Henry Ford Hospital Medical Journal Henry Ford Hospital Medical Journal

Volume 26 Number 2 Article 8

6-1978

Effect of Glucagon and Methylprednisolone on Effect of Glucagon and Methylprednisolone on

Pancreatectomized Recipients of Whole Pancreas Allografts Pancreatectomized Recipients of Whole Pancreas Allografts

Luis H. Toledo-Pereyra

Michael Zammit

Krishna D. Valjee

Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal

Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons

Recommended Citation Recommended Citation Toledo-Pereyra, Luis H.; Zammit, Michael; and Valjee, Krishna D. (1978) "Effect of Glucagon and Methylprednisolone on Pancreatectomized Recipients of Whole Pancreas Allografts," Henry Ford Hospital Medical Journal : Vol. 26 : No. 2 , 41-46. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol26/iss2/8

This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons.

Henry Ford Hosp Med Journal

Vol 26, No 2, 1978

Effect of Glucagon and Methylprednisolone on Pancreatectomized Recipients of Whole Pancreas Allografts Luis H. Toledo-Pereyra, MD, PhD,* Michael Zammit, MD,* and Krishna D. Valjee, MD*

Glucagon alone or in combination with methylpred­nisolone was an adequate therapeutic adjuvant for pan­createctomized recipients of whole pancreas allografts. All recipients were minimally immunosuppressed with azathioprine, 5.0 mg/K/day for three days, then 2.5 mg/K/day. The morphological, functional, and survival response after whole pancreas transplantation indicated a trend of improvement in the treated groups. Only the groups of dogs receiving glucagon alone or in combination with methylprednisolone survived more than two weeks after transplantation. This therapy has proven to be effective for whole pancreas transplantation.

Introduction

M ANY attempts have been made to protect the pancreas from severe pancreatitis, edema, and hemorrhagic necrosis after transplantation.1 Tersigni and his group^'^ used meth­ylprednisolone, glucagon, and allopurinol to protect pan-creatico-duodenal allografts preserved by hypothermic pulsati le perfusion for twenty- four hours. Recently, Kyriakides and his colleagues""^ analyzed the beneficial effect of glucagon, trasylol, and steroids in duct-ligated, porcine pancreas transplants. We used mongrel dogs whose pancreatic ducts were not ligated. This work was designed to evaluate the effect of glucagon alone or in combination with methylprednisolone on the survival of pancreatectomized recipients of whole pancreas allografts.

Submitted for publication: April 18, 1978

Accepted for publication: May 8,1978

This work was supported by an Institutional Grant, No. 730-0786, from the Henry Ford Hospital through the Ford Foundation.

* Departmentof Surgery, Section ofTransplantation and Surgical Research, Henry Ford Hospital.

Address reprint requests to Dr. Toledo-Pereyra, Department of Surgery, Section of Transplantation and Surgical Research, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, Ml 48202

Material and Methods Adult mongrel dogs of either sex, weighing between 15-25 kg, were anesthetized with sodium thiamylal for induction and halothane (0.5-2.0%) for maintenance. Donor dogs received 500-750 ml of Ringer's lactate during the opera­tion. Total pancreatectomy was performed according to Aquino's technique.'No warm ischemia was applied. A cuff of celiac trunk and portal vein was obtained forthe vascular anastomosis. After the organ was removed, it was flushed with cold (4°C) Ringer's lactate (200 ml) containing heparin (10,000 U/L), procaine (0.1 g/L), and methylprednisolone (250 mg/L) buffered with bicarbonate to a pH of 7.4.

After total pancreatectomy, the pancreas from the donor animal was placed into the right iliac fossa with vascular continuity established between the host's right common iliac artery end-to-end to the celiac trunk and the donor's portal vein end-to-side to the inferior vena cava. The pancreatic duct was implanted using a technique modified from the one described by Aquino.' Almost all ofthe papilla was eliminated in order to leave the duct alone for the anastomosis wfth the jejunum or ileum. No blood transfu­sions were given. The recipient dogs received approxi­mately 750 ml of Ringer's lactate with dextrose 5% during

41

Toledo-Pereyra, Zammit, and Valjee

CAUSES OF DEATH OF ALL CANINE PANCREAS TRANSPLANTS'

CAUSES GROUPS

1 II III

Pancreatitis 2 1 0 Vascular thrombosis 1 0 0 Intussusception 1 1 1 Sepsis 1 1 1 Pneumonia 0 1 1 Pancreas rejection 2 2 2 Cachexia 0 2 2 Unknown 1 0 1

TOTAL 8 8 8

"This count excludes five dogs that died of unrelated or technical failures in the first three days posttransplantation.

the operation and for six hours thereafter. Intravenous antibiotics were administered daily for one week, and oral alimentation was established in the third to fourth day. All dogs were minimally immunosuppressed with azathioprine, 5 mg/K/day for three days, then 2.5 mg/K/day until death. Blood glucose and serum amylase tests were carried out daily for one week, then every third to fifth day until death. Autopsy was performed on all dogs with pancreas histologic examination. Statistical analysis was obtained with the method of analysis of variance in all data.

