Prevention of Bleeding After Islet Transplantation: Lessons Learned from a Multivariate Analysis of 132 Cases at a Single Institution

Abstract

Islet transplantation is being offered increasingly for selected patients with unstable type 1 diabetes. Percutaneous transhepatic portal access avoids a need for surgery, but is associated with potential risk of bleeding. Between 1999 and 2005, we performed 132 percutaneous transhepatic islet transplants in 67 patients. We encountered bleeding in 18/132 cases (13.6%). In univariate analysis, the risk of bleeding in the absence of effective track ablation was associated with an increasing number of procedures (2nd and 3rd procedures with an odds ratio (OR) of 9.5 and 20.9, respectively), platelets count <150 000 (OR 4.4), elevated portal pressure (OR 1.1 per mm Hg rise), heparin dose ≥45 U/kg (OR 9.8) and pre-transplant aspirin (81 mg per day) (OR 2.6, p = 0.05). A multivariate analysis further confirmed the cumulative transplant procedure number (p < 0.001) and heparin dose ≥45 U/kg (p = 0.02) as independent risk factors for bleeding. Effective mechanical sealing of the intrahepatic portal catheter tract with thrombostatic coils and tissue fibrin glue completely prevented bleeding in all subsequent procedures (n = 26, p = 0.02). We conclude that bleeding after percutaneous islet implantation is an avoidable complication provided the intraparenchymal liver tract is sealed effectively.

Thrombin-Activatable Fibrinolysis Inhibitor Is Activated in an Instant Blood-Mediated Inflammatory Reaction After Intraportal Islet Transplant

“…3,[16][17][18] However, it is difficult to apply these anticoagulants in the clinical environment because systemic administration is associated with an increased risk of severe bleeding. 19 Therefore, there is an urgent need to explore new therapeutic target for treating IBMIR with fewer bleeding complications. The present study shows that TAFI is activated and accumulated during the first hour after islet infusion, indicating that TAFIa is sufficient to affect fibrinolysis in IBMIR.…”

Tissue Factor Knockdown in Porcine Islets: An Effective Approach to Suppressing the Instant Blood-Mediated Inflammatory Reaction

“…Thus, it is our hypothesis that the development complement, and suppressed neutrophil infiltration. In (38). Several other strategies to prevent or suppress IBMIR have been investigated.…”

Trying to Prevent the Clogged Drain: Optimizing the Yield and Function of Portal Vein-Infused Islets

“…They also further investigated whether partial portal thrombosis was associated with detrimental loss of islet functional reserve. The incidence of portal thrombosis was low (3.2 %); despite partial portal thrombosis there was no detectable loss of islet graft function as measured by the SUITO index or insulin requirements [13,14]. Furthermore, Bucher et al [15] reported no association between portal thrombosis and increased IP pressure in islet autograft and allogeneic transplants when they limited the tissue volume infused to a mean of 13 cc [15].…”