Search

Background Pancreas transplant is an effective treatment for insulin-dependent diabetic individuals with end-stage renal disease, yet immunosuppression-associated adverse events may adversely affect patient and graft survival. The aim of the study was to document whether mammalian target of rapamycin inhibitors (mTORi) are safe and effective as a second-line drug after pancreas transplant. Methodology An observational single-center study was performed in a cohort of 490 simultaneous pancreas–kidney transplant and 45 pancreas-after-kidney transplant individuals after conversion to mTORi (n = 13) owing to adverse events of either tacrolimus or mycophenolate. Results mTORi conversion was performed 11.5 ± 10.1 (range, 1-28) months after pancreas transplant, mainly owing to cytomegalovirus infection and gastrointestinal intolerance. We frequently observed clinical complications after mTORi conversion, yet creatinine, eGFR, proteinuria, fasting plasma glucose, HbA1c, and C-peptide remained stable throughout the study (mean follow-up 8.2 ± 5, range 1-17) years, as did the lipid profile (P > .05). However, graft loss occurred in almost 20% of patients owing to chronic alterations. Limitations The small number of patients and a single-center cohort were limitations of the study. Conclusions Late mTORi conversion is a safe and effective approach when tacrolimus or mycophenolate-mediated adverse events occur after pancreas transplant.

Simultaneous pancreas/kidney transplants require a long graft survival and the recipient to present with more benefits than risks. We evaluated the risk factors of receptor's death and pancreatic graft loss on 2 occasions (3 and 12 months' postoperatively) in 292 transplants in whom 22 variables were evaluated. Variables were selected, 9 receivers, 8 donors, and 5 variables related to the surgical procedure. All independent variables were compared with the dependent variables of pancreatic graft losses and patient deaths. Those considered significant according to univariate analysis were analyzed by using multiple logistic regression techniques in an attempt to develop a mathematical model capable of predicting both pancreatic graft and patient losses. Lastly, based on the resulting models with all significant variables, scores were created to determine the risk of patient death and pancreatic graft loss. In the adjusted multivariate analysis, the significant variables were donor age, receiver's body mass index, initial pancreas implant, iliac venous drainage, and use of induction therapy related to pancreatic loss within 3 months after transplantation. Independent risk factors regarding the loss of patients within 12 months were body mass index and receptor induction therapy. The variables related to pancreatic graft loss within 3 months were donor age, receiver body mass index, initial use of pancreatic graft, iliac venous drainage, and induction therapy; these variables can be used for creating a risk score. The donor body mass index and the induction therapy were independently related to patient loss within 12 months after the transplant.

OBJETIVO: O transplante pâncreas-rim é efetivo para pacientes com doença renal crônica terminal e diabetes mellitus insulino-dependente. A função retardada do enxerto pancreático é condição frequente exercendo impacto significativo nos resultados em curto prazo dos transplantes pâncreas-rim. O objetivo foi analisar o impacto da função retardada do enxerto pancreático no transplante pâncreas-rim. MÉTODOS: Análise retrospectiva de 180 receptores de transplante pâncreas-rim, incluindo dados demográficos dos doadores e dos receptores, a reatividade contra painel, a incidência de rejeição aguda e as sobrevidas do paciente e dos enxertos pancreático e renal. RESULTADOS: A incidência de função retardada do enxerto pancreático foi 11%. A idade do receptor superior a 45 anos apresentou associação com o risco de desenvolvimento de função retardada do enxerto pancreático (Razão de chances 2,26; p < 0,05). Os pacientes com função retardada do enxerto pancreático apresentaram maior incidência de rejeição aguda renal (47 versus 24%; p < 0,05), glicemia de jejum alterada (25 versus 5%; p < 0,05) e média de hemoglobina glicada (5,8 versus 5,4%; p < 0,05) ao final do primeiro ano de acompanhamento em relação aos pacientes sem função retardada do enxerto pancreático. Não houve diferenças estatisticamente significativas entre os grupos de pacientes com e sem função retardada do enxerto pancreático quanto à sobrevida do paciente (95 versus 88,7%; p = 0,38), do enxerto pancreático (90 versus 85,6%; p = 0,59) e do enxerto renal (90 versus 87,2%; p = 0,70), respectivamente, nesse mesmo período. CONCLUSÃO: A função retardada do enxerto pancreático não exerceu impacto significativo nos resultados em curto prazo dos transplantes pâncreas-rim desta casuística. Embora a função retardada do enxerto pancreático não tenha influenciado a sobrevida do enxerto pancreático ao final do primeiro ano após o transplante, contribuiu para a disfunção pancreática precoce, indicando maior necessidade de uso de insulina e hipoglicemiantes orais.

