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Simultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal failure due to type 1 diabetes mellitus. With advances in surgical techniques and immunosuppression management, outcomes have improved, with current 1- and 10-year pancreas graft survival rates of 86% and 53%, respectively. Induction therapy with either alemtuzumab or rabbit antithymocyte globulin (rATG) in combination with a calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) or sirolimus appears to be safe and effective in the setting of rapid steroid withdrawal (RSW), with excellent graft survival and low rejection rates. There are no large randomized trials between alemtuzumab and rATG to determine whether one is better than the other. Anti-interleukin (IL)-2 receptor antibody induction and no induction in combination with a CNI, MMF or sirolimus, and prednisone have demonstrated excellent graft survival rates but are associated with a higher incidence of acute rejection. The efficacy of anti-IL-2 receptor antibodies or no induction in the setting of RSW is unproven. Both of the CNIs, ciclosporin and tacrolimus, are effective in preventing acute rejection in SPKT recipients; however, pancreas allograft survival may be better with tacrolimus. MMF is more effective than azathioprine in preventing acute rejection. Sirolimus appears to be effective in preventing acute rejection, but the combination of sirolimus with a CNI may accentuate the nephrotoxicity of the CNI. RSW with induction therapy is safe and effective in SPKT recipients, but longer follow-up data on outcomes are needed. Recent analysis of registry data shows that most transplant centres are using an induction agent followed by a combination of tacrolimus, MMF and corticosteroids in SPKT recipients.

Although it is well established that acute rejection is one of the major risk factors for chronic graft loss following kidney transplantation, its effect on long-term graft survival following simultaneous kidney-pancreas transplants (SKPTs) is less well known. We analyzed a large cohort of SKPTs and cadaver kidney transplants reported to the United Network for Organ Sharing database during 1988-97, to determine the impact of acute rejection episodes on long-term kidney and pancreas graft survival. Only patients whose kidney and pancreas grafts had survived for at least 1 year were included. Other potential risk factors influencing long-term graft survival were included in the analysis. Of the 4251 SKPTs, 45% had no acute rejection, 36% had kidney only rejection, 3% had pancreas only rejection, and 16% had both kidney and pancreas rejection within the 1st year post transplant. The 5-year kidney and pancreas graft survival rates adjusted for other risk factors were 91% and 85%, respectively; for those with no acute rejection episodes, 88% and 84%, respectively; for those with kidney only rejection, 94% and 83%, respectively; for those with pancreas only rejection; and 86% and 78%, respectively, for those with both kidney and pancreas rejection. The relative risk (RR) of kidney graft failure was 1.32 when acute rejection involved the kidney graft only, while the RR was 1.53 when the rejection involved both organs. We conclude that acute rejection episodes have a negative impact on the long-term kidney graft survival in the SKPT population similar to that in the cadaver kidney transplant population. Patients who had acute rejection episodes of both kidney and pancreas have the worst long-term graft survival.

Background: Experience with organ transplantation in patients with indolent lymphoma is limited, and it is unknown how the natural history of the disease is altered by chronic immunosuppressive therapy., Methods: A patient with type 1 diabetes and renal failure who underwent simultaneous kidney-pancreas transplantation was found to have stage IV small lymphocytic lymphoma at the time of transplantation. He received quadruple immunosuppressive therapy using interleukin (IL)-2 receptor antibody, tacrolimus, mycophenolate mofetil, and prednisone., Results: Patient is doing well 3 years posttransplant with excellent graft function of both the kidney and pancreas without any evidence of progression of the disease., Conclusion: Indolent lymphoma should not be considered an absolute contraindication to organ transplantation.

Background: Pancreas transplantation improves quality of life and prevents the progression of secondary complications of diabetes. Whether these benefits translate into a long-term survival advantage is not entirely clear., Methods: Using the United Network for Organ Sharing database, we analyzed long-term survival in 18,549 patients with type 1 diabetes and renal failure who received a kidney transplant between 1987 and 1996. Patient survival was calculated using the Kaplan-Meier method. Proportional hazards models were used to adjust for effects of differences in recipient and donor variables between simultaneous kidney-pancreas transplants (SKPTs) and kidney-alone transplants., Results: SKPT and living donor kidney recipients had a significant crude survival distribution advantage over cadaver kidney transplant recipients (8-year survival rates: 72% for SKPT recipients, 72% for living donor kidney recipients, and 55% for cadaver kidney recipients). The survival advantage for SKPT recipients over cadaver kidney recipients diminished, but persisted after adjusting for donor and recipient variables and kidney graft function as time-varying covariates. SKPT recipients had a high mortality risk relative to living donor kidney recipients through 18 months posttransplantation (hazards ratio, 2.2; P < 0.001), but had a lower relative risk (hazard ratio, 0.86; P < 0.02) thereafter. In SKPT recipients, maintenance of a functioning pancreas graft was associated with a survival benefit., Conclusion: The long-term survival of SKPT recipients is superior to that of cadaver kidney transplant recipients with type 1 diabetes. There is no difference in survival of SKPT recipients and living donor kidney recipients with type 1 diabetes at up to 8 years' follow-up; the former have a greater early mortality risk and the latter have a greater late mortality risk. Results of this study suggest that successful simultaneous kidney-pancreas transplantation is not only life enhancing, but life saving., (Copyright 2003 by the National Kidney Foundation, Inc.)

