Pancreas Transplant Alone Research Articles

2011 Update on Pancreas Transplantation: Comprehensive Trend Analysis of 25,000 Cases Followed Up Over the Course of Twenty-Four Years at the International Pancreas Transplant Registry (IPTR)

This study aimed to analyze the outcome of pancreas and pancreas-kidney transplantations based on the comprehensive follow-up data reported to the International Pancreas Transplant Registry (IPTR). As of December 2010, more than 35,000 pancreas transplantations have been reported to the IPTR: more than 24,000 transplantations in the US and more than 12,000 outside the US. Cases with follow-up information until March 2011 were included in the analysis. Pancreas transplantations in diabetic patients were divided into 3 categories: those performed simultaneously with a kidney (SPK) (75%), those given after a previous kidney transplantation (PAK) (18%), and pancreas transplantation alone (PTA) (7%). The total number of pancreas transplantations steadily increased until 2004 but has since declined. The largest decrease was seen in PAK, which decreased by 50% from 2004 through 2010. Comparatively, the number of SPK decreased by 7% during this time. Era analysis of US transplantations between 1987 and 2010 showed changes in recipient and donor characteristics. Recipient age at transplantation increased significantly as well as transplantations in type 2 diabetes patients. The trend over time was towards tighter donor criteria. There was a concentration on younger donors, preferable trauma victims, with short preservation time. Surgical techniques for the drainage of the pancreatic duct changed over time, too. Now enteric drainage is the predominantly used technique in combination with systemic drainage of the venous effluent of the pancreas graft. Immunosuppressive protocols developed towards antibody induction therapy with tacrolimus and MMF as maintenance therapy. The rate of transplantations with steroid avoidance increased over time in all 3 categories. These changes have led to improved patient and graft survival. Patient survival now reaches over 95% at one year post-transplant and over 83% after 5 years. The best graft survival was found in SPK with 86% pancreas and 93% kidney graft function at one year. PAK pancreas graft function reached 80%, and PTA pancreas graft function reached 78% at one year. In all 3 categories, early technical graft loss rates decreased significantly to 8-9%. Likewise, the 1-year immunological graft loss rate also decreased: in SPK, the immunological 1-year graft loss rate was 1.8%, in PAK 3.7%, and in PTA 6.0%. Patient survival and graft function improved significantly over the course of 24 years of pancreas transplantation in all 3 categories. With further reduction in surgical complications and improvements in immunosuppressive protocols, pancreas transplantation offers excellent outcomes for patients with labile diabetes.

Pancreata From Pediatric Donors Restore Insulin Independence in Adult Insulin-Dependent Diabetes Mellitus Recipients

Context The use of pediatric donors can increase the number of donors available for pancreas transplantation. Aim The aim of this study was to verify if pancreas transplantation from pediatric donors is as effective as transplantation from adult donors to restore metabolic control in type 1 diabetic patients. Materials and Methods From 2000 to April 2009 we performed 17 pancreas transplantations from pediatric donors: 9 simultaneous kidney-pancreas (SPK), 6 pancreas transplantation alone (PTA), and 2 pancreas after kidney (PAK). All subjects received whole organs with enteric diversion of exocrine secretions; 11 underwent systemic and 6 underwent portal venous graft drainage. The immunosuppressive therapy was as follows: prednisone, mycophenolate mofetil, anti-thymocyte globulin (ATG), and cyclosporine or tacrolimus. The pediatric donor population had a mean age of 15.3 years (range, 12–17), a mean weight of 60.1 kg (range, 42–75), and a mean body mass index (BMI) of 21 (range, 17.9–23.4). Results After 9 years the overall patient survival rate was 94.12%, whereas the graft survival rate was 63.35%. Normal glucose and insulin levels were maintained either fasting or during oral glucose tolerance test (OGTT). The group of recipients of pediatric organs was compared with patients receiving organs from adult donors (n = 125); the mean glucose values were lower in the pediatric group, whereas insulin production was higher in the adult patients. Early venous thrombosis was 17.6% in the pediatric group and 20% in adult recipients (Fisher exact test, P = not significant [NS]). Conclusion Pediatric donors restored insulin independence in adult diabetic recipients, representing a valid source of organs for pancreas transplantation.

