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Patterns of angiogenesis in neural transplant models: II. Fetal neocortical transplants.

Vascular integration between transplanted fetal CNS tissues and host brain is essential for long-term transplant survival. This study compares the time course and mechanism of vascularization in allografts of fetal cerebral cortex inserted either into the fourth ventricle or directly into the parietal cortex or hippocampus of perinatal rats. Recipient animals were administered 3H-thymidine after various postoperative time periods. The tissues were processed for light microscopic autoradiography to determine the temporal pattern of endothelial proliferation at the graft sites. Correlative electron microscopy depicted the morphological changes in transplant vasculature. Some recipients were prelabelled with 3H-thymidine prior to transplantation to determine if host vessels invaded the grafts; conversely, some donor tissues were prelabelled in utero to ascertain if the intrinsic vascular anlagen survived. Intraventricular transplants contained patent vessels, probably originating from the host pia mater, as early as 24 hours postoperative. Intraparenchymal transplants had patent vessels by 72 hours and a more complete network by 5 days. Prelabelling experiments and ultrastructural observations demonstrated that adjacent host pial vessels became incorporated into the perimeter of the intraventricular transplants and later grew centrally into the grafts. Intraparenchymal transplants also contained host vessels that exhibited a similar growth pattern. Intrinsic graft vessels remained viable and continued their development, and presumably anastomosed with the ingrowing host vasculature. Temporal labelling studies revealed that both vessel populations attained their highest proliferative rates within 72 hours after transplantation. This study demonstrates that the vasculature which develops within both intraventricular and intraparenchymal fetal CNS transplants is chimeric, consisting of intrinsic fetal vasculature and proliferating host vessels. The mechanism of transplant vascularization may be significant with regard to astrocytic, immunological, or blood-brain-barrier characteristics at these transplantation sites.

Animals↗

Neural transplantation: autoradiographic analysis of histogenesis in neocortical transplants.

Neurohistogenesis in neocortical transplants obtained from 15-, 16-, 17-, 18-, 19-, 20- and 21-day-old embryos, was studied employing [3H]thymidine autoradiography. The neural tissues were transplanted in the midvermis of cerebellum of the host animals. Following transplantation the host animals in different groups were injected with the radiochemical at 6 hr, 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 day intervals, to label the neurons forming on different days in the developing transplants. Analysis of autoradiograms showed that all the neocortical transplants did undergo histogenesis in the host cerebellum, and that it was similar to that seen in a normally developing neocortex. Transplants from the 15-day embryos showed histogenesis lasting for 9 days, and at the other extreme transplants from the 21-day embryos showed histogenesis lasting only for 1 day. Histogenesis in other transplants fell between these two extremes in a graded fashion in relation to the age of the donor embryos. The magnitude of histogenesis in transplants from different donor embryos was closely related to the final size of the transplants. Transplants from 15-day embryos were the largest in size, and they were followed by those from 16-, 17-, 18-, 19-, 20- and 21-day donor embryos in a graded fashion. All transplants were intraparenchymal, and histologically appeared normal. They contained fully differentiated neurons, and were anatomically integrated with the host cerebellum without any glial scar tissue or necrotic tissue intervening between them.

Animals↗

Intrasplenic hepatocyte transplantation: evaluation of DNA synthesis and proliferation in auxiliary transplanted cells.

The value of isolated hepatocyte transplantation as a temporary support in acute hepatic failure remains controversial regarding the functional capacities of freshly isolated and transplanted hepatocytes. To evaluate the survival rate of intrasplenically transplanted liver cells and their response to a proliferation stimulus like partial hepatectomy, 3H-thymidine incorporation into hepatic and auxiliary transplanted hepatocyte DNA was determined. The survival rate of intrasplenically transplanted hepatocytes was evaluated by analyses of m-albumin-RNA within the splenic tissue and compared to the morphological findings. The histological results show a marked decrease (greater than x 100) of intrasplenically transplanted hepatocytes within 1 week after injection. The amount of surviving cells then remained constant for 3 months without any signs of proliferation. After partial hepatectomy a stimulation of hepatic regeneration was observed in the remaining liver tissue but not in auxiliary transplanted hepatocytes. M-albumin-RNA determination of auxiliary transplanted hepatocytes revealed a decrease of m-albumin-RNA concentration of greater than 100 times within 24 h after transplantation indicating early cell necrosis of the transplanted cells. Since intrasplenically transplanted hepatocytes underwent an early cell necrosis without any evidence for a directly postoperatively inducible cell proliferation, it is concluded that a sufficient metabolic support in acute hepatic failure cannot be taken into consideration.

