Simultaneous pancreas-kidney transplantation is a therapeutic option for type I diabetics with end-stage renal disease. It aims to correct the uremic state, to normalize glucose hemeostasis, and to ameliorate diabetic complications. Careful donor-recipient selection and meticulous intra-operative and postoperative care will substantially impact recipient morbidity. An understanding of the technical aspects of the surgical procedure and its metabolic and immunological consequences is necessary to successfully manage a pancreas-kidney transplant recipient, many of whom are nursed in intensive care units. A successful outcome is predicted in early recognition of technical complications and aggressive management of rejection to achieve the current 1-year graft survival rates of 75% for pancreas transplants and 84% for kidney transplants.
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References
1.
SollingerHWStrattaRJD'AlessandroAM. Experience with simultaneous pancreas-kidney transplantation. Ann Surg1988; 208: 475–483.
2.
SutherlandDERMoudry-MunnsKCGillinghamK. Solitary pancreas transplantation: Alone in non-uremic and after a kidney in uremic diabetic patients. Transplant Proc1991; 23: 1637–1639.
3.
The University of Michigan Pancreas Transplant Evaluation Committee. Pancreatic transplantation as treatment for IDDM—proposed candidate criteria before end-stage diabetic nephropathy. Diabetes Care1988; 11: 669–675.
4.
DeFronzoRAFerranniniE.Insulin resistance: A multi-faceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia and atherosclerotic cardiovascular disease. Diabetes Care1991; 14: 173–194.
5.
SutherlandDERGillinghamKMoudry-MunnsKC.Results of pancreas transplantation in the United States for 1987–90 from the United Network for Organ Sharing (UNOS) registry with comparison to 1984–87 results. Clin Transplant1991; 5: 330–341.
6.
KatzHHomanMVelosaJ. Effects of pancreas transplantation on postprandial glucose metabolism. N Engl. J Med1991; 325: 1278–1283.
7.
NakacheRTydenGGrothCG.Quality of life in diabetic patients after combined pancreas-kidney or kidney transplantation. Diabetes1989; 38: 40–42.
8.
CorryRJZehrP.Quality of life in diabetic recipients of kidney transplants is better with the addition of the pancreas. Clin Transplant1990; 4: 238–241.
9.
GaberAOCardosoSParsonS. Improvement in autonomic function following combined pancreas-kidney transplantation. Transplant Proc1991; 23: 1660–1662.
10.
SecchiAMartinenghiSGalardiG. Effects of pancreatic transplantation on diabetic polyneuropathy. Transplant Proc1991; 23: 1658–1659.
11.
KennedyWRNavarroXGoetzFC. Effects of pancreatic transplantation on diabetic neuropathy. N Engl J Med1990; 332: 1031–1037.
12.
AridgeDReeseJNiehoffM. Effect of successful renal and segmental pancreatic transplantation on peripheral and autonomic neuropathy. Transplant Proc1991; 23: 1670–1671.
13.
BilousRWMauerSWSutherlandDER. The effects of pancreas transplantation on the glomerular structure of renal allografts in patients with insulin-dependent diabetes. N Engl J Med1989; 321: 80–85.
14.
RamsayRCGoetzFCSutherlandDER. Progression of diabetic retinopathy after pancreas transplantation for insulin-dependent diabetes mellitus. N Engl J Med1988; 318: 208–214.
15.
SutherlandDERGruessnerAMoudry-MunnsK.Analysis of United Network for Organ Sharing (UNOS) United States of America (USA) pancreas transplant registry data according to multiple variables. In: TerasakiPICeckaJM, eds. Clinical transplants 1992. Los Angeles: UCLA Tissue Typing Laboratory, 1992: 45–59.
16.
De FranciscoAMMauerSMSteffesMW. The effect of cyclosporine on native renal function in non-uremic diabetic recipients of pancreas transplants. J Diabetic Compl1987; 1: 128–131.
17.
SutherlandDER.Who should get a pancreas transplant?Diabetes Care1988; 11: 681–685.
18.
NajarianJSKaufmanDBFrydDS. Survival into the second decade following kidney transplantation in type I diabetic patients. Transplant Proc1989; 21: 2012–2015.
19.
TrochuJ-NCantarovichDRenaudeauJ. Assessment of coronary artery disease by Thallium scan in type I diabetic uremic patients awaiting combined pancreas and renal transplantation. Angiology1991; 42: 302–307.
