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INTRODUCTION:Pancreas enzyme replacement therapy (PERT) is used to improve nutrient digestion, especially of lipids, in patients with exocrine pancreas insufficiency who otherwise may experience maldigestion, malabsorption, malnutrition, and steatorrhea. Although underdosage of PERT is common, adequate dosing is particularly important in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT). Current PERT dosing guidelines do not explicitly provide recommendations following TPIAT so we determined the adequacy of PERT dosing in a cohort of patients with TPIAT.METHODS:The TPIAT database from 2009-2018 was searched to determine PERT dosing in subjects before TPIAT (n = 14), immediately after TPIAT and at 6 and 12 months (n = 11). Adequate weight based dosing was established using Cystic Fibrosis Foundation guidelines. Average PERT dose was calculated and the ranges were reported, P < 0.05 was significant.RESULTS:Data was available in 14 patients, and 6 and 12 month data was available in 11 patients. Indication for TPIAT included 6 idiopathic chronic pancreatitis (CP), 4 genetic CP (4 PRSS1, 1 CFTR), 3 idiopathic recurrent AP, 1 alcohol induced CP. 3 patients were not using PERT before TPIAT, 7 were underdosed (average 62,000 U/day, range 6,000–108,000), and 4 were adequate (205,250 U/day; 125,000–228,000). At discharge 9 patients were underdosed (72,222 U/day; 6000–108,000), and 5 were adequate (248,200 U/day; 125,000–360,000). At 6 months 3/11 pts (27%) were underdosed (56,666 U/day; 30,000–80,000) and 8/11 pts (73%) were adequate (228,000 U/day; 144,000–432,000). At 12 months 2/11 pts (18%) were underdosed (108,000 U/day each) and 9/11 (82%) pts were adequate (430,222 U/day; 144,000–384,000). PERT dose increase was significant for the period post-TPIAT to 6 months (P = 0.04). The graph shows the trend of PERT during the study period.CONCLUSION:Underdosing of PERT was common before and immediately after TPIAT. It is possible that poor oral intake dictated the immediate low post TPIAT dose. Significant PERT dose increase was noted in the first 6 months, and was sustained at 12 months. PERT dosing needs to be monitored closely and weight based dosing should be considered to achieve optimal nutritional benefit.

Hepatic parenchymal disease, including chronic viral hepatitis, has traditionally been considered a relative contraindication to islet transplantation as the islets are infused into the recipient’s liver. We present a case study of a patient with treated chronic hepatitis C infection (HCV) who safely received an autologous islet transplant following total pancreatectomy with excellent clinical outcomes. The patient was a 60-year-old woman diagnosed with debilitating abdominal pain secondary to chronic pancreatitis and with preserved islet function. She had previously been treated >10 years prior to surgical evaluation with interferon monotherapy for 1 year that led to sustained virologic response, including at the time of surgical evaluation for total pancreatectomy and islet autotransplantation (TPIAT). She underwent comprehensive preoperative evaluation of the liver, including liver biopsy, which showed no significant portal inflammation or fibrosis. Following a multidisciplinary meeting and discussion of the potential risks for the patient, the decision was made to proceed with TPIAT. The patient underwent a standard total pancreatectomy, and an autologous islet dose of 6638 islet equivalents/kg body weight was infused into the liver via the portal vein. Portal vein pressure was monitored throughout the infusion with a transient peak pressure of 27 cm H2O (basal pressure of 14 cm H2O) and final pressure of 23 cm H20 at 10 min post-infusion. Aside from a transient transaminitis, liver enzymes were normal at the time of hospital discharge. At greater than 1 year of follow-up, the patient has improved quality of life, with reduction in narcotic analgesia, remains insulin independent (with normal islet function), and has normal liver function. This case illustrates that islet autotransplant into the liver can be safely performed and suggests that carefully selected patients with liver disease may be eligible for TPIAT.

