The Norwegian Pancreas Transplantation (PTx) Study
Several studies have shown acceptable results after Pancreas Transplantation (PTx) by substituting ATG with basiliximab, which is considered to convey a considerably lower number of adverse events. However, our experiences with ATG in PTx (introduced in 2004) are good, and our presumably gentle way of administrating the drug - directed by T-cell counts - is in fact unique. The potential advantages of reducing the overall corticosteroid (CS) load is obvious, as CS is a well-known pro-diabetic agent and causes severe long term adverse effects.
On this background, the investigators have very recently reduced our CS dosing (in the routine protocol) to a level corresponding to our Kidney Tx protocol (valid since 2009).
Thus, the investigators intend to prospectively investigate a single PTx cohort with the reduced CS immunosuppressive protocol by an observational study design, and compare with previous (historical) cohorts, who have received high dose CS.
Study hypotheses: i) Low-dose CS is as effective as high-dose corticosteroids with regards to efficacy/rejections; ii) The rate of surgical and infectious complications will be similar or lower in the low-dose group; iii) PTx rejection surveillance by DD (duodenoduodeno-stomy) and EUSPB (Endoscopic Ultra-Sound guided Pancreas Biopsies) is superior to traditional rejection surveillance; iv) Patient and graft survival is similar in the two groups
Surgical Complication Nec
|Study Type:||Observational [Patient Registry]|
|Study Design:||Observational Model: Cohort
Time Perspective: Prospective
|Target Follow-Up Duration:||5 Years|
|Official Title:||A Prospective, Observational Study in Pancreatic Allograft Recipients: The Effect of Risk Factors, Immunosuppressive Level and the Benefits of Scheduled Biopsies - on Surgical Complications, Rejections and Graft Survival|
- Incidence of acute rejection episodes after pancreas- or pancreas- + kidney- transplantation [ Time Frame: 5 years ] [ Designated as safety issue: Yes ]
Compare the incidence of acute rejection episodes at 6, 12, 36 and 60 months after pancreas transplantation, between our single prospective cohort with lower CS vs a historic, retrospective control group (PTx performed during 2011-2013). The incidence of rejection is defined as the fraction of patients in which rejections episodes (one or more) have been proven by biopsies. For SPK rejection in either organ, pancreas or kidney, counts.
Furthermore, we will compare the number and severity of rejection episodes in the pancreas allograft to the ones occurring in the kidney allograft (SPK), and the ones diagnosed by the duodenal segment biopsies.
- Surgical complications [ Time Frame: 5 years ] [ Designated as safety issue: Yes ]Compare the incidence of surgical complications, involving reoperations and reinterventions, between the prospective study cohort and retrospective control group.
- Graft survival [ Time Frame: 5 years ] [ Designated as safety issue: Yes ]Record kidney (and pancreas) graft survival (SPK) 12, 36 and 60 months post-Tx
- Patient survival [ Time Frame: 5 years ] [ Designated as safety issue: Yes ]Compare patient survival at 12, 36 and 60 months post-Tx.
- Non-surgical complications [ Time Frame: 5 years ] [ Designated as safety issue: Yes ]Compare the incidence of non-surgical complications; infections, cardial complications, pulmonary complications and neurological complications.
- Immunological analyses in blood samples [ Time Frame: 5 years ] [ Designated as safety issue: No ]
Blood samples will be obtained at the time of transplantation and later scheduled time points:
- Study of immune cell activation (CD25, FOXP3, CD4, CD3, CD8, CD45RO, perforin, granzyme A/B, etc) and cytokines (IL-2, TNF-a, IFN-g, IL-10, IL-12 etc).