Albumins↗

Fate of transplanted bone-marrow-derived mesenchymal cells during osteochondral repair using transgenic rats to simulate autologous transplantation.

OBJECTIVE: The fate of transplanted cells used in tissue engineering strategies should be followed. With this aim in view, the survival of transplanted bone-marrow-derived mesenchymal cells within osteochondral defects was determined using transgenic rats to simulate autologous transplantation. DESIGN: An autologous transplantation model was simulated using transgenic rats - whose transgenes produce no foreign proteins - as donors, and wild-type rats as recipients. Dense masses of mesenchymal cells were prepared from the transgenic rats using the hanging-drop culture technique. These cell masses were then transplanted into osteochondral defects created within the medial femoral condyle of wild-type rats, wherein they are affixed with fibrin glue. The course of repair was assessed histologically. The survival of the transplanted cells was ascertained by in situ hybridization of the transgenes. RESULTS: Twenty-four weeks after transplantation, the defects were repaired with hyaline-like cartilage, which was thicker than normal, and with subchondral bone. Using the in situ hybridization technique, cells derived from the transplanted ones were detected within both the cartilaginous and the subchondral bone layers. CONCLUSION: Using this simulated autologous transplantation model, the survival of transplanted mesenchymal cells was monitored in vivo. The findings indicate that the transplanted mesenchymal cells contributed to the repair of the osteochondral defects.

Animals↗

Transplant "twins": the experience of sharing transplanted thoracic organs from the same donor.

BACKGROUND: Many thoracic transplant recipients who receive organs from the same donor share facilities for 3 months, and are aware that they have received organs from the same donor. METHODS: A confidential questionnaire including open and closed questions assessed relationships between "twins" and the experience of having a twin. The Significant Others Scale assessed social support. Of 141 heart and 58 lung transplants, 25 pairs of transplant twins were identified. Questionnaires were sent to the 32 surviving twins. RESULTS: Twenty-six twins responded; 17 had received a heart and nine a lung. The 17 men and 9 women had a mean age of 51 years. Eighteen respondent's "twins" remained alive at the time of participation and eight had died. Sixty-six percent of the both- twin alive group and 43% of one-twin alive group felt they had a special bond with their twin, different from the other relationships that they have experienced. Fifty-six percent of the both-twin alive group and 43% of one-twin alive group felt having a twin enriched their transplant experience. Transplant twins rated social support last behind: the transplant support personnel; close family members; other transplant recipients; and good friends and general practitioners, both in levels of ideal and actual support. Transplant twins showed the largest discrepancy between levels of ideal and actual support than any other individual ranked. CONCLUSIONS: Being a transplant twin is a special experience that generally enriches the overall transplant experience but having a transplant twin, does not appear to enhance the amount of social support.

Cadaver↗

Autologous transplants for chronic myelogenous leukaemia: results from eight transplant groups.

Chronic myelogenous leukaemia (CML) can be cured by donor marrow transplant. Unfortunately, suitably HLA-matched related or unrelated donors are not available for the majority of patients. Transplant of stem cells derived from a patient's own marrow or peripheral blood (autologous transplant) avoids the need for an HLA-matched donor, is associated with a less complicated and shorter hospital course than donor transplantation, and has been successful in the treatment of other haematological malignancies. We report results of autologous transplants in 200 patients with CML at eight marrow transplant centres over seven years. This is the first multicentre analysis of autologous transplants for CML and reports on the largest number of patients studied to date. We show that autologous transplants provide a plateau in the survival curve not observed in conventional treatments. Autologous transplants are associated with a high engraftment rate, low mortality, and prompt return of both younger and older patients to normal activity levels. Our results suggest that autologous transplants provide an alternative to conventional treatment in the care of patients not eligible for donor transplant.

