Pediatric Pancreas Transplantation

Abstract

Guidelines for pancreas transplantation became first available in 2021 in the form of recommendations generated by a group of experts at a world conference [1]. Their main message was that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone (PTA) can improve long-term survival, and all types of pancreas transplantation will improve the quality of life. Pancreas transplantation may also improve secondary complications of diabetes. Therefore, advantages of pancreas transplantation apparently surpass its potential disadvantages. PTA is reported to increase risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Inevitably, time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Unfortunately, the level of evidence supplementing these recommendations is weak and is basically all based on the experience gained in adult pancreas transplantation. Initial reports of pediatric transplantation were not encouraging and might have haltered the pancreas transplantation in the pediatric population. For adults most pancreas transplants are performed as either SPK or PAK transplants; the majority of recipients suffer from advanced diabetic nephropathy, a condition that has been associated with an increase in all-cause mortality due to higher incidence of micro- and macrovascular complications of diabetes. Additionally, pancreas transplantation is a relatively low volume but high complexity procedure that has never gained widespread acceptance and few patients are referred for pancreas transplant alone at a stage when extrarenal diabetic complications are still reversible in nature. Recently, there is an additional decline in the number of pancreas transplants in the United States, Europe, and the United Kingdom.