.03), but not versus bladder diversion group and on pancreas graft survival in enteric diversion versus duct occlusion group (p < 0.01). CONCLUSIONS: These data suggest that SKPT has become a successful intervention for patients with type I diabetes and end stage renal disease. Reasons for these improvements include improved donor and patient selection criteria, refinements in surgical technique and better immunosuppression.

Surgical treatment of benign and borderline neoplasms of the pancreatic body.

BACKGROUND: Conventional operations for benign and borderline tumors of the pancreatic body are distal pancreatectomy and enucleation. An unusual operation allowing the preservation of the proximal and distal pancreas is median pancreatectomy. METHOD: A retrospective analysis of prospectively collected data on 67 patients with nonmalignant neoplasms of the pancreatic body was performed. The operations were: 32 median pancreatectomies (22 with duct occlusion of the distal pancreas, 10 with pancreaticojejunostomy), 21 distal pancreatectomies, and 14 enucleations. The operative and long-term outcomes of the different operations were compared. RESULTS: Enucleation had a shorter operative time and less blood loss than the other operations. No mortality was observed. The pancreatic fistula rate was 50% after median pancreatectomy (59% in case of distal duct occlusion, 30% in case of pancreaticojejunostomy), 14% after distal pancreatectomy and 14% after enucleation. Diabetes appeared in 3 patients after distal pancreatectomy and 3 patients after median pancreatectomy with duct occlusion. CONCLUSIONS: When indicated, enucleation is the operation of choice for a nonmalignant neoplasm of the pancreatic body. With respect to distal resection, the higher fistula rate of median pancreatectomy with pancreaticojejunostomy could be the price for a better long-term endocrine function; median pancreatectomy with duct occlusion had worse operative results and no long-term advantages.

Cardiovascular outcomes after kidney-pancreas and kidney-alone transplantation.

BACKGROUND: This study retrospectively assessed, with an intention-to-treat analysis, the effect of kidney-pancreas transplantation (KP) on survival and cardiovascular outcome in type 1 diabetic uremic patients. METHODS: A total of 351 uremic type 1 diabetic patients were enrolled on a waiting list for KP: 130 underwent KP transplantation, 25 underwent kidney transplantation alone (KA), whereas 196 patients remained on dialysis (WL). The three populations had similar cardiovascular conditions. Actuarial survival rates and causes of death were recorded over a period of seven years. Finally, 23 KP and 13 KA patients underwent left radionuclide ventriculography, during a follow-up of four years. RESULTS: In the entire group of 351 patients the seven-year survival rate was 77.4% for KP, 56.0% for KA and 39.6% for WL (KP vs. WL, P = 0.01). Cardiovascular death rate was 7.6% in KP, 20.0% in KA and 16.1% in WL (KP versus WL, P = 0.03; KP vs. KA, P = 0.16). In the subsample studied with radionuclide ventriculography, left ventricular ejection fraction improved in KP, but did not in KA, with significant differences between groups at two and four years. At four years only the KP patients presented normal values of diastolic parameters, including the peak filling rate, time-to-peak filling rate, and peak filling rate/peak ejection rate ratio. Glycated hemoglobin was negatively associated with the ejection fraction, peak filling rate and peak filling rate/peak ejection rate ratio, and positively associated with the time-to-peak filling rate. CONCLUSIONS: Normalization of blood glucose metabolism and improvement of blood pressure control obtained with KP transplant is associated with positive effects on survival, cardiovascular death rate, and left ventricular function.

Effects of kidney-pancreas transplantation on atherosclerotic risk factors and endothelial function in patients with uremia and type 1 diabetes.

