Results of Pancreas Transplantation with Portal Venous and Enteric Drainage

Gaber, A. Osama; Shokouh-Amiri, M H; Hathaway, Donna; Hammontree, Lee N.; Kitabchi, Abbas E.; Gaber, Lillian W.; Saad, Mohammed F.; Britt, L. G.

doi:10.1097/00000658-199506000-00001

Cited by 167 publications

(92 citation statements)

References 24 publications

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“…The results of the present study clearly show that hyperinsulinemia is associated with KPT-S and confirm our previous findings (2) as well as those of others (5,27). The demonstration of higher insulin response to glucose despite a similar C-peptide response, similar immunosuppressive regimen, and similar renal function in KPT-S recipients versus KPT-P recipients supports the concept that the hyperinsulinemia in KPT-S is due to diminished insulin clearance (3) and not simply from compensatory hypersecretion of insulin due to the immunosuppressive drugs and denervation of the pancreas graft (6).…”

Section: Discussionsupporting

confidence: 94%

“…Others (5,(25)(26)(27), as well as our group (2), have shown that this new technique results in fewer postoperative complications and less peripheral hyperinsulinemia compared with the systemic-bladder approach. Because hyperinsulinemia is associated with insulin resistance and perhaps with an increased risk of cardiovascular disease (28,29), and because portal anastomosis of the pancreas graft reestablishes a more physiological state of insulin delivery and normalizes peripheral insulin levels, it has been argued that it may lead to normalization of the metabolic profile of the patients and to a reduction of cardiovascular complications (27). However, the effects of KPT-S versus KPT-P on peripheral and hepatic insulin action as well as on VLDL metabolism have not been previously investigated.…”

mentioning

confidence: 85%

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The Effect of Systemic Versus Portal Insulin Delivery in Pancreas Transplantation on Insulin Action and VLDL Metabolism

Carpentier¹,

Patterson

Uffelman³

et al. 2001

Diabetes

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Combined kidney-pancreas transplantation (KPT) with anastomosis of the pancreatic vein to the systemic circulation (KPT-S) or to the portal circulation (KPT-P) provides a human model in which the chronic effects of portal versus systemic insulin delivery on glucose and VLDL metabolism can be examined. Despite similar plasma glucose and C-peptide levels, KPT-S (n ‫؍‬ 9) had an approximate twofold elevation of fasting and intravenous glucose-stimulated plasma insulin levels compared with both KPT-P (n ‫؍‬ 7) and healthy control subjects (n ‫؍‬ 15). The plasma free fatty acid (FFA) levels were elevated in both transplant groups versus control subjects, but the plasma insulin elevation necessary to lower plasma FFA by 50% was approximately two times higher in KPT-S versus KPT-P and control subjects. Endogenous glucose production was similar in KPT-S and KPT-P, despite ϳ35% higher hepatic insulin levels in the latter, and was suppressed to a greater extent during a euglycemic-hyperinsulinemic clamp in KPT-S versus KPT-P. Total-body glucose utilization during the euglycemic-hyperinsulinemic clamp was ϳ40% lower in KPT-S versus KPT-P, indicating peripheral tissue but not hepatic insulin resistance in KPT-S versus KPT-P. Both transplant groups had an approximate twofold elevation of triglyceride (TG)-rich lipoprotein apolipoprotein B (apoB) and lipids versus control subjects. Elevation of VLDL-apoB and VLDL-TG in both transplant groups was entirely explained by an ϳ50% reduction in clearance of VLDL compared with healthy control subjects. In the presence of increased FFA load but in the absence of hepatic overinsulinization and marked hepatic insulin resistance, there was no elevation of VLDL secretion in KPT-S versus KPT-P and control subjects. These findings suggest that chronic systemic hyperinsulinemia and peripheral tissue insulin resistance with the consequent elevation of plasma FFA flux are insufficient per se to cause VLDL overproduction and that additional factors, such as hepatic hyperinsulinemia and/or gross insulin resistance, may be an essential prerequisite in the pathogenesis of VLDL overproduction in the common form of the insulin resistance syndrome.