Adolescent↗

First human trial of pancreatic islet allo-transplantation in Korea--focus on re-transplantation.

Over the past 20 years, allo-transplantation of islet or whole pancreas for reaching and sustaining near-normoglycemia, as close as possible to the physiological model, have been undertaken. As previously known, even though islet transplantation is possible as a safe re-transplant, it is not well known whether re-transplantation of islets is suitable for patients who have lost the grafted islet function. We have performed a human islet allo-transplantation and re-transplantation on an IDDM patient for the first time in Asia and Korea. The recipient was a 32-year-old male and his insulin requirement was 75-85 U per day. After islet transplantation, the basal C-peptide increased from 0.6 to 2.1 ng/ml and insulin requirement decreased from 80 to 36 U per day, indicating that the grafted islets were functional. However, the grafted islets lost function 70 days after the transplantation. So, we performed re-transplantation of the islets. After the re-transplantation, the glucose profile became more stable and frequent episodes of severe hypoglycemia completely disappeared. His severe neuropathic pain improved dramatically and he could engage his ordinary daily life without any antineuropathic drugs. The success of this re-transplantation is one step closer to becoming a viable alternative for the millions of individuals who are suffering from diabetes.

Adult↗

Long-term results after allogeneic bone marrow transplantation for chronic myelogenous leukemia in chronic phase: a report from the Chronic Leukemia Working Party of the European Group for Blood and Marrow Transplantation.

The purpose of this study was to determine the long-term results of allogeneic bone marrow transplantation for chronic myeloid leukemia. A retrospective analysis was carried out of the outcome of 373 consecutive transplants performed at 38 European institutions between 1980 and 1988 and reported to the registry of the European Group for Blood and Marrow Transplantation. All transplants were carried out for first chronic phase of chronic myelogenous leukemia using unmanipulated marow cells from HLA-identical sibling donors. The probability of survival and leukemia-free survival at 8 years were 54% (95% CI: 49-59) and 47% (95% CI: 41-52) respectively. The probabilities of developing acute GVHD (II-IV) at 100 days and chronic GVHD at 4 years after transplant were 47% (95% CI: 41-53) and 52% (95% CI: 46-58) respectively. The probabilities of transplant-related mortality and leukemic relapse 8 years after BMT were 41% (95% CI: 36-48) and 19% (95% CI: 14-25), respectively. Transplant within 12 months of diagnosis was associated with reduced transplant-related mortality (34 vs 45%, P = 0.013) and resulted in improved leukemia-free survival (52 vs 44%, P = 0.03). The probability of relapse was significantly reduced in patients who developed chronic GVHD (RR = 0.33, P = 0.004). The probability of relapse occurring more than 2 years after transplant was increased more than five-fold in patients transplanted from a male donor (RR = 5.5, P = 0.006). Sixty-seven patients in hematologic remission were studied for residual disease by two-step RT/PCR for BCR-ABL mRNA and 61 (91%) tested negative. We conclude that bone marrow transplantation can induce long-term survival in approximately one-half of CML patients; the majority of survivors have no evidence of residual leukemia cells when studied by molecular techniques. The probability of late relapse is increased with use of a male donor.

Adolescent↗

Pre-transplant elevations of interleukin-12 and interleukin-10 are associated with acute rejection after renal transplantation.

BACKGROUND: Methods for predicting patients at higher risk for rejection before transplantation may help improve outcomes. We hypothesized that pre-transplant elevations of serum interleukin-12 (IL-12), a pro-inflammatory cytokine, would predict acute rejection, while pre-transplant IL-10, an immunoregulatory cytokine, would be down-regulated in patients subsequently experiencing acute rejection. MATERIALS AND METHODS: Thirty patients experiencing acute rejection after cadaveric renal allograft transplantation and a control group of 30 patients, undergoing the same procedure but without the occurrence of rejection, were identified. Serum samples taken before transplantation from each patient were then analyzed quantitatively for IL-12 and IL-10 using ELISA assays. RESULTS: The mean pre-transplant serum IL-12 level was higher in patients who subsequently underwent acute rejection vs. those who did not (181 +/- 143 pg/mL vs. 81.2 +/- 71.5 pg/mL, respectively, p = 0.007). Unexpectedly, pre-transplant serum IL-10 levels were also elevated in patients who underwent rejection (559 +/- 293 pg/mL vs. 332 +/- 163 pg/mL, respectively, p = 0.002). Multivariate analysis demonstrated that elevations of IL-12 and IL-10 were independent risk factors for rejection when adjusted for confounding variables. CONCLUSIONS: Pre-transplant elevations of IL-12 and, unexpectedly, IL-10 are associated with acute rejection after cadaveric renal transplantation and may be useful in predicting which patients are at increased immunological risk at the time of transplantation. Further studies are necessary to assess the role of occult systemic inflammation in contributing to poor outcomes after transplantation.

