COMMENTARY Commentary on “Utilization of Small Pediatric Donors Including Infants for Pancreas and Kidney Transplantation”
I
read with interest and congratulate Biglarnia and colleagues1 on their study, “Utilization of Small Pediatric Donors Including Infants for Pancreas and Kidney Transplantation,” in this issue of Annals of Surgery. This study details the use of 4 hemodynamically stable, functional normal, carefully procured, brain-dead pediatric donor pancreata [15 kg/pancreas + single kidney; 10 kg/pancreas alone; two 4 kg/en bloc pancreas (P) + kidneys (K)] transplanted into 4 adults with type 1 diabetes mellitus with body mass index of 25 or less, tightly controlled blood pressure, and 2 weeks of continuous venous hemodialysis immediate posttransplant in the 2 en bloc P/K recipients. The en bloc P + K technique is concisely annotated with a nice illustration and is a modification of a technique described previously by Buggenhout et al.2 This small series importantly documents durable, extrinsic, insulin-free glucose control and a radiological volume timeline of pancreas hypertrophy/growth in 3 of the 4 recipients surviving more than 40 days.1 Pediatric pancreata for the use in adult recipients represent an underutilized organ source. The authors estimate that their 4 pancreatic cases represent 10% of the potential transplantable pediatric pancreata, from review of Scandia transplant data from 2000 to 2011.3 The important variables to expand this donor pool for successful use of pediatric pancreata illustrated in this series of 4 case studies are supported in the single and en bloc kidney from pediatric donors weighing less than 10 kg to adult transplant experience.4,5 First, meticulous donor and recipient surgical selection and technique, to prevent vascular kinking and torsion, can eliminate early technical allograft loss and late vascular stenosis.5 Donor cold ischemia time of more than 24 hours is associated with increased venous thrombosis in pediatric en bloc kidneys,6
and the cold ischemia times of the 4 pediatric pancreata and pediatric kidneys in the article of Biglarnia and colleagues were 19 hours or less. Arterial stenosis in pediatric en bloc kidneys is associated with early, severe, acute cellular rejection, and induction immunosuppression is recommended for prevention.5,7 Thymoglobulin induction with triple-drug immunosuppression maintenance was used judiciously in this series of 4 case studies. Biglarnia and colleagues used dextran 70, enoxaparin, and acetyl salicylic acid perioperatively with a surgical bleed and a duodenojejunostomy leak from 1 en bloc P/K recipient. This aggressive anticoagulation may be justifiable to prevent thrombosis of the pancreas allograft, but it has not been shown to be necessary for thrombosis prevention (acute or chronic) in the en bloc kidney from donors weighing less than 10 kg to adult recipient transplant experience.5,8 Biglarnia and colleagues carefully selected diabetic recipients without hypercoagulable states and in whom hypertension was not a problem to maintain meticulous arterial blood pressure control early posttransplant. These recipient selection characteristics did not include rigorous coronary evaluation with cardiac catheterization to treat or exclude recipients with a risk of coronary artery plaque rupture5 that might have prevented the 1 death at 47 days, in this report, due to unrecognized diabetic coronary angiopathy and myocardial infarction. The present case review recipients had body mass index of 25 or less, and a review of the Scientific Registry of Transplant Recipients database found that single kidneys from pediatric donors weighing less than 20 kg had significantly higher glomerular filtration rates when transplanted into recipients with a body mass index of less than 24.9 Preservation and long-term adequacy of nephron mass in en bloc kidneys from pediatric donors weighing less than 10 kg transplanted into adult recipients, with the 5-year allograft survival and glomerular filtration rates comparable or better than living donor adult to adult kidney transplantation, without 2 weeks of continuous venous hemodialysis are reported.4,5 This use of continuous venous hemodialysis may be a center-specific practice, of uncertain significance, to achieve the rigorous metabolic and fluid and electrolyte control that would not be cost-effective or
