Ideally, a combined kidney and pancreas transplantation should be recommended for patients with severe diabetes and end-stage renal disease. Therefore, SPK is the most common type of pancreas transplantation, accounting for 79% of procedures in the United States in 2016.2 Both organs are usually procured from a single deceased organ donor. PAK transplantation is offered to diabetic patients who have already undergone kidney transplantation. PTA is offered to candidates without end-stage renal disease, but with frequent, acute, and potentially life-threatening complications of diabetes such as ketoacidosis, hypoglycemia unawareness, and incapacitating problems with insulin therapy. For this group, pancreas transplantation would be life-saving, but must be weighed against the untoward risks of life-long immunosuppression.2
In Taiwan, it is very competitive for a uremic patient to have a decreased kidney graft because there are always >7000 uremic patients waiting for kidney transplantation.3 Moreover, the waiting lists of pancreas and kidney transplantation are separate. PTA (48%, 73/151) is the most common type of pancreas transplantation, followed by SPK (24%, 36/151) transplantation, PBK (16%, 24/151), PAK (11%, 17/151), and PAL (1%, 1/151).
3. INDICATIONS FOR PANCREAS TRANSPLANTATION
Traditionally, pancreas transplantation has been reserved for T1DM patients suffering from uremia, and considered as a relative, if not absolute, contraindication for type 2 diabetic mellitus (T2DM) due to its pathophysiology. The reluctance could rely on the pathophysiology of T2DM where insulin resistance on peripheral tissues has been considered as the prevailing disorder, instead of pancreas itself. Therefore, T2DM patients need better peripheral tissue responsiveness to insulin, instead of extra insulin or pancreas graft. However, the distinction between T2DM and T1DM is not always obvious, and many patients may present with overlapping clinical syndromes. Although many criteria, including a family history of diabetes, age of DM onset, body mass index (BMI), human leukocyte antigen association, and detectable connecting peptide, have been proposed to differentiate these two types of DM, several patients are still found to categorically overlap. Moreover, older age, associated cardiovascular risks, and advanced secondary diabetic complications might also be suggested as the listed deterrents.4–7 The official indications for pancreas transplantation in Taiwan3 include the following:
- T1DM patients with diabetic complications such as nephropathy, retinopathy, neuropathy, and cardiocerebral vasculopathy
- T1DM patients with frequent life-threatening hypoglycemia or hyperglycemia
- T1DM patients suffering from severe disability in school earning, working, and living
- T2DM patients with end-stage renal disease waiting for or undergoing kidney transplantation, and requiring insulin injection for blood sugar control with the dosage of insulin requirement <1.5 units/kg/day
According to the Scientific Registry of Transplant Recipients report, the proportion of T2DM candidates waiting for SPK transplantation increased from 10.5% to 11.7% in 2015 and the proportion of T2DM candidates waiting for PAK transplantation increased from 6.8% to 8.3% in 2016, while the rate of T2DM candidates waiting for PTA decreased from 3.9% to 2.9%.8,9 Although the popularity of pancreas transplantation in T2DM patients remains disproportionately lower than in T1DM, a growing body of evidence has revealed that the endocrine outcome in carefully selected T2DM patients could mirror that of T1DM.4,7,10–14
The most common cause of patient death after pancreas transplantation is cardiovascular event. All-cause mortality rate after pancreas transplantation is 4% at 1 year and 9% at 5 years.2,15 Pancreas graft survival defined as insulin independence and a normal hemoglobin A1c is 86% at 1 year and 54% at 10 years for SPK recipients.16 Pancreas graft survival PAK and PTA is lower, probably due to unavailability of serum creatinine as a warning marker of graft rejection. Pancreas graft outcomes are inversely related to recipient age, donor age, BMI, and the burden of cardiovascular disease.2,17–19 The most common causes of graft loss are thrombosis (31%), chronic rejection (21%), and acute rejection (15%).2
At Taipei Veterans General Hospital, the technique success rate in pancreas transplantation is 97% (n = 151). Patient survival rate is 96.5% at 1 year and 89.6% at 5 and 10 years. The overall pancreas rejection rate after pancreas transplantation is 26% (n = 145), with 17% for acute rejection and 9% for chronic rejection. Acute rejection occurs most commonly, 23%, in PTA group, followed by 17% in SPK, 10% in PAK, and 4% in PBK group. Chronic rejection occurs also most commonly, 14%, in PTA group, followed by 11% in SPK, and no chronic rejection in PAK and PBK groups. The overall pancreas survival rate is 95.8% at 1 year, 89.6% at 5 and 10 years, excluding those with technique failure. Table lists the pancreas graft survival outcomes after pancreas transplantation at Taipei Veterans General Hospital. There is no significant difference regarding the pancreas graft survival between the subgroups, p = 0.055 (Fig. 6).
This study was supported by grants from Taipei Veterans General Hospital (V106C-028, VTA106-V1-1-1) and the Ministry of Science and Technology (MOST 106-2314-B-075-048-MY2) and Ministry of Health and Welfare (MOHW107-TDU-B-212-114026A).
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Keywords:© 2019 by Lippincott Williams & Wilkins, Inc.
Pancreas transplantation; Simultaneous pancreas and kidney transplantation; Type 1 diabetes mellitus