Recent experience with pancreatic transplantation at Huddinge Hospital.
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Biomedical subjects
Publications and source records attributed to G Klintmalm.
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Segmental pancreatic transplantation is now the most widely favoured form of pancreatic transplantation, but the major difficulty with this procedure is the handling of the exocrine secretion. The use of a pancreaticoenteric anastomosis for exocrine diversion has been re-evaluated and several ancillary measures to reduce the risk of fistula and bacterial contamination have been applied. In three consecutive patients there have been no complications related to the exocrine pancreas. The pancreatic and renal grafts of these patients are functioning well 7, 3, and 2 months, respectively, after transplantation.
Seven patients were operated on for stenosis of the internal carotid artery (ICA) with endarterectomy under neurolept anesthesia. The ICA blood flow was found to be unchanged after reconstruction following an operative blood loss of one fifth of the patient's blood volume despite variations in cardiac output. The relationship between carbon dioxide tension and cerebral blood flow remained unchanged during hypovolemia. It is concluded that the autoregulation of the cerebral blood flow is maintained under neurolept anesthesia.
Reduction of lymphoid tissue by splenectomy and/or thymectomy has been used as a part of immunosuppression in organ transplantation (4). More recently Walker (7), Johnson (2), Franksson (1) and Starzl (5,6) and their associates have shown that chronic depletion of lymphocytes by thoracic duct drainage decreases the incidence of rejection and hence increases renal graft survival. Mechanical removal of lymphocytes from circulation peripheral blood should theoretically achieve the same or similar effect on the immunity as thoracic duct drainage. Since September, 1979, five organ transplant recipients have received multiple lymphocytapheresis by IBM 2997 Blood Cell Separator as a mechanical pretransplant immunosuppression. The changes in cellular and humoral immunity and the clinical outcome are presented in this report.
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Inflow of blood into intraarterial catheters in dogs following single and continuous injections of saline, contrast medium and polysaccharide fluids were analysed with special reference to the influence of their density and viscosity. Clot formation was also analysed and the favourable properties of one variant of the polysaccharide fluids were demonstrated.
Eighteen patients were treated with primary cadaveric renal transplantation using cyclosporin A therapy, and four more patients undersent cadaveric retransplantation. Eleven of the 22 recipients were conditioned with lymphoid depletion before transplantation, using thoracic duct drainage or lymphapheresis for two to eight and one-half weeks. Cyclosporin A was begun a few hours before grafting. The other 11 patients were pretreated with cyclosporin A for from one day to 18 days. After transplantation, the majority of patients in both subgroups of 11 had rejection develop, but in most, the immunologic process was readily controlled with relatively small dosages of prednisone. After follow-up periods of two to four and one-half months, one patient has died of the complications of a coronary artery reconstruction that was not related to the transplantation. Another graft was lost from rejection, and a third organ was removed because of ureteral necrosis. Nineteen of the original 22 cadaveric kidneys are functioning, including 17 of the 18 kidneys given to patients who were undergoing transplantation for the first time. The only loss in the latter group of 18 patients was in the patient who died after an open heart operation. Results of these studies have shown that cyclosporin A is a superior and safe immunosuppressive drug but that, for optimal use in cadaveric transplantation, it usually should not be given alone. Steroid therapy greatly amplified the value of cyclosporin A. Unless major delayed morbidity develops which is not obvious so far, this drug combination should permit revolutionary advances in the transplantation of all organs. Other adjuncts to the cyclosporin A-steroid combination, including lymphoid depletion techniques, will require further investigation.
Typing for HLA-DR has been performed in cadaver renal transplantations in Stockholm since 1977, but there was no donor-recipient selection based on HLA-DR. During the period 1977-78 76 cadaver renal transplantations were carried out; in 61 of them typing for HLA-DR was performed. There were 4 exclusions, 2 because of a hyperacute rejection of the graft and 2 because the kidney never started to function after the operation owing to irreversible ischemic damage. In 29 of the 57 transplantations remaining for analysis there was one antigen common to the donor and the recipients, and in 28 there was no common antigen; there was no instance of 2 common antigens. The distribution by degree of HLA-A, -B match was the same for the two groups. Graft survival after one year was better for the group with one common HLA-DR antigen, but the difference was not statistically significant.
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