PANCREATIC TRANSPLANTATION IN ABDOMINAL VISCERAL RECIPIENTS: INDICATIONS, IMMUNOGENICITY AND FUNCTIONAL OUTCOME

Abstract

O380 Aims: With the recent evolution of intestinal transplantation, the pancreas has frequently been transplanted en-bloc with intestine, liver and other abdominal viscera. On the contrary to combined pancreas-kidney and solitary pancreas transplantation, the gland is commonly included in the visceral graft for non-diabetic indications. The objective of this report is to identify the common indications for the procedure and it’s potential impact on the current United Network of Organ Sharing (UNOS) pancreatic transplant coding system and database. The immunogenicity and functional survival of the pancreatic gland transplanted en-bloc with the other abdominal visceral organs will also be addressed. Methods: Between May 2 and November 3, 2003, the whole pancreatic gland was transplanted en-bloc in 78 (32%) of 246 consecutive primary cadaveric abdominal visceral transplants. The pancreas was combined with: intestine only (n=4), stomach and intestine (n=14), liver and intestine (n=28), and stomach, intestine and liver (n=32). The indications for pancreatic transplant were technical (n=48), vascular thrombosis (n=18), gastrointestinal tumors (n=9), diabetes (n=2), and trauma (n=1) with 75 (96%) of the patients not previously diabetic. All grafts were ABO identical except one, but HLA match was random with positive lymphocyte cross-match in 13 (17%). The intestine of 61 allografts was irradiated with a single dose of 7.5 Gy and adjunct donor bone marrow was given in 53 recipients. Tacrolimus-prednisone based immunosuppression was used for 37 transplants with cyclophosphamide or daclizumab induction in 23. The remaining 41(53%) recipients were enrolled in a tolerogenic protocol with rATG/alemtuzumab pretreatment and post-transplant tacrolimus monotherapy. Results: Actuarial patient survival was 81% at 1 year and 77% at 5 years with pancreatic functional survival rates of 76% and 62%, respectively. The causes of pancreatic graft loss were related to loss of the visceral graft or patient death because of opportunistic infections and/or intestinal rejection. Despite patient complexity, one year survival has recently improved (91%) due to technical innovations, early viral detection, allograft immune-modulation and recipient pretreatment. With antibody pretreatment, 50% of recipients were on spaced doses of tacrolimus. Acute and chronic rejection of the pancreas was significantly less compared to intestine or liver with an incidence of 6% and 1%, respectively. Conclusions: En-bloc pancreas transplantation is commonly indicated for previously non-diabetic patients in need of abdominal visceral transplantation. The gland is immune-protected by the concomitantly transplanted organs. Accordingly, the current UNOS coding system and pancreatic transplant data registry should be modified for logistic reasons and accurate scientific representation of this unique population.