conducive to expansion of this donor pool utilization in experienced transplant practice. In conclusion, this small case report serves as an early proof of concept of safe and feasible utilization of pancreas and kidneys from pediatric donors weighing 4 to 15 kg for transplantation into adult type 1 diabetic recipients to achieve durable and normal glycemic and renal function. The study provides technical, selection, and management methods/results that can be both supported and tested for future clinical transplant expansion. Robert A. Fisher, MD Department of Surgery, Transplant Surgery Division, Virginia Commonwealth University, MCV Campus, Richmond, VA [email protected]
REFERENCES 1. Biglarnia AR, et al. Utilization of small pediatric donors including infants for pancreas and kidney transplantation: exemplification of the surgical technique and the surveillance. Ann Surg. 2014;260: e5–e7. 2. Buggenhout A, Hoang AD, Hut F, et al. Pediatric en bloc dual kidney pancreas transplantation into an adult recipient: a simplified technique. Benefits of the en bloc kidney-pancreas transplantation technique in pediatric donors. Am J Transplant. 2004;4:663–665. 3. Scandia Transplant. Available at: http://www. scandiatransplant.org. Accessed March 26, 2014. 4. Sharma A, Ramanathan R, Behnke M, et al. Single pediatric kidney transplantation in adult recipients: comparable outcomes with standard-criteria deceased-donor kidney transplantation. Transplantation. 2013;95:1354–1359. 5. Sharma A, Fisher RA, Cotterell AH, et al. En bloc kidney transplantation from pediatric donors: comparable outcomes with living donor kidney transplantation. Transplantation. 2011;92: 564–569. 6. Burrows L, Knight R, Polokoff E, et al. Expanding the donor pool with the use of en bloc pediatric kidneys in adult recipients. Transplant Proc. 1996;28:173–174. 7. Merkel FK, Matalon TA, Brunner MC, et al. Shortand long-term results with en bloc transplantation of pediatric kidneys into adults. Transplant Proc. 1993;25:2167–2169. 8. Sanchez-Fructuoso AI, Prats D, Perez-Contin MJ, et al. Increasing the donor pool using en bloc pediatric kidneys for transplant. Transplantation. 2003;76:1180–1184. 9. Kayler LK, Zendejas I, Gregg A, et al. Kidney transplantation from small pediatric donors: does recipient body mass index matter? Transplantation. 2012;93:430–460.
Disclosure: The author declares no conflicts of interest. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-e0008 DOI: 10.1097/SLA.0000000000000752
e8 | www.annalsofsurgery.com
Annals of Surgery r Volume 260, Number 2, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
I
read with interest and congratulate Biglarnia and colleagues1 on their study, “Utilization of Small Pediatric Donors Including Infants for Pancreas and Kidney Transplantation,” in this issue of Annals of Surgery. This study details the use of 4 hemodynamically stable, functional normal, carefully procured, brain-dead pediatric donor pancreata [15 kg/pancreas + single kidney; 10 kg/pancreas alone; two 4 kg/en bloc pancreas (P) + kidneys (K)] transplanted into 4 adults with type 1 diabetes mellitus with body mass index of 25 or less, tightly controlled blood pressure, and 2 weeks of continuous venous hemodialysis immediate posttransplant in the 2 en bloc P/K recipients. The en bloc P + K technique is concisely annotated with a nice illustration and is a modification of a technique described previously by Buggenhout et al.2 This small series importantly documents durable, extrinsic, insulin-free glucose control and a radiological volume timeline of pancreas hypertrophy/growth in 3 of the 4 recipients surviving more than 40 days.1 Pediatric pancreata for the use in adult recipients represent an underutilized organ source. The authors estimate that their 4 pancreatic cases represent 10% of the potential transplantable pediatric pancreata, from review of Scandia transplant data from 2000 to 2011.3 The important variables to expand this donor pool for successful use of pediatric pancreata illustrated in this series of 4 case studies are supported in the single and en bloc kidney from pediatric donors weighing less than 10 kg to adult transplant experience.4,5 First, meticulous donor and recipient surgical selection and technique, to prevent vascular kinking and torsion, can eliminate early technical allograft loss and late vascular stenosis.5 Donor cold ischemia time of more than 24 hours is associated with increased venous thrombosis in pediatric en bloc kidneys,6
