Pancreas-Kidney Transplantation: Complications and Readmissions in 9-Years of Follow-up

Abstract

Over 9 years, we have performed 93 simultaneous pancreas-kidney transplants (SPKT). The morbidity of this procedure is high compared with kidney transplantation alone; readmissions are frequent and costs are higher. Herein we have presented the complications during follow-up of these 93 patients. Their mean age was 34 Ϯ 6 years and prior dialysis time was 32 Ϯ 25 months. The median hospital stay on the first admission for the transplant procedure was 22 days, including 2 days in the intensive care unit. Bleeding, thrombosis, and infection were the most frequent reasons for prolonged hospitalization. Thirty patients underwent Ն1 surgical reinterventions. Incidence of acute rejection episodes was 11.8%. After discharge, 74.2% of the patients had 197 readmission episodes with infection being the main cause, urinary tract infections, the most frequent; however, systemic viral and fungal infections required the longest readmission periods. The need for surgical interventions, graft dysfunction, and vascular problems were the remaining causes of readmission. At the end of follow-up, 87 patients were alive, 86 with well-functioning kidneys and 74 with normal functioning pancreata. Global survival rates for patient, kidney, and pancreas were 96%, 95%, and 81% at 1-year; 93%, 90%, and 79% at 5-years; and 93%, 90% and 79% at 9-years. Although pancreas-kidney transplant patients are complex presenting many management difficulties, our overall results represent a positive stimulus for diabetic patients. S imultaneous pancreas-kidney transplantation (SPKT)display greater morbidity, length of admission, and number of complications when compared to kidney transplantation alone (KTA), leading to higher costs. However, SPKT remains the best treatment option for good longterm results among type 1 diabetic patients with chronic kidney failure. A recently published review of 1000 SPKT from a single center 1 reinforced this position statement of the American Diabetes Association. We have presented herein the results of our SPKT program, including the rate and type of complications, causes of surgical reinterventions, and readmission episodes after the initial discharge. PATIENTS AND METHODSFrom May 2000 to May 2009, we performed 93 SPKT always using enteric diversion and vascular anastomoses to the systemic circulation. Immunosuppression included antithymocyte globulin (ATG) tacrolimus, mycophenolate mofetil (MMF), and steroids. After the 6th month, it was our policy to progressively taper steroids to complete withdrawal whenever possible. Infection prophylaxis comprised vancomycin, fluconazole, and a third-generation cephalosporin in the first days, with contrimoxazole and valgancyclovir thereafter. We also prescribed aspirin and low-molecularweight heparin as soon as possible after surgery, if there were no bleeding complications. RESULTSThe mean age of the 93 patients was 34 Ϯ 6 years with a 23 Ϯ 5.5 years, duration of diabetes. They had been on dialysis for 32 Ϯ 25 months excepting 4 who were grafted preemptively. Twenty...

Early Hospital Readmission After Simultaneous Pancreas–Kidney Transplantation: Patient and Center-Level Factors

“…Existing long-term sequelae of diabetes, such as gastroparesis, neurogenic bladder, and autonomic neuropathy, can compound complications posttransplant (23)(24)(25). Given the high risk of perioperative complications, SPK recipients, on average, remain in the hospital longer than their KTA counterparts and have a higher risk of perioperative mortality (16,17,(24)(25)(26). We hypothesize that the high-risk perioperative period following SPK is associated with increased EHR.…”

Risk factors for intra‐abdominal fungal infection after simultaneous pancreas‐kidney transplantation: A single‐center retrospective experience

“…When IAFI occurred in simultaneous PKT, it had a toll on our patients where all underwent surgical re‐intervention and 86% of them lost their pancreatic graft function; an appalling result compared with the previously reported pancreatic graft survival rate reaching 81% to 89% 26,27 . However, post‐PKT IFI had already been associated with an 8.4‐fold higher risk of pancreatic graft dysfunction 3 …”

“…Treatment of intra‐abdominal candidiasis should also include source control with appropriate drainage and/or debridement. Shortening the time interval between the onset of IAFI and that of the treatment might improve the prognosis of patients 26,27 . Starting a pre‐emptive antifungal treatment with echinocandin i) in patients with positive PF cultures, even though they have no clinical symptoms of infection; and ii) in PKT patients with clinical evidence of intra‐abdominal infection, before having the result of mycological samples, may also limit the risk of graft loss and of complications, as recommended in 2019 25 .…”

Late recurrent bleeding episodes from duodenojejunostomy after pancreas transplantation

“…Due to the fact that follow‐up visits are not solely performed at a single center, these data likely underestimate the occurrence of late complications. Late bleeding episodes are mainly caused by the herein described late hemorrhage from the enteric graft site, by fistulae (arterioenteric, arterioureteric, arteriocystic, or arteriovenous), pseudoaneurysms, rejection, or invasive infections …”