Patient-reported outcomes following islet cell or pancreas transplantation (alone or after kidney) in Type 1 diabetes: a systematic review.

For selected individuals with complex Type 1 diabetes, pancreatic islet transplantation (IT) offers the potential of excellent glycaemic control without significant hypoglycaemia, balanced by the need for ongoing systemic immunosuppression. Increasingly, patient-reported outcomes (PROs) are considered alongside biomedical outcomes as a measure of transplant success. PROs in IT have not previously been compared directly with the closest alternate treatment option, pancreas transplant alone (PTA) or pancreas after kidney (PAK). We used a Population, Intervention, Comparisons, Outcomes (PICO) strategy to search Scopus and screened 314 references for inclusion. Twelve studies [including PRO assessment of PAK, PTA, islet-after kidney (IAK) and islet transplant alone (ITA); n = 7-205] used a total of nine specified and two unspecified PRO measures. Results were mixed but identified some benefits which remained apparent up to 36 months post-transplant, including improvements in fear of hypoglycaemia, as well as some aspects of diabetes-specific quality of life (QoL) and general health status. Negative outcomes included short-term pain associated with the procedure, immunosuppressant side effects and depressed mood associated with loss of graft function. The mixed results may be attributable to limited sample sizes. Also, some PRO measures may lack sensitivity to detect actual changes, as they exclude issues and domains of life likely to be important for QoL post-transplantation and when patients may no longer perceive themselves to have diabetes. Thus, the full impact of islet/pancreas transplantation (alone or after kidney) on QoL is unknown. Furthermore, no studies have assessed patient satisfaction, which may highlight further advantages and disadvantages of transplantation.

Experiência obtida em 100 transplantes de pâncreas

Report our experience with 100 pancreas transplants performed in a period of seven years. METHODS. Between January 2001 and January 2008, 100 patients underwent pancreatic transplantation at our center, 88 simultaneous pancreas kidney transplantation (SPK) and 12 pancreas transplantation alone (PTA). All of these were primary transplants. Pancreas graft management of the exocrine drainage technique involved enteric drainage in 8 (all SPK) and bladder in 92 cases. The recipient systemic venous system was used for the pancreas graft venous effluent in all cases. Our last thirty patients submitted to SPK did not receive any induction therapy regardless of the PRA. SPK received basiliximab and PTA patients received thymoglubulin. Maintance imunossupression was with TAC, MMF and corticosteroids. Graft perfusion volume was limited to 800 ml of Celsior or UW solution. RESULTS. Overall results show that the number of functioning pancreatic grafts is 64 after 100 performed. Graft losses were: rejection (8 cases), venous thrombosis (9 cases) arterial thrombosis(1 case), or surgical complications such as anastomotic leak (3 cases), perigraft infection (10 cases), pancreatitis of the graft(5 cases). Rejection was observed less frequently in SPK recipients 5 cases (5/92 recipients) than PTA recipients (3/12). Death was observed in 24 cases. CONCLUSION. Our impression is that pancreas transplantation is highly effective therapy for diabetes mellitus and there is still a role in the diabetes treatment for allograft transplantation in a near future.