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Section: Discussionsupporting

confidence: 94%

mentioning

confidence: 85%

The Effect of Systemic Versus Portal Insulin Delivery in Pancreas Transplantation on Insulin Action and VLDL Metabolism

Carpentier¹,

Patterson

Uffelman³

et al. 2001

Diabetes

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“…Currently, we rarely use open pancreatic biopsy or percu taneouspancreaticbiopsy. Our data and those of Gaber et al [ 11] suggestthat the portalâ€"en teric technique is not associated with signifi cant delay in diagnosis or treatment of rejection and offers significant advantages. For thesereasons, this techniqueis now being eval uated at a number of major transplantcenters, and we believe that this technique will be more widely applied and that radiologists should be come familiar with the radiologic appearance of uncomplicated and complicated pancreatic allograft transplants.…”

Section: Discussionsupporting

confidence: 69%

Imaging of pancreatic transplantation using portal venous and enteric exocrine drainage.

Dachman¹,

Newmark²,

Thistlethwaite³

et al. 1998

American Journal of Roentgenology

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AbrahamH.DaChman1 GeraldineM. Newmark1 J. RichardThistlethwaite,Jr.2 AytekinOto1'3 DavidS. Bruce2 KennethA. Newell2OBJECTIVE. We describethe normalradiologicappearance of pancreatic allografts transplantedusing portal venousdrainagewith enteric drainageof exocrinesecretions. We also describe the radiologic appearanceof postsurgical complications. MATERIALSAND METHODS. Of 56 patients whoreceived pancreatic transplants usingthe portalâ€"enterictechnique, 24 patients subsequently required radiologic examination for sus pected complications involving the pancreatic allograft. Twenty-three patients underwent CT scanning; a total of 58 CT scans were obtained. Nine abdominal sonograms were obtained in five patients, andonepatientunderwentangiography. The radiologicappearance of eachtransplant andthecomplications wereanalyzedretrospectively andcorrelatedwith theclinicalcourse. RESULTS.The mostcommon indications for CT scanning werefever,elevated levelsofserum amylase, and evaluation or follow-up of fluid collections. CT showed the normal and abnormalanatomyof the allograft.Abnormal findingsseenin the 58 CT scansincludedfat stranding (30 scans),ascites(2 1 scans),peripancreatic fluid or pseudocyst( 13 scans),and het erogeneityofthe allograft(five scans). One patienthadpancreaticinfarctionwith pneumatosis and pneumoperitoneum. The allograft was obscured by bowel gas on three sonograms. Four sonograms showed no abnormalities (one Doppler sonogram showed the arterial supply and venous drainage), and one sonogram showed a pseudocyst. In the one patient who underwent angiography, imaging showed no arterial blood flow to the transplant. CONCLUSION. Pancreatic transplantation with portalvenousdrainageand entericdrainageof exocrinesecretionsand the complicationsof suchtransplantation were revealed with CT, sonography, and angiography. Knowledge of normal anatomic configuration will al low proper interpretation of normal and abnormal findings. M ost whole-organ pancreatic trans plantations continue to use the technique first reported by Cony et al. [1] and Nghiem and Cony [2]. With thistechnique, the veins of the pancreatic allograft drain into the systemiccirculation through the externaliliac vein,andthepancreatic exocrine secretions drain into the recipient bladder througha segmentof donor duodenum.Re ported complications of this techniqueinclude dehydrationand acidosis,recurrenturinary tract infections, reflux graft pancreatitis, and hematuria, with the occasional need for con version to enteric drainage [3]. In addition to thesecomplications, systemicvenousdrainage has been reportedto causehyperinsulinemia and peripheral insulin resistance [4â€"7]. In re sponseto experimental evidence of the detri mentaleffectsattributedto systemicdrainage andin anattemptto avoidthesecomplications, described a technique for pancreatic transplantation with portal venousdrainageand entericdrainageof exo crimesecretions. This new techniquehasbeen reportedto decreasethe incidenceof acidosis and dehydrationand to favorably influence lipid profile...

