Laparoscopic Biopsies in Pancreas Transplantation.

As there is no precise laboratory test or imaging study for detection of pancreas allograft rejection, there is increasing interest in obtaining pancreas tissue for diagnosis. Pancreas allograft biopsies are most commonly performed percutaneously, transcystoscopically, or endoscopically, yet pancreas transplant surgeons often lack the skills to perform these types of biopsies. We have performed 160 laparoscopic pancreas biopsies in 95 patients. There were 146 simultaneous kidney-pancreas biopsies and 14 pancreas-only biopsies due to pancreas alone, kidney loss, or extraperitoneal kidney. Biopsies were performed for graft dysfunction (89) or per protocol (71). In 13 cases, an additional laparoscopic procedure was performed at the same operation. The pancreas diagnostic tissue yield was 91.2%; however, the pancreas could not be visualized in eight cases (5%) and in 6 cases the tissue sample was nondiagnostic (3.8%). The kidney tissue yield was 98.6%. There were four patients with intraoperative complications requiring laparotomy (2.5%) with two additional postoperative complications. Half of all these complications were kidney related. There were no episodes of pancreatic enzyme leak and there were no graft losses related to the procedure. We conclude that laparoscopic kidney and pancreas allograft biopsies can be safely performed with very high tissue yields.

First result from the Alpha Magnetic Spectrometer on the International Space Station: precision measurement of the positron fraction in primary cosmic rays of 0.5-350 GeV.

A precision measurement by the Alpha Magnetic Spectrometer on the International Space Station of the positron fraction in primary cosmic rays in the energy range from 0.5 to 350 GeV based on 6.8 × 10(6) positron and electron events is presented. The very accurate data show that the positron fraction is steadily increasing from 10 to ∼ 250 GeV, but, from 20 to 250 GeV, the slope decreases by an order of magnitude. The positron fraction spectrum shows no fine structure, and the positron to electron ratio shows no observable anisotropy. Together, these features show the existence of new physical phenomena.

Results of a prospective allocation policy of expanded criteria donors kidneys based on clinical parameters.

The ideal system to allocate expanded criteria donors (ECD) kidneys has not been fully elucidated. In a previous retrospective study, we reported that donor clinical characteristics were more predictive of transplant outcome than biopsy findings. Subsequently, we decided to use ECD kidneys solely based on a clinical scoring system. To elucidate the value of the pre-transplant biopsy, the patients were divided in two groups according to the suitability of the kidney they received for single or double transplantation as determined by a histological scoring system (HS). All kidneys were transplanted as a single (vs. dual) transplant. We studied whether a HS of the pre-transplant biopsy was predictive of outcome of single transplant ECD kidneys. Recipients (n = 48) were divided into two groups by whether the histologic system suggested single or double transplants be done. There were no differences between groups in two-yr outcomes. We conclude that a clinical scoring system can predict which ECD kidney donors can be safely used as single transplants in a cohort of low immunological risk de novo kidney transplant recipients. Use of the clinical scoring system maximizes organ use.

Results of a calcineurin-inhibitor-free immunosuppressive protocol in renal transplant recipients of expanded criteria deceased donors.

The increasing number of patients on waiting lists and the relatively stable organ procurement rate provide the groundwork for the use of expanded criteria deceased donors. While calcineurin-inhibitors (CNI) are excellent immunosuppressive drugs, their nephrotoxicity is largely responsible for the lack of improvement in long-term graft survival. The objective of this study was to analyze the results obtained with the use of a calcineurin inhibitor-free immunosuppressive protocol (polyclonal antibody induction, plus sirolimus, mycophenolate mofetil, and low doses of steroids) in terms of graft and patient survival as well as posttransplant clinical complications over 2 years. Under this immunosuppressive protocol, 78.04% of the patients completed the follow-up. A protocol biopsy was performed on 17 patients (53.1%) within 2 years posttransplant of which 82.31% were diagnosed as chronic allograph nephropathy grade I. The incidence of clinical complications was low and not significantly different from that reported with other immunosuppressive schemes. Death-censored graft survival was 95.12%. In conclusion, the use of a calcineurin inhibitor-free protocol in renal-transplant recipients of expanded criteria deceased donors was associated with excellent graft and patient survival rates and a low incidence of adverse events.

Comparison between clinical and histopathological scoring in cadaveric kidney transplantation and its correlation with posttransplant evolution.

INTRODUCTION: There are several scoring systems, both clinical (Deceased Donor Score [DDS]) and histopathological (Remuzzi [REM]), that attempt to determine acceptability criteria for deceased donor kidney transplant. A retrospective study was performed among a group of kidney transplant recipients to evaluate posttransplant evolution with clinical and histopathological scores. MATERIALS AND METHODS: Among 107 first deceased donor kidney transplant patients, 95 had undergone a pretransplant biopsy. Donor age was 38.46 +/- 16.9 years; recipient age: 49.2 +/- 16.3 years; DDS was 15.58 +/- 7.29. REM was 2.89 +/- 1.7. Delayed graft function was 64.2%. Induction therapy was administered to 49.5%. Cold ischemia time (CIT) was 1364 +/- 348 minute. Time on dialysis was 2275 +/- 1501 days. Induction therapy, immunosuppressive regimens, CIT, and time on dialysis were not significantly different among the groups. One-year patient and graft survival were 94.5% and 86%, respectively and 2-year values, 92.6% and 81%, respectively. CONCLUSION: DDS showed a significant correlation with serum creatinine values over 1 and 2 years. REM did not show a significant association with any events. The differences were sustained after adjusting for other variables. Graft survival maintained a strong correlation with DDS categories and no association with REM. The clinical characteristics of a deceased donor appeared to be of greater importance than the biopsy findings in terms of posttransplant events.

