Pancreas Transplantation

A

History and Epidemiology

• 1.

  First pancreas transplant was performed in 1966 at the University of Minnesota.

• 2.

  More than 25,000 US and 10,000 worldwide pancreas transplants have taken place since the original operation.

• 3.

  Type 2 diabetes mellitus (DM) is associated with an increased risk of blindness (25×), kidney disease (17×), gangrene (20×), heart disease (2×), and stroke (2×) compared with patients without DM.

B

INdications for Pancreas Transplantation

• 1.

  Insulin-dependent (type 1) diabetics who show C-peptide deficiency, although some insulin-independent (type 2) diabetics may be considered

• 2.

  “Brittle diabetics”: patients who are insulin dependent and suffer from wide fluctuations in glucose levels

  • a.

    Urgency increases with “hypoglycemic unawareness,” in which hypoglycemic episodes are not recognized by the patient.

• 3.

  Patients with end-stage or impending renal disease secondary to diabetes

C

Types of Pancreas Transplants

• 1.

  Simultaneous pancreas and kidney (SPK) transplant—80% of pancreas transplants

  • a.

    Patients with concurrent DM and end-stage renal disease (ESRD)

  • b.

    Provides a dialysis-free and insulin-independent life

  • c.

    Advantage—insulin control protects longevity of renal allograft.

  • d.

    Lowest incidence of pancreas graft thrombosis (5%) and immunologic graft loss (2%)

• 2.

  Pancreas after kidney (PAK) transplant—15% of pancreas transplants

  • a.

    Patients with prior renal transplant and difficult-to-control diabetes

  • b.

    Limits damage of poorly controlled diabetes on renal allograft

  • c.

    Higher rates of graft thrombosis (8%) and immunologic graft loss (5.5%) than with SPK

• 3.

  Pancreas transplant alone (PTA)—5% of pancreas transplants

  • a.

    Nonuremic, labile diabetics with hypoglycemic unawareness

  • b.

    Consider when risk of secondary complications from DM outweighs the risk of surgery and immunosuppression

  • c.

    Similarly, higher rates of graft thrombosis (7%) and immunologic graft loss (6.6%) than with SPK

D

Organ Selection

Almost all are performed from cadaveric donors. In addition to standard criteria for donor selection, specific contraindications to pancreas donor eligibility at most centers include:

• 1.

  Presence of DM or first-degree relative with DM

• 2.

  Chronic pancreatitis

• 3.

  Pancreatic damage secondary to trauma

• 4.

  History of alcohol abuse