Three groups of eight dogs each were studied. Group 1, the pancreas transplant control, received no treatment except for minimal immunosuppression. In Group II, donor dogs received glucagon (1 mg) infused intravenously in saline for over one hour, thirty minutes before and during pancreas excision, with atotal infusion rateof40 ju,g/k/h.Thereafter, the recipient animal received the same intravenous infusion duringtransplantation and 2 mg IM every six hours daily for three days. In Group 111, donor and recipient dogs were pretreated with 30 mg/K of methylprednisolone two hours before pancreatectomy in addition to receiving glucagon in the same dosages as the dogs in Group II. Thereafter, 500 mg IV were given duringtransplantation and 250mg IM twice a day for three days afterwards.

Results Figure 1 shows the survival rates for all groups of dogs. The animals transplanted with pancreases treated wfth glucagon survived longer (p>0.08) than those in the untreated group. The addition of methylprednisolone to glucagon improved survival results even more when compared to the control group (p>0.01) or to the group treated with glucagon alone (p>0.1).

o >

cn o

1/5 D CU k-u c o

LL

100

G/uca gon

G/ucagon -h I 4 Meftiy/predniso/one

10 15 20 25 30 35

Days Postlransplantation

Fig.1

Canine pancreas transplants treated wi th glucagon alone or in combina­tion w i th methylprednisolone had better survival results than the un­

treated transplanted animals.

The causes of death of all dogs included in this study are listed in the accompanying table. Five dogs that died of unrelated or technical failures in the first three days after transplantation were eliminated from this study. The causes of death were venous anastomotic bleeding (one dog from Group II), pancreatic duct leakage and peritonitis (two dogs from Group I, one dog from Group III), and anesthetic death (one dog from Group II).

The blood glucose levels (Figure 2) were within normal limits in all groups of dogs for the first five days post­transplantation. Thereafter, atone week after surgery, higher levels were observed in the control than in the treated groups (p>0.1->0.8). A continuous rise was observed from one week post-transplantation until death (Figure 2).

The serum amylase levels (Figure 3) were normal in all groups only for the first two days post-transplantation. Thereafter, there was a steady and continuous increase, which was more dramatic at day 10 (Figure 3). Higher levels were observed in the control group than in the treated group of animals at days 7, 10, and 15 post-transplantation (p>0.08->0.1). No difference (p>0.5) was noted between the two groups of treated dogs at any t ime after transplantation.

There were no significantdifferences (p>0.1->0.8) noted in the white blood cells between the three groups of animals. However, at one week post-transplantation higher levels were observed in the control group (24,050±1275 x mm) (M±SE) than in the treated groups (18,785 ±1067 x mm) (M±SE) (p>0.1). No significant changes (p>0.1->0.8)

42

Glucagon and Methylprednisolone in Pancreas Transplantation

300

250 1^

200 a> w o 150 o 100

O T3 75 O

75 o 50

25

Contro/

G/ucagon f Metliy/prednisolone

JD

0

NORMAL

1 1 1 1 / 1 1 1 1 3 5 7 10 15 20 25

Days Posttransplantation Fig. 2

Average blood glucose levels in all groups of animals. A delayed increase in blood glucose was observed in the treated groups.

were observed in the hematocrit of all dogs after transplantation.

Histologically, the pancreas of the control transplant dogs showed some duct dilatation, edema, lymphocytic infiltra­tion, and architectural distortion (Figure 4). The groups treated wfth glucagon alone showed minimal ductdilatation and edema; cellular infiltration was not prominent, and architectural changes were moderate. The group treated with glucagon and methylprednisolone had no edema, and ductdilatation was occasionally seen. Cellular infiltration in this group was less significant than in Groups I and II. There were minimal to moderate architectural changes (Figure 5).