Cardiovascular disease and the development of coronary artery disease play a pivotal role in increasing mortality in patients with type 1 diabetes. The aim of our study was to evaluate the effects of pancreas transplantation on atherosclerotic risk factors, endothelial-dependent dilation (EDD), and progression of intima media thickness (IMT) in patients with uremia and type 1 diabetes after kidney-alone (KA) or kidney-pancreas (KP) transplantation. A cross-sectional study comparing two groups of patients with type 1 diabetes was performed. Sixty patients underwent KP transplantation and 30 patients underwent KA transplantation. Age and cardiovascular risk profile were comparable in patients before transplantation. In all patients, atherosclerotic risks factors (lipid profile, fasting and post-methionine load plasma homocysteine, von Willebrand factor levels, D-dimer fragments, and fibrinogen) were assessed and Doppler echographic evaluation of IMT and endothelial function with flow-mediated and nitrate dilation of the brachial artery was performed. Twenty healthy subjects were chosen as controls (C) for EDD. Compared with patients undergoing KA transplantation, patients undergoing KP transplantation showed lower values for HbA1c (KP = 6.2 +/- 0.1% vs. KA = 8.4 +/- 0.5%; P < 0.01), fasting homocysteine (KP = 14.0 +/- 0.7 mcromol/l vs. KA = 19.0 +/- 2.0 micromol/l; P = 0.02), von Willebrand factor levels (KP = 157.9 +/- 8.6% vs. KA = 212.5 +/- 16.2%; P < 0.01), D-dimer fragments (KP = 0.29 +/- 0.02 microg/ml vs. KA = 0.73 +/- 0.11 microg/ml;P < 0.01), fibrinogen (KP = 363.0 +/- 11.1 mg/dl vs. KA = 397.6 +/- 19.4 mg/dl; NS), triglycerides (KP = 122.7 +/- 8.6 mg/dl vs. KA = 187.0 +/- 30.1 mg/dl; P = 0.01), and urinary albumin excretion rate (KP = 13.5 +/- 1.9 mg/24 h vs. KA = 57.3 +/- 26.3 mg/24 h; P < 0.01). Patients undergoing KP transplantation showed a normal EDD (KP = 6.21 +/- 2.42%, KA = 0.65 +/- 2.74%, C = 8.1 +/- 2.1%; P < 0.01), whereas no differences were observed in nitrate-dependent dilation. Moreover, IMT was lower in patients undergoing KP transplantation than in patients undergoing KA transplantation (KP = 0.74 +/- 0.03 mm vs. KA = 0.86 +/- 0.09 mm; P = 0.04). Our study showed that patients with type 1 diabetes have a lower atherosclerotic risk profile after KP transplantation than after KA transplantation. These differences are tightly correlated with metabolic control, fasting homocysteine levels, lower D-dimer fragments, and lower von Willebrand factor levels. Normal endothelial function and reduction of IMT was observed only in patients undergoing KP transplantation.

Reversal of left ventricular diastolic dysfunction after kidney-pancreas transplantation in type 1 diabetic uremic patients.

OBJECTIVE: Diastolic function is frequently impaired in diabetic patients. Our aim was to evaluate the effects of glycometabolic control achieved by pancreas transplantation on left ventricular function in uremic type 1 diabetic patients. RESEARCH DESIGN AND METHODS: Left ventricular systolic and diastolic functions were evaluated using radionuclide ventriculography in 42 kidney-pancreas transplant patients and 26 kidney-alone recipients who had similar clinical characteristics before transplantation. Patients were grouped according to 6, 24, and 48 months of follow-up. Control subjects consisted of 20 type 1 diabetic patients. RESULTS: The left ventricular ejection fraction was normal in all of the patients. However, kidney-pancreas transplant patients with 4 years of graft function had a higher ejection fraction (75.7 +/- 1.8%) than kidney-alone patients with 4 years of graft function (65.3 +/- 2.8%, P = 0.02) and type 1 diabetic patients (61.3 +/- 3.7%, P = 0.004). In patients with 4 years of graft function, normal diastolic parameters were evident in kidney-pancreas but not in kidney-alone or in type 1 diabetic patients (peak filling rate: 4.46 +/- 0.15 end diastolic volume (EDV)/s in kidney-pancreas patients vs. 2.73 +/- 0.24 EDV/s [P < 0.01] and 3.39 +/- 0.30 EDV/s [P < 0.01] in kidney-alone and type 1 diabetic patients, respectively; time-to-peak filling rate: 141.9 +/- 7.8 ms in kidney-alone patients vs. 209.4 +/- 13.5 ms in kidney-alone patients [P < 0.01]; peak filling rate/peak ejection rate ratio: 1.10 +/- 0.04 in kidney-pancreas patients vs. 0.81 +/- 0.08 in kidney-alone patients [P < 0.01]). A significant reduction in diastolic dysfunction rate was observed only in kidney-pancreas patients. CONCLUSIONS: Kidney-pancreas transplantation results in complete insulin independence, a better glycometabolic pattern and blood pressure control, an improvement of left ventricular function, and a reversal of diastolic dysfunction.