and the cold ischemia times of the 4 pediatric pancreata and pediatric kidneys in the article of Biglarnia and colleagues were 19 hours or less. Arterial stenosis in pediatric en bloc kidneys is associated with early, severe, acute cellular rejection, and induction immunosuppression is recommended for prevention.5,7 Thymoglobulin induction with triple-drug immunosuppression maintenance was used judiciously in this series of 4 case studies. Biglarnia and colleagues used dextran 70, enoxaparin, and acetyl salicylic acid perioperatively with a surgical bleed and a duodenojejunostomy leak from 1 en bloc P/K recipient. This aggressive anticoagulation may be justifiable to prevent thrombosis of the pancreas allograft, but it has not been shown to be necessary for thrombosis prevention (acute or chronic) in the en bloc kidney from donors weighing less than 10 kg to adult recipient transplant experience.5,8 Biglarnia and colleagues carefully selected diabetic recipients without hypercoagulable states and in whom hypertension was not a problem to maintain meticulous arterial blood pressure control early posttransplant. These recipient selection characteristics did not include rigorous coronary evaluation with cardiac catheterization to treat or exclude recipients with a risk of coronary artery plaque rupture5 that might have prevented the 1 death at 47 days, in this report, due to unrecognized diabetic coronary angiopathy and myocardial infarction. The present case review recipients had body mass index of 25 or less, and a review of the Scientific Registry of Transplant Recipients database found that single kidneys from pediatric donors weighing less than 20 kg had significantly higher glomerular filtration rates when transplanted into recipients with a body mass index of less than 24.9 Preservation and long-term adequacy of nephron mass in en bloc kidneys from pediatric donors weighing less than 10 kg transplanted into adult recipients, with the 5-year allograft survival and glomerular filtration rates comparable or better than living donor adult to adult kidney transplantation, without 2 weeks of continuous venous hemodialysis are reported.4,5 This use of continuous venous hemodialysis may be a center-specific practice, of uncertain significance, to achieve the rigorous metabolic and fluid and electrolyte control that would not be cost-effective or
conducive to expansion of this donor pool utilization in experienced transplant practice. In conclusion, this small case report serves as an early proof of concept of safe and feasible utilization of pancreas and kidneys from pediatric donors weighing 4 to 15 kg for transplantation into adult type 1 diabetic recipients to achieve durable and normal glycemic and renal function. The study provides technical, selection, and management methods/results that can be both supported and tested for future clinical transplant expansion. Robert A. Fisher, MD Department of Surgery, Transplant Surgery Division, Virginia Commonwealth University, MCV Campus, Richmond, VA [email protected]
REFERENCES 1. Biglarnia AR, et al. Utilization of small pediatric donors including infants for pancreas and kidney transplantation: exemplification of the surgical technique and the surveillance. Ann Surg. 2014;260: e5–e7. 2. Buggenhout A, Hoang AD, Hut F, et al. Pediatric en bloc dual kidney pancreas transplantation into an adult recipient: a simplified technique. Benefits of the en bloc kidney-pancreas transplantation technique in pediatric donors. Am J Transplant. 2004;4:663–665. 3. Scandia Transplant. Available at: http://www. scandiatransplant.org. Accessed March 26, 2014. 4. Sharma A, Ramanathan R, Behnke M, et al. Single pediatric kidney transplantation in adult recipients: comparable outcomes with standard-criteria deceased-donor kidney transplantation. Transplantation. 2013;95:1354–1359. 5. Sharma A, Fisher RA, Cotterell AH, et al. En bloc kidney transplantation from pediatric donors: comparable outcomes with living donor kidney transplantation. Transplantation. 2011;92: 564–569. 6. Burrows L, Knight R, Polokoff E, et al. Expanding the donor pool with the use of en bloc pediatric kidneys in adult recipients. Transplant Proc. 1996;28:173–174. 7. Merkel FK, Matalon TA, Brunner MC, et al. Shortand long-term results with en bloc transplantation of pediatric kidneys into adults. Transplant Proc. 1993;25:2167–2169. 8. Sanchez-Fructuoso AI, Prats D, Perez-Contin MJ, et al. Increasing the donor pool using en bloc pediatric kidneys for transplant. Transplantation. 2003;76:1180–1184. 9. Kayler LK, Zendejas I, Gregg A, et al. Kidney transplantation from small pediatric donors: does recipient body mass index matter? Transplantation. 2012;93:430–460.
Disclosure: The author declares no conflicts of interest. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-e0008 DOI: 10.1097/SLA.0000000000000752
e8 | www.annalsofsurgery.com
Annals of Surgery r Volume 260, Number 2, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
