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R J Stratta

Publications and source records attributed to R J Stratta.

At least 145 records · Page 8Linked to original sources
PubMed1994

Kidney/pancreas transplantation: a review of the current status.

KPT has become the treatment of choice for many Type I diabetics with impending or actual end-stage renal disease. The techniques of organ procurement, surgical transplantation, and postoperative management are well established. The current 1- and 3-year patient and graft survival rates are at least equal to those obtained in both diabetic and nondiabetic patients receiving kidney transplants alone. Although there is significant associated morbidity unique to the pancreas transplant, this is usually manageable without influencing the outcome. With the improvement in quality of life and the potential for arresting diabetic complications, KPT is a procedure that should be seriously considered for many Type I diabetic patients with advanced nephropathy.

Diabetes Mellitus, Type 1↗
PubMed1994

Consequences of pancreas transplantation.

PKT has become an important option in selected IDDM patients being considered for kidney transplantation because of its ability to offer superior glycemic control and improved quality of life. As both kidney graft survival and overall mortality are comparable following PKT and kidney transplantation alone at many centers, neither the survival of the patient nor the success of the kidney transplant need be jeopardized by the addition of a pancreas graft. The greater morbidity of PKT can be justified by the evidence that a pancreas graft will prevent recurrent diabetic nephropathy, result in greater improvements in sensory/motor neuropathy, and in some but not all studies, cause greater stabilization of eye disease. Improvements in lipid profiles observed after PKT but not after kidney transplant alone may predict better cardiovascular outcomes as well. Determination of who should receive an isolated pancreas transplant is more complex. Success rates are lower than after PKT. It remains important to ascertain that the candidate is susceptible to diabetic complications, or has repeated bouts of hypoglycemia or ketoacidosis unresponsive to other measures to justify the risks of long-term immuno-suppression. More difficult to determine is whether or when individuals who have advancing diabetic complications yet relatively preserved renal function (creatinine clearance > 70 mL/min) should become candidates. For now, each individual is considered on a case by case basis and the relative risks and benefits for each individual are carefully assessed. However, patient selection will be greatly aided by further research assessing the long-term risks and benefits of all types of pancreas transplantation. Pancreas transplantation will remain an important option in the treatment of IDDM until alternative strategies are developed that can provide equal glycemic control with less or no immunosuppression or less overall morbidity. Most of the research to date has concentrated on the consequences of pancreas transplantation on microvascular complications. However, cardiovascular disease events represent the greatest cause of mortality in pancreas transplant candidates. Thus, changes in cardiovascular risk after pancreas transplantation may be more important to long-term survival than any other factor and should receive greater attention in future studies.

Adolescent↗
PubMed1993

Selective use of Sandostatin in vascularized pancreas transplantation.

Despite improving results, the management of exocrine complications after pancreas transplantation remains problematic. During a 30-month period, we performed 65 pancreas transplants with bladder drainage. A total of 23 patients (35%) were managed with a long-acting somatostatin analogue (Sandostatin) for persistent hyperamylasemia or allograft pancreatitis. Sandostatin was begun at a mean of 29 days after transplant with a mean duration of therapy of 13 days. Sandostatin therapy was associated with significant reductions in the serum, urine, and peritoneal fluid amylase levels (p < 0.05). Sandostatin also caused a decrease in cyclosporine levels during oral cyclosporine use. In patients receiving Sandostatin, pancreas allograft survival was 83%. We conclude that pancreatitis remains a major cause of morbidity after pancreas transplantation. The selective use of Sandostatin can result in excellent graft salvage with low morbidity. Sandostatin appears to be safe and effective in reducing the exocrine output of the denervated pancreas allograft but also reduces cyclosporine levels.

Adult↗
PubMed1993

The utility of urine cytology in the diagnosis of allograft rejection after combined pancreas-kidney transplantation.