Postabsorptive muscle protein metabolism in type 1 diabetic patients after pancreas transplantation.

Insulin was shown to induce protein anabolism in vivo mainly by inhibiting proteolysis. Heterotopic pancreas transplantation in type 1 diabetes mellitus is characterized by peripheral hyperinsulinemia due to systemic rather than portal insulin delivery. Therefore, we studied the postabsorptive muscle protein metabolism in type 1 diabetic patients with or without pancreas transplantation. The forearm balance technique was performed in 9 type 1 diabetic patients on exogenous insulin treatment, in 4 type 1 diabetic patients following successful pancreas transplantation and in 6 healthy volunteers. Labelled leucine and phenylalanine were infused to quantify whole-body and muscle protein synthesis, respectively. In the postabsorptive state, whole-body protein synthesis (leucine kinetics) was similar in pancreas-transplanted patients and controls. In contrast, muscle protein synthesis tended to be less negative in pancreas-transplanted patients with respect to type 1 diabetic patients and healthy volunteers. The present data suggest that recipients with peripheral insulin delivery and chronic hyperinsulinemia are characterized by a preferential stimulation of protein synthesis in muscle rather than in the splanchnic district. When insulin was infused acutely, while maintaining euglycemia, the whole-body and muscle protein synthesis rates were approximately halved in type 1 diabetic patients with and without pancreas transplantation. We conclude that pancreas transplantation is able to normalize basal and insulin-stimulated protein metabolism. Chronic hyperinsulinemia counteract steroid-induced protein degradation by means of a mild, but persistent stimulation of muscle protein synthesis.

Surgical treatment of gastric adenocarcinoma: impact on survival and quality of life. A prospective ten year study.

BACKGROUND/AIMS: The objective of this prospective study was to compare the results of total (TG) versus subtotal (SG) gastrectomy in patients with adenocarcinoma of the lower two-thirds of the stomach. PATIENTS AND METHODS: Two hundred and twenty-seven patients underwent curative operation. Preoperative nutritional assessment, postoperative tumor stage, postoperative morbidity/mortality, five-year survival, postgastrectomy dietary intake and nutritional sequelae were recorded in all patients. RESULTS: Postoperative mortality rate was 2.8% in the TG group and 1.1% in the SG group. The number of reoperations, anastomotic dehiscence rate and the length of postoperative stay were higher in the TG group. Five-year survival was closely related to lymph node involvement and gastric wall invasion. The extent of gastric resection did not influence survival when patients were matched for cancer stage. In the SG group, no recurrence in the gastric stump was observed. SG group showed a higher dietary energy intake than the TG group (p < 0.01). This might explain the ability of the SG group to increase body weight more than the TG group (p < 0.01). Only the TG group needed a monthly parenteral vitamin B12 supplements starting 36 months after surgery. CONCLUSION: The results suggest that SG should be considered the treatment of choice of the gastric adenocarcinoma when a cancer-free proximal resection margin can be guaranteed.

Avidin-biotin system in radioimmunoguided surgery for colorectal cancer. Advantages and limits.