Objetivos: Os sintomas gastrointestinais são freqüentes após o uso de derivados do ácido micofenólico. Os objetivos do trabalho foram relatar a incidência de diarréia aguda e descrever os fatores de risco associados a sua ocorrência após o transplante simultâneo de pâncreas- rim (TSPR). Métodos: Inclusão de 165 pacientes submetidos a TSPR no período de Dez/00 a Maio/07. Realizada regressão logística binária, de modo que a ocorrência de diarréia aguda foi a variável dependente; as variáveis independentes incluíram idade, sexo, raça, tempo de diabetes e diálise, modalidade de diálise, ocorrência de função retardada do enxerto renal e uso de Micofenolato de Mofetil (MMF) vs Micofenolato de Sódio (MPS). P < 0,05 foi considerado significante. Resultados: As médias de idade, tempo de diálise e tempo de diabetes foram: 34,9 ± 8,2 anos, 27,3 ± 18,3 meses e 21,9 ± 16,2 anos. 63% dos pacientes usaram MMF, 36,4% usaram MPS e 0,6% usaram Azatioprina. A análise multivariada mostrou que o tempo de diabetes (p = 0,049, IC 95% 1,0-1,13) e uso de MMF (p = 0,013, IC 95% 0,2-0,82) foram os principais determinantes da diarréia aguda não-infecciosa após o TSPR. O MMF esteve associado à maior necessidade de redução da dose (79,2% vs 62,3%, p = 0,024) e a episódios mais severos de diarréia aguda associados à hipotensão ortostática (42,4% vs 15,1%, p = 0,001) do que o MPS, respectivamente. Não houve diferença entre o MMF e o MPS em relação à ocorrência de infecção por citomegalovírus (36,5% vs 32,8%, p = 0,6) e de rejeição aguda do enxerto renal após redução da dose (30,8% vs 26,7%, p = 0,53), respectivamente. Conclusões: A diarréia aguda após o TSPR está relacionada ao tempo de diabetes e ao uso de MMF. O uso preferencial de MPS está associado à menor necessidade de redução da dose e a episódios menos severos de diarréia aguda. No entanto, a ocorrência de rejeição aguda do enxerto renal após redução da dose é similar entre o MMF e o MPS.