A major problem in pancreas transplantation is the lack of a reliable method for the early detection of rejection. Over a 32-month period, we performed 61 combined pancreas-kidney transplants with pancreaticoduodenocystostomy. All patients received quadruple immunosuppression with OKT3 induction. Urine cytologic monitoring was performed on Papanicolaou-stained membrane filters for cell counts and cytocentrifuge preparations for HLA-DR antigen staining. The final diagnosis of rejection was based on clinical criteria, a rise in serum creatinine, histopathology, and hypoamylasuria. Cytologic features of acute rejection included hypercellularity with lymphocyturia, increased numbers of epithelial cells and positive antibody staining for HLA-DR antigen. A total of 36 definite acute rejection episodes occurred in 28 patients, with 19 confirmed by histopathology. Satisfactory urine cytologic specimens were available in 28 rejection episodes and corroborated the diagnosis in 21 cases, for a sensitivity of 75% compared with 75% and 50% with serum creatinine and urine amylase, respectively. When the urine cytologic score was combined with HLA-DR antigen staining, sensitivity improved to 93%. Thirteen false-positive diagnoses occurred in the remaining 1444 urine cytologic specimens available for evaluation, for a specificity for rejection of 99%. The positive predictive value of cell counts was 62% and negative predictive value was 99%. Patient survival is 98.4%, kidney allograft survival is 96.7%, and pancreas allograft survival is 93.4% after a mean follow-up of 15 months. Only 2 immunologic graft losses occurred (1 kidney, 1 pancreas). In conclusion, urine cytologic monitoring shows promise as a simple, reliable, and noninvasive method to detect rejection after combined pancreas-kidney transplantation with bladder drainage. Prospective studies are needed to assess the role of urine cytologic monitoring after solitary pancreas transplantation.

Adult↗
PubMed1993

Recipient selection and evaluation for vascularized pancreas transplantation.

Vascularized pancreas transplantation (PT) is becoming an accepted therapy for selected type I diabetic patients. However, selection and evaluation criteria remain uncertain. In the last 3.5 years, we have interviewed 205 and evaluated 151 diabetic patients for PT. The degree of renal dysfunction (creatinine clearance below 45 ml/min) was used to select patients for combined pancreas-kidney transplantation (PKT) or solitary pancreas transplantation (PTA) (clearance above 70 ml/min). The cardiovascular evaluation (stress thallium study with liberal use of coronary angiography) was used to determine operative risk and provided the other major selection criterion. A total of 104 patients were selected as candidates for PT; 70 have undergone PKT with 98.6% patient survival (1 cardiovascular death), 97.1% kidney graft survival, and 94.2% pancreas graft survival. Thirty-three evaluated patients (24.1%) were not accepted as candidates for PT; 13 have undergone cadaveric kidney transplantation, 5 were placed on the kidney waiting list, and 9 have died. Criteria for PTA include 2 or more diabetic complications or hyperlabile diabetes. Patient (n = 12) and pancreas graft survival after PTA is 83.3 and 50%, respectively. Our conclusion is that a multidisciplinary approach was used for recipient selection for PT based on degree of nephropathy, cardiovascular risk, and presence of diabetic complications. Nearly 75% of diabetic patients evaluated were acceptable candidates for PT. Only 4 (3.8%) of these selected patients died while awaiting or undergoing PT, thus optimizing the use of scarce allograft resources and providing evidence for appropriate patient selection.

Adult↗
PubMed1993

A comparative analysis of results and morbidity in type I diabetics undergoing preemptive versus postdialysis combined pancreas-kidney transplantation.