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“…RESEARCH DESIGN AND METHODS -Type 1 diabetic patients (n ϭ 11) after successful combined PKT were matched for age, sex, and BMI with nine healthy control subjects and six nondiabetic patients after successful kidney transplantation (Table 1). Type 1 diabetic patients (duration of type 1 diabetes: 31 Ϯ 2 years) had received a whole pancreas with systemic venous anastomosis to the iliac vein (2.4 Ϯ 0.5 years [range 0.8 -5.2]) before the study (12). By this method of systemic drainage, pancreatic endocrine secretions bypass the physiological first-pass clearance of the liver (9,12,20).…”

mentioning

confidence: 99%

Increased Plasma Amylin in Type 1 Diabetic Patients After Kidney and Pancreas Transplantation

Stadler

Anderwald²,

Karer³

et al. 2006

Diabetes Care

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OBJECTIVE -In response to hyperglycemia, ␤-cells release insulin and C-peptide, as well as islet amyloid pancreatic polypeptide, which is involved in glucose homeostasis. After successful pancreas-kidney transplantation (PKT), type 1 diabetic patients may revert to a nondiabetic metabolism without exogenous insulin therapy and re-secrete all ␤-cell hormones. RESEARCH DESIGN AND METHODS-Using mathematical models, we investigated hormone (amylin, insulin, C-peptide) and metabolite (glucose, free fatty acids) kinetics, ␤-cell sensitivity to glucose, and oral glucose insulin sensitivity index (OGIS) in 11 nondiabetic type 1 diabetic patients after PKT (BMI 25 Ϯ 1 kg/m 2 , 47 Ϯ 2 years of age, 4 women/7 men, glucocorticoid-free), 6 matching nondiabetic patients after kidney transplantation (25 Ϯ 1 kg/m 2 , 50 Ϯ 5 years, 3 women/3 men, on glucocorticoids), and 9 matching nondiabetic control subjects (24 Ϯ 1 kg/m 2 , 47 Ϯ 2 years, 4 women/5 men) during a 3-h 75-g oral glucose tolerance test (OGTT).RESULTS -PKT patients had higher fasting amylin (19 Ϯ 3 vs. control subjects: 7 Ϯ 1 pmol/l) and insulin (20 Ϯ 2 vs. control subjects: 10 Ϯ 1 U/ml; each P Ͻ 0.01) levels. Kidney transplant subjects showed increased OGTT plasma insulin at 90 min and C-peptide levels (each P Ͻ 0.05). In PKT patients, plasma glucose from 90 to 150 min was 9 -31% higher (P Ͻ 0.05 vs. control subjects). Amylin clearance was comparable in all groups. Amylin's plasma concentrations and area under the concentration curve were up to twofold higher in PKT patients during OGTT (P Ͻ 0.05). OGIS was not significantly different between groups. ␤-Cell sensitivity to glucose was reduced in PKT patients (Ϫ64%, P Ͻ 0.009). Fasting plasma amylin was inversely associated with ␤-cell sensitivity to glucose (r ϭ Ϫ0.543, P Ͻ 0.004).CONCLUSIONS -After successful PKT, type 1 diabetic patients with nondiabetic glycemia exhibit increased fasting and post-glucose load plasma amylin, which appears to be linked to impaired ␤-cell function. Thus, higher amylin release in proportion to insulin might also reflect impaired ␤-cell function in type 1 diabetic patients after PKT.

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Results of Pancreas Transplantation with Portal Venous and Enteric Drainage

Cited by 167 publications

References 24 publications

The Effect of Systemic Versus Portal Insulin Delivery in Pancreas Transplantation on Insulin Action and VLDL Metabolism

The Effect of Systemic Versus Portal Insulin Delivery in Pancreas Transplantation on Insulin Action and VLDL Metabolism

Imaging of pancreatic transplantation using portal venous and enteric exocrine drainage.

Increased Plasma Amylin in Type 1 Diabetic Patients After Kidney and Pancreas Transplantation

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