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Graft Failure After Solitary Pancreas Transplantation
Graft Failure After Solitary Pancreas Transplantation R.J. Stratta
A
CCORDING to Registry Data, over 600 solitary pancreas transplants (PTXs) have been performed in the United States.1 In the recent past, solitary PTX has been limited by a higher incidence of technical and immunologic graft failures (GF). To study this issue, a retrospective analysis of the timing and causes of GF after solitary PTX was performed to identify risk factors predictive of outcome. MATERIALS AND METHODS Over a 5-year period, we performed 62 solitary PTXs in 57 diabetic patients including 42 PTXs alone (PTA) and 20 sequential PTX after kidney transplants (PAKT). All patients underwent wholeorgan PTX with bladder drainage and received either quadruple (all PTA and the first 6 PAKT) or triple (remaining 14 PAKT) immunosuppression. Ten patients received pancreas retransplants. Mean human leukocyte antigen match was 2.7 6 0.6 and the mean pancreas cold ischemia time was 16.7 6 4 hours. Minimum follow-up was 1 year (mean, 3).
RESULTS
A total of 36 pancreas GFs (58%) occurred, including 26 (62%) after PTA and 10 (50%) after PAKT. The mean time of GF was 14 months after PTA and 4 months after PAKT (P 5 .09). In the PTA group, 13 GFs (50%) occurred within 6 months, but 9 GFs occurred more than 1 year after PTA. In the PAKT group, 9 of the 10 GFs (90%) occurred within 4 months. Causes of GF including acute rejection plus chronic rejection (9), chronic rejection (7), infection (7), death with a functioning graft (DWFG; 4), thrombosis (4), acute rejection with thrombosis (2), pancreatitis (2), and primary nonfunction (1). Rejection accounted for over half of GFs after PTA, while infection was the most common cause of GF after PAKT. Since switching from cyclosporine to Tacrolimus or Prograf-based therapy after PTA (n 5 11), only 2 GFs have occurred due to rejection. In the PAKT group, since switching from quadruple to triple immunosuppression without anti–T-cell induction therapy (n 5 14),
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 30, 289 (1998)
only one GF has occurred due to infection. Four-year actuarial pancreas graft survival rates are 41% after PTA and 48% after PAKT. DISCUSSION
In the last 8 years, the number of solitary PTXs performed in the United States has increased from about 60 to over 100 per year, representing about 13% of all PTX activity reported to the Registry.1 Further analysis of Registry data reveals that the increased incidence of pancreas GF after solitary PTX when compared with simultaneous kidney– pancreas transplantation (SKPT) is due to a number of factors including a higher rate of GF due to rejection, thrombosis, pancreatitis, and infection. However, with the recent availability of new immunosuppressive agents such as Neoral, Prograf, and Cellcept, the results of solitary PTX are beginning to approach those already achieved after SKPT.2– 4 In this study, improving outcomes after solitary PTX may be related to advances in immunosuppression, resulting in fewer early and late immunologic GFs after PTA and fewer infectious GFs after PAKT. REFERENCES 1. Sutherland DER, Gruessner A: In Cecka JM, Terasaki PI (eds): Clinical Transplants 1996. Los Angeles, Calif: UCLA Tissue Typing Laboratory; 1997, p 47 2. Bartlett ST, Schweitzer EJ, Johnson LB, et al: Ann Surg 224:440, 1996 3. Gruessner RWG, Sutherland DER, Najarian JS, et al: Transplantation 64:1572, 1997 4. Stratta RJ, Weide LG, Sindhi R, et al: Diabetes Care 20:362, 1997 From the University of Tennessee, the University of Nebraska Medical Center and Clarkson Hospital, Memphis, Tennessee, USA. Address reprint requests to Dr R.J. Stratta, University of Tennessee-Memphis, 956 Court Avenue, Memphis, TN 381632116.
0041-1345/98/$19.00 PII S0041-1345(97)01272-4 289
A
CCORDING to Registry Data, over 600 solitary pancreas transplants (PTXs) have been performed in the United States.1 In the recent past, solitary PTX has been limited by a higher incidence of technical and immunologic graft failures (GF). To study this issue, a retrospective analysis of the timing and causes of GF after solitary PTX was performed to identify risk factors predictive of outcome. MATERIALS AND METHODS Over a 5-year period, we performed 62 solitary PTXs in 57 diabetic patients including 42 PTXs alone (PTA) and 20 sequential PTX after kidney transplants (PAKT). All patients underwent wholeorgan PTX with bladder drainage and received either quadruple (all PTA and the first 6 PAKT) or triple (remaining 14 PAKT) immunosuppression. Ten patients received pancreas retransplants. Mean human leukocyte antigen match was 2.7 6 0.6 and the mean pancreas cold ischemia time was 16.7 6 4 hours. Minimum follow-up was 1 year (mean, 3).
RESULTS
A total of 36 pancreas GFs (58%) occurred, including 26 (62%) after PTA and 10 (50%) after PAKT. The mean time of GF was 14 months after PTA and 4 months after PAKT (P 5 .09). In the PTA group, 13 GFs (50%) occurred within 6 months, but 9 GFs occurred more than 1 year after PTA. In the PAKT group, 9 of the 10 GFs (90%) occurred within 4 months. Causes of GF including acute rejection plus chronic rejection (9), chronic rejection (7), infection (7), death with a functioning graft (DWFG; 4), thrombosis (4), acute rejection with thrombosis (2), pancreatitis (2), and primary nonfunction (1). Rejection accounted for over half of GFs after PTA, while infection was the most common cause of GF after PAKT. Since switching from cyclosporine to Tacrolimus or Prograf-based therapy after PTA (n 5 11), only 2 GFs have occurred due to rejection. In the PAKT group, since switching from quadruple to triple immunosuppression without anti–T-cell induction therapy (n 5 14),
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 30, 289 (1998)
only one GF has occurred due to infection. Four-year actuarial pancreas graft survival rates are 41% after PTA and 48% after PAKT. DISCUSSION
In the last 8 years, the number of solitary PTXs performed in the United States has increased from about 60 to over 100 per year, representing about 13% of all PTX activity reported to the Registry.1 Further analysis of Registry data reveals that the increased incidence of pancreas GF after solitary PTX when compared with simultaneous kidney– pancreas transplantation (SKPT) is due to a number of factors including a higher rate of GF due to rejection, thrombosis, pancreatitis, and infection. However, with the recent availability of new immunosuppressive agents such as Neoral, Prograf, and Cellcept, the results of solitary PTX are beginning to approach those already achieved after SKPT.2– 4 In this study, improving outcomes after solitary PTX may be related to advances in immunosuppression, resulting in fewer early and late immunologic GFs after PTA and fewer infectious GFs after PAKT. REFERENCES 1. Sutherland DER, Gruessner A: In Cecka JM, Terasaki PI (eds): Clinical Transplants 1996. Los Angeles, Calif: UCLA Tissue Typing Laboratory; 1997, p 47 2. Bartlett ST, Schweitzer EJ, Johnson LB, et al: Ann Surg 224:440, 1996 3. Gruessner RWG, Sutherland DER, Najarian JS, et al: Transplantation 64:1572, 1997 4. Stratta RJ, Weide LG, Sindhi R, et al: Diabetes Care 20:362, 1997 From the University of Tennessee, the University of Nebraska Medical Center and Clarkson Hospital, Memphis, Tennessee, USA. Address reprint requests to Dr R.J. Stratta, University of Tennessee-Memphis, 956 Court Avenue, Memphis, TN 381632116.
0041-1345/98/$19.00 PII S0041-1345(97)01272-4 289