Although combined pancreas-kidney transplantation (PKT) has become a valid treatment option for selected type I diabetics, the timing of PKT relative to the degree of nephropathy remains controversial. We analyzed results and morbidity in 30 type I diabetics undergoing PKT after starting dialysis (PKT:D) versus 31 type I diabetics undergoing PKT prior to dialysis (PKT:ND). The two groups were similar with the respect to age, duration and severity of diabetes, gender, race, preservation time, retransplants, sensitization, HLA-matching, and CMV status. The mean preoperative serum creatinine was higher in the PKT:D group (9.9 +/- 3.4 vs. 3.9 +/- 1.9 mg/dl PKT:ND, P < 0.01). All patients were managed with quadruple immunosuppression with OKT3 induction. Actuarial patient survival is 100% (PKT:D) and 96.8% (PKT:ND). Renal and pancreas allograft survival are 97% and 93%, respectively, in both groups. The incidence of rejection, infection, operative complications, reflux pancreatitis, and total hospital days was similar in both groups. Long-term renal and pancreas allograft function and quality of life were like-wise comparable. No adverse coagulation or immunologic effects were noted in the PKT:ND group. Rehabilitation potential favored the PKT:ND group. PKT can be performed safely and effectively in the absence of uremia. In selected type I diabetics with significant nephropathy, we believe that PKT is the best treatment option and need not be considered as preemptive, especially in view of increasing waiting times and the variable progressive nature of diabetic complications.

Adult↗
PubMed1993

Frozen section evaluation of donor livers before transplantation.

Frozen section examination was performed on 385 donor livers before transplantation. Exclusion criteria were applied to the donor livers examined to exclude potentially dysfunctional livers. The exclusion criteria included the following: severe macrovesicular steatosis, ischemic necrosis, prominent chronic portal inflammation, prominent periductular fibrosis, granulomatous inflammation, bridging fibrosis, and malignancy. Twenty-seven of the 385 donor livers examined were excluded before transplantation. The following histologic features were present in the excluded livers: severe steatosis (22), ischemic necrosis (2), portal inflammation (1), and periductular fibrosis (2). Steatosis was present in 51 of the 385 (13.25%) organs examined, including 22 of the donor organs excluded before transplantation. Twenty-nine livers with mild to moderate steatosis were implanted into size and blood type-matched recipients. Indicators of allograft function (prothrombin time and bilirubin) and damage (aspartate aminotransferase and alanine aminotransferase) were measured daily for the first 10 days after transplant. There was no statistically significant difference between the group of nonfat livers and donor livers containing mild steatosis. Statistically significant higher posttransplant serum alanine aminotransferase and prothrombin time levels were present in the patients with livers implanted with mild versus moderate steatosis. The 1-year survival rate for patients receiving fatty versus nonfatty donor livers was not statistically different (Kaplan-Meier, P = 0.592). No significant differences were found in the clinical and laboratory characteristics of donors whose organs were implanted compared with the clinical and laboratory characteristics of donors whose organs were excluded. The primary nonfunction rate after applying the exclusion criteria was 1.4%, which is a significant decrease compared with our primary nonfunction rate of 8.5% before using frozen section examination. Frozen section examination is useful in excluding donor organs which may become dysfunctional after transplantation.

Adenosine↗
PubMed1993

Results of liver transplantation in diabetic recipients.

BACKGROUND: The results of orthotopic liver transplantation (OLTx) in patients with diabetes mellitus (DM) are not well defined. METHODS: Between 1985 and 1991, 45 adult patients with pretransplantation DM (5 type I, 40 type II) underwent OLTx at our center as identified by retrospective chart review. We compared this diabetic recipient group to a case-control nondiabetic group matched for age, gender, primary liver disease, weight, and timing of OLTx. A total of 30 variables were collected and analyzed with McNemar's test for categorical data, paired t tests for continuous data, and survival and repeated measures analysis for longitudinal data. RESULTS: No differences between diabetic and nondiabetic recipients were noted in patient or graft survival, the incidence or severity of rejection, blood transfusions, operative complications, readmissions, major infections, or number of hospital days after OLTx. However, the incidence of minor bacterial (p = 0.046) and minor fungal (p = 0.035) infections were higher in the DM group. Serum blood urea nitrogen (p = 0.02) and creatinine (p = 0.03) levels were also higher in patients with diabetes versus control patients during the first year after OLTx. CONCLUSIONS: In carefully selected patients with pretransplantation DM, OLTx can be accomplished with results similar to nondiabetic recipients in spite of a higher incidence of minor infections and renal dysfunction.