Background: Laparoscopic live donor nephrectomy is becoming increasingly popular as it has been shown to minimize donor morbidity, length of hospital stay and length of time to return to work. Initial experience suggested that kidneys procured laparoscopically had higher rates of delayed graft function and ureteric complications but with increasing experience, these complications have become less common., Methods: Retrospective chart review of all patients who underwent living donor kidney transplant using kidneys procured laparoscopically at our centre was performed. From the initiation of the laparoscopic donor nephrectomy programme at our institution in November 1998 until February 2002, we performed 71 living donor kidney transplants (69 kidneys procured laparoscopically and two procured by open donor nephrectomy after failed laparoscopic approach). Donor left kidney was used in all except in one patient. Mean duration of warm ischaemia time was 206 +/- 79 s., Results: The mean age of the recipients was 42 +/- 15 years (range 1-68) including five paediatric recipients (age < 18 years). There were 48 males and 23 females. Nine (13%) were retransplants (seven second transplants and one each of third and fourth transplants). Two patients died with functioning grafts and four patients lost the graft (three thrombosis, one anastomotic rupture). No patient developed ureteric complications. The incidence of delayed graft function (need for dialysis in the first week post-transplant) was 4%. Patient and graft survival rates (actual) were 97% and 91%, respectively. Mean length of hospital stay was 9 +/- 7 days (median 7 days)., Conclusions: Recipient outcome is not compromised and excellent results can be achieved with living donor kidney transplantation using laparoscopically procured kidneys.

Faced with an extreme shortage of organs transplant professionals continue to explore various strategies to expand the donor pool. Transplantation of kidneys from older and very young donors are two such options. Although kidneys from young donors (less than 5 years of age) have been associated with a high rate of technical complications and suboptimal results, use of these kidneys en bloc has been advocated to improve the outcomes. We reviewed our experience with en bloc kidney transplantation at the University of Kentucky over the past 10 years. Between 1991 and 2000 ten patients underwent kidney transplantation using kidneys en bloc from donors <5 years age. The mean age of the donors was 2.8 years with a mean weight of 16 kg (range 13-21). Mean age of the recipients was 42 years. One patient lost the graft on day one from venous thrombosis. One patient lost the graft 7 years post-transplant from chronic rejection. All of the remaining patients are doing well with functioning grafts (mean follow-up 4.5 years; range 6 months to 10 years). Both one-year and five-year graft survival rates are 89 per cent. The present study confirms that excellent results can be achieved with kidney transplantation using kidney transplantation using kidneys en bloc from donors younger than 5 years of age.

Potential donors with congenital renal anomalies but normal renal function are often overlooked because of a possible increase in technical difficulty and complications associated with the surgery. However, as the waiting list for a deceased donor kidney transplant continues to grow, it is important to consider these kidneys for potential transplant. This paper describes the procurement of a crossed fused ectopic kidney, and subsequent parenchymal transection prior to transplantation as part of a combined simultaneous kidney pancreas transplant. The transplant was uncomplicated, and the graft had immediate function. The patient is now two years from transplant with excellent function. [ABSTRACT FROM AUTHOR]

Background. Enteric drainage (ED) is associated with reduced morbidity compared with bladder drainage (BD) after simultaneous kidney–pancreas transplantation (SKPT) and is becoming increasingly common (more than 50% of SKPTs done in the US in 1998 were performed with enteric drainage). Although several studies have reported the morbidity and graft survival of ED compared with BD previously, there are limited data available comparing the length of stay and hospital charges between these two drainage procedures. Methods. Fourteen SKPTs were performed during the period January 1995–May 1998 using BD and 20 during June 1998–August 1999 using ED. Hospital charges analyzed included the following categories: pharmacy, inpatient room, laboratory, operating room, medical–surgical supply, radiology/nuclear medicine, and miscellaneous. Organ acquisition charges and professional fees were not included in this analysis. Results. The mean hospital stay for patients with ED was 7.8±2.2 d (range 5–12 d; median 7.5 d) compared with 15.9±7 d (range 8–38 d; median 15 d) for patients with BD (p=0.002). The mean hospital charges during initial hospitalization for the ED group were $36 582±11 424 compared with $64 555±29 054 for the BD group (p=0.005). There was a significant decrease in the charges relating to pharmacy, inpatient room, laboratory, radiology/nuclear medicine, and miscellaneous category in the ED group compared with the BD group, while the charges relating to operating room and medical–surgical supply were no different between the two groups. One-year actuarial kidney and pancreas graft survival rates were 83% and 93%, respectively, for the BD group and 90% and 80%, respectively, for the ED group (p=NS). Conclusions. SKPT patients with ED had a 43% reduction in hospital charges and equivalent pancreas and kidney graft survival rates compared with SKPT patients with BD. A shorter hospital stay a... [ABSTRACT FROM AUTHOR]