Systematic Evaluation of Pancreas Allograft Quality, Outcomes and Geographic Variation in Utilization

Pancreas allograft acceptance is markedly more selective than other solid organs. The number of pancreata recovered is insufficient to meet the demand for pancreas transplants (PTx), particularly for patients awaiting simultaneous kidney-pancreas (SPK) transplant. Development of a pancreas donor risk index (PDRI) to identify factors associated with an increased risk of allograft failure in the context of SPK, pancreas after kidney (PAK) or pancreas transplant alone (PTA), and to assess variation in allograft utilization by geography and center volume was undertaken. Retrospective analysis of all PTx performed from 2000 to 2006 (n = 9401) was performed using Cox regression controlling for donor and recipient characteristics. Ten donor variables and one transplant factor (ischemia time) were subsequently combined into the PDRI. Increased PDRI was associated with a significant, graded reduction in 1-year pancreas graft survival. Recipients of PTAs or PAKs whose organs came from donors with an elevated PDRI (1.57-2.11) experienced a lower rate of 1-year graft survival (77%) compared with SPK transplant recipients (88%). Pancreas allograft acceptance varied significantly by region particularly for PAK/PTA transplants (p < 0.0001). This analysis demonstrates the potential value of the PDRI to inform organ acceptance and potentially improve the utilization of higher risk organs in appropriate clinical settings.

Metabolic Long-Term Follow-Up of Functioning Simultaneous Pancreas-Kidney Transplantation Versus Pancreas Transplantation Alone: Insights and Limitations

Pancreas transplantation involves a set of procedures that, in some cases, lead to different complications and outcomes. The aim of this study was to analyze the long-term effects of pancreas transplantation regarding carbohydrate and lipid metabolism parameters to determine differences between simultaneous pancreas-kidney (SPK) transplantation and pancreas transplantation alone (PTA). Sixty-four patients (46 SPK and 18 PTA), with an immunosuppression protocol based on tacrolimus plus mycophenolate mofetil and prednisone, were evaluated for at least 1 year after transplantation. No patient made use of any hypoglycemic or hypolipidemic drugs. Comparisons were performed between SPK and PTA patients using the chi-square test, Fischer's exact test, and unpaired Student's t test, as appropriate. Patients were 39.8+/-9.3 years old, predominantly male (60.9%), with a mean follow-up of 25.4+/-10.4 months after transplantation. The PTA group exhibited worse renal function and higher tacrolimus levels than the SPK group. Fasting glucose, 2 hr plasma glucose after overload, C-peptide, and HbA1C were within the normal range, with no statistically significant differences between the PTA and SPK groups. Insulin (INS) and the homeostasis model assessment of INS resistance index were above the normal range in both the groups. Lipids were also similar between groups. The majority of patients with long-term functioning pancreas transplant achieved good glucose control without use of exogenous INS or oral antidiabetic drugs, although they were hyperinsulinemic. There were no significant differences concerning glucose and lipid parameters between the SPK and PTA groups, even though the PTA patients exhibited higher tacrolimus levels and worse renal function.

Availability of Pancreatic Allograft Biopsies Via a Laparotomy

Objective The aim of this study was to evaluate the availability of a pancreatic allograft biopsy via a laparotpmy. Patients and Methods From September 2004 to November 2007, 17 pancreas transplantations were performed: 15 simultaneous pancreas and kidney transplantations (SPK), 1 pancreas transplant alone (PTA), and one pancreas after kidney transplantation (PAK). Thirteen pancreatic allograft biopsies were obtained via an open laparotomy. This study evaluated the complications associated with this procedure, the rate of obtaining an adequate sample, and the relationship between biopsy-proven rejections and laboratory markers. In SPK cases we evaluated the synchronization between pancreas and kidney rejection. The pancreatic samples were diagnosed according to the Drachenberg classification. Results No complications resulted from the procedure. The rate of obtaining adequate samples was 84.6%. Pancreas rejection correlated with elevation of the laboratory markers in 71.4%. Simultaneous pancreas and kidney rejection occurred in 62.5%, only kidney in 25%, and only pancreas in 12.5%. Conclusion A pancreas graft biopsy was absolutely imperative to improve the outcome in PTA, and even in SPK cases. A pancreatic allograft biopsy via a laparotomy was a safe, necessary and easy procedure to obtain an accurate diagnosis of rejection among pancreas transplantation patients.