Diabetes Complications↗
PubMed1993

Cholelithiasis in pancreas and kidney transplant recipients with diabetes.

BACKGROUND: Vascularized pancreas transplantation (PTx) for type I diabetes mellitus results in euglycemia at the expense of chronic immunosuppression, hyperinsulinemia, and dyslipidemia. However, the effect of PTx on native biliary lithogenesis remains unknown. METHODS: To address this issue, we retrospectively studied 72 consecutive pancreas transplant recipients and compared them with patients both with (n = 35) and without (n = 52) diabetes mellitus undergoing kidney transplantation alone (KTA). All patients underwent pretransplantation abdominal ultrasonography, which was repeated at 6- to 12-month intervals after transplantation. PTx recipients were managed with quadruple immunosuppression with OKT3 induction. Kidney transplant recipients received cyclosporine and prednisone. RESULTS: Seventeen (30.4%) of 56 evaluable PTx recipients had gallstones at a mean interval of 13 months (range, 5 to 24) after PTx. Eleven patients underwent open cholecystectomy (with one surgical exploration of common bile duct for choledocholithiasis), three underwent laparoscopic cholecystectomy, and the other three are being managed expectantly. Gallstone analysis revealed predominantly cholesterol stones. The incidence of cholelithiasis in kidney transplant recipients with and without diabetes mellitus was 27.3% and 12.2%, respectively (p = 0.04). CONCLUSIONS: Pancreas transplant and kidney transplant recipients with diabetes are predisposed to the development of gallstones compared with recipients without diabetes. An interaction between diabetes mellitus-induced gallbladder dysmotility and cyclosporine-induced cholestasis may be a possible mechanism. We recommend serial ultrasonographic examinations in pancreas transplant and kidney transplant recipients, and cholecystectomy in pancreas transplant recipients with cholelithiasis should be considered.

Adult↗
PubMed1993

The analysis of benefit and risk of combined pancreatic and renal transplantation versus renal transplantation alone.

Currently, diabetes mellitus is the most common cause of renal failure in adults. However, combined pancreatic and renal transplantation (PRT) remains controversial when compared with renal transplantation alone (RTA) in diabetic recipients. We analyzed the results and morbidity in four age-matched groups--31 patients with Type I diabetes undergoing PRT before dialysis, 30 patients with diabetes who are dependent of dialysis undergoing PRT, 31 concurrent and historic patients with Type I diabetes undergoing RTA and 31 concurrent patients without diabetes undergoing RTA. All patients received cadaver donor organs and were managed with cyclosporine and prednisone immunosuppression with selective OKT3 induction. The four groups were comparable with respect to age, weight, gender, duration and severity of diabetes, dialysis type, number of retransplants, degree of sensitization, preservation time and matching. The groups differed with regard to duration of dialysis and period of follow-up evaluation, pretransplant blood transfusions, racial distribution and OKT3 induction therapy. PRT was associated with a greater morbidity rate as evidenced by a slightly higher incidence of rejection, infections and reoperations. The number of readmissions and hospitalization period during the first 12 months was also greater after PRT versus RTA. However, none of these differences were significant. No detrimental effect was noted on renal allograft function at one year; patient and graft survival was actually higher in the PRT groups. Quality of life was improved in nearly 90 percent of PRT recipients. Although the improved results after PRT may be attributed to selection bias, only lesser differences were noted among the four study groups. The aforementioned data suggest that appropriate patient selection can overcome the morbidity associated with PRT, resulting in excellent patient and graft survival with the potential for complete rehabilitation.

Actuarial Analysis↗