Discussion This study confirms that glucagon alone or in combination with methylprednisolone is beneficial for canine pancreas transplantation. Morphological and functional response after transplantation, as well as the survival results, indicated improvement in the canine grafts treated with glucagon alone or combined with methylprednisolone.

The mechanism of action of glucagon in improving pan­creas transplant survival is not known. Glucagon has a definiteeffect in reducingexocrine pancreatic f u n c t i o n . I t affects the rate of flow, bicarbonate concentration, and rate of enzyme secretion by the pancreas with and without inflammation. It has been postulated that glucagon activates cycl ic 3 ' ,5 ' -AMP by increasing the act ivi ty of adenyl c y c l a s e . T h i s might also be an important factor.

The most effective dosage of glucagon has not been worked out, and it is necessary to develop a good method to

3 5 7 10 15 20 25 Days Posttransplanlation

Fig. 3

Average serum amylase levels in all groups of animals. Lower values were observed in the treated groups than in the control.

maximize its effect on pancreatic transplantation. Thirty minutes afterthe infusion has been administered glucagon practically disappears from the circulation. Its short-lasting eftect has to be considered for studies like this which are designed to protect pancreatic allografts for transplantation. Thirty to forty mg/K/hour appear to cause a significant inhibitory effect on pancreatic secretion.""^' However, Kyriakides and his associates^ demonstrated that 2 mg of glucagon administered IM daily were effective for auto­grafts, but had no beneficial effect on allografts. Increasing the dose to 4 mg twice a day was also ineffective in prevenfing pancreatic fluid accumulation, although it ap­peared to prevent hyperamylasemia.'' When the same total dose was administered more frequently (2 mg IM every six hours), significant decrease in fluid accumulation around the pancreas was observed. From the work of Kyriakides etal and from other studies, it appears that a dosage of 2 mg IM every six hours is the most adequate way to treat pancreatic allografts at the present time.

The beneficial effect of steroids on pancreas allografts is probably due to the anti-inflammatory^'"^^ and membrane stabilizing properties ofthese s u b s t a n c e s . I n addition, it is possible that their immunosuppressive effect could be an important factor in the prolongation of survival. Although there is some evidence in the literature that steroids can cause pancreatitis,"'" in our work and others""^-^"-^^ their beneficial effect has been well established. The question is not whether steroids are beneficial, but mainly what is their most effecfive use in terms of dosage and timing.

In summary, canine pancreas allografts survived an average of 11.6 days when no treatment was given except minimal

43

Toledo-Pereyra, Zammit, and Valjee

Amiipw

I-Fig. 4

Histological appearance of an untreated pancreas several days posttransplantation (X325). Note architectural distortion and poor preservation of acini and islets.

Fig. 5

Histological appearance of pancreas treated wi th glucagon and methylprednisolone several days posttransplantation (X325). Good preservation of islets and acini is observed.

44

Glucagon and Methylprednisolone in Pancreas Transplantation

immunosuppression. The administration of glucagon pro­longed survival to an average of 16.8 days. The combination of glucagon and methylprednisolone was even more effec­tive, improving pancreas allograft survival to an average of 19.5 days. Thus, ft is evident that glucagon alone or in combinat ion w i th methylprednisolone is an adequate therapeutic adjuvant for canine pancreas allografts.

References 1. Lillehei RC, Simmons RL, Najarian JS, Weil R, Uchida H, Ruiz JO,

Kjellstrand CM, and Goetz FC: Pancreaticoduodenal allotransplanta­t ion: Experimental and clinical experience. Ann Surg 172:405, 1970.

2. Tersigni R, Toledo-Pereyra LH, Pinkham J, and Najarian JS: Pan­creaticoduodenal preservation by hypothermic pulsatile perfusion for twenty-four hours, Ann Surg 182:743, 1975.

3. Tersigni R, Toledo-Pereyra LH, and Najarian JS: Effects of methylpred­n iso lone, g lucagon and a l lopur ino l in the protect ion of pan­creaticoduodenal allografts perfused for twenty-four hours. Surg 78:599, 1975.

4. Kyriakides GK, Arora VK, Lifton J, Nuttal FO, and Miller J: Porcine pancreatic transplantation. I, Autotransplantation of duct ligated seg­ments.; 5urg Res 20:451, 1976.

5. Kyriakides G, Miller J, Lifton J, and Najarian JS: Effect of steroids on the structure and endocrine function of the duct I igated porcine pancreatic autografts. Surg forum 25:384, 1974.