Pancreas transplantation alone in children: a case report

Pancreas transplantation (PT) is a relatively uncommon therapy for non-uremic type 1 diabetes, as the severity of diabetes must warrant the risk of immunosuppression. In pediatric diabetic patients, who are less likely to display uremia because of the duration of diabetes, there is very little experience with pancreas transplantation alone (PTA). This report describes a 13-yr-old male PTA recipient. This patient was initially diagnosed with type 1 diabetes mellitus at the age of four yr. Following a multidisciplinary evaluation, PTA was found to be indicated based on a history of severe labile diabetes and hypoglycemic unawareness resulting in frequent episodes of hypoglycemia and hospital admissions. Because of the failure of medical management of the patient's diabetes, a whole organ bladder and systemic drained PTA was performed. Immunosuppression included thymoglobulin, tacrolimus, mycophenolate mofetil, and steroids. Early outcome was uneventful and patient was discharged 12 d after surgery normoglycemic and insulin-free. An episode of acute rejection (Maryland grade II) 20-d post-transplant was successfully treated with corticosteroids. A second and more severe episode of rejection (Maryland grade IV) occurred 13 months post-transplant, requiring treatment with thymoglobulin and conversion from steroid to sirolimus. On tacrolimus, sirolimus, and mycophenolic acid, he remains euglycemic and insulin-free 38 months after PTA. His quality-of-life is judged to be superior to his insulin dependent state prior to transplantation. According to the medical literature, this is the youngest patient ever to undergo PTA.

Counterpoint: Clinical Islet Transplantation: Not Ready for Prime Time

β-Cell replacement therapy's great promise is that it can safely and effectively restore insulin-independent euglycemia to individuals with diabetes. Although difficult and expensive, modern insulin-based treatment for type 1 diabetes has lead to remarkable improvements in disease prognosis (1–3). Based on recent population-based epidemiological studies, we have estimated that an individual diagnosed with type 1 diabetes today faces an excess mortality over the next 20 years of ∼2% or ∼0.1% per year (4). Even individuals with long-standing type 1 diabetes sufficiently problematic to be listed for a pancreas transplant have an annual mortality <2.0% per year (5). The perceived weaknesses associated with intensive insulin therapy are its cost estimated in 1996 to be 116,000 USD over a lifetime (6) and its inconvenience requiring meticulous attention to diet, exercise, frequent daily blood glucose measurements, and multiple daily injections. In addition, insulin therapy carries with it an increased risk of serious hypoglycemia (1). We attempt to address whether current β-cell replacement therapies overcome the shortcomings associated with medical management. Certainly, β-cell replacement therapy should not increase the subjects' risk above that associated with standard clinical care. For patients with type 1 diabetes and end-stage kidney disease, simultaneous pancreas-kidney (SPK) transplantation has appropriately achieved standard of care status. SPK recipients can reasonably expect improved and sustained insulin-independent metabolic control, and the surgery demonstrably improves survival rates compared with those medically treated (5). However, the options are much less clear for subjects with long-standing diabetes and preserved kidney function defined as a serum creatinine <2.0 mg/dl. (And with modern therapies, an ever-decreasing minority will develop renal failure.) For such patients, pancreas transplant alone (PTA) or pancreas-after-kidney (PAK) transplantation, despite reasonable insulin-independence rates, does not improve survival and may even increase mortality (5). The underlying cause of the apparent excess mortality post–pancreas transplantation …

Use of Small Donors (&lt;28 kg) for Pancreas Transplantation

Small donors have long been considered a potential source of organs for simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone (PTA). Our aim was to analyze our experience with SPK and PTA using small donors weighing <28 kg. Between September 2006 and October 2008, we performed 68 SPK, 3 PTA, and 3 pancreas after kidney transplantations (PAK). All recipients were adults with type 1 diabetes mellitus, including 8 who received small donor organs (<28 kg): 6 SPK and 2 PTA. We used 3 graft combinations for SPK: pancreas and single kidney; pancreas and en bloc kidneys; and en bloc dual kidney-pancreas. In contrast, we used conventional grafts for PTA. Mean weight among donors was 20.82 kg (range, 9.6-27 kg). We observed neither delayed graft function nor mortality. At a follow-up of approximately 281 days, all patients were free of insulin and dialysis treatments. Kidneys and pancreas from donors weighing <28 kg can be used in adult type 1 diabetic patients with excellent results. These small pediatric donors enabled us to enlarge the number of transplantations by 10.81%.

