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Pancreas-kidney transplantation in DM

Pancreas-kidney Tx combination is now stabilized therapy for selected diabetics with ESRD. Pancreas Tx is performed as SPK transplants (most commonly

 

Pancreas-kidney transplantation in DM: Surgical insights & immunosuppression

 


Abbreviations:

o   AB: Antibody.

o   Alm: Alemtuzumab.

o   Aza: azathioprine

o   CNI: calcineurin inhibitors

o   CyA: Cyclosporine.

o   EC-MPS: enteric-coated mycophenolate sodium.

o   ESRD: end-stage renal disease.

o   GC: Glucocorticoids.

o   IL2: interleukin-2

o   IM/M: Immunosuppression.

o   IVC: inferior vena cava.

o   MMF: mycophenolate mofetil.

o   PAK: pancreas after kidney.

o   Prd: Prednisone.

o   PTAs: pancreas transplants alone. 

o   rATG: rabbit Antithymocyte globulin.

o   SPK: simultaneous pancreas-kidney.

o   Tac:  Tacrolimus 

o   TR: Transplant recipients

o   Tx: Transplant.

o   TG: Thymoglobulin.

 

Pancreas-kidney Tx combination is now stabilized therapy for selected diabetics with ESRD. Pancreas Tx is performed as SPK transplants (most commonly applied), sequential PAK Tx, or pancreas transplants alone (PTAs). In the US, the most commonly applied technique for SPK Tx is consisting of placing both organs intra-peritoneal via a vertical midline surgical incision. Transplant centers may differ regarding to either contralateral or ipsilateral placement of these organs as well as the surgical therapeutic approach of the exocrine pancreas secretory & the venous outflow. Pancreas Tx are mostly placed on the Rt. side & performed via enteric exocrine drainage (≥ 90 %) & systemic venous drainage (i.e., from the graft portal vein either to the Rt iliac vein or distal IVC). 

 

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IM/M IS usually consisting of induction + maintenance therapy.  Ptns receiving either an SPK or PAK Tx, we recommend induction therapy consisting of an AB + standard triple im/m. therapy. In TR of an SPK or PAK Tx, we suggest providing  T cell-depleting medication (either rATG-Thymoglobulin or Alm) rather than a non-depleting IL-2 receptor antagonist:

o   If rATG is given, we start intraoperative IV rATG-Thymoglobulin as 1-1.5 mg/kg. The intraoperative starting dosing of rATG is followed by 1.5- 2 mg/kg of rATG /d. for the next 2-3 days reaching a total cumulative induction dose of 4.5-6 mg/kg. rATG is given if, at presentation, the WBCs is > 2000/microL & the platelet count is > 75,000/ microL. If rATG cannot be given, we give Alm.

o   Alm is given as single IV or SQ dose of 30 mg at the timing of Tx.

In ptns receiving either an SPK Tx, we give a maintenance im/m protocol that consists of triple im/m therapy with a CNI + antimetabolite + tapering GC:

o   With CNI, we suggest Tac rather than CyA. 

o   For antimetabolites, we suggest MMF (MMF or EC-MPS) rather than Aza. 

o   Majority of ptns can start GC, oral Prd tapered to 5 mg/d by 1-2 mo after Tx.  

At timing of pancreas Tx, most TR of a PAK Tx are maintained on im/m to guard against rejection of the kidney allograft. If the ptn is already on a triple im/m protocol that consists of  Tac + MMF or EC-MPS +  Prd, we should not modify the maintenance plan if kidney graft function is stabilized and the ptn is tolerating the maintenance protocol with no or little significant untoward effects. However, considering the observed high immunogenicity of the Tx pancreas, many ptns may necessitate some modification of their maintenance protocol that augmenting im/m after pancreas Tx.

 

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Pancreas-kidney transplantation in DM
Pancreas-kidney Tx combination is now stabilized therapy for selected diabetics with ESRD. Pancreas Tx is performed as SPK transplants (most commonly
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