Simultaneous pancreas-dual kidney transplantation: a case report
Concetta Cacace1, Niccolo' Napoli1, Emanuele Federico Kauffmann1, Gabriella Amorese3, Giacomo Taddei1, Carlo Lombardo1, Michael Ginesini1, Piero Marchetti2, Ugo Boggi1, Fabio Vistoli1.
1Division of General and Transplant Surgery, Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Pisa, Italy; 2Division of Metabolism, Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Pisa, Italy; 3Division of Anesthesia and Intensive Care, Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Pisa, Italy
Introduction: The quality of pancreas and kidney grafts from deceased donors can be extremely wide and age is not a reliable parameter of evaluation. Young donors should be carefully evaluated, in case of dubious clinical data, biopsy used to evaluate the graft and decide whether to perform a single or a double kidney transplant. We present a case involving a young donor with a kidney biopsy score unexpected in relation to her age and known comorbidities.
Method: Organs from a 43year-old woman (BMI 31.0 Kg/m2), brain dead donor due to cerebral hemorrhage, CMV IgG positive, KDPI 46%, KDRI 0.96, PDRI 1.88 were offered for a simultaneous pancreas-kidney transplant. Donor apparently had no comorbidities but a serum creatinine of 1.50 mg/dl (e-GFR 40.9 ml/min) to hospitalization, worsened during the observation period. Wedge kidney biopsies (159/208 glomeruli) were performed, graded according Karpinski-Remuzzi score 8/12 for each of the two kidneys (glomerular sclerosis: 1/3, tubular atrophy: 2/3, interstitial fibrosis: 2/3, arterial narrowing: 3/3). Due to these unexpected data, it was performed a simultaneous pancreas-double kidney transplantation on a 49year-old man (BMI 24.2 Kg/m2) with type 1 diabetes, laser treated diabetic retinopathy and end stage renal disease on dialysis (since 4 years).
Results: Transplantation was performed placing pancreas in retrocolic position with systemic-enteric drainage (vena cava and Roux-en-Y jejunal loop) and was completed placing the left kidney in the left iliac fossa and the right kidney in right iliac fossa. Cold ischemia time lasted 485 min for pancreas, 600 min for right kidney and 680 min for left kidney. Induction immunosuppression was obtained with basiliximab and steroids. Maintenance was based on LCP tacrolimus(Envarsus®; Chiesi, Italy), mycophenolic acid (720 mg twice a day) and steroids, rapidly tapered. On POD 7, recipient suffered of spontaneous pneumothorax. The following postoperative period was uneventful and he was discharged with 1.7 mg/dl serum creatinine. At 1-year follow-up he is insulin-indipendent and serum creatinine is 2.0 mg/dl.
Conclusion: According to Karpinski-Remuzzi’s criteria, the high biopsy score would not have allowed the single kidney transplant. It was also conflicting with the donor’s age that would not have required a biopsy based on her medical history. However, it was decided to perform a SPDKTx to improve the patient outcome rather than to perform a pancreas transplant alone leaving the patient on dialysis. The donor kidney biopsy remains a very helpful tool in the evaluation of the graft. However, it is a data to be interpreted case-by-case.
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