20.
WeinrauchLD'EliaJAHealyRW. Asymptomatic coronary artery diseases: Angiographic assessment of diabetics evaluated for renal transplantation. Circulation1978; 58: 1184–1190.
21.
BraunWEPhillipsDFVidtDG. Coronary artery disease in 100 diabetics with end-stage renal failure. Transplant Proc1984; 16: 603–607.
MorrowCESchwartzJSSutherlandDER. Predictive value of Thallium stress testing for coronary and cardiovascular events in uremic diabetic patients before renal transplantation. Ann J Surg1983; 146: 331–335.
24.
PhilipsonJDCarpenterBJItzkoffJ. Evaluation of cardiovascular risk for renal transplantation in diabetic patients. Ann J Med1986; 81: 630–634.
25.
MarwickTHSteinmullerDRUnderwoodDA. Ineffectiveness of Dipyridamole spect thallium imaging as a screening technique for coronary artery disease in patients with end-stage renal failure. Transplantation1990; 49: 100–103.
26.
ManskeCLWangYRectorT. Coronary revascularization in insulin-dependent diabetic patients with chronic renal failure. Lancet1991; 340: 998–1002.
27.
IqbalAGibbonsRJMcGoonMDSterioffS. Non-invasive assessment of cardiac risk in insulin-dependent diabetic patients being evaluated for pancreatic transplantation using thallium-201 myocardial perfusion scintigraphy. Clin Transplant1991; 5: 13–19.
28.
GruberSACerraFB.General principles of perioperative transplant care. Crit Care Clin1990; 6: 893–898.
29.
SutherlandDERNajarianJSGreenbergBZ. Hormonal and metabolic effects of a pancreatic endocrine graft. Ann Intern Med1981; 95: 537–541.
30.
van der VlietJANavarroXKennedyWR. The effect of pancreas transplantation on diabetic polyneuropathy. Transplantation1988; 45: 368–370.
31.
De FranciscoAMMauerSMSteffesMW. The effect of cyclosporine on native renal function in non-uremic diabetic recipients of pancreas transplants. J. Diabetic Compl1987; 1: 128–131.
32.
BraymanKLVianelloAMorelP. The organ donor. Crit Care Clin1990; 6: 821–839.
33.
FisherRAAlexanderJW.Management of the multiple organ donor. Clin Transplant1992; 6: 328–335.
34.
GoresPFGillinghamKJDunnDL. Donor hyperglycemia as a minor risk factor and immunologic variables as major risk factors for pancreas allograft loss in a multivariate analysis of a single institution's experience. Ann Surg1992; 215: 217–230.
35.
ShafferDLewisWDJenkinsRLMonacoAP.Combined liver and whole pancreas procurement in donors with a replaced right hepatic artery. Surg Gynecol Obstet1991; 175: 204–207.
36.
MarshCLPerkinsJDSutherlandDER. Combined hepatic and pancreaticoduodenal procurement for transplantation. Surg Gynecol Obstet1989; 168: 254–258.
37.
MorelPMoudry-MunnsKNajarianJS. Influence of preservation time on outcome and metabolic function of bladder-drained pancreas transplants. Transplantation1990; 49: 294–303.
38.
TesiRJHenryMLElkammusEA. Decreased wound complications of combined kidney/pancreas transplants using intraabdominal pancreas graft placement. Clin Transplant1990; 4: 287–291.
39.
PescovitzMDDunnDLSutherlandDER.Use of the circular stapler in construction of the duodenoneocystostomy for drainage into the bladder in transplants involving the whole pancreas. Surg Gynecol Obstet1989; 169: 169–171.
40.
ShapiroRSimmonsRL.Renal Transplantation. In: StarzlTEShapiroRSimmonsRL, ed. Atlas of organ transplantation. New York: Gower Medical, 1992: 4.1–4.21.
41.
DubernardJMTraegerJPiattiPM. Report of 54 human segmental pancreatic allografts prepared by duct obstruction with neoprene. Transplant Proc1985; 17: 312–314.
42.
SutherlandDERGoetzFCNajarianJS.One hundred pancreas transplants at a single institution. Ann Surg1984; 200: 414–440.
43.
PrietoMSutherlandDERFenandez-CruzL. Experimental and clinical experience with urine amylase monitoring for early diagnosis of rejection in pancreas transplantation. Transplantation1987; 43: 73–79.