- Compare biomarkers in serum, indicative of acute rejection, by at least weekly blood sampling post-Tx (RNA microarray on a series of genes related to rejection, quantitative PCR on selected genes)
- Study Pancreas Auto-antibodies
- Immunological analyses in allograft biopsies [ Time Frame: 12 mts ] [ Designated as safety issue: No ]
Scheduled biopsies will be taken at 3 wks, 6 wks and 12 mts post-Tx; as well as indication biopsies, simultaneously from these four transplant/organ sources: Pancreas-Tx (P); Kidney-Tx (K); Duodenal segment of pancreas-Tx (tD); Native Duodenum (nD; serves as control)
- Immunohistochemistry on immunologic markers (CD25, FOXP3, CD4, CD3, CD8, CD45RO, perforin, granzyme A/B, etc)
- DNA/RNA- analyses on immunologic markers; PCR, RNA microarray
- Endoscopic mucosal imaging and ultrasound [ Time Frame: 12 mts ] [ Designated as safety issue: No ]
- During upper endoscopy for scheduled biopsies (at 3 wks, 6 wks and 12 mts post-Tx), pictures of the transplant duodenal mucosa will be taken. The mucosal images will be rated regarding rubor, edema villous atrophy etc. and compared to biopsy rejection scores.
- Endoscopic ultrasound (EUS) will be used during biopsying of the pancreas. EUS images will be sampled and stored, for comparative analysis. The EUS analysis will mainly involve circulatory parameters.
- Donor and recipient baseline characteristics [ Time Frame: 5 years ] [ Designated as safety issue: Yes ]
We will investigate relationships between the below mentioned donor/recipient characteristics and graft survival/surgical complications/non-surgical complications:
- Donor age
- Donor gender
- Donor BMI
- Recipient age
- Recipient gender
- Recipient BMI
- Recipient PRA (Panel Reactive Antibody) status
- Recipient comorbidity status; particularly cardiovascular status
- Non-immunological rejection markers [ Time Frame: 12 mts ] [ Designated as safety issue: No ]
The following analyses will be performed and correlated to rejection, functional parameters (glucose levels/need for insulin (P) and creatinine (K)), and graft survival. By daily blood samples during the first 10 days, 3 times a week until week 10, at 3 & 12 mts, and on indication.
- Amylase (pancreas specific amylase)
- Amylase/Lipase/CRP combined parameter
- C-peptide and C-peptide/Glucose/Creatinine-ratio (C-peptide : Glucose x Creatinine)
- In addition, amylase in drainage fluid will be measured daily, until the drains are removed (usually at day 4-8 post-Tx).
Biospecimen Retention: Samples With DNA
Blood samples will be obtained at the time of Tx and later scheduled time points to:
- Study of immune cell activation (CD25, FOXP3, CD4, CD3, CD8, CD45RO, perforin, granzyme A/B, etc) and cytokines (IL-2, IL-12 etc)
- Compare biomarkers in serum, indicative of acute rejection; RNA microarray on a series of genes related to rejection, quantitative PCR on selected genes)
Scheduled biopsies will be taken according to our present routine protocol at 3 wks, 6 wks and 12 mts post-Tx, as well as indication biopsies; simultaneosly from these four transplant/organ sources:
Pancreas-Tx (P); Kidney-Tx (K); Duodenal segment of pancreas-Tx (tD; Native Duodenum (control)
Histological and molecular evaluations will involve:
- Rejection histology scores
- Immunoshistochemistry on immunologic markers (CD25, FOXP3, CD4, CD3, CD8, CD45RO, perforin, granzyme A/B, etc)
- DNA/RNA analyses on immunologic markers: PCR, RNA microarray
|Study Start Date:||September 2013|
|Estimated Study Completion Date:||October 2020|
|Estimated Primary Completion Date:||October 2020 (Final data collection date for primary outcome measure)|
Pancreas-Tx recipients; single cohort
This is a prospective, single cohort observational study, aimed at using a historical control group as comparison. It will be conducted at our single, national centre for organ transplantation in Oslo. All pancreas recipients > 18 years of age, who fulfill the inclusion criteria, will prior to transplantation be asked for inclusion.
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|Contact: Ole M Øyen, MD, PhD||+47 firstname.lastname@example.org|
|Contact: Rune Horneland, MD||+47 email@example.com|
|Oslo University Hospital||Recruiting|
|Oslo, Norway, 0027|
|Contact: Ole M Øyen, MD, PhD +47 92264777 firstname.lastname@example.org|
|Contact: Rune Horneland, MD +47 91177121 email@example.com|
|Principal Investigator: Ole M Øyen, MD, PhD|
|Principal Investigator:||Ole M Øyen, MD, PhD||Oslo University Hospital|