Long-term normoglycaemia cannot be achieved in patients with insulin dependent diabetes mellitus neither with conventional nor with intensified insulin therapy. The only ideal method to obtain this seems the islet cell or pancreas transplantation. The number of pancreas transplantation approaches 5000 all over the world. The first simultaneous pancreas-kidney transplantation in Germany was performed in 1979 by the Munich group. Till 1991 in Grosshadern 141 pancreas transplantations have been performed. At the beginning duct occlusion (n = 106) later bladder drainage (n = 35) were used as a standard procedure. The authors discuss in detail the indications and contraindications, the types of pancreas transplantation, the different diversions of exocrine secretion. They analyse the effect of pancreas transplantation upon diabetic metabolism, retinopathy, neuropathy, nephropathy and quality of life, based on own experiences and literary data. At present the indication for pancreas transplantation is the stadium of late complications in IDDM. Because of the definitive lesions its beneficial effect is limited. After successful transplantation the peripheral (and autonomic?) neuropathy improves, the retinopathy seems to remain stabile, and the pancreas protects the transplanted kidney against recurrent diabetic nephropathy. Most patients will become insulin independent with tight metabolic control, but the complications of immunosuppressive therapy must be taken into consideration. The working ability and the quality of life seem to improve considerably.

Contraindications↗

PubMed1994

Impact of the reperfusion injury on acute and chronic rejection events following clinical cadaveric renal transplantation.

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Graft Rejection↗

PubMed1994

Laparoscopic deroofing of post-transplant lymphoceles.

Lymphocele is a most common surgical complication following renal transplantation. The indication for treatment is given when the lymphocele becomes symptomatic. We succeeded in laparoscopically deroofing large lymphoceles in nine patients that were causing ureter compression in eight and ipsilateral leg edema in six cases. The postoperative course was uneventful, and the surgery-related hospitalization did not exceed 7 days. Severe adhesions and a thick lymphocele wall, which made preparation difficult, resulted in the transection of the transplant ureter in one case. Techniques and prerequisites that would help to avoid this type of complication are discussed. According to CT scan or sonography, there was no recurrence in any of the patients after a mean follow-up of 11 months. This technique seems to be superior to other methods of treatment because not only is a cure obtained with a single intervention, but there is also a low risk of infection and a short hospitalization.

Adult↗

PubMed1994

The beneficial effect of human recombinant superoxide dismutase on acute and chronic rejection events in recipients of cadaveric renal transplants.

In a prospective randomized double-blind placebo-controlled trial, the effect of rh-SOD, given in a dose of 200 mg intravenously during surgery to cyclosporine-treated recipients of cadaveric renal allografts, on both acute and chronic rejection events as well as patient and graft survival was investigated by analyzing the patients' charts retrospectively. The results obtained show that rh-SOD exerts a beneficial effect on acute rejection events as indicated by a significant reduction of (1) first acute rejection episodes from 33.3% in controls to 18.5%, as well as (2) early irreversible acute rejection from 12.5% in controls to 3.7%. With regard to long-term results, there was a significant improvement of the actual 4-year graft survival rate in rh-SOD-treated patients to 74% (with a projected half-life of 15 years) compared with 52% in controls (with an extrapolated half-life of 5 years). The beneficial effect of rh-SOD observed in this trial is not fully understood, although one can assume that the effect is related to its antioxidant action on ischemia/reperfusion injury of the renal allograft, thereby potentially reducing the immunogenicity of the graft. In addition and in accordance with the "response-to-injury hypothesis" in the pathogenesis of general atherosclerosis, rh-SOD has the potential to mitigate free radical-mediated reperfusion injury-induced acute endothelial cell damage that potentially may contribute to the process of chronic obliterative rejection arteriosclerosis.

Acute Disease↗

PubMed1994

Positive donor and negative recipient cytomegalovirus status is a detrimental factor for long-term renal allograft survival.

In 524 allogeneic cadaveric kidney transplants, the impact of cytomegalovirus (CMV) donor/recipient status on the incidence of CMV infection, CMV disease, early and long-term graft, and patient survival have been analyzed with respect to rejection episodes. Most CMV infections (59%) and diseases (17%) were found in CMV-negative recipients of CMV-positive kidneys. The 1-year function rate of CMV-positive kidneys (75%) dropped about 10% below that of CMV-negative organs (85%), and in the case of CMV-negative recipients an additional graft loss of more than 10% happened within the 4th and 5th years (5-year graft survival pos./neg.: 56%). This detrimental effect was exaggerated if it coincided with antibody-treated rejection episodes.