44.
PrietoMSutherlandDERFernandez-CruzL. Urine amylase monitoring for early diagnosis of rejection in pancreas transplantation. J Surg Res1986; 40: 597–602.
45.
PrietoMSutherlandDERGoetzFC. Pancreas transplant results according to the technique of duct management: Bladder vs. enteric drainage. Surgery1987; 102: 680–691.
46.
StoutRW, Overview of the association between insulin and atherosclerosis. Metabolism1985; 34(suppl 1): 7–12.
47.
ModanMHalkinHAlmogS. Hyperinsulinemia: A link between hypertension, obesity and glucose intolerance. J Clin Invest1985; 75: 809–817.
48.
ReavenGM.Role of insulin resistance in human disease. Diabetes1988; 37: 1595–1607.
49.
MuhlbacherFGnantMFXAuingerM. Pancreatic venous drainage to the portal vein: A new method in pancreatic transplantation. Transplant Proc1990; 22: 636–637.
50.
RosenlofLKEarnhardtRCPruittTL. Pancreas transplantation an initial experience with systemic and portal drainage of pancreatic allografts. Ann Surg1992; 215: 586–597.
51.
BronsIGMCalneRYRollesKOlczakSEvansDB.Paratopic segmental pancreas with simultaneous kidney transplantation in man: A 1 year follow-up study. Transplant Proc1986; 18: 1129–1130.
52.
MadsbadS.Prevalence of residual B cell function and its metabolic consequence in type 1 (Insulin-dependent) diabetes. Diabetologia1983; 24: 141–147.
OzakiCFStrattaRJTaylorRJ. Surgical complications in solitary pancreas and combined pancreas-kidney transplantations. Am J Surg1992; 164: 546–551.
55.
MelzerJSD'AlessandroAMKalayogluM. The use of OKT3 in combined pancreas-kidney allotransplantation. Transplant Proc1990; 22: 634–635.
56.
SchulakJAMayesJTHricikDE.Combined kidney and pancreas transplantation a safe and effective treatment for diabetic nephropathy. Arch Surg1990; 125: 881–885.
57.
SutherlandDERDunnDLGoetzFC. A 10 year experience with 290 pancreas transplants at a single institution. Ann Surg1989; 210: 274–288.
58.
SchulakJAMayesJTHricikDE.Kidney transplantation in diabetic patients undergoing combined kidney-pancreas or kidney-only transplantation. Transplantation1992; 53: 685–687.
59.
TydenGBrattstromCLundgrenG. Improved results in pancreatic transplantation by avoidance of nonimmunological graft failures. Transplantation1987; 43: 674–676.
60.
DeierhoiMHSollingerHWBozdechMJBelzerFO.Lethal graft-versus-host disease in a recipient of a pancreas-spleen transplant. Transplantation1986; 41: 544–546.
61.
StarzlTEIwatsukiSShawBW. Pancreaticoduodenal transplantation in humans. Surg Gynecol Obstet1984; 159: 265–272.
62.
KinSTamuraKNagamiH. The effect of a distal splenic arteriovenous fistula on tissue blood flow in the pancreatic segment. Transplant Proc1989; 21: 2812–2814.
63.
GarvinPJCastanedaMANiehoffML. An in situ evaluation of distal splenic arteriovenous fistula on pancreas function in an isolated pancreas segment. Arch Surg1985; 120: 1148–1151.
64.
DuToitDFReece-SmithHMcShaneP. A successful technique of segmental pancratic autotransplantation in the dog. Transplantation1981; 31: 395–396.
65.
RasmussenKBurcarthFThomsenHSRygaardH.Monitoring of pancreas-graft perfusion by radionuclide and digital subtraction angiography. Diabetes1989; 38(suppl 1): 21–23.
66.
LongleyDGDunnDLGruessnerR. Detection of pancreatic fluid and urine leakage after pancreas transplantation: Value of CT and cystography. AJR1990; 155: 997–1000.
67.
GruessnerRWGDunnDLTzardisPJ. Complications occuring after whole organ duodenopancreatic transplantation: Relation to the allograft duodenal segment. Transplant Proc1990; 22: 578–579.
68.
LetourneauJGHunterDWCrassJR. Percutaneous aspiration and drainage of abdominal fluid collections after pancreatic transplantation. AJR1988; 150: 805–809.