Case-Control Studies↗

Interpreting post-transplant proteinuria in patients with proteinuria pre-transplant.

Increasing numbers of patients receive kidney transplants before initiation of dialysis or shortly thereafter. Some of these patients have significant proteinuria pre-transplant making the interpretation of post-transplant proteinuria problematic. In this study, we evaluated post-transplant proteinuria in 115 patients who had urine protein measured within 3 months of transplant and assessed the association of proteinuria with allograft pathology. Proteinuria declined rapidly from 3650 +/- 3702 mg/day pre-transplant to 550 + 918 at 3 weeks (p < 0.0001) and continued to decline until 1 year post-transplant (472 +/- 1116, p < 0.0001 vs. 3 weeks). Proteinuria greater than 3000 mg/day was present in 48 patients (42%) pre-transplant, in 1 patient (1%) at 3 weeks and in 4 patients (4%) at 1 year. Surveillance graft biopsies were done at 1 year in 93% of patients. Proteinuria > or = 1500 mg/day and/or an absolute increase in proteinuria > 500 mg/day after 3 weeks post-transplant was associated with allograft glomerular pathology. In conclusion, pre-transplant proteinuria, even when high grade, declines rapidly after transplantation. Failure to decline or persistence of proteinuria greater than 1500 mg/day is indicative of allograft pathology.

Adolescent↗

Intrathoracic organ transplantation in the United Kingdom 1995-99: results from the UK cardiothoracic transplant audit.

OBJECTIVE: To describe the current practice and outcomes of intrathoracic transplantation in the United Kingdom. DESIGN: Prospective observational cohort study. SETTING: Multicentre study involving all nine UK intrathoracic transplant units. PATIENTS: 2588 patients added to the national waiting list between April 1995 and March 1999 and 1737 patients who underwent heart, lung, or heart-lung transplantation in the same period. MAIN OUTCOME MEASURES: Waiting list mortality and post-transplant graft survival. RESULTS: There was a slight fall in transplant activity over the four years. Within six months of listing, 52.5% of patients on the heart transplant list had been transplanted and 11.0% had died, compared with 31.3% and 15.2% for lung, and 23.4% and 20.4% for heart-lung. The median time to transplant in days (95% confidence interval) was 133 (115 to 149) for heart, 386 (328 to 496) for lung, and 471 (377 to 577) for heart-lung. After three years, the waiting list mortality was 16.9% (6.1% to 46.8%) for heart, 33.1% (9.0% to 100%) for lung, and 36.5% (10.5% to 100%) for heart-lung. The three year graft survival after transplantation was 74.2% (71.2% to 77.0%) for heart, 53.8% (48.2% to 59.2%) for lung, and 57.2% (49.0% to 64.6%) for heart-lung. CONCLUSIONS: This validated database defines the current state of thoracic transplantation in the United Kingdom and is a useful source of data for workers involved in the field. Thoracic transplantation is still limited by donor scarcity and high mortality. Overoptimistic reports may reflect publication bias and are not supported by data from this national cohort.

Adult↗

Single-institute comparative analysis of unrelated bone marrow transplantation and cord blood transplantation for adult patients with hematologic malignancies.