The portal vein is currently the site of choice for clinical islet transplantation, even though it is far from being an ideal site. Low oxygen tension and the induction of an inflammatory response impair islet implantation and lead to significant early loss. Even if enough islets survive the early implantation period to render insulin independence, few patients maintain it. Therefore, the search for an ideal site for islet transplantation continues. Experimentally, islets have been transplanted into the portal vein, kidney subcapsule, spleen, pancreas, peritoneum, omentum, gastrointestinal wall, testis, thymus, bone marrow, anterior chamber of the eye, cerebral ventricles, and subcutaneous and intramuscular spaces. Some of these sites are suitable for gathering scientific data, whereas others have potential clinical application. Varying degrees of success have been reported with the use of all these transplant sites in an experimental setting. However, the optimal transplant site remains to be finally established.

Kidney allograft torsion (KAT) is a rare but critical complication of kidney transplantation that can lead to graft loss due to acute ischemia. This report presents a case of KAT resulting in graft loss 9 months following intraperitoneal simultaneous pancreas and kidney (SPK) transplant and reviews previous reports to identify potential high‐risk features. A 38‐year‐old female with end‐stage renal disease secondary to Type 1 diabetes mellitus underwent an intraperitoneal enteric drained SPK transplant. Nine months post‐transplantation, she presented with nausea, vomiting, severe abdominal pain, decreased urine output, and diarrhea. An ultrasound showed moderate hydronephrosis and no blood flow to the renal hilum. Exploratory laparotomy revealed a necrotic renal allograft twisted 360° counterclockwise on its vascular pedicles. Despite detorsion, the graft showed no signs of viability, necessitating transplant nephrectomy. This case highlights the rarity and severity of KAT, particularly in intraperitoneal kidney transplants. The patient’s low body mass index (BMI) (23.4 kg/m 2 ), female sex (wider pelvis), and minimal intra‐abdominal adhesions may have contributed to increased graft mobility, predisposing to KAT. Other potential risk factors include elongated vascular pedicle and immunosuppression‐related reduced adhesion formation. The nonspecific presentation of KAT emphasizes the need for high clinical suspicion and prompt ultrasonographic evaluation in cases of graft abnormalities. This report underscores the importance of considering patient‐ and graft‐specific factors in assessing KAT risk and the critical nature of early detection and intervention to prevent graft loss.

Background. Core needle and wedge biopsies are the two main pathologic ways to determine the suitability of a kidney allograft and to have a baseline allograft biopsy in case of future rejection. Case Presentation. A 57-year-old patient developed a renal arteriovenous fistula causing postoperative and recurrent hematuria after allograft pretransplant renal core needle biopsy and treated with selective Interventional radiology coil embolization. Conclusion. Delayed profound hematuria can be seen after pretransplant core needle renal biopsies and can recur again even after complete resolution, due to arteriovenous fistula formation in the renal calyceal system.

Background. Patients with more than two prior kidney transplant procedures pose unique surgical challenges. Once both the right and left retroperitoneal spaces have been dissected, intra-abdominal implantation is usually necessary. If the external iliac arteries have been used previously, it is sometimes necessary to use the aorta and vena cava for implantation. Gaining safe exposure in these cases can be complicated by history of prior laparotomy, adhesive disease, and other surgical histories. Case Presentation. A 58-year-old female with type 1 diabetes and end-stage renal disease presented for surgical evaluation for kidney transplant. Surgical history was notable for prior simultaneous kidney-pancreas transplant followed by both a living donor kidney transplant and a pancreas after kidney transplant. She had undergone both an allograft nephrectomy and an allograft pancreatectomy and currently had a nonfunctioning kidney in the left retroperitoneal position and a nonfunctioning pancreatic allograft on the right common iliac artery. The entire distal aortoiliac system was surgically inaccessible. She was listed for transplantation, and a cadaveric graft was allocated. Intraoperatively, severe lower abdominal and pelvic adhesions prevented any use of the iliac system. A left native nephrectomy was performed, and the allograft was implanted in the left orthotopic position. The native left renal vein was used for outflow, the donor renal artery was joined end-to-side to the infrarenal aorta, and a uretero-ureterostomy was created. The operation was uneventful. The allograft functioned without delay, and almost one year later, the GFR is approximately 50 mg/dL. Conclusion. The left orthotopic position can be a good choice for kidney transplant candidates with histories of prior complex lower abdominal surgery.