69.
LandgrafRLandgraf-LeursMMCBurgD. Longterm follow-up of segmental pancreas transplantation in type I diabetics. Transplant Proc1986; 18: 1118–1124.
70.
RosenbergLDafoeDCSchwartzR. Administration of somatostatin analog (SMS 201–995) in the treatment of a fistula occurring after pancreas transplantation. Transplantation1987; 43: 764–766.
71.
KonturekSJ.Somatostatin and gastrointestinal secretion and motility. Adv Exp Med Biol1978; 106: 227–234.
72.
TorresAJLandaJIMoreno-AzcoitaM. Somatostatin in the management of gastrointestinal fistulas. Arch Surg1992; 127: 97–100.
73.
LandgrafRLandgraf-LewisMMCNusserJ. Effect of somatostatin analogue (SMS 201–995) on cyclosporine levels. Transplantation1987; 44: 724–725.
74.
SamnegardHTydenGThulinL. Effect of somatostatin on splanchnic blood flows in man: Angiographic studies. Acta Chir Scand1980; 500(suppl): 71–73.
75.
NicholsonCPBarrDOeltjenMR. The effect of somatostatin 201–995 on the early course of porcine pancreaticoduodenal allotransplantation. Transplantation1991; 51: 31–36.
76.
TibellATydenGBrattstromC. Surgical complications after segmental pancreatic transplantation with enteric exocrine diversion. Transplant Proc1989; 21: 2801–2802.
77.
BackmanLBrattstromCReinholtFP. Intrapancreatic abcess formation in pancreatic transplant recipients with positive cytomegalovirus serology: A rare cause of graft loss which may be prevented. Transplant Proc1990; 22: 639–640.
78.
MargreiterRSchmidTDünserM. Cytomegalovirus (CMV)-pancreatitis: A rare complication after pancreas transplantation. Transplant Proc1991; 23: 1619–1622.
79.
MittalVKToledo-PereyraLHProughDFrantzisP.Effect of graft pancreatitis on the outcome of whole pancreatic transplants. Transplants Proc1989; 21: 2856–2857.
80.
StrattaRJTaylorRJSpeesEC. Refinements in cadaveric pancreas-kidney procurement and preservation. Transplant Proc1991; 23: 2320–2322.
81.
SpillenaarEJMarquetRLBaumgartnerD. Attempts to reduce post-transplant pancreatitis in rats and dogs with the somatostatin analogue SMS 201-995. Transplant Proc1989; 21: 2829–2830.
82.
BoudreauxJPNealonWHCarsonRCFishJC.Pancreatitis necessitating urinary undiversion in a bladder: Drained pancreas transplant. Transplant Proc1990; 22: 641–642.
83.
GrothCGLundgrenGArnerP. Rejection of isolated pancreatic allografts in patients with diabetes. Surg Gynecol Obstet1976; 143: 933–940.
84.
SchulakJADrevyankoTF.Experimental pancreas allograft rejection: Correlation between histologic and functional rejection and the efficacy of antirejection therapy. Surgery1985; 98: 330–337.
CasanovaDGruessnerRBraymanK. Retrospective analysis of the role of pancreatic biopsy (open and transcystoscopic technique) in the management of solitary pancreas transplants. Transplant Proc1993; 25: 1192–1193.
87.
TydenGLundgrenGGunnarssonR. Laboratory findings during rejection of segmental pancreatic allografts. Transplant Proc1984; 16: 715–717.
88.
StrattaRJSollingerHWGroshekM. Differential diagnosis of hyperamylasemia in pancreas allograft recipients. Transplant Proc1990; 22: 675–677.
89.
NybergGOlavssonMNordenG. Pancreas specific protein monitoring in pancreas transplantation. Transplant Proc1991; 23: 1604–1605.
90.
OgawaMMatsudaKShibataT. Elevation of serum pancreatic secretory trypsin inhibitor (PSTI) in patients with serious injury. Res Commun Chem Pathol Pharmacol1985; 50: 259–266.
91.
NghiemDDBeutelWDCorryRJ.Duodenocystostomy for exocrine pancreatic drainage in experimental and clinical pancreaticoduodenal transplantation. Transplant Proc1986; 18: 1762–1764.
92.
