The case of anoxia was the case of suicide. The period of cardiorespiratory arrest was estimated at about 20 minutes.
By using ISRC-PK, the average warm ischemic time could be limited to 3.0±0.8 min. All the pancreata were exposed to minimal warm ischemic period because they were almost immediately perfused with cold lactate ringer solutions. There is no correlation between warm ischemic time and islet yield before (R2=0.1811, P=0.2931) or after (R2=0.0047, P=0.8719) purification.
The operations for procurement of the kidneys and pancreata lasted 45.6±3.6 min and 10.6±1.8 min, respectively. Total storage period was between 105 and 305 min.
Pancreatic Islet Variables and Transplantation
Islet characteristics are shown in Table 3. Islet yield per isolation was 444,426±35,172 islet equivalent, purity was 51.9±5.0%, and viability was 95.5±1.4%, whereas previous studies reported a successful islet isolation rate of only 55 to 61% (2, 12). All of our cases (100%) met the criteria for islet transplantation based on the Edmonton protocol, and seven of the eight islet preparations were transplanted into four patients with type 1 diabetes. The remaining case was our first human pancreas isolation, but this islet preparation was not transplanted because at the time of the isolation there was not yet a procedure in Japan for the use of fresh islets. Therefore, that islet preparation was cryopreserved. At that time, we did not have any agreement of fresh islet transplantation in Japan. After this case, the Japan committee of pancreas and islet transplantation fixed the protocol for the fresh islet transplantation. We transplanted the first islets into a type 1 diabetic patient for the first time in Japan on April 7, 2004. The patient was sedated and a percutaneous transhepatic approach was used for the access to the portal vein. The Kumpe catheter was placed within the main portal vein. Islets were infused by gravity using bag technique (13). This patient received a second transplantation three months after the initial transplantation, and became insulin independent 19 days after secondary transplantation (7). Furthermore, all patients were showed after PIT that insulin requirements were improved from 0.6±0.1 units/kg to 0.3±0.1 units/kg and also hemoglobin A1c levels changed from 8.0±0.4% to 5.1±0.2%, respectively.
The first successful PIT in Japan was performed by our team. The favorable outcome may spread islet transplantation as an alternative to whole organ pancreas transplantation for the type 1 diabetes patients. Theoretically, PIT has several advantages over whole organ transplantation. It is less invasive because the procedure can be performed percutaneously and recipients do not require prolonged hospitalization.
The most important issue affecting islet transplantation is related to donor quality (14, 15). In spite of a serious shortage of donors in Japan, it is prohibited by law to use the pancreas from heart-beating brain death donors for PIT. This fact made it necessary to perform PIT by using islets isolated from NHBD. Although some institutions have tried to perform PIT with islets isolated from NHBD, it proved to be difficult to isolate human islets successfully from NHBD (3, 4). In fact, only one case of successful islet transplantation with NHBD was reported (3). To obtain better results for islet isolation from marginal donors, we implemented several procurement strategies.
First, we used ISRC to prevent from warm ischemic injury during organ procurement. Kato et al. developed ISRC for the kidney procurement (5). The only modification we made was the position of the double balloon catheter to ensure pancreas and kidney protection. This ISRC system reduced warm ischemic time to only 3 minutes, whereas the University of Pennsylvania group had 20 minutes of warm ischemic time (3). We used lactate ringer solution instead of University of Wisconsin solution for perfusion. Lactate ringer solution has low potassium concentration and low viscosity compared with University of Wisconsin solution. Low potassium concentration could prevent potassium induced vasospasms and low viscosity help rapid perfusion. Therefore, using lactate ringer for perfusion might be important in ISRC. Our results showed no correlation between islet yield and warm ischemia time. In our speculation, this was caused by remarkable shortening of warm ischemic time in all cases by ISRC (3, 16).
Second, the pancreas procurement team met with the kidney procurement team to discuss details of the procedure and to explain any risk of organ injury during the procurement procedures. This communication enabled us to protect pancreas during kidney retrieval.
Third, after the peritoneal cavity had been opened, the lesser sac was filled with some crushed ice. Lee et al. have previously reported that for their procurement technique involving mobilization of the pancreas, slush was packed onto the posterior and anterior surfaces of the pancreas to maintain a core pancreas temperature of 4°C (12). Our ISRC did not require mobilization of the pancreas. After the ISRC had been performed, the cadaver body—especially “the back”—was chilled down immediately. It was reflected that the core of pancreas was chilled suitably.
Fourth and last, KPT usually do not consider the pancreas, so it is vulnerable to injury. Therefore, the injuries of the pancreas had been avoided by one surgeon from the pancreas procurement team. Of special interest in connection with our procurement procedure was that there was no reduction in the number of renal transplant or function of the kidney grafts. Additionally, our novel technique prevents the possibility of contaminating the kidney since kidney was procured first. If kidney is excised after the pancreas procurement, contamination of the kidney might occur. (Note: Under “Procurement of Human Pancreas,” it says that under Japanese rules pancreas procurement for islet must be performed after kidney procurement.)