OBJETIVO: Analisar o perfil dos principais centros de transplantes do Brasil, quanto às opções técnicas no transplante de pâncreas. MÉTODO: Foi encaminhado um questionário por correio eletrônico (email) para um membro de cada equipe de 12 centros de transplante do Brasil, com casuística mínima de um transplante de pâncreas. O questionário continha 10 perguntas, abordando aspectos controversos e não padronizados. RESULTADOS: A maioria dos centros (90,9%) utiliza incisão mediana. O órgão de escolha a ser implantado primeiro foi principalmente o rim, em 63% dos centros. Em relação à drenagem venosa, 90,9% utilizam a drenagem sistêmica. A ligadura da veia ilíaca interna é realizada em 54,5% dos centros. A maioria dos centros (90,9%) utiliza a drenagem entérica para transplante combinado pâncreas-rim. Para o transplante de pâncreas isolado, apenas cinco centros responderam, sendo que dois utilizam a drenagem entérica e três a vesical. A utilização de dreno na cavidade abdominal ocorre em 63% dos centros. Em 72,7% dos centros é realizada algum tipo de indução na imunossupressão para o transplante combinado pâncreas-rim, sendo a imunossupressão básica a associação de tacrolimus (FK506), micofenolato mofetil (MMF) e corticóide. A antibioticoprofilaxia é realizada por todos os centros e profilaxia para fungos é realizada por seis centros (54,5%). Oito centros (72,7%) utilizam algum tipo de profilaxia para trombose vascular, em esquemas diversos. CONCLUSÃO: Existem diversos caminhos técnicos na condução do transplante pancreático. A falta de padronização dificulta a análise e a comparação dos resultados. Apesar dessa heterogeneidade das equipes, observamos uma tendência para a realização de incisão mediana, drenagem venosa sistêmica e exócrina entérica, com a utilização de algum tipo de profilaxia para trombose vascular nos transplantes combinados pâncreas-rim. BACKGROUND: To analyze the profile of the most important Brazilian Transplant Centers regarding technical options in the pancreas transplant. METHODS: A query was sent by electronic mail for the 12 Brazilian Transplant Centers with at least one pancreas transplant performed. The query included ten questions approaching controversial and non-standard technical aspects. RESULTS: Midline abdominal incision is used in 90.9% of the Centers. The first organ to be implanted is the kidney in 63% of the Centers. Regarding the venous drainage, 90.9% perform systemic drainage. In 54.5% of the Centers the internal iliac vein is ligated. For combined pancreas-kidney transplant 90.9% of the teams perform enteric drainage. Five Centers answered about isolated pancreas transplant, two of them use enteric drainage and the other three prefer to utilize the bladder. 63% of the surgical teams use abdominal drain. 72.7% of the Centers adopt immunosupression induction for the combined pancreas-kidney transplant. The basic immunosuppression was an association between tacrolimus (FK506), and mofetil microfenolato (MMF), and corticoids. While antibiotic prophylaxis is performed in all the 12 Centers, fungus prophylaxis is routinely made in six of them. Eight Centers (72.7%) adopt vascular thrombosis prophylaxis by several different protocols. CONCLUSION: There are various technical medical protocols on how to conduct a pancreas transplant patient. The lack of homogeneity in the protocols makes it more difficult to analyze and compare the results. Nevertheless we can conclude that in combined pancreas-kidney transplant there is a preference towards midline abdominal incision, and vein systemic and enteric drainage, and vascular thrombosis prophylaxis.

This paper aims to evaluate results from pancreas-kidney transplants, in type 1 diabetes mellitus patients, comparing the use of Euro-Collins and Belzer or Celsior solutions for organ storage while awaiting transplant. One hundred and twenty two transplants were performed by the same transplant group, between November 2006 and June 2011. All pancreas grafts were perfused during the harvesting process through infusion of the aorta using standard solutions (Belzer or Celsior). Fifty-seven pancreas graft were stored in Euro-Collins solution (EC Group) and sixty six stored with Belzer or Celsior solutions (BC Group). The parameters analyzed were: postoperative complications, graft loss, mortality, hospitalization time and three-month follow-up period. The average cold ischemia time was 15.25 ± 1.98 hours in EC Group and 15.3 ± 2.66 hours in BC Group. The mortality rate was 15.8% in BC Group and 9.2% in EC Group. The loss of graft was 16.9% in EC Group and 8.8% in BC Group. The average hospitalization time was 13.8 days in EC Group and 18.4 days in BC Group. No significant statistical difference was observed in any parameters. It could be concluded that the use of Euro-Collins solution to store pancreas could be used without compromising the outcome of transplants.