Chronic pancreatitis (CP) is a progressive disease that leads to eventual loss of endocrine and exocrine function. Total pancreatectomy and islet autotransplantation (TPIAT) is a treatment option for patients with CP; however, predicting postoperative metabolic outcomes remains elusive. In this single-center retrospective study, we report pre-TPIAT characteristics, beta cell function indices, islet yield, and post-TPIAT glucose management data to further understand their relationship. Islet yield, glucose level, and insulin requirement for 72 hours postoperatively were collected for a total of 13 TPIAT recipients between 9-2013 and 9-2018. In addition, their glucose control and basal insulin requirements at 3, 6, and 12 months post-TPIAT were analyzed. All 13 subjects had normal baseline fasting glucose levels. Median islet yield was 4882 IEq/kg (interquartile range 3412 to 8987). Median postoperative total insulin requirement on day 3 was 0.43 units/kg. Pre-TPIAT baseline glucose, insulin, or c-peptide level did not have a significant correlation with the islet yield. Similarly, there was no correlation between islet yield and insulin requirement at 72-hour postoperatively. However, there was an inverse correlation between the absolute islet yield (IEq) and insulin requirement at 6 months and 12 months following post-TPIAT. Further analysis of the relationship between 72-hour post-op insulin requirement and insulin requirement at discharge, 3, 6, and 12 months showed a positive correlation. Despite the finding of inverse correlation of islet yield with long-term basal insulin requirement, this study was not able to detect a correlation between the preoperative parameters to postoperative short-term or long-term outcome as noted in other studies. The 72-hour postoperative insulin requirement is a helpful postoperative predictor of patients needing long-term insulin management following TPIAT. This observation may identify a high-risk group of patients in need of more intensive diabetes education and insulin treatment prior to hospital discharge.

Complications are a part of surgery. Spinal infarctions are a dreaded complication of aortic surgery. We present a patient who developed a spinal infarct after a kidney transplant. We were unable to find a causative factor in our search for etiology. In our review of the literature, we were unable to find a similar report. We present this case report to highlight a rare complication of kidney transplantation and to reinforce that patients requiring kidney transplant are complex patients with multiple comorbidities that can cause a multitude of complications in the periop period.

Epstein-Barr virus (EBV)-associated post-transplant lymphoproliferative disorder (PTLD) is a serious complication of organ transplantation. The gastrointestinal (GI) tract is a common site involved, but non-specific signs and symptoms often delay the diagnosis. We report a case of EBV-associated GI-PTLD in a 68-year-old kidney transplant patient who received the kidney ten months earlier. He presented with chronic diarrhea and developed massive pneumo-peritoneum secondary to multiple colonic perforations.

The present study was conducted at the Department of Plant Protection, College of Agriculture, University of Tikrit, with the aim of controlling white mold disease caused by Sclerotinia sclerotiorum (K-5) in pepper plants using four CO2 gas concentrations: 500 ppm (control – the natural atmospheric concentration), - 4000 ppm, applied for 8 hours/day. Results revealed an inverse relationship between CO2 concentration and both colony diameter and number of sclerotia. The 4000ppm concentration exhibited the highest inhibition of S. sclerotiorum (K-5) colony growth and sclerotial production, reaching 0.86 cm and 1.22 sclerotia, respectively, compared to 4.23 cm and 18.21 sclerotia at the control level (500 ppm). In the pot experiment under pathogen infection conditions, 4000 ppm CO2 was most effective in reducing disease incidence and severity, achieving 24.72% and 26.66%, respectively, compared to 90.21% and 89.47% at 500 ppm. Furthermore, CO2 concentrations between 3000–4000 ppm promoted vegetative growth indicators, such as plant height, root and shoot dry weights, and chlorophyll content, under infection conditions.