Cardiovascular disease and neoplasms after pancreas transplantation

Abstract

Sir—With respect to Edmond Ryan’s April 11 commentary on the clinical indications of pancreas transplantation, we would briefly report our experience. Since 1985 we have enrolled 333 insulin-dependent diabetic patients to the kidney-pancreas transplantation programme: 107 patients received kidney-pancreas (KP) transplantation (25 duct-obstruction [KPS group], 82 bladder diversion [KPW group]); 34 patients received kidney transplantation alone (KA group; pancreas not available); and 192 patients remained on the waiting-list (WL group). Clinical conditions before listing were the same in all patients, the criteria of exclusion being previous strokes, severe dilated myocardiopathy, and major amputations. Immunosuppression was similar in the three groups and was based on prophylactic antilymphocytic globulins (lymphoglobulin or thymoglobulin, IMTIX Merieux) and triple therapy. Patients’ survival at 7 years was higher in the KPW group (75%) than in WL group (37%) (figure). Actuarial kidney graft survival at 1, 4, and 7 years, respectively, was 95%, 91%, and 81% in the KPW group, and 94%, 81%, and 69% in the KA group. Actuarial pancreas survival at 1, 4, and 7 years was 80%, 77%, and 68%. Ejection fraction, assessed with left ventriculography radionucleotide, was 67·8% and 63·6% in kidneypancreas transplant patients and those who received kidney alone. At 4 years, a significant improvement was seen only in kidney-pancreas patients (KP 76·5%, KA 64·3%; KP 4 years vs baseline p<0·001, KP vs KA p=0·003). A significant reduction of the rate of hypertension was noted in kidneypancreas patients at 1 year (KP 44% vs KA 85%, p=0·02). Causes of death were cardiovascular disease in 9·8% of KPW, 17·6% of KA and 18·1% of WL patients. Lethal infectious diseases were recorded in 4·2% of the WL and in 2·9% of KA groups, whereas the KP group did not have this complication. Neoplasms were recorded in 12 (11%) kidney-pancreas transplant recipients and in two (6%) patients receiving kidney alone, resulting in death of six (6%) in the KP and one (3%) in the KA group. Typical post-transplant cancers (cutaneous or haematological) were recorded in eight of the KP group (66%) and in one patient who received kidney alone (50%). Our data show that, despite severe immunosuppression, diabetic patients who undergo kidney-pancreas transplantation do not show a higher rate (or risk) of post-transplant neoplasms than that reported for kidney transplantation (Dantal 20–32%, Mantagnino 8·9%, Birkeland 8·3%, London 14%), some of these studies being done in the precyclosporin era. On the contrary, these patients show a higher survival rate than diabetic patients receiving only kidney transplantation or still in dialysis. It is noteworthy that pancreas transplantation seems to have a protective role against the progression of cardiovascular disease: ejection faction improved in kidney-pancreas transplant patients only and death due to cardiovascular disease was lower in these patients than in diabetic patients who received only kidney transplantation or who were still in dialysis.