A randomized and prospective study comparing treatment with high-dose intravenous immunoglobulin with monoclonal antibodies for rescue of kidney grafts with steroid-resistant rejection.

BACKGROUND: The aim of this study was to compare the effectiveness of intravenous immunoglobulin (IVIg) versus monoclonal anti-CD3 as a treatment for steroid-resistant rejections. From January 1995 to June 1997, 30 patients were analyzed. They were randomized into two groups. Resistant rejections were diagnosed by core biopsy. Group A received 500 mg/ kg/day IVIg (Sandoglobulin) for 7 consecutive days, whereas group B received 5 mg/day of OKT3 for 14 consecutive days. Daily T cell CD3+ peripheral count was performed for 14 days for group B. The immunosuppression was similar for both groups. Cyclosporine was stopped during both treatments. METHODS: Demographic factors, HLA mismatch, creatinine levels before and after treatment, and the incidence of rejections after treatment (up to 1 month) were taken into account for this study. RESULTS: Data from different samples were compared using Fisher's exact test. Graft and patient survival were analyzed using the Kaplan-Meier method. The were no significant differences found in age, graft origin, HLA mismatch, or time of follow-up until the episode of rejection. Success was achieved for 11 (73.3%) of 15 of group A and 13 (86.6%) of 15 of group B (P=0.79). Creatinine levels before and after treatment were as follows: A, 2.99+/-1.30 mg/dl and 2.1+/-0.70 mg/dl versus B, 3.1+/-1.1 mg/dl and 2.5+/-0.8 mg/dl. Besides, we did not observe differences in the creatinine 1 month after treatment (A: 2.35+/-0.78 mg/dl; B: 2.51+/-1.10 mg/dl; P=0.66) nor in the third month (A: 1.83+/-0.58 mg/dl; B: 2.30+/-0.89 mg/dl; P=0.24). The incidence of rejections after treatment was 5 (46%) of 11 for group A and 9 (75%) of 12 for group B (P=0.4). The patient survival rates 2 years after treatment were 87 and 92% for A and B groups, respectively. Graft survival was identical (80% in both groups). CONCLUSION: Should the favorable result presented in this report be confirmed in larger number of patients, IVIg could become the preferable choice of rejection treatment for steroid-resistant rejection because of a complete absence of the unwanted side effects commonly associated with OKT3.

[Rapid correction of acute hyperkalemia with nebulized salbutamol]. / Corrección rápida de la hiperkalemia aguda con salbutamol en nebulización.

Fifteen patients on chronic hemodialysis received twenty-two treatments with 20 mg nebulized salbutamol (4 ml of 0.6 g% in 4 ml of saline), to control an episode of acute hyperkalemia, (6.58 +/- 0.14 range: 5.7-7.9 mEq/l) and as a previous step before dialysis. Plasma potassium concentration at 20, 40, 60, 90 and 180 min post-salbutamol, were: 5.85 +/- 0.21, 5.58 +/- 0.21, 5.48 +/- 0.27, 5.46 +/- 0.17 and 5.57 +/- 0.34 mEq/l, respectively. (Fig. 1). The decrease of plasma potassium was significant at 40' and maximal at 90': 1.12 +/- 0.10 mEq/l, and persisted for at least 3 hours (in 3 patients up to 6 hours). No correlation was found between the grade of hyperkalemia and the magnitude of plasma potassium decrease after therapy. The systolic and diastolic blood pressure decreased significantly at 60 and 80 min post-treatment: 134 +/- 6.45 vs 119 +/- 6.79 and 74 +/- 4.12 vs 64.66 +/- 3.88 mmHg (p < 0.02 and p < 0.001). The heart rate and respiratory frequency increased significantly at 60-80 and 20 min respectively (90 +/- 4.45 vs 113 +/- 4.55 beats/min and 19.57 +/- 0.98 vs 23.42 +/- 1.24 resp/min) (p < 0.001) (Table 1). The secondary effects of the administration of the drug, such as sinus tachycardia, fine tremor and anxiety in 6, 4 and 1 patient respectively, were moderate and well tolerated. It is concluded that, due to its technical feasibility, promptness of action, duration of hypokalemic effect, few side effects and repeatability, nebulized salbutamol can be considered a first choice in the treatment of acute hyperkalemia.

Case report: pancreas graft with a duodenal complication rescued using total duodenectomy.

Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice for type 1 diabetics with end-stage renal disease. Recently patients with type 2 diabetes have been considered for transplantation. Despite that the patient and graft survival rates have improved over the past years, it continues to be a procedure with high surgical complication rates. We herein report a case of a pancreatic graft with a duodenal complication rescued using a total duodenectomy, a procedure that is seldom used. A 57-year-old type 2 diabetic underwent a SPK transplantation with systemic-enteric drainage. He was converted to a Roux en Y at day 7 for a small duodenal fistula without peritonitis. At day 13, with good graft function, he presented with gastrointestinal and abdominal bleeding. At laparotomy he had a congestive duodenum with intraluminal bleeding and an anastomotic fistula. We performed a total duodenectomy with enteric drainage. The patient was discharged home on day 39 with a pancreatic fistula on intramuscular Octretotide that lasted for 3 months. He was never readmitted and has good pancreas and kidney function at 16 months of follow-up. We think this is an option to rescue a pancreas graft with duodenal complications in selected cases.