Unrelated cord blood transplantation (CBT) has now become more common, but as yet there have been only a few reports on its outcome compared with bone marrow transplantation (BMT), especially for adults. We studied the clinical outcomes of 113 adult patients with hematologic malignancies who received unrelated BM transplants (n = 45) or unrelated CB transplants (n = 68). We analyzed the hematopoietic recovery, rates of graft-versus-host disease (GVHD), risks of transplantation-related mortality (TRM) and relapse, and disease-free survival (DFS) using Cox proportional hazards models. The time from donor search to transplantation was significantly shorter among CB transplant recipients (median, 2 months) than BM transplant recipients (median, 11 months; P < .01). Multivariate analysis demonstrated slow neutrophil (P < .01) and platelet (P < .01) recoveries in CBT patients compared with BMT patients. Despite rapid tapering of immunosuppressants after transplantation and infrequent use of steroids to treat severe acute GVHD, there were no GVHD-related deaths among CB transplant recipients compared with 10 deaths of 24 among BM transplant recipients. Unrelated CBT showed better TRM and DFS results compared with BMT (P = .02 and P < .01, respectively), despite the higher human leukocyte antigen mismatching rate and lower number of infused cells. These data strongly suggest that CBT could be safely and effectively used for adult patients with hematologic malignancies.

Adolescent↗

Impact of donor type on outcome of bone marrow transplantation for Wiskott-Aldrich syndrome: collaborative study of the International Bone Marrow Transplant Registry and the National Marrow Donor Program.

Human leukocyte antigen (HLA)-identical sibling bone marrow transplantation is an effective treatment for Wiskott-Aldrich syndrome. However, most children with this disease lack such donors and many patients receive transplants from alternative donors. This study compared outcomes of HLA-identical sibling, other related donor, and unrelated donor transplantation for Wiskott-Aldrich syndrome. The outcome of 170 transplantations for Wiskott-Aldrich syndrome, from 1968 to 1996, reported to the International Bone Marrow Transplant Registry and/or National Marrow Donor Program were assessed. Fifty-five were from HLA-identical sibling donors, 48 from other relatives, and 67 from unrelated donors. Multivariate proportional hazards regression was used to compare outcome by donor type and identify other prognostic factors. Most transplant recipients were younger than 5 years (79%), had a pretransplantation performance score greater than or equal to 90% (63%), received pretransplantation preparative regimens without radiation (82%), and had non-T-cell-depleted grafts (77%). Eighty percent received their transplant after 1986. The 5-year probability of survival (95% confidence interval) for all subjects was 70% (63%-77%). Probabilities differed by donor type: 87% (74%-93%) with HLA-identical sibling donors, 52% (37%-65%) with other related donors, and 71% (58%-80%) with unrelated donors (P =.0006). Multivariate analysis indicated significantly lower survival using related donors other than HLA-identical siblings (P =.0004) or unrelated donors in boys older than 5 years (P =.0001), compared to HLA-identical sibling transplants. Boys receiving an unrelated donor transplant before age 5 had survivals similar to those receiving HLA-identical sibling transplants. The best transplantation outcomes in Wiskott-Aldrich syndrome are achieved with HLA-identical sibling donors. Equivalent survivals are possible with unrelated donors in young children.

Actuarial Analysis↗

[Medical and economic evaluation of organ transplantation in France. The example of liver transplantation].

BACKGROUND: Organ transplantation is an expensive and risky medical procedure. Estimating the cost is difficult because the care is complex and involves many actors. We present a methodological framework for the economic evaluation of organ transplantation in France which include a detailed collection of all the direct costs and the simultaneous analysis of health status. It was applied to evaluate the cost of liver transplantation in France. METHODS: All consecutive adults transplanted or placed on the waiting list of liver transplantation in the Department of Surgery of Cochin Hospital, Paris, between 1994 and 1996 were included. All resource use was measured during one year: staff wages, pharmacy and blood, laboratory and radiology, supplies, overhead hospital services. Mean quality of life was estimated by the survival weighted by the Karnofsky index. RESULTS: Transplantation: 38 patients were included. The first year mean cost after transplantation was 561,000FF (included rehospitalizations cost of 120,000FF). Care outside the hospital induced 10% of the total cost. Mean quality of life was 63% (from 0% to 93%) and increased with time, whereas cost decreased. Waiting list: 26 of 33 patients on waiting list were transplanted. The first year mean cost was 95,000FF (included 32,000FF for first evaluation) and increased with time. 44% of cost was supported by another hospital than the transplanting one. Sickness allowance added 20% to the cost. The mean quality of life was 56% during the first year. CONCLUSIONS: This complete approach of organ transplantation cost respected the medical procedure over the time. Detailed costs take into account the care outside the hospital. This method can be used in other countries and generalised to all surgical or medical procedure as heavy as the organ transplantation.

