Abstract
A single center experience with pancreas transplantation (PTx) over an 11+ year period is reviewed. Methods: We retrospectively studied outcomes in 202 consecutive PTxs in 192 patients at our center. All patients received either rATG or alemtuzumab (Alem) induction with tacrolimus/MMF and tapered steroids or early withdrawal. 179 PTxs (89%) were performed with portal-enteric and 23 with systemic-enteric drainage. Results: From 11/01 to 3/13, we performed 162 simultaneous kidney-PTxs (SKPT), 35 sequential PTxs after kidney (PAK), and 5 PTx alone (PTA; 40 solitary PTxs [SPT]). 186 PTxs (92%) were primary and 16 pancreas retransplants. With a mean follow-up of 5.5 years, overall patient (87% SKPT versus 87.5% SPT), kidney (74% SKPT versus 82.5% SPT) and pancreas graft survival (both 65%) rates were comparable. Causes of PTx loss were also similar between SKPT and SPT; the rates of early thrombosis were 8.6% and 5%, respectively. Acute rejection rates were similar between groups (SKPT 29% versus SPT 26%, p=NS). A randomized trial of Alem versus rATG induction in SKPT demonstrated lower rates of acute rejection and infection in the Alemgroup; consequently, Alem induction has been used exclusively in all PTxs since 2009. Early steroid elimination has been feasible in most patients. Surveillance PTx biopsy-directed immunosuppression has contributed to equivalent long-term outcomes in SKPT and SPT. Good results have been achieved in African-American patients and in patients with a type 2 diabetes phenotype. Conclusions: Excellent 5 year outcomes following PTx can be achieved as >86% of patients are alive, >87% of surviving patients are dialysisfree, 80% of surviving patients remain insulin-free, and 88% of surviving patients have detectable C-peptide levels.
Highlights
Vascularized pancreas transplantation (PTx) was initially developed as a means to re-establish endogenous insulin secretion (C-peptide production) responsive to normal feedback controls and has evolved over time to a form of auto-regulating total pancreatic endocrine replacement therapy that reliably achieves a euglycemic state without the need for either exogenous insulin therapy or close glucose monitoring
PTx in diabetic patients is divided into 3 major categories; those performed simultaneously with a kidney transplant (SKPT), usually from a deceased donor; those performed after a successful kidney (PAK) transplant in which the kidney came from either a living or deceased donor; and PTx alone (PTA) in the complete absence of a kidney transplant
From 11/1/01 through 3/1/13, a total of 202 PTxs were performed in 192 patients, including 162 SKPT, 35 sequential PAK, and 5PTA (40 solitary pancreas transplants (SPT)). 186 PTxs (92%) were primary and 16 pancreas retransplants (10 of which had their primary PTx performed at our center)
Summary
Vascularized pancreas transplantation (PTx) was initially developed as a means to re-establish endogenous insulin secretion (C-peptide production) responsive to normal feedback controls and has evolved over time to a form of auto-regulating total pancreatic endocrine replacement therapy that reliably achieves a euglycemic state without the need for either exogenous insulin therapy or close glucose monitoring. PTx in diabetic patients is divided into 3 major categories; those performed simultaneously with a kidney transplant (SKPT), usually from a deceased donor; those performed after a successful kidney (PAK) transplant in which the kidney came from either a living or deceased donor; and PTx alone (PTA) in the complete absence of a kidney transplant. The latter 2 (PAK and PTA) categories are usually combined together as solitary pancreas transplants (SPT) because of similar outcomes and the absence of uremia at the time of transplant. The majority (75%) of PTxs are performed as SKPTs whereas approximately 16% are performed as PAK and 9% as PTA transplants [1,2,3,4]
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