Kidney-Pancreas Transplantation

Abstract

During the past decade, simultaneous pancreas kidney transplantation has been widely accepted as the most effective way to achieve normoglycemia in patients with type 1 diabetes and end-stage renal disease. This procedure was performed for the first time on a human in 1966 but it was in the 1980s, with advances in surgical technique and introduction of cyclosporine for immunosuppression, that the success rates of SPK became acceptable. According to international pancreas transplant (IPTR) report as of December 31, 2004, 23,043 pancreas transplants were performed worldwide. These included more than 17,000 (17,127) performed in the United States (US) and nearly 6,000 (5,916) from outside the US (nonUS). In the US, the majority of the cases, 78% (n=11,898), have been simultaneous pancreaskidney transplants (SPK); 16% (n=2427) are pancreas after kidney (PAK) transplants; 7% (n=1,008) are pancreas transplants alone (PTA). Indications for pancreas transplantation include the development of diabetic complications such as ESRD, retinopathy or multiple attacks of hypoglycemic unawareness. Unfortunately, pancreas transplantation has been associated with the highest surgical complication rate of all the routinely performed organ transplant procedures (except for small intestinal or multivisceral transplantation) and the risk of pancreas graft loss from surgical complications (technical failures) is higher than from immunological reasons. The overall incidence of surgical complications in PTx is reported to be around 10% to 38%. This high rate of complications leads US centers to preclude PTA in most centers and now over 95% of pancreas transplantations are performed in patients with renal disease or a previous functioning kidney transplant. One year patient, kidney, and pancreas survival rates for recipients of an SPK transplant are 95%, 91%, and 86%, respectively. Compared to patients with diabetes who receive a kidney alone, the addition of a pancreas improves long-term patient and kidney graft survival. Recipients of a pancreas-after-kidney transplant or a pancreas transplant alone have an average 1-year pancreas graft survival rate of 78-83%. In this chapter we will thoroughly describe many aspects of this complex transplantation procedure including: The history of pancreas transplantation Indications for pancreas transplantation Surgical aspects of pancreas graft procurement from the deceased donor Current surgical techniques for pancreas transplantation Immunosuppressive regimens