6. Kyriakides GK, Arora VK, Lifton J, Nuttal FO, and Miller J: Porcine pancreas transplants, II. Allotransplantation of duct ligated segment, y Surg Res 20:461, 1976.

7. Aquino C, RuizJO, Schultz LS, and Lillehei RC: Pancreatic transplanta­tion without duodenum in the dog. Am / Surg 125:240, 1973.

8. Boggs DR, Athens JW, Cartwright GE, and Wintrobe M M : The effect of adrenal corticosteroids upon the cellular composition of inflammatory exudates. Amer / Patho/ 44:763, 1964,

9. Dyck WP, Texter EC, Lasater JM, and Hightower NC, Jr: Influence of glucagon on pancreatic exocrine secretion in man, Castroentero/ogy 58:532, 1970.

10. Jarrett L and Lacy PE: Effect of glucagon on the acinar portion of the pancreas. Endocrinology 70:867, 1961.

11. Thau A, Paliola G, Ziparo V, et al: L'uso del glucagone nell-amotra-pianto enterotopico del pancreas senza duodeno nel cane. // Pot-id in ico 81:47, 1974.

12. Zajtchuk R, Amato JT, Paloyan E, and Baker RJ: Inhibition of pancreatic exocrine secretion by glucagon, Surg Forum, 18:410, 1967.

13. Orloff J and Handler JS: The role of adenosine 3'5' - phosphate in the action of antidiuretic hormone, Amer / Med 42:757,1967.

14. PryorJ and BerthetJ:The action of adenosine 3'5' - monophosphate on the incorporation of leucine into liver proteins. Biochim Biophys Acta 43:556, 1960.

Glucagon therapy in acute 15, Condon JR, Knight M, and Day JL: pancreatitis, Br I Surg 60:510, 1973.

16, Condon RE, Woods JH, Poulin TL, and Pissiotis CA: Experimental pancreatitis treated with glucagon or lactated Ringer's solution. Arch Surg 109:154, 1974.

17, Miller TA, Watson LC, Rayford PL, and Thompson JC: The effect of glucagon on pancreatic secretion and plasma secretion in dogs. World I Surg 1:93, 1977.

18. Boggs DR, Athens JW, Cartwright GE, and Wintrobe M M : The effect of adrenal corticosteroids upon the cellular composition of inflammatory exudates. Amer / Pathol 44:763, 1964.

19. Howes EL, Plotz CM, Blunt JW, and Tagan C: Retardation of wound healing by cortisone, Surg 28:177, 1950,

20. Weissman G and Thomas L: Studies on lysosomes. I, The effect of endotoxin tolerance and cortisone on the release of acid hydrolases from a granular function of rabbit liver. / f xp Med 116:433, 1962.

21. Weissman G and Dingle JR: Release of lysosomal protease by ultravio­let irradiation and inhibition by hydrocortisone. Exp Celt Res 25:207, 1961.

22. Carone FA and Liebow AA: Acute pancreatic lesion in patients treated with ACTH and adrenal corticoids. N £ng/ / Med 257:690, 1957.

23. Nelp WB: Acute pancreatitis associated with steroid therapy. Arch Intern Med 108:702, 1961,

24. Anderson MC, Booher DL, and Lim TB: Treatment of acute pancreatitis with adrenocorticosteroids, Surg 55:551, 1964.

25. Brockis JG and Jones ET: Treatment of acute pancreatitis with cor­tisone, Brit Med I 2:1524, 1956,

26. Eskwith IS, Case VA, and Sallosy A: Acute hemorrhagic pancreatitis treatment with cortisone. N £ng/1 Med 252:494, 1955.

27. Gliedman M, Gold M, Whittaker J, Rifkin H, Soberman R, Freed S, Tellis V, and Veith FJ: Clinical segmental pancreatic transplantation with ureter-pancreatic duct anastomosis for exocrine drainage, Surg 74:171, 1973.

28. Litke PA: Lysosome stabilizing agents for hypothermic kidney preser­vation. Nature 212:512, 1966.

29. Starling JR, Rudolf LE, Ferguson W, and Wangensteen SL: Benefits of methylprednisolone in the isolated perfused organ, Ann Surg 177:566, 1973,

30. Toledo-Pereyra LH and Najarian JS: Preservation ofthe small intestine for allotransplantation. Surg Gynecot Obstet 137:445,1973.

31. Toledo-Pereyra LH, Simmons RL, and Najarian JS: Comparative effects of chlorpromazine, methylprednisolone, and allopurinol during small bowel preservation. Am / Surg 126:631, 1973.

45

46