We welcome the comments by Callaghan and colleagues from the Cambridge Transplant Unit (1).Our report on DCD pancreas transplantation in the United Kingdom (2) was based upon information supplied by the centers to the UK Transplant Registry. The assumption stated in our paper of a maximum of 60 min from withdrawal to cardiac arrest reflected a general consensus amongst the centers involved in DCD pancreas transplantation in the United Kingdom and we accept both that this is an arbitrary stipulation and that there were exceptions to this rule.We fully agree that the time from treatment withdrawal to cardiac arrest does not predict the ischemic injury sustained by the organ. Ischemic injury does not (necessarily) start at the time that treatment is withdrawn, but at the point that tissue oxygenation is compromised. The dynamics of circulatory failure are, therefore, of clinical relevance and the concept of "functional warm ischemia" (the time elapsed from a blood pressure of 50 mmHg to cold perfusion) is now accepted as a more useful clinical parameter than the time from cardiac arrest to perfusion.A detailed analysis of the progression of vital signs might provide a more sensitive method by which to assess the degree of damage sustained by a DCD organ. Such a study would require a level of information that has not been collected routinely and would be best performed prospectively. Also, as the Cambridge group point out, even this is likely to provide no more than an approximation.Pending such a study, we commend the pioneering work of Callaghan and colleagues (3) in exploring the boundaries of pancreas utilization in DCD donors.

Thrombosis of the transplanted pancreas is a common and often catastrophic event. Predisposing factors include the hypercoagulable state of many patients with diabetic renal failure, preservation-related graft endothelial injury, and low-velocity venous flow. Clinical management includes optimization of modifiable risk factors, controlled anticoagulation, graft monitoring, and early therapeutic intervention.

Pancreas graft loss due to venous thrombosis is the leading non-immunological cause for graft failure following kidney-pancreas transplantation. Thromboelastography (TEG)-directed anticoagulation protocol has shown that approximately one-third of the patients undergoing pancreas transplantation require therapeutic anticoagulation to prevent the occurrence of graft thrombosis. This article presents the argument for individualised anticoagulation in these patients based on their TEG tracings and suggests the use of TEG in patients undergoing pancreas transplantation.

Implanting a ureteric stent during ureteroneocystostomy reduces the risk of leakage and ureteral stenosis after kidney transplantation (KTx), but it may also predispose to urinary tract infections (UTIs). The aim of this study is to determine the optimal timing for ureteric stent removal after KTx. Searches were performed in EMBASE, MEDLINE Ovid, Cochrane CENTRAL, Web of Science, and Google Scholar (until November 2017). For this systematic review, all aspects of the Cochrane Handbook for Interventional Systematic Reviews were followed and it was written based on the PRISMA-statement. Articles discussing JJ-stents (double-J stents) and their time of removal in relation to outcomes, UTIs, urinary leakage, ureteral stenosis or reintervention were included. One-thousand-and-forty-three articles were identified, of which fourteen articles (three randomised controlled trials, nine retrospective cohort studies, and two prospective cohort studies) were included (describing in total n = 3612 patients). Meta-analysis using random effect models showed a significant reduction of UTIs when stents were removed earlier than three weeks (OR 0.49, CI 95%, 0.33 to 0.75, p = 0.0009). Regarding incidence of urinary leakage, there was no significant difference between early (<3 weeks) and late stent removal (>3 weeks) (OR 0.60, CI 95%, 0.29 to 1.23, p = 0.16). Based on our results, earlier stent removal (<3 weeks) was associated with a decreased incidence of UTIs and did not show a higher incidence of urinary leakage compared to later removal (>3 weeks). We recommend that the routine removal of ureteric stents implanted during KTx should be performed around three weeks post-operatively.