Background: Simultaneous pancreas/kidney transplants require a long graft survival and recipient with to achieve more benefits than risks. In order to access the risk for this procedure, we evaluate the risk factors of death receptor with one year postoperatively in 292 simultaneous pancreas/kidney transplants evaluated 22 variables. Materials and Methods: Twenty-two variables were selected for the study, nine from receivers, eight from donors and five variables related to the surgical procedure. To determine the survival of patients, we evaluated dates of transplants, the latest consultation and dates of deaths. All independent variables were compared with the dependent variable: patient lost in a year. Those with statistical significance through univariate analyzes, were also analyzed by multiple logistic regression technique in an attempt to develop a mathematical model capable of predicting 1-year patient loss. Results: Relatively to the loss of patient in one year, the multivariate analysis identified body mass index receptor (p ≤ 0.008) and induction therapy (negative factor p ≤ 0.008) as independent risk factors. Conclusion: Based on the results of this research can be concluded that the independent variables related to one year loss of receptor are: body mass index of the donor and induction therapy.

Background. Immunosuppressive regimen is associated with several metabolic adverse effects. Bone loss and fractures are frequent after transplantation and involve multifactorial mechanisms. Methods. A retrospective analysis of 130 patients submitted to simultaneous pancreas-kidney transplantation (SPKT) and an identification of risk factors involved in de novo Charcot neuroarthropathy by multivariate analysis were used; PG0.05 was considered significant. Results. Charcot neuroarthropathy was diagnosed in 4.6% of SPKT recipients during the first year. Cumulative glucocorticoid doses (daily dose plus methylprednisolone pulse) during the first 6 months both adjusted to body weight (978 mg/kg) and not adjusted to body weight were associated with Charcot neuroarthropathy (P=0.001 and PG0.0001, respectively). Age, gender, race, time on dialysis, time of diabetes history, and posttransplantation hyperparathyroidism were not related to Charcot neuroarthropathy after SPKT. Conclusions. Glucocorticoids are the main risk factors for de novo Charcot neuroarthropathy after SPKT. Protocols including glucocorticoid avoidance or minimization should be considered.

INTRODUCAO: A doenca renal cronica (DRC) e uma enfermidade grave, comum e tratavel, cuja deteccao envolve exames de baixo custo. OBJETIVO: Avaliar o efeito de uma intervencao multidisciplinar (nefrologista, assistente social, enfermeira, nutricionista e psicologa) em parâmetros clinicos e laboratoriais de pacientes com DRC. METODOS: Estudo prospectivo de 2.151 pacientes atendidos no Centro Estadual de Doencas Renais do Vale do Paraiba, SP, de fevereiro de 2008 a marco de 2011. A funcao renal foi avaliada no inicio e ao final do seguimento por testes de albuminuria e taxa de filtracao glomerular estimada (TFGe) pela formula do MDRD. Os desfechos clinicos foram: ocorrencia de eventos cardiovasculares (ECV), episodios de hospitalizacao, necessidade de terapia renal substitutiva (TRS) e obito. RESULTADOS: A idade media foi 62 anos (variacao: 14 a 101), com acompanhamento medio de 546 dias (variacao: 90 a 1540), havendo predominio do estagio tres da DRC (59%). Os diagnosticos de base mais comuns foram: hipertensao arterial (41,2%) e diabetes (32,4%). A media da pressao arterial antes e ao final do seguimento foi de 143 ± 26 mmHg x 87 ± 14 mmHg e 123 ± 16 mmHg x 79 ± 9 mmHg, respectivamente (p < 0,001); a TFGe reduziu de 58,5 ± 31 ml/min para 56,3 ± 23 ml/min (p < 0,01). A proteinuria caiu de 1,04 ± 1,44 g/dia para 0,61 ± 1,12 g/dia (p < 0,001); e a glicemia de jejum de 137 ± 73 mg/dl para 116 ± 42 mg/dl. Cento e vinte e dois pacientes (5,7%) apresentaram eventos cardiovasculares, a taxa geral de hospitalizacoes foi de 6,6% (n = 143 pacientes), foram observados 156 (7,3%) obitos e 23 (1,1%) pacientes evoluiram para TRS. O risco de ECV, hospitalizacao e obito aumentou de forma inversa a TFGe, mas sao considerados baixos quando comparados a literatura internacional. CONCLUSOES: A intervencao multidisciplinar com metas bem definidas e efetiva para preservacao da funcao renal e reducao da morbidade e mortalidade de pacientes com DRC.

