Background. In the Leiden University Medical Centre, a two-step approach is routinely used in simultaneous pancreaskidney (SPK) transplantations: primary bladder drainage (BD) followed by elective enteric conversion. The rationale for this approach is to prevent the short-term disadvantages of primary enteric drainage (intra-abdominal abscesses, pancreas graft loss) and the long-term urological complications related to bladder drainage. Aim of the present study is to evaluate survival and (urological) complications of this approach compared to enteric drainage (ED). Methods. Patient records of all 98 SPK transplantations in the period 1997-2004 were reviewed for complications during the initial hospitalization until 30 days after discharge, and to assess urological complications and graft survival until the last hospital visit. Median duration of follow-up was 4.3 years for pancreas graft survival, 4.7 years for kidney graft survival, and 4.8 years for patient survival. Results. Patient survival was significantly better in BD patients than in ED patients (χ2=9.89 P<0.01). Pancreas graft survival was also better in BD patients after adjustment for the longer pancreas warm ischemia time in BD patients (P=0.05). The survival rates in our patient population seem higher than reported by the International Pancreas Transplant Registry, particularly in BD patients. Urological complications occurred in nine BD patients (10.3%), comparable to the rates reported for enteric-drained grafts. Conclusions. This two-step approach of SPK transplantation results in excellent survival rates, with urological complication rates comparable to those reported for enteric-drained grafts, and may thus be viewed as a safe and effective procedure of SPK transplantation.@en

Health related quality of life (HRQoL) of living kidney donors on average is good, but some donors experience a low HRQoL after donation. This study assessed the prevalence of reduced HRQoL and explored associations with pre- and post-donation variables. 316 donors (response rate 74%) who donated a kidney between 1997 and 2009 filled in a questionnaire. HRQoL was measured using the Short-Form 36; fatigue using the Multidimensional Fatigue Inventory; societal participation using the Utrecht Scale for Evaluation of Rehabilitation- Participation. Donors on average had better HRQoL than the general population. However, 12% had a reduced physical (PCS) and 18% a reduced mental (MCS) HRQoL. Donors with reduced HRQoL reported greater fatigue (P < 0.01), lower societal participation (P < 0.01) and showed a trend towards statistical significance in experiencing more donor-recipient relationship changes (P = 0.07). Prior to donation, donors with reduced PCS had a higher BMI (P < 0.05) and more often smoked (P < 0.05). Donors with reduced MCS had higher expectations (P < 0.05). Reduced HRQoL is associated with higher BMI, smoking and higher expectations prior to donation. These results may be used to develop a screening instrument to select donors at high risk for reduced HRQoL.@en

Background: Limited data exist on the impact of living kidney donation on the donor-recipient relationship. Purpose of this study was to explore motivations to donate or accept a (living donor) kidney, whether expected relationship changes influence decision making and whether relationship changes are actually experienced. Methods. We conducted 6 focus groups in 47 of 114 invited individuals (41%), asking retrospectively about motivations and decision making around transplantation. We used qualitative and quantitative methods to analyze the focus group transcripts. Results: Most deceased donor kidney recipients had a potential living donor available which they refused or did not want. They mostly waited for a deceased donor because of concern for the donors health (75%). They more often expected negative relationship changes than living donor kidney recipients (75% vs. 27%, p=0.01) who also expected positive changes. Living donor kidney recipients mostly accepted the kidney to improve their own quality of life (47%). Donors mostly donated a kidney because transplantation would make the recipient less dependent (25%). After transplantation both positive and negative relationship changes are experienced. Conclusion: Expected relationship changes and concerns about the donors health lead some kidney patients to wait for a deceased donor, despite having a potential living donor available. Further research is needed to assess whether this concerns a selected group.@en

Quality of most procured pancreata is considered acceptable or good by surgeons, but remains difficult to ascertain. Little is known on how often pancreata are refused for transplantation during back-table inspection. Purpose of this study was to determine the frequency and type of problems responsible for refusal during back-table inspection and to identify possible risk factors. All 134 pancreata accepted and procured for whole-organ transplantation and transported to the Leiden University Medical Center in the period February 2002 until May 2008 were included. These were retrospectively analyzed on donor characteristics, procurement characteristics, and (non-)critical problems. A total of 111 (82.8%) pancreata were transplanted while 23 (17.2%) were refused for transplantation during back-table inspection, regardless of procurement region (χ 2=0.16 p=0.93). Fourteen pancreata (13.4%) were refused solely because of surgical injuries. In refused pancreata, on average 2.7 critical problems per pancreas were found and 0.6 non-critical problems (vs. 0.3 in transplanted pancreata, t=1.83 p=0.08). Chances of refusal increased in pancreata from older donors (odds ratio 1.08 [1.02-1.14]) procured in centers not performing pancreas transplantations (odds ratio 7.95 [2.43-25.97]). We conclude that pancreatic allografts are frequently refused during back-table inspection, partly because of the surgical injuries suggesting that quality of procurement may be improved.@en

