Rogers Jeffrey, Farney Alan C, Orlando Giuseppe, Iskandar Samy S, Doares William, Gautreaux Michael D, Kaczmorski Scott, Reeves-Daniel Amber, Palanisamy Amudha, Stratta Robert J
Jeffrey Rogers, Alan C Farney, Giuseppe Orlando, Michael D Gautreaux, Robert J Stratta, Department of General Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC 27157, United States.
World J Diabetes. 2014 Dec 15;5(6):951-61. doi: 10.4239/wjd.v5.i6.951.
To investigate the Wake Forest experience with pancreas transplantation in the new millennium with attention to surgical techniques and immunosuppression.
A monocentric, retrospective review of outcomes in simultaneous kidney-pancreas transplant (SKPT) and solitary pancreas transplant (SPT) recipients was performed. All patients underwent pancreas transplantation as intent-to-treat with portal venous and enteric exocrine drainage and received depleting antibody induction; maintenance therapy included tapered steroids or early steroid elimination with mycophenolate and tacrolimus. Recipient selection was based on clinical judgment whether or not the patient exhibited measureable levels of C-peptide.
Over an 11.25 year period, 202 pancreas transplants were performed in 192 patients including 162 SKPTs and 40 SPTs. A total of 186 (92%) were primary and 16 (8%) pancreas retransplants; portal-enteric drainage was performed in 179 cases. A total of 39 pancreas transplants were performed in African American (AA) patients; of the 162 SKPTs, 30 were performed in patients with pretransplant C-peptide levels > 2.0 ng/mL. In addition, from 2005-2008, 46 SKPT patients were enrolled in a prospective study of single dose alemtuzumab vs 3-5 doses of rabbit anti-thymocyte globulin induction therapy. With a mean follow-up of 5.7 in SKPT vs 7.7 years in SPT recipients, overall patient (86% SKPT vs 87% SPT) and kidney (74% SKPT vs 80% SPT) graft survival rates as well as insulin-free rates (both 65%) were similar (P = NS). Although mortality rates were nearly identical in SKPT compared to SPT recipients, patterns and timing of death were different as no early mortality occurred in SPT recipients whereas the rates of mortality following SKPT were 4%, 9% and 12%, at 1-, 3- and 5-years follow-up, respectively (P < 0.05). The primary cause of graft loss in SKPT recipients was death with a functioning graft whereas the major cause of graft loss following SPT was acute and chronic rejection. The overall incidence of acute rejection was 29% in SKPT and 27.5% in SPT recipients (P = NS). Lower rates of acute rejection and major infection were evidenced in SKPT patients receiving alemtuzumab induction therapy. Comparable kidney and pancreas graft survival rates were observed in AA and non-AA recipients despite a higher prevalence of a "type 2 diabetes" phenotype in AA. Results comparable to those achieved in insulinopenic diabetics were found in the transplantation of type 2 diabetics with detectable C-peptide levels.
In the new millennium, acceptable medium-term outcomes can be achieved in SKPT and SPTs as nearly 2/3rds of patients are insulin independent following pancreas transplantation.
探讨新千年维克森林大学胰腺移植的经验，重点关注手术技术和免疫抑制情况。
对同期肾胰腺移植（SKPT）和单独胰腺移植（SPT）受者的结局进行单中心回顾性研究。所有患者均接受意向性胰腺移植，采用门静脉和肠道外分泌引流，并接受清除性抗体诱导治疗；维持治疗包括逐渐减量的类固醇或早期停用类固醇并联合霉酚酸酯和他克莫司。受者选择基于临床判断，即患者是否表现出可测量的C肽水平。
在11.25年期间，对192例患者进行了202例胰腺移植，其中包括162例SKPT和40例SPT。共有186例（92%）为初次移植，16例（8%）为胰腺再次移植；179例采用门静脉-肠道引流。共有39例胰腺移植在非裔美国（AA）患者中进行；在162例SKPT中，30例在移植前C肽水平>2.0 ng/mL的患者中进行。此外，2005年至2008年，46例SKPT患者参加了一项关于单剂量阿仑单抗与3 - 5剂量兔抗胸腺细胞球蛋白诱导治疗的前瞻性研究。SKPT受者的平均随访时间为5.7年，SPT受者为7.7年，总体患者（SKPT为86%，SPT为87%）和肾脏（SKPT为74%，SPT为80%）移植存活率以及无胰岛素率（均为65%）相似（P =无显著性差异）。虽然SKPT受者的死亡率与SPT受者几乎相同，但死亡模式和时间不同，因为SPT受者未发生早期死亡，而SKPT后的死亡率在1年、3年和5年随访时分别为4%、9%和12%（P < 0.05）。SKPT受者移植失败的主要原因是移植肾功能正常时死亡，而SPT后移植失败的主要原因是急性和慢性排斥反应。SKPT受者急性排斥反应的总体发生率为29%，SPT受者为27.5%（P =无显著性差异）。接受阿仑单抗诱导治疗的SKPT患者急性排斥反应和严重感染的发生率较低。尽管AA患者中“2型糖尿病”表型的患病率较高，但AA和非AA受者的肾脏和胰腺移植存活率相当。在C肽水平可检测的2型糖尿病患者的移植中，发现了与胰岛素缺乏型糖尿病患者相似的结果。
在新千年，SKPT和SPT可取得可接受的中期结局，因为近三分之二的患者在胰腺移植后无需使用胰岛素。
