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Pancreas transplantation: In for the long run

Paraskevas, Steven

Current Opinion in Organ Transplantation: February 2012 - Volume 17 - Issue 1 - p 71–72
doi: 10.1097/MOT.0b013e32834f31b0
PANCREAS TRANSPLANTATION: Edited by Steven Paraskevas
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Pancreas and Islet Transplant Program, McGill University Health Centre, Montreal, Canada

Correspondence to Steven Paraskevas, MD, PhD, Associate Professor of Surgery, Director, Pancreas and Islet Transplant Program, McGill University Health Centre, Royal Victoria Hospital, S10.30, 687 Pine Avenue, W., Montreal, QC, H3A 1A1, Canada. Tel: +1 514 934 1934 ext 36522; fax: +1 514 843 1503; e-mail: steven.paraskevas@mcgill.ca

Although born in the same decade as the transplantation of other nonrenal organs, such as the liver, heart, and lungs, the transplantation of the pancreas did not come of age until much later, in the mid-1990s [1]. The reason for this situation is likely because of multiple factors, most importantly: equivocation regarding the benefits of transplantation to the diabetic recipient, continued enthusiasm for the advent of the much more experimental option of islet transplantation, and the recognition that the immediate complications were potentially more significant than for other types of solid-organ transplantation [2]. In the late 1990s and early 2000s, evidence of long-term benefits, in particular at the level of end-organ diabetic complications, began to mount, which included important evidence of survival benefit conferred by pancreas–kidney transplants compared with kidney alone [3]. More recent evidence has solidified the position of the pancreas transplant as a standard of care in the treatment of end-stage type 1 diabetic nephropathy [4], as well as having significant protective effects on the progression of nonrenal diabetic complications [5,6].

In 2012, the field finds itself now comfortably alongside the other commonly transplanted solid organs, with outcomes over 5 and 10 years roughly matching those of liver, lung, and heart, and benefits to long-term recipient survival exceeding those of kidney transplantation. Similarly, the focus of research in pancreas transplantation has shifted. A query of the Clinical Trials.gov site reveals 16 actively recruiting studies that specifically involve pancreas transplantation, a segment of the transplant population that, a decade ago, was usually excluded from most trials. The majority of these studies now focuses on immunological risks, immunosuppressive options, infectious complications, and such concepts that are familiar to the renal, hepatic, and cardiac transplant fields. Clinical trial networks that are specifically devoted to pancreas transplantation now operate in Europe and Canada. The procedure has succeeded, and its efficacy in treating diabetes is not the focus of debate, as it used to be.

The reviews presented in this issue of Current Opinion in Organ Transplantation reflect the abovementioned success and the changing perspective of challenges to the field. The focus on graft survival has now shifted to 10 and even 20 years after transplant, as described by Gruessner et al.[7]. Meanwhile, among the chronic conditions faced in the management of the pancreas transplant recipient, some of the most important ones are clearly reminiscent of those faced in other transplant contexts: chronic renal insufficiency and antibody-mediated rejection. The occurrence of end-stage renal disease, as discussed by Smail et al.[8] is of particular importance to the recipients of pancreas transplant alone (PTA). In this less commonly transplanted group, the trade-off of risks and benefits has tried to balance the improvement in diabetic nephropathy with the medication-related risks to native kidney function seen in all nonrenal transplant recipients [9,10]. Papadimitriou and Drachenberg [11] provide an expert analysis of the pathologic features of cellular- and antibody-mediated rejection in the allograft pancreas.

This is not to say that acute complications are not an ongoing problem. Farney et al.[12] address pancreas graft thrombosis and approaches to preventing this devastating complication.

In addition, the question of which option is best for the recipient candidate with renal failure is addressed by Wiseman [13]. Close to a decade ago, pancreas transplantation following kidney transplantation was hampered by the absence of data that demonstrated a benefit to this sequential approach. Newer evidence that supports its outcomes will certainly renew the value of this option to the physician considering the pretransplant diabetic candidate, particularly in light of ever-increasing wait times for kidneys from deceased donors and the aging of the deceased donor population. Finally, from a group which has defined the procedure for so many years, Sutherland et al.[14] look at another frontier that can be considered to address the shortage of deceased donors: hemi-pancreatic grafts from living donors.

In all, the reviews in this section provide a wide survey of the field in 2012, with the challenges of the ‘successful’ transplant being faced: of graft function extending well into the second decade, of continued need to expand the donor pool, and of the risks of chronic immunosuppression.

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Acknowledgements

None.

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Conflicts of interest

There are no conflicts of interest.

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REFERENCES

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