Peter Girman

Pancreatic islet (PI) transplantation (Tx) to the portal vein is an established therapeutic modality for selected type 1 diabetic patients. However, a comprehensive review considering the effects of PIs on surrounding liver tissue is lacking. Typical interactions can be detected in the early and delayed phases. This review summarizes known side effects of PI transplantation. In early phase the interaction occurs immediately upon contact of the PI into portal vein blood. Mechanical obstruction, exacerbated by thrombosis as part of the instant blood-mediated inflammatory reaction (IBMIR), leads to ischemic injury to adjacent liver tissue. Delayed changes, such as focal steatosis and glycogen accumulation appear days to weeks after Tx and are caused by local overstimulation of hepatocytes by insulin in supraphysiological concentrations. In animal models these lesions could progress over months to cystic cholangiomas or hepatocellular carcinomas. Such neoplastic changes have been observed in experimental animals; they have not been reported in human patients. In conclusion, while PITx into the liver is not an optimal procedure, it currently represents the site offering the best functional integration of the graft. The adverse effects discussed are pronounced but generally not severe, nor do they appear to compromise the overall health status of the recipients.

Background: Adequate glucose control is an important, yet a challenging task, in the early postoperative care after liver transplantation (LTx). Potential of continuous glucose monitoring (CGM) in this context had not been fully explored because of concerns about sensors’ precision in critical care. Objectives: We initiated a trial to assess feasibility, accuracy, and benefit of CGM used in addition to standard blood glucose (BG) management. Design: Prospective randomized trial. Methods: Patients undergoing LTx were included and randomized to wearing (1) unblinded (“active”) CGM which could help guiding insulin therapy, (2) blinded CGM serving as controls. Dexcom G6 was applied immediately after surgery, arterial BG values measured with blood gas analyzer served as reference and for calibration. We evaluated mean absolute relative difference (MARD), Diabetes Technology Society (DTS) Error Grid zones, bias, 15/15 agreement rate, evolvement of accuracy over time, and possible interfering factors. Fisher test, Mann–Whitney test, DTS software, and linear mixed model were used for statistical analysis. Results: We included 155 LTx recipients, 13 were excluded (1 died during surgery, 12 experienced sensor failure—6 from each group), data from 142 patients (80 in active and 62 in blinded CGM group) were analyzed. Overall, MARD was 9.1% in active and 10.7% in the blinded group ( p < 0.0001). DTS error grid in active group had shown 90% in zone A versus 85.3% in the blinded group. These results were consistent for reference glucose ranges 3.9–10 mmol/L and above 10 mmol/L, with less precision in the low ranges (these values were however rare). Sensor accuracy peaked on days 2–3 and deteriorated over time with significant worsening from day 7 on in both groups. Conclusion: Our study demonstrates feasibility and acceptable accuracy of CGM comparable to reports from the outpatient care. We believe this could be attributed to sensor calibration, reflected by more favorable outcomes in the active CGM group. In addition, we demonstrate decline in accuracy over time, suggesting their use in critical care could be limited to less days to secure sufficient reliability. Trial registration: This study is part of an ongoing prospective trial registered on ClinicalTrials.gov (NCT05585801) and was registered on October 12, 2022.

Background: Urinary tract infections (UTIs) are common complications following simultaneous pancreas and kidney transplantation (SPK). The role of specific immunosuppressive agents in modulating UTI incidence and recurrence remains poorly understood. Methods: In this retrospective, single‐center study, we analyzed 164 SPK recipients randomized to receive either sirolimus or mycophenolate mofetil (MMF) in combination with tacrolimus. The incidence of UTIs, relapses, recurrences, and UTI‐related hospitalizations was assessed over a 10‐year follow‐up. Univariable and multivariable negative binomial regression models were used to evaluate associations with immunosuppressive regimens and clinical outcomes in both intention‐to‐treat (ITT) and per‐protocol analyses. Results: A total of 572 UTI episodes were recorded during follow‐up (0.102 per 100 recipient‐transplant days). No significant differences in overall UTI incidence or UTI‐related hospitalizations were observed between the sirolimus and MMF groups. However, in the multivariable per‐protocol analysis, the sirolimus group experienced significantly fewer UTI‐related hospitalizations (IRR 0.46; 95% CI, 0.23–0.94; p = 0.034) and relapses (IRR 0.54; 95% CI, 0.30–0.97; p = 0.039). Significant risk factors for UTIs included female sex, JJ stent placement, and pretransplant urological abnormalities. Recurrent UTIs were associated with lower 10‐year kidney graft survival (52% vs. 75%; p = 0.01) but had no impact on pancreas graft or patient survival. Conclusions: While overall UTI incidence did not differ between immunosuppressive regimens, sirolimus use was associated with fewer hospitalizations and relapses. These findings indicate a potential clinical benefit of sirolimus in selected high‐risk SPK recipients, highlighting the need for further prospective investigation. Trial Registration: ClinicalTrials.gov identifier: NCT00140543

Se zvy?uj?c?m se po?tem diabetik? v populaci doch?z? tak? ke zv??en? mikrovaskul?rn?ch a makrovaskul?rn?ch komplikac?. Po?kozen? ledvin p?edstavuje jednu z hlavn?ch p???in mortality u pacient? s diabetem. Klasifikace diabetick? nefropatie je z... Se zvy?uj?c?m se po?tem diabetik? v populaci doch?z? tak? ke zv??en? mikrovaskul?rn?ch a makrovaskul?rn?ch komplikac?. Po?kozen? ledvin p?edstavuje jednu z hlavn?ch p???in mortality u pacient? s diabetem. Klasifikace diabetick? nefropatie je z...

OBJECTIVE: Glycemia management in critical care is posing a challenge in frequent measuring and adequate insulin dose adjustment. In recent years, continuous glucose measurement has gained accuracy and reliability in outpatient and inpatient settings. The aim of this study was to assess the feasibility and accuracy of real-time continuous glucose monitoring (CGM) in ICU patients after major abdominal surgery. RESEARCH DESIGN AND METHODS: We included patients undergoing pancreatic surgery and solid organ transplantation (liver, pancreas, islets of Langerhans, kidney) requiring an ICU stay after surgery. We used a Dexcom G6 sensor, placed in the infraclavicular region, for real-time CGM. Arterial blood glucose measured by the amperometric principle (ABL 800; Radiometer, Copenhagen, Denmark) served as a reference value and for calibration. Blood glucose was also routinely monitored by a StatStrip bedside glucose meter. Sensor accuracy was assessed by mean absolute relative difference (MARD), bias, modified Bland-Altman plot, and surveillance error grid for paired samples of glucose values from CGM and acid-base analyzer (ABL). RESULTS: We analyzed data from 61 patients and obtained 1,546 paired glucose values from CGM and ABL. Active sensor use was 95.1%. MARD was 9.4%, relative bias was 1.4%, and 92.8% of values fell in zone A, 6.1% fell in zone B, and 1.2% fell in zone C of the surveillance error grid. Median time in range was 78%, with minimum (<1%) time spent in hypoglycemia. StatStrip glucose meter MARD compared with ABL was 5.8%. CONCLUSIONS: Our study shows clinically applicable accuracy and reliability of Dexcom G6 CGM in postoperative ICU patients and a feasible alternative sensor placement site.