When studying histological characteristics of human donor-pancreata, a remarkably high number of hyperemic islets (HIs) were encountered. The abnormalities in these HIs ranged from single/multiple dilated vessels to hemorrhages extending into the exocrine tissue. We aimed to determine the relevance of the presence of HIs in human donor-pancreata for isolation outcome and to identify donor and procurement factors associated with the occurrence of HIs. The presence of HIs was scored semi-quantitatively (HI, HI+) in 102 human donor-pancreata. Islet isolation was performed in 40 cases. Donor and procurement factors were retrospectively analyzed in 94 donors. HIs were found in 54.6% of all donor-pancreata. However, only 4.5% of all islets in the affected pancreata was hyperemic. The affected pancreata contained slightly more endocrine tissue, but produced significantly lower yields. When corrected for other factors known to influence isolation outcome, the presence of HIs and endocrine content were the only factors significantly influencing isolation outcome. Prolonged ICU stay and pre-procurement hypertension were associated with the presence of HIs. This study is a first indication that the presence of HIs in human donor-pancreata are associated with reduced isolation outcomes and suggest an impact of the procurement procedure and pre-procurement hemodynamic status of the donor on the islet quality. It is tempting to speculate that this contributes to the generally experienced difficulties in obtaining sufficient amounts of human islets.@en

Background: Many donor and recipient factors are known to affect pancreas graft survival. However, their relative importance in explaining differences in graft survival is unknown. Purpose of this study was to retrospectively evaluate the impact of donor and recipient factors on pancreas graft survival, and compare their contribution in explaining graft survival differences. Material/Methods: Patient records of all 170 pancreas transplantations (158 Simultaneous Pancreas- Kidney; 12 Pancreas-after-kidney) in the period 1997-2008 were reviewed retrospectively to assess recipient factors before/during transplantation, and to assess graft survival. Eurotransplant reports were reviewed to assess donor factors. Results: Death-censored 1-year graft survival was 88.4% and 82.3% at 3 years. Several factors significantly influenced graft survival: female recipient gender (Hazard Ratio (HR) 2.81[1.10-7.14]), enteric graft drainage (HR 2.85[1.15-7.05]), and donor-recipient match on BMI (HR 2.46[1.01-6.02]). None of the donor factors significantly affected survival. Similar results were found for 1-year survival, except for enteric graft drainage and donor-recipient BMI matching. In total, donor factors explained 3.6% and recipient factors 10.0% of the variance in graft survival. Donor factors were more important for 1-year survival (3.1%), but still less important than recipient factors which explained 6.4%. Conclusions: Recipient factors are more important in explaining differences in pancreas graft survival than donor factors.@en

Urological complications after kidney transplantation may result in significant morbidity and mortality. However, the incidence of such complications after deceased cardiac death (DCD) donor kidney transplantation and their effect on survival is unknown. Purpose of this study was to estimate the incidence of urological complications after DCD kidney transplantation, and to estimate their impact on survival. Patient records of all 76 DCD kidney transplantations in the period 1997-2004 were reviewed for (urological) complications during the initial hospitalization until 30 days after discharge, and graft survival until the last hospital visit. Urological complications occurred in 32 patients (42.1%), with leakage and/or obstruction occurring in seven patients (9.2%). The latter seems to be comparable with the incidence reported in the literature for deceased heart-beating (DHB) transplantations (range 2.5-10%). Overall graft survival was 92% at 1 year and 88% at 3 years, comparable to the rates reported in the literature for kidneys from DHB donors, and was not affected by urological complications (χ2 = 0.27, P = 0.61). Only a first warm-ischaemia time of 30 min or more reduced graft survival (χ2 = 4.38, P < 0.05). We conclude that urological complications occur frequently after DCD kidney transplantation, but do not influence graft survival. The only risk factor for reduced graft survival in DCD transplant recipients was the first warm-ischaemia time.@en