Trends in Organ Donation and Transplantation in the United States, 1998–2007

The articles in this report are based on the reference tables in the 2008 OPTN/SRTR Annual Report. Table numbers are noted in brackets and may be found online at: http://www.ustransplant.org.

The impact of functioning pancreas-kidney transplantation and pancreas alone transplantation on the lipid metabolism of statin-naïve diabetic patients

To compare the lipid profile (total cholesterol - TC, triglycerides - TG, high density lipoprotein cholesterol - HDL-c, low density lipoprotein cholesterol - LDL-c and non-HDL cholesterol - NHDL-c) of patients with functioning pancreas-kidney transplantation (PKT) or pancreas transplantation alone (PTA) after one (T1) and two yr (T2) following their pre-transplantation data (T0). Fifty-three type 1 diabetic patients underwent pancreas transplantation (42 PKT and 11 PTA) remaining euglycemic after transplantation were evaluated before and one and two yr after the procedures. They were using predominantly tacrolimus-mycophenolate mofetil-based immunosuppression and low glucocorticoid dose with systemic venous drainage of the pancreatic graft. None of them used hypolipidemic agents for economical reasons. Lipids were reported as means +/- standard error of the mean. Data obtained in T0 were compared with T1 and T2 using ANOVA followed by Student's t-test. TC, LDL-c, NHDL-c and TG were lower in T1 and T2 when compared with T0 (p < 0.05) in PKT, while no change was observed for HDL-c (p > 0.05). PTA group showed no significant changes in lipids. In spite of the known side effects of tacrolimus-based immunosuppression to lipids, our study with a statin-naïve sample showed improvements (PKT) or stabilization (PTA) in the serum lipid profile after pancreas transplantation.

Pancreas Transplant Alone as an Independent Risk Factor for the Development of Renal Failure: A Retrospective Study

Pancreas transplant alone (PTA) is a controversial procedure. Without clearly demonstrated patient survival, recipients report improved quality of life. Nephrotoxic immunosuppression (IS) may exacerbate diabetic renal injury post-PTA. A single institution retrospective review of patients receiving PTA over a 14-year period was completed. Patient and donor demographics, surgical outcomes, rejection, and patient or graft survival were analyzed. Pre- and Postoperative estimated glomerular filtration rates (eGFR) were calculated based on the modification of diet and renal disease. Multivariate analysis was performed. One hundred twenty-three patients undergoing 131 PTAs had an average age of 40.0 years. Seven patients were retransplanted and one received a third pancreas. Mean graft survival was 3.26 years (0-11.3 years) with 21 patients (17%) lost to follow-up. One- and 5-year patient survivals were 96.6% and 91.5%, respectively (mean, 7.15 year). Seventeen patients had an eGFR less than 50 mL/min/1.73 m preoperatively, whereas 64 patients did so post-PTA and 24 had an eGFR less than 30 mL/min. Mean eGFR pretransplantation was 88.9 vs. 55.6 posttransplantation (P<0.0001) with mean follow-up of 3.68 years. All but 16 (12%) patients showed a decrease in eGFR. Mean decrement was 32.1 mg/min/1.73 m. Thirteen developed end-stage renal disease chronic kidney disease (CKD 5) requiring kidney transplantation (KT) at a mean of 4.36 years. Eighty-three patients had an episode of rejection. In post-PTA RF, graft survival was 3.2 vs. 2.4 years (P=0.13). In those requiring KT, graft survival was 7.9 vs. 2.9 years (P<0.0001). Cold ischemia times, donor age, and preoperative eGFR for those with and without RF-requiring KT were not significant. Body mass index was statistically significant. Leukocyte-depleting agents was evaluated, but was not significant. All patients received calcineurin inhibitor IS. Patients who undergo PTA may be at increased risk for RF. After comparing patient and donor demographics, IS, and human leukocyte antigen mismatch, it seems that PTA is an independent risk factor for the development of renal failure. Patients with more successful pancreatic grafts demonstrated lower eGFR. Patients should be made aware of the risks of long-term IS. Only the most appropriate patients should be chosen for PTA.

