Pancreas and Kidney Transplantation

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22.1 Simultaneous Pancreas and Kidney Transplantation

Preoperative Planning and Consideration

Pancreas transplantation is currently a therapeutic option for patients with type 1 diabetes mellitus and, in selected circumstances, those with type 2 diabetes mellitus. The primary goal of the procedure is to replace insulin that is otherwise absent as a result of islet cell loss from the native pancreas. There are three possible scenarios for pancreas transplantation, including simultaneous pancreas and kidney transplant (SPK), pancreas after kidney transplant (PAK), and pancreas transplant alone (PTA). SPK is the most common procedure performed and has the best pancreas graft survival rates. Although the risks of the SPK operation include those related to chronic immunosuppression, as well as the inherent morbidity and mortality of the surgery, the benefits of the transplant include freedom from exogenous insulin, superior blood glucose control compared with all other insulin replacement strategies, no further need for dietary restrictions, and decreased progression, or potential improvement in, secondary diabetic complications (i.e., neuropathy and cardiovascular disease).

Aside from ABO blood group compatibility and negative human leukocyte antigen cross-matching, the next most important factor when considering a potential recipient for pancreas transplantation is the presence and/or extent of underlying coronary artery disease. Patients with diabetes mellitus often have comorbid diseases, including hypertension, hyperlipidemia, and peripheral vascular disease. To avoid life-threatening complications during or after a surgery, a thorough cardiac and possible vascular surgery evaluation is critical before listing for transplantation.

Appropriate organ donor selection limits complications such as bowel anastomotic leaks and vascular thrombotic events. The preferred donor age ranges from 10 to 45 years old. When potential donors are considered, graft outcomes are generally better from donors with traumatic cause of death in contrast to donor death secondary to cerebrovascular disease. Donor size is critical and ideally greater than 45 kg to avoid issues related to small donor vessels at time of Y-graft reconstruction. A donor BMI less than 30 is favored to prevent transplanting pancreata with high proportions of fatty intrusion, which has been shown to increase rates of graft thrombosis, pancreatitis, worsened ischemia reperfusion injury, and higher rates of postoperative infection. There are many additional factors involved in choosing the appropriate recipient and donor pair; however, a full list of criteria is beyond the scope of this chapter.

Simultaneous Pancreas and Kidney Transplantation