To evaluate the risk factors for pancreas graft loss within 3 months postoperatively among 170 simultaneous pancreas–kidney transplantation (SPKT) we examined 38 variables. Methods Twenty-two variables were related to recipients; 12 to donors and 4 to the surgical procedure. In addition the latest follow-up dates as well as the transplant and/or death dates. Independent variables were examined with reference to the dependent pancreatic loss variable, excluding losses owing to deaths. Variables with statistical significance were analyzed to predict early graft loss. Results Univariate analyses determined the following significant variables: kidney cold ischemia time, older donors, non-white donors, death cause related to vascular disease, wound infection, and length of extended hospitalization. However, multivariate analysis showed that only donor age and kidney cold ischemia time were significant predictors for early pancreastic graft loss. Conclusion Donor age and kidney cold ischemia time were independently related to pancreatic loss after SPKT within 3 months posttransplantation.

We used homeostasis model assessment to investigate insulin sensitivity and secretion after a simultaneous pancreas-kidney transplant or kidney transplant alone. In that model, fasting plasma glucose and C-peptide levels are used to evaluate insulin sensitivity and beta-cell function.Factors (eg, age, sex, race, delayed kidney allograft function) were correlated with homeostasis model assessment of beta-cell function and homeostasis model assessment of insulin sensitivity values after simultaneous pancreas-kidney transplant (n=89) or kidney transplant alone (n=68), and the results were compared with those in healthy subjects (n=49).Homeostasis model assessment of beta-cell function values were similar in patients who underwent kidney transplant alone or a simultaneous pancreas-kidney transplant, and were higher than homeostasis model assessment of beta cell function values in healthy subjects. The homeostasis model assessment of insulin sensitivity showed intermediate values for patients who underwent a simultaneous pancreas-kidney transplant and correlated with prednisone dosages (in those who underwent kidney transplant alone) and tacrolimus levels (in patients who underwent a simultaneous pancreas-kidney transplant). Homeostasis model assessment of beta-cell function values correlated with prednisone dosages in both groups and with tacrolimus levels in only those who underwent a simultaneous pancreas-kidney transplant. The body mass index of subjects who underwent kidney transplant alone correlated with both homeostasis model assessment of beta-cell function results and homeostasis model assessment of insulin sensitivity results. A family history of diabetes in subjects who underwent a simultaneous pancreas-kidney transplant correlated with homeostasis model assessment of beta-cell function results and homeostasis model assessment of insulin sensitivity results.Immunosuppressive regimen and body mass index were linked with reduced insulin sensitivity after kidney transplant. A family history of diabetes was linked with higher values of insulin secretion and lower insulin sensitivity in patients who underwent a simultaneous pancreas-kidney transplant.

Diabetes mellitus with resistance to insulin administered subcutaneously or intramuscularly (DRIASM) is a rare syndrome and is usually treated with continuous intravenous insulin infusion. We present here two cases of DRIASM in 16 and 18 years female patients that were submitted to pancreas transplantation alone (PTA). Both were diagnosed with type 1 diabetes as young children and had labile glycemic control with recurrent episodes of diabetic ketoacidosis. They had prolonged periods of hospitalization and complications related to their central venous access. Exocrine and endocrine drainages were in the bladder and systemic, respectively. Both presented immediate graft function. In patient 1, enteric conversion was necessary due to reflux pancreatitis. Patient 2 developed mild postoperative hyperglycemia in spite of having normal pancreas allograft biopsy and that was attributed to her immunosuppressive regimen. Patient 1 died 9 months after PTA from septic shock related to pneumonia. In 8 months of follow-up, Patient 2 presented optimal glycemic control without the use of antidiabetic agents. In conclusion, PTA may be an alternative treatment for DRIASM patients.

