When Is Pancreas Transplantation Indicated?
Kim A. Carmichael, MD—Series Editor
Carmichael KA. When is pancreas transplantation indicated? Consultant. 2011;51(11):842-843.
Q: If pancreas transplantation can cure diabetes, why is it not available to more patients?
A: Pancreas transplantation can eliminate the need for insulin and oral medication, improve neuropathy, and halt the progression of retinopathy and atherosclerosis. However, in some patients, the risks and complications of the procedure and the adverse effects of antirejection medications may outweigh the potential benefits.
Q: Do the data show improvements in the risks and complications of pancreas transplantation?
A: With advances in surgical techniques and immunosuppressive therapy, the overall post- transplant survival rate for persons with type 1 diabetes mellitus has improved (higher than 95% at 1 year and higher than 90% at 3 years),1 but it is still generally lower than that of persons treated with conventional therapy. Pancreas graft survival rates are also higher than 95% at 1 year and higher than 90% at 5 years.
Q: Who is a candidate for pancreas transplantation?
A: Generally, transplant recipients are younger than 60 years old,1 are medically and emotionally able to withstand surgery and immunosuppression, understand the risks as well as the benefits of transplantation, and are willing to comply with long-term follow-up. A strong family and/or community support system is also essential. Persons with diabetes whose blood glucose levels are not controlled with standard treatment, despite advanced patient education and self-care, may be candidates for transplantation. This is especially true in those with serious, frequent, insulin-related hypoglycemic reactions because hypoglycemia unawareness increases the potential for accidental injury and/or death. The primary indication for solitary pancreas transplantation is severe hypoglycemia unaware- ness, and the procedure is generally performed only on those with type 1 diabetes (93%).
Patients who also have severe renal disease should be considered for combined transplantation of the kidneys and pancreas because most persons with type 1 diabetes who undergo only renal transplantation will show evidence of renal damage within 2 years.
Although about 93% of patients who receive a pancreas transplant have type 1 diabetes (International Pancreas Transplant Registry data), a growing number of candidates with type 2 diabetes are being identified.2 To be considered, those with “complicated” type 2 diabetes should be younger than 55 to 60 years old, have C-peptide levels of less than 10 ng/mL, have required insulin (less than 1 μg/kg/d) for at least 5 years, and have a body mass index (BMI) of less than 30 to 32 kg/m2. Recent data have shown comparable outcomes for persons with type 2 and type 1 diabetes.
Patients with diabetes secondary to a previous pancreatectomy may also be candidates for transplantation.
Q: Are there different types of pancreas transplantation?
A: The majority of transplants are from deceased donors (99.7%), with living donor transplants performed in only three centers in the United States. The transplanted organ(s) are generally placed in the lower abdomen with enteric (pancreas) and bladder (renal) drainage and the recipient pancreas is left intact.
The three categories of pancreas transplantation are:
- Simultaneous pancreas-kidney transplant (SPK).
- Pancreas-after-kidney transplant (PAK).
- Pancreas-alone (PTA).
Approximately 85% to 90% of patients need pancreas and kidney transplant, and 80% of these are SPK transplants. SPK may be more cost-effective; however, it usually involves a longer wait- ing time, while PAK allows for earlier renal transplantation from a living donor and offers earlier correction of uremia.3 Longer waiting times may also be necessary for PTA because most trans- plant centers require at least three HLA antigen matches or one match for each HLA locus.4
Q: What are the risks associated with transplantation?
A: Along with the usual surgical risks, additional risks include venous thrombosis, clotting which can cause infarction of the new pancreas, and pancreatitis. Other complications include an increased risk of cardio-cerebrovascular events, serious infections, malignancy, and renal insufficiency. If the transplanted pancreas fails, diabetes will return and there will be a three-fold increase in the relative risk of death.1
Q: When is pancreas transplantation contraindicated?
A: Patients with a history of severe heart or lung disease, cancer, or blood vessel disorders of the neck and lung, and those with chronic infections (such as hepatitis or HIV infection) are not good candidates for transplantation.5 Persons with diabetes who are obese (BMI of more than 28 kg/m2) must lose weight before the procedure. Candidates who smoke or abuse alcohol and/or other substances are not considered until those issues are resolved.
Q: Where can I find additional resources on transplantation?
A: There are several Web resources that provide updated statistics and information:
- Arbor Research Collaborative for Health (http://www.USTransplant.org).
- International Pancreas Transplant Registry (http://www.iptr.umn.edu/).
- United Network for Organ Sharing (http://www.unos.org).
Dr Carmichael is associate professor of medicine, department of internal medicine, division of endocrinology, diabetes, and lipid research at Washington University School of Medicine in St Louis, Missouri.
- Gruessner AC, Sutherland DER, Gruessner RGW. Pancreas transplantation in the United States: a review. Curr Opin Organ Transplant. 2010;15:93-101.
- Orlando G, Strata RJ, Light J. Pancreas transplantation for type 2 diabetes mellitus. Curr Opin Organ Transplant. 2011;16:110-115.
- White SA, Shaw JA, Sutherland DER. Pancreas transplantation. Lancet. 2009;373:1808-1817.
- Han DJ, Sutherland DER. Pancreas transplantation. Gut Liver. 2010;4:450-465.
- MedlinePlus. Pancreas transplant. US National Library of Medicine, National Institutes of Health. http://www.nlm.nih.gov.medlineplus/article/003007.htm.
1. Gruessner AC, Sutherland DER, Gruessner RGW. Pancreas transplantation in the United States: a review. Curr Opin Organ Transplant. 2010;15:93-101.
2. Orlando G, Strata RJ, Light J. Pancreas transplantation for type 2 diabetes mellitus. Curr Opin Organ Transplant. 2011;16:110-115.
3. White SA, Shaw JA, Sutherland DER. Pancreas transplantation. Lancet. 2009;373:1808-1817.
4. Han DJ, Sutherland DER. Pancreas transplantation. Gut Liver. 2010;4:450-465.
5. MedlinePlus. Pancreas transplant. US National Library of Medicine, National Institutes of Health. http://www.nlm.nih.gov/ medlineplus/ar ticle/003007.htm.