Absenteeism↗

[Donor selection for allogenic bone marrow transplantation from 1991 to 1995. (The Prague Center for Bone Marrow Transplantation)].

BACKGROUND: The prerequisite of successful transplantation of haematopoietic stem cells is to find a suitable, i.e. HLA matched bone marrow donor. In the submitted paper the authors give an account of the strategy of selection of bone marrow donors, as practised by the Prague transplantation group. METHODS AND RESULTS: In 1991 to 1995 (end of first quarter) the authors sought suitable bone marrow donors for 421 patients where an allogenic bone marrow transplantation was indicated. During that period 95 transplantations were performed (22.5% of all indicated cases), incl. 82 from siblings (86.3%) of the implemented allogenic bone marrow transplantations). A HLA matched donor from the wider family circle was selected for 15 donors, transplantation were performed in 6 patients (6.4% of the implemented allogenic bone marrow transplantations). An unrelated bone marrow donor was sought for 41 patients as no donor was found in the wider family. Transplantation was implemented in 7 of these patients (7.3% of the implemented transplantations. CONCLUSIONS: With the increasing experience of our transplantation centre, no doubt, the ratio of other than sibling transplantations of bone marrow will increase. At present it accounts for 13.7%. The task of our HLA group must be selection of donors matched as well as possible with the recipient according to all available tests of tissue compatibility - from the wider family circle as well as from the register of unrelated donors.

Bone Marrow Transplantation↗

The impact of pre-transplant obesity on renal transplant outcomes.

The impact of obesity on graft survival after renal transplantation continues to be controversial. We have reviewed our experiences with living donor and cadaver transplantation in the current decade, focusing specifically on the impact of obesity on transplant outcome. Preoperative body mass index (BMI, kg/m2) was calculated for all adult renal transplant recipients between January 1990 and December 1995 and was used to classify patients as non-obese, moderately obese or morbidly obese. The effect of the degree of obesity on early and late outcomes after renal transplantation was examined. Three hundred and thirty-three recipients had pre-transplant BMI < 30 (normal or mild obesity), 68 BMI 30-40 (moderate obesity), and 7 BMI over 40 (morbid obesity). There was no correlation between obesity and other demographic factors. Wound infections and delayed graft function occurred more commonly in moderately and morbidly obese than in other cadaver donor recipients. Obese patients gained more weight after surgery and were given lower doses per kilogram of cyclosporine. There was, however, no significant correlation between obesity and graft survival for either cadaver or living donor transplants. Although obese patients have an increased risk of delayed graft function with cadaver donor transplantation, obesity has no discernible impact on either immunologic or overall graft survival with cadaver or living donor transplantation. The impact of moderate obesity on transplant outcome is modest and should not prevent these patients from receiving a transplant.

Adult↗

Tacrolimus in pancreas transplantation: a multicenter analysis. Tacrolimus Pancreas Transplant Study Group.