PURPOSE: Radiolabeled monoclonal antibodies (MAbs) have been reported to allow tumor intraoperative detection by means of a gamma-detecting probe. The technology is called the Radioimmunoguided Surgery (RIGS) system. The main inconveniences of the method are 1) the long interval needed for clearance of unattached MAbs from the patient's body, between the injection of the MAb and surgery, and 2) the low sensitivity of current MAbs used in detecting small tumors. We describe a new method to overcome these inconveniences using biotinylated MAbs and avidin in order to obtain a rapid blood clearance of the radiolabeled MAbs both anticarcinoembryonic antigen and antitumor-associated glycoprotein-72 MAbs. METHODS: Twenty patients with primary and recurrent colorectal cancer have been enrolled in the study; 125I-biotinylated MAbs FO23C5 (anticarcinoembryonic antigen) and B72.3 (antitumor-associated glycoprotein-72) followed by cold avidin were injected in 13 patients and 7 patients, respectively. RESULTS: A decrease of 94 +/- 3 percent of circulating radioactivity was achieved in 3 to 5 days. Patients underwent surgery approximately seven days after MAb injections rather than after four weeks. Tumors were localized in 14/20 (70 percent) patients (true positive), 2 (10 percent) were false negative, and 4 (20 percent) were true negative. The overall sensitivity level in early-stage primary cancers was 37 percent when related to the presence of disease and 75 percent when related to antigenic expression. The sensitivity for more advanced cancer and for recurrences was 100 percent. Moreover, the in vivo tumor targeting of biotinylated MAb was demonstrated in frozen tumor section by direct streptoavidin-peroxidase staining. CONCLUSIONS: The avidin-biotin system may enhance applicability and effectiveness of radioimmunoguided surgery (RIGS).

Influence of meal ingestion on insulin profiles following intraperitoneal delivery.

This study evaluated the effect of meal ingestion on intraperitoneal insulin absorption in type I diabetic patients with an implanted pump for long-term intraperitoneal insulin delivery. On four separate occasions, patients (n = 7) were administered 15 IU insulin as a 20-minute square-wave infusion using their implanted device; hypoglycemia was prevented by intravenous infusion of 10% dextrose at a variable rate. Two studies were performed during fasting conditions (n = 2 fasting tests) and two studies after the administration of an 800-kcal standard meal (n = 2 postprandial tests). An insulin peak of 630 +/- 545.4 pmol/L (mean +/- SD) in fasting tests and 696 +/- 420.5 pmol/L in postprandial tests was reached in the peripheral circulation after 45 +/- 11.7 and 45 +/- 14.7 minutes, respectively, with no significant difference between the two experimental conditions. Areas under the insulin curves were not significantly different in fasting and postprandial tests (51,500 +/- 34,278 v 50,916 +/- 20,558 pmol/L.min-1, respectively; NS). In type I diabetic patients receiving long-term intraperitoneal insulin therapy, the increase in splanchnic blood flow following ingestion of a standard meal does not accelerate the appearance of insulin in the peripheral circulation.

Catabolic response and parenteral nutrition after simultaneous kidney-pancreas transplantation.

The aim of the study was to quantify the catabolism rate induced by simultaneous kidney-pancreas transplantation and to evaluate the impact of parenteral nutrition (PN) on recovery of graft function. Twenty-six diabetic uremic patients were studied. The average urea nitrogen production (UNP) was 5.2 +/- 1.7 g during the first 24 h after transplantation, while patients did not receive energy and nitrogen support. Energy (30 kcal.kg-1.day-1) and nitrogen (0.15 g.kg-1.day-1) intake started 24 h after surgery. In 14 patients, a mixed regimen was adopted (70% carbohydrates, 30% lipids), and 12 patients received only hypertonic glycidic solutions. The recovery of kidney function was immediate in all cases, with a prompt decrease in blood urea nitrogen and serum creatinine levels. C-peptide levels rose immediately after the revascularization of the pancreas graft and remained within the normal range during the PN period. No significant difference was observed in UNP or glucose tolerance between the mixed-regimen and glycidic groups. However, on average 6.6, and 1.5 hyperglycemic episodes occurred during the 1st wk of PN in the glycidic and mixed-regimen groups, respectively. The posttransplantation catabolism rate was similar to that induced by an elective major surgical procedure. Eucaloric PN did not affect the recovery of kidney and pancreas graft function. A mixed energy regimen seems to be most suitable for kidney-pancreas transplant patients because it prevents hyperglycemia which might be misdiagnosed as rejection.