Pancreas transplantation is an invasive procedure that can restore and maintain normoglycemic level very successfully and for a prolonged period in DM1 patients. The procedure elevates the morbimortality rates in the first few months following the surgery if compared to kidney transplants with living donors, but it offers a better quality of life to patients. Although controversial, several studies have shown the stabilization or the improvement of some of the chronic complications related to diabetes, as well as the extra number of years of life that patients submitted to a double pancreas-kidney transplantation may gain. Recent studies have demonstrated clashing outcomes regarding isolated pancreas transplantations, a fact which reinforces the need for a more discerning selection of patients for this procedure.

Background. Simultaneous pancreas-kidney transplantation (SPKT) is one of the treatments for insulin-dependent chronic renal failure patients. Methods. One-year patient and kidney allograft survival rates of 150 patients undergoing SPKT were subjected to Cox regression and Kaplan-Meier analyses. Uni- and multivariate methods identified risk factors involved in allograft and patient survival. Results. One-year patient and kidney allograft survival rates were 82% and 80%, respectively. Delayed graft function (DGF) (P .001; hazard ratio [HR]5.41) and acute kidney rejection episodes (P .016; HR 3.36) were related to 1 year patient survival as well as intra-abdominal infection (IAI) rates. (IAI). One-year kidney allograft survival was related to DGF (P .013; odds ratio [OR] 3.39), acute rejection (P .001; OR 4.74), and IAI (P .003, OR 6.29). DGF was related to a time on dialysis 27 months (P .046; OR 2.59), cold kidney ischemia time 14 hours (P .027; OR 2.94), donor age 25 years (P .03; OR 2.82), and donor serum sodium concentration 155 mEq/L (P .0001; OR 1.09). Female kidney to male recipient in 17% of the cases did not increase the risk of DGF. We observed an important correlation between donor serum sodium and creatinine (P .0001), which suggested undertreatment of diabetes insipidus secondary to brain death. Conclusions. DGF, acute rejection, and IAI were the main determinants of survival after SPKT. Improving the care of deceased donors may reduce DGF occurrence.

Background Diabetes is a disease of increasing worldwide prevalence and is the main cause of chronic renal failure. Type 1 diabetic patients with chronic renal failure have the following therapy options: kidney transplant from a living donor, pancreas after kidney transplant, simultaneous pancreas-kidney transplant, or awaiting a deceased donor kidney transplant. For type 2 diabetic patients, only kidney transplant from deceased or living donors are recommended. Patient survival after kidney transplant has been improving for all age ranges in comparison to the dialysis therapy. The main causes of mortality after transplant are cardiovascular and cerebrovascular events, infections and neoplasias. Five-year patient survival for type 2 diabetic patients is lower than the non-diabetics' because they are older and have higher body mass index on the occasion of the transplant and both pre- and posttransplant cardiovascular diseases prevalences. The increased postransplant cardiovascular mortality in these patients is attributed to the presence of well-known risk factors, such as insulin resistance, higher triglycerides values, lower HDL-cholesterol values, abnormalities in fibrinolysis and coagulation and endothelial dysfunction. In type 1 diabetic patients, simultaneous pancreas-kidney transplant is associated with lower prevalence of vascular diseases, including acute myocardial infarction, stroke and amputation in comparison to isolated kidney transplant and dialysis therapy. Conclusion Type 1 and 2 diabetic patients present higher survival rates after transplant in comparison to the dialysis therapy, although the prevalence of cardiovascular events and infectious complications remain higher than in the general population.