We developed a novel procurement technique in cooperation with our kidney procurement team. This collaborative effort has resulted in successful islet isolation in all cases. Our current protocol for the procurement of pancreas and kidney from a NHBD enabled us to transplant islets into a type 1 diabetic patient and kidney into a renal failure patient.
The authors wish to thank Tetsuo Kanno, Hirotoshi Sano, Motoi Shoda, Yoko Kato, Fumihiro Imai, Takafumi Kaito, Shingo Maeda, Tsunetoshi Araki, Hirotoshi Ishise, Takamitsu Morikawa, Hitomi Sasaki, Mamoru Kusaka, Nobuyuki Oyama, Hironobu Akino, Osamu Yokoyama, Yoshikazu Tsuji, Kenji Mizuno, Masahiro Ito, Shin Ishihara, Yuji Iwase, Akihiko Horiguchi, Makoto Hayakawa, Naotatsu Niwamoto, Yasumitsu Ukai, Chikao Yamazaki, Osamu Kato, Akika Uwano, Tomoko Asai, Yukiko Kobayashi, Yumiko Yonemitsu, Kazuyo Fujii and Miyuki Hara for their assistance and arrangement of organ procurement; Yasunari Kasai, Taira Maekawa, Yusuke Nakai, Michiko Ueda, Yurika Uchida, Yoko Nakagawa, Hiroko Muramatsu, Akemi Ishii, Yumi Yoshida for their technical assistance and maintenance of the GMP facility; and Kazuhito Fukuda, Yuichiro Yamada, Katsushi Tsukiyama as well as all members of the Department of Diabetes and Clinical Nutrition of the Kyoto University Graduate School of Medicine.
1. Shapiro AMJ, Lakey JRT, Ryan EA, et al. Islet transplantation
in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med
2000; 343: 230.
2. Ricordi C. Islet transplantation
: a brave new world. Diabetes
2003; 52: 1595.
3. Markmann JF, Deng S, Desai NM, et al. The use of non-heart-beating donors for isolated pancreatic islet transplantation
2003; 75: 1423.
4. Clayton HA, Swift SM, Turner JM, et al. Non-heart-beating organ donors: a potential source of islets for transplantation? Transplantation
2000; 69: 2094.
5. Kato M, Mizutani K, Hoshinaga K, et al. In situ renal cooling for kidney transplantation from non-heart-beating donors. Transplant Proc
2000; 32: 1608.
6. Matsumoto S, Qualley S, Goel S, et al. Effect of the two-layer (University of Wisconsin solution-perfluorochemical plus O2) method of pancreas preservation on human islet isolation, as assessed by the Edmonton Isolation Protocol. Transplantation
2002; 74: 1414.
7. Matsumoto S, Okitsu T, Iwanaga Y, et al. Successful islet transplantation
from non-heart-beating donor pancreata using modified Ricordi islet isolation method. Transplantation
8. Matsumoto S, Zhang HJ, Gilmore T, et al. Large-scale isopycnic isletpurification utilizing non-toxic, endotoixn-free media facilitates immediate single-donor pig islet allograft function. Transplantation
1998; 66: S30.
9. van der Burg MP, Basir I, Zwaan RP, Bouwman E. Porcine islet preservation during isolation in University of Wisconsin solution. Transplant Proc
1998; 30: 360.
10. Ricordi C, Gray DW, Hering BJ, et al. Islet isolation assessment in man and large animals. Acta Diabetol Lat
1990; 27: 185.
11. Bank. Rapid assessment of islet viability with acridine orange and propidium iodide. In Vitro Cell Dev Biol
1988; 24: 266.
12. Lee TC, Barshes NR, Brunicardi FC, et al. Procurement of the human pancreas for pancreatic islet transplantation
2004; 78: 481.
13. Baidal DA, Froud T, Ferreira JV, et al. The bag method for islet cell infusion. Cell Transplant
2003; 12: 809.
14. Lakey JRT, Warnock GL, Rajotte RV, et al. Variables in organ donors that affect the recovery of human islets of Langerhans. Transplantation
1996; 61: 1047.
15. Matsumoto S, Zhang G, Qualley S, et al. Analysis of donor factors affecting human islet isolation with current isolation protocol. Transplant Proc
2004; 36: 1034.
16. Tanioka Y, Hering BJ, Sutherland DER, et al. Effect of warm ischemia on islet yield and viability in dogs. Transplantation
1997; 64: 1637.
Keywords:© 2006 Lippincott Williams & Wilkins, Inc.
Islet transplantation; Nonheart-beating donor; Organ procurement