[The usefulness of dietetic supplementation in feeding after gastric and pancreatic surgeries]. / Utilità di un integratore dietetico nella rialimentazione dopo chirurgia gastrica e pancreatica.

We evaluated the efficacy of an oral artificial supplementation in 22 patients who underwent surgery for gastric or pancreatic cancer. From 8th to 14th postoperative day, 11 patients (cases) received a diet consistent in their REE, and an oral integrator (40% of REE); controls received only the diet. On 7th and 15th day, nutritional and anthropometric parameters were evaluated, and bioelectrical impedance analysis (BIA) was performed to assess body composition. The dietary caloric input was similar in cases (1154 kcal, 86.0% of REE) and controls (1393 kcal, 92.3% of REE). Due to the integrator, cases reached 121.4% of REE (p less than 0.001). The nutritional and anthropometric parameters studied did not show significant variations in the two groups, but BIA showed a decrease of fat mass in controls with respect to cases (p less than 0.02). Our results demonstrate that the oral artificial supplementation was well tolerated, and did not reduce food intake, but induced a significant increase of total caloric input.

Role of bioelectrical impedance analysis in acutely dehydrated subjects.

15 young healthy volunteers were studied to assess the reliability of bioelectrical impedance analysis (BIA) to determine body composition during acute dehydration. Body weight (BW), resistance and reactance measurements were performed before and 4h after a 40 mg intravenous administration of furosemide. BW decreased on average from 69.09 +/- 9.83 kg to 67.43 +/- 9.72 kg (p < 0.001), while resistance, reactance, and phase angle showed significant increases. The individual variations in bioelectrical parameters were not related to the BW loss. Formulae to derive body composition predicted poorly the true water loss (mean individual error: 40% of real loss). The errors in body composition prediction were unrelated to basal percentage of fat free mass, to body mass index, or to BW loss after furosemide administration. In conclusion, BIA proved unreliable in calculating the body composition of acutely dehydrated subjects.

Evaluation of the predictive performance of nutritional indicators by receiver-operating characteristic curve analysis.

Four hundred twenty-two cancer patients who underwent major surgery were studied. At admission, nutritional status was evaluated in all patients by assessing serum albumin (SA), total iron-binding capacity (TIBC), total lymphocyte count (TLC), serum cholinesterase activity (CHE), and weight loss (WL). All patients received perioperative short-term antibiotic prophylaxis and postoperative total parenteral nutrition. Prognostic ability of nutritional indicators was assessed by receiver-operating characteristic (ROC) curve analysis. The area beneath the ROC curve (Az) is an index of predictor performance when its value ranges from 0.5 (chance performance) to 1 (perfect prediction). Specificity, sensitivity, Youden index, and predictive values were determined for each nutritional parameter within a wide range of potential threshold values. Postoperative septic complications were observed in 85 (20.14%) patients. The Az values for the considered nutritional parameters ranged from 0.52 to 0.57 and that showed the low predictive ability of the parameters. When sensitivity and specificity for each nutritional parameter were examined at different thresholds, a clearly more predictive cutpoint was not observed, but ranges of values with a similar predictivity were observed. Significant ranges of predictivity were found for SA (33 to 35 g/L), for TIBC (2200 to 2300 micrograms/L), for TLC (2100 to 2200 million/L), for CHE (1700 to 1900 U/L), and for WL (7% to 12%). The higher values of Youden index were as follows: 1.183 for WL (cutoff 11%), 1.150 for TLC (cutoff 2100 million/L), and 1.145 for SA (cutoff 35 g/L). In conclusion, ROC curve analysis showed that the nutritional parameters had a low predictive ability.(ABSTRACT TRUNCATED AT 250 WORDS)