Introduction Adverse gastrointestinal events are frequent after mycophenolate use. The objectives of the present study were to report the incidence of acute noninfectious diarrhea, to determine the risk factors, and to compare the severity of reactions between mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS) after simultaneous pancreas kidney transplantation (SPKT). Methods We included 165 SPKT patients from December 2000 to May 2007. Uni- and multivariate analyses were performed, using acute noninfectious diarrhea as the dependent variable. P Results Mean age and duration of dialysis and of diabetes were 34.9 ± 8.2 years, 27.3 ± 18.3 months, and 21.9 ± 16.2 years, respectively. Sixty-three percent used MMF, 36.4% used EC-MPS, and 0.6% used azathioprine. Multivariate analysis showed that the duration of diabetes ( P = .049, confidence interval [CI] 1.0– 1.13) and MMF use ( P = .013, 95% CI 0.2–0.82) were the main determinants of acute diarrhea after SPKT. MMF dose reduction (79.2% vs 62.3%, P = .024) and severity of diarrhea associated with orthostatic hypotension were more pronounced among MMF than EC-MPS patients (42.4% vs 15.1%, P = .001). There was no difference between MMF and EC-MPS after dose reduction in relation to the occurrence of acute kidney rejection (30.8% vs 26.7%, P = .53). Conclusions Acute noninfectious diarrhea after SPKT was related to the duration of diabetes and to prescription of MMF. Preferential use of EC-MPS was associated with a lower necessity of dose reduction and less severe episodes of acute diarrhea compared with MMF, although dose reduction was equally associated with acute episodes of kidney rejection.

O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica. Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients. Universidade Federal de São Paulo (UNIFESP) Departamento de Medicina Departamento de Cirurgia Pontifícia Universidade Católica do Rio Grande do Sul Hospital São Lucas Serviço de Nefrologia Universidade de São Paulo Núcleo de Terapia Celular e Molecular Sistema de Saúde Centro de Pesquisa Médica Notre-Dame Intermédica USP Faculdade de Medicina Departamento de Clínica Médica Universidade Federal do Rio Grande do Sul Departamento de Medicina Interna Hospital Israelita Albert Einstein Serviço de Transplante de Pâncreas UNIFESP, Depto. de Medicina Depto. de Cirurgia SciELO

In this paper, the authors evaluate if the use of a venous drainage system in the cava vein (instead of the external iliac vein) presents differences in pancreatic transplantation. Between December 2000 and 2004, 105 pancreas-kidney transplants were performed. Patients in group A (n=49) underwent complete liberation of the right iliac vein for venous drainage. In group B (n=56), the venous drainage system was placed in the cava vein or in the confluence. Analyzed clinical parameters included: insulin replacement, vascular thrombosis in the graft, intraabdominal collections, graft loss, reoperation, and deaths. When compared to the external iliac vein, venous drainage to the cava vein did not result in significant differences. Venous drainage to the cava vein is a valuable alternative when the right iliac fossa has been previously approached. It is a practical, rapid procedure and it is not necessary to expose the internal iliac vein.

Background. Belzer solution is considered to be the best preservation media used for pancreas transplantation; however, its high cost accounts for approximately 14.5% of all resources allocated by the Brazilian government toward each pancreatic transplant. The objective of the present study was to test a reduction of Belzer solution during pancreas harvest, thereby lowering procedural cost. Methods. The patients received pancreas-kidney transplantations during the period from January 2003 to August 2004. Patients were divided into two groups. Patients assigned to Group A (n=30) received only Belzer solution (2 L through the aorta artery), whereas patients in Group B (n= 16) were perfused first with 1 L of Eurocollins solution followed by 1 L of Belzer solution. The two groups were assessed for differences in the following clinical parameters: the need for insulin replacement or antifungal and anticytomegalovirus treatment, pancreatitis, acute cellular rejection, graft vascular thrombosis, fistulas, intra-abdominal collection, graft loss, deaths, pancreatic ischemia time, and average hospitalization time. Results. No statistically significant differences were observed in any of the parameters analyzed (P