Adult↗

PubMed1994

Long-term follow-up of lipid metabolism and rheologic properties after successful pancreas and kidney transplantation.

The long-term effect of pancreatic and kidney transplantation (spkt) on blood viscosity, lipid metabolism and skin microcirculation in insulin-dependent diabetes mellitus (IDDM) was studied because impaired rheological properties of blood may play a role in the development of diabetic micro- and macroangiopathy. 46 IDDM-patients (16 f/30 m; 23 +/- 34 y mean duration of diabetes; 60 +/- 14 mos mean follow up period) underwent spkt (Gr.I: n = 28) or solitary kidney (Gr.II: n = 18) transplantation, and were compared with healthy controls (C). Rheological measurements were performed with Mooney-Ewart rotation-viscosimeter determining whole blood viscosity (WBV), at shear rates 1, 5, 10, 20, 50, 100, 200 sec(-1). Triglycerides, total and HDL-, LDL- and VLDL cholesterol and fibrinogen were measured. Microcirculation was estimated by transcutaneous oxygen tension measurement (tcpO2) and laser speckle method, in the forefoot area. Hemoglobin A1 was normalized only in group I (I: 7.2 +/- 0.2%; II: 8.3 +/- 0.3%; C: < 8%). WBV at low shear (1, 5, 10) was increased in both groups, when compared to healthy controls (I: 12.4 +/- 2; 12.5 +/- 1; 6.8 +/- 0.5 mpas; II: 18.7 +/- 2; 13.4 +/- 15; 9.4 +/- 1 mpas; C: 7.5 +/- 0.5; 6.7 +/- 0.3; 5.4 +/- 0.2 mpas; P < 0.05). Plasma fibrinogen was elevated in both groups compared to normals: (I: 384 +/- 19; II: 448 +/- 20; C: 250 +/- 50 mg/dl; P < 0.05). There was a positive influence of spkt on skin microcirculation: tcpO2/prior tx: I: 44 +/- 3; II: 49 +/- 6 mmHg; post tx: I: 59 +/- 4; II: 42 +/- 3 mmHg. Laser speckle prior tx I: 3.3 +/- 0.3; II: 4.7 +/- 0.2 rel. U.; post tx: 3.8 +/- 0.2; II: 4.3 +/- 0.2 rel. U. Patients with progression of angiopathy showed still higher fibrinogen and shear rates (P < 0.05). There was no significant difference for total HDL-, LDL- and VLDL cholesterol. Despite normalization of glucose metabolism and significant improvement of microcirculation in spkt patients, fibrinogen and the shear rates are increased indicating a persisting "individual" vascular risk. It is suggested that an additional hemorheological approach in the treatment posttrransplant might prevent the progression of vascular complications.

Adult↗

PubMed1994

Early infiltration of renal allografts with 27E10-positive macrophages and graft outcome.

Recently, we have demonstrated that acute cellular rejection is correlated with a massive infiltration of 27E10-positive macrophages. To examine the distribution of macrophage differentiation markers in the infiltrate in the very early post-transplantation period, two biopsies were taken intraoperatively, approximately 1 h following reperfusion, in each of 16 renal transplant recipients. One biopsy was taken for conventional histology and the other biopsy was snap-frozen. The sections were stained using an ABC indirect immunoperoxidase technique. A panel of monoclonal antibodies against three macrophage differentiation markers (27E10, 25F9 and RM3/1) was used to stain the sections. Using the early inflammation macrophage marker 27E10, there was an unexpected strong staining in 3 out of 16 biopsies. This severe infiltration of 27E10-positive macrophages with 10-20 macrophages per high power field (compared to 0-2 in others) was correlated in all cases with a poor outcome of the graft. All seven kidneys with no 27E10-positive infiltration showed a good function 6 weeks post-transplantation. The other macrophage markers, 25F9 and RM3/1, showed a less marked correlation with graft outcome. In conclusion, a massive infiltration of renal allografts with 27E10-positive macrophages 1 h post-transplantation may be a very early predictor of poor graft outcome.

Antigens, Surface↗

PubMed1994