This follow-up multicenter analysis is based on 362 pancreas allograft recipients at 14 institutions who were given tacrolimus between 1 May 1994 and 15 November 1995. Three groups were studied: (1) recipients given tacrolimus initially for induction and maintenance therapy (n = 250; 215 without, 35 with, a concurrent bone marrow transplant), (2) recipients who converted to tacrolimus for rescue or rejection therapy (n = 89), and (3) recipients who converted to tacrolimus for other reasons (n = 23). Of 215 recipients without a bone marrow transplant in the induction group, 166 (77%) underwent a simultaneous pancreas-kidney transplant (SPK), 29 (14%) a pancreas transplant alone (PTA), and 20 (9%) a pancreas after previous kidney transplant (PAK). Initial antibody therapy was given to 185 (86%) recipients. All 215 received tacrolimus and prednisone; 202 (94%) also received azathioprine (AZA) and 11 (5%) mycophenolate mofetil (MMF). The most common side effects of tacrolimus were neurotoxicity in 21%, nephrotoxicity in 21%, gastrointestinal (GI) toxicity in 13%, and diabetogenicity in 13% of these recipients. No recipient in this group developed new-onset insulin-dependent diabetes mellitus. Of 89 recipients in the rescue group, 71 (79%) had an SPK, 11 (13%) a PTA, and 7 (8%) a PAK. Before conversion, all had been on cyclosporine (CsA)-based immunosuppression; 74% of them had 2 or more rejection episodes previously. The most common side effects were nephrotoxicity in 27%, neurotoxicity in 26%, GI toxicity in 18%, and diabetogenicity in 8% of these recipients. No recipient in this group developed new-onset insulin-dependent diabetes mellitus. In the induction group patient survival at 1 yr was 98% for SPK, 79% for PTA, and 100% for PAK recipients. According to a matched-pair analysis, pancreas graft survival for SPK recipients at 1 yr was 88% with tacrolimus vs. 73% with CsA (p = 0.002); for PTA recipients, 68% vs. 70% (p > 0.35); and for PAK recipients, 85% vs. 65% (p = 0.13). Graft loss from rejection was not different with tacrolimus vs. CsA in all 3 pancreas recipient categories. At 1 yr, 17% of recipients had converted from tacrolimus to CsA for diabetogenicity, nephrotoxicity, or rejection; 23% had converted from AZA to MMF. The incidence of post-transplant lymphoma was < 2%. In the rescue group, patient survival rates at 1 yr were 96% for SPK, 100% for PTA, and 86% for PAK recipients (p < 0.08). Pancreas graft survival at 1 yr was 89% for SPK, 58% for PTA, and 69% for PAK recipients (p = 0.004). Graft loss from rejection was significantly lower for SPK vs. PTA or PAK recipients. At 1 yr, 20% of recipients had reconverted from tacrolimus to CsA for rejection, neurotoxicity, or nephrotoxicity; 19% had converted from AZA to MMF. There were no post-transplant lymphomas in the rescue group. This follow-up multicenter analysis shows that tacrolimus after pancreas transplantation is associated with high graft survival rates when used for induction and with high graft salvage rates when used for rescue therapy. The rate of graft loss from rejection is low in all 3 pancreas recipient categories. The overall incidence of new-onset insulin-dependent diabetes mellitus is < 1%, as is the incidence of post-transplant lymphoma. Converting from tacrolimus to CsA and, in patients on tacrolimus, from AZA to MMF, is safe; interchangeable use of drugs appears to be of immunologic benefit. To determine the best immunosuppressive regimen after pancreas transplantation, a prospective randomized study comparing tacrolimus and MMF vs. Neoral plus MMF is mandatory.

Adult↗

Sunscreen use before and after transplantation and assessment of risk factors associated with skin cancer development in renal transplant recipients.

OBJECTIVE: To determine the degree of compliance with sunscreen use among renal transplant recipients before and after transplantation and to determine risk factors associated with skin carcinogenesis. DESIGN: Single-observer study with structured interview using a standardized questionnaire. Medical records and histology reports were examined for details of prior skin cancer. Cox proportional hazards regression was used for analysis of risk factors for developing skin cancer after transplantation. SETTING: Patients attending Beaumont Hospital, the national renal transplantation center in Dublin, Ireland. PATIENTS: The study population comprised 270 patients (182 male and 88 female). MAIN OUTCOME MEASURES: Patients' use of sunscreens before and after transplantation relative to known skin cancer risk factors and subsequent skin carcinogenesis. RESULTS: Prior to transplantation, 68.5% of patients never applied sunscreen on a sunny day compared with 25.9% after transplantation. Patients 50 years or younger were more likely to always apply sunscreen both before and after transplantation (P = .01), as were female patients prior to transplantation (P = .02). Those patients who participated in an outdoor recreation were more likely to subsequently develop nonmelanoma skin cancer (P = .04), as were those older than 50 years (P<.001) and those with a history of 2 or more painful sunburns (P = .03). CONCLUSIONS: Transplant recipients are poorly compliant with the use of sunscreens both before and after transplantation. Compliance is poorest in those groups at higher risk of nonmelanoma skin cancer.

Adolescent↗