RadioSJStrattaRJTaylorRJLinderJ.The utility of urine cytology in the diagnosis of allograft rejection after combined pancreas-kidney transplantation. Transplantation1993; 55: 509–516.
93.
MittalVKToledo-PereyraLH.Urinary cytology as a complementary marker of rejection in combined kidney and pancreatic transplants with urinary drainage. Transplant Proc1990; 22: 629–631.
94.
ReinholtFPTydenGBohmanSO. Pancreatic juice cytology in the diagnosis of pancreatic graft rejection. Clin Transplant1988; 2: 127–133.
95.
KlimaGMargreiterR.Pancreatic juice cytology in the monitoring of pancreas allografts. Transplantation1989; 48: 980–985.
96.
KubotaKReinholtFPTydenG. Cytologic patterns in juice from human pancreatic transplants: Correlation with histologic findings in the graft. Surgery1991; 109: 507–514.
97.
StrattaRJSollingerHWPerlmanSB. Early detection of rejection in pancreas transplantation. Diabetes1989; 38: 63–67.
98.
MunnSREngenDEBarrD. Differential diagnosis of hypoamylasuria in pancreas allograft recipients with urinary exocrine drainage. Transplantation1990; 49: 359–362.
99.
AmesSACorryRJ.Diagnosis of pancreas transplant rejection: Use of noninvasive tests to assess initial dysfunction in combined pancreas-kidney transplants. Transplant Proc1989; 21: 3639–3642.
100.
MargreiterRKlimaGBosmullerC. Rejection of kidney and pancreas after pancreas-kidney transplantation. Diabetes1989; 38(suppl 1): 79–81.
101.
GruessnerRWGDunnDLTzardisPJ. Simultaneous pancreas and kidney transplants versus single kidney transplants and previous kidney transplants in uremic patients and single pancreas transplants in nonuremic diabetic patients: Comparison of rejection, morbidity and longterm outcome. Transplant Proc1990; 22: 622–623.
102.
PerkalMMarksCLorberMIMarksWH.A three-year experience with serum anodal trypsinogen as a biochemical marker for rejection in pancreatic allografts. Transplantation1992; 53: 415–419.
103.
MarksWHBorgstromASollingerH. Serum anodal trypsinogen is a predictive biochemical marker for pancreas allograft rejection. Transplant Proc1990; 22: 673–674.
104.
NakhlehREGruessnerRWGTzardisPJ. Pathology of transplanted human duodenal tissue: A histologic study, with comparison to pancreatic pathology, in resected pancreaticoduodenal transplants. Clin Transplant1991; 5: 241–247.
105.
CarpenterHAEngenDEMunnSR. Histologic diagnosis of rejection by using cystoscopically directed needle biopsy specimens from dysfunctional pancreatoduodenal allografts with exocrine drainage into the bladder. Am J Surg Pathol1990; 14: 837–846.
106.
PerkinsJDMunnSRMarshCL. Safety and efficacy of cystoscopically directed biopsy in pancreas transplantation. Transplant Proc1990; 22: 665–666.
107.
GaberAOGaberLWShokouh-AmiriMHHathawayD.Percutaneous biopsy of pancreas transplants. Transplantation1992; 54: 548–550.
108.
AllenRDMWilsonTGGriersonJM. Percutaneous pancreas transplant fine needle aspiration and needle core biopsies are useful and safe. Transplant Proc1990; 22: 663–664.
SchangTTimmermannWThiedeA. Detrimental effects of fluid and electrolyte loss from duodenum in bladder-drained pancreas transplants. Transplant Proc1991; 23: 1617–1618.
112.
PeltenburgHGMutsaertsKJGMHardyELMvan HoofJP.Sodium lactate as an alternative to sodium bicarbonate in the management of metabolic acidosis after pancreas transplantation. Transplantation1992; 53: 225–226.
113.
ElkhammasEAHenryMLTesiRJ. Control of metabolic acidosis after pancreas transplantation using acetazolamide. Transplant Proc1991; 23: 1623–1624.
114.
NghiemDDGonwaTACorryRJ.Metabolic effects of urinary diversion of exocrine secretions in pancreatic transplantation. Transplantation1987; 43: 70–73.
BurkeGWGruessnerRDunnDLSutherlandDER.Conversion of whole pancreaticoduodenal transplants from bladder to enteric drainage for metabolic acidosis or dysuria. Transplant Proc1990; 22: 651–652.