We sought to determine the risk factors involved in the development of posttransplantation diabetes mellitus (PTDM) following simultaneous pancreas and kidney transplantation. Correlations were sought between tacrolimus (FK-506) levels/dose 2-hour capillary glucose (CG) and glycosylated hemoglobin (HbA1c), cyclosporine (CSA) levels/dose with HbA1c, 2-hour CG with prednisone dose and body mass index (BMI) and PTDM. Four patients (9.3%) developed PTDM. Three treated with FK-506 had altered 2-hour CG at 3 months after transplantation; 1 prescribed CSA displayed diabetes diagnosed after 1 year. There was no statistically significant difference among HbA1c values and FK-506 (P = .18) or CSA (P = .81) doses or FK-506 (P = .53) and CSA (P = .54) levels. In contrast, there was a statistically significant relationship between elevated 2-hour CG (≥200 mg/dL) and daily prednisone dose (9.7 mg vs. 16.2 mg; P = .003). There was no correlation between 2-hour CG and FK-506 dose (P = .084) or FK-506 levels (P = .075). The greater BMI correlated with an increased risk of PTDM (21.25 ± 3.13 kg/m2 vs 24.67 ± 2.38 kg/m2; P = .034). Two-hour CG may be a useful tool to screen the diabetogenic effects of corticosteroids. A BMI increase should be discouraged due to the risk of PTDM.

A neuroartropatia de Charcot foi inicialmente descrita na Tabes Dorsalis, mas ocorre com mais freqüência em pacientes diabéticos. Sua patogênese inclui (a) neuropatia sensorial; perda da sensibilidade levando a micro-fraturas de repetição, (b) neuropatia motora; atrofia e fraqueza muscular que alteram os pontos de pressão nas articulações levando a traumas e úlceras e finalmente (c) neuropatia autonômica; que resultam no aumento do fluxo sanguíneo local com shunts artério-venosos e na reabsorção óssea, o que leva, por sua vez, a luxações, sub-luxações e micro-fraturas.1,2 O evento desencadeante costuma ser traumático, embora nem sempre reportado pelos pacientes, com acometimento geralmente unilateral. Na fase aguda, o pé encontra-se quente e edemaciado, doloroso ou não, podendo apresentar eritema. Na fase crônica, há deformidade do pé associada ao desabamento do arco plantar, calosidades e úlceras. No nosso centro, observamos incidência de 4,6% de neuroartropatia de Charcot de novo no TSPR (mediana: 10 meses), sendo o principal fator de risco a dose cumulativa do corticóide ajustada para o peso nos seis primeiros meses do transplante.3 Relatamos um caso numa paciente de 42 anos com quadro clínico-radiológico após seis meses do TSPR (Figuras 1 e 2). O diagnóstico da neuroartropatia de Charcot é clínico e deve incluir Raio-X (procurar pelas alterações dos “5 D’s”: distensão articular, deslocamento, debris, desorganização e aumento da densidade), cintilografia óssea com tecnécio e/ou ressonância nuclear magnética. O tratamento pode ser clínico (imobilização e medicações que inibem a reabsorção óssea) ou cirúrgico de acordo com a gravidade do quadro1,2,4.

Objective: The purpose of this study was to describe the clinical and microbiological characteristics of the infectious complications among simultaneous pancreas-kidney transplantations (SPKT). Materials and methods. Among the first 45 SPKT the mean age was 34 years (range, 21 to 49) and the mean duration of follow-up 13 months (range, 2 to 27 months). Results: Twenty-three patients (51%) presented at least one to three episodes (1.7 mean) of infectious complications that needed hospitalization. The etiology of the infections included 71% bacterial (44% gram-negative rods and 27% gram-positive cocci), 16% viral (12% from CMV and 4% from Herpes sp) and 13% fungal (8% by Candida sp and 4% by others fungus). Wound and urinary infections were most frequent, occurring in 22% and 28% of the patients, respectively. All patients who were submitted to vesical drainage developed infections in contrast a rate of only 44% among patients undergoing enteric drainage. Conclusion: Infectious complications are the main cause of morbidity and mortality following simultaneous pancreas-kidney transplantation, especially with vesical drainage. The use of enteric drainage combined with administration of broad spectrum prophylactic antibiotics is recommended.