Over 500 Solitary Pancreas Transplants in Nonuremic Patients with Brittle Diabetes Mellitus

A pancreas transplant alone (PTA) in a nonuremic patient with brittle diabetes mellitus remains a rare procedure because the tradeoff for insulin independence is lifelong immunosuppression. Herein we report our results at the University of Minnesota of 513 PTAs from December 17, 1966, through December 31, 2006. Of these recipients, 87% had previously experienced hypoglycemic unawareness and 23% experienced coma and/or seizures. These transplants spanned four immunosuppressive eras: pre-cyclosporine A (pre-CsA) era (16%), CsA era (23%), tacrolimus (TAC) era (47%), and calcineurin-inhibitor (CNI)-free era (14%). The overall patient survival rate at 1 year posttransplant was about 95%; at 5 years, it was 90%. The pancreas graft survival rate at 1 year increased significantly from the pre-CsA era (31%) to the TAC era (75%), thanks to a significant decline in immunologic and technical failures. The CNI-free protocol, because of its high infection and hematologic infection rate, did not further improve outcome. Risk factors for subsequent kidney failure (13% at 5 years posttransplant) were serum creatinine levels>1.5 mg/dl at the time of the pancreas transplant and recipient age<30 years. A technically successful PTA is currently the only treatment option that allows nonuremic patients with brittle diabetes to become insulin-independent in the long term.

Isolated Pancreatic Transplantation in a Brazilian Centre

Purpose. Simultaneous pancreas-kidney transplantation (SPK) is an accepted treatment for patients with type 1 diabetes mellitus and end- stage renal disease. Modern immunosuppression and biopsy techniques have improved the success of pancreas alone (PA) transplantations to the point where the outcome is now equivalent to that of SPK. Methods. From 120 pancreas transplants at Angelina Caron Hospital since 2001, 12 were PA transplants. Results. Patient and graft survival rates at 1 year were respectively 83 % and 75 %. Two patients died due to sepsis in the first and second month after surgery, both with functioning grafts. One graft was lost due to venous thrombosis during the fist transplant week. Patient survival rate was 100 % at hospital discharge. Conclusion. The present report describes our data with PA transplantation with fine results for a limited experience in such transplantation modality.

The History of Pancreas Transplantation: Past, Present and Future

The first attempt to cure type 1 diabetes by pancreas transplantation was done at the University of Minnesota, in Minneapolis, on December 17, 1966, followed by a series of whole pancreas transplantation. Due to the lack of potent immunosuppressive drugs, rejections and infections, it was concluded that pancreas was less antigenic than the kidney which was less antigenic than the duodenum. It opened the door to a period, between the mid 70’s to mid 80’s where only segmental pancreatic grafts were used in the recipient. Numerous techniques for diverting or dealing with the pancreas juice secretion were described, none of them being satisfactory. In the late 70ȉs - early 80’s, three major events happened and boosted the development of pancreas transplantation: firstly the introduction of Cyclosporine A in the clinical field, secondly the organization on March 1980, of the first international meeting on Pancreas Transplantation with the first report of the International Pancreas Transplantation Registry (IPTR) and finally in 1982, the organization of the first informal so-called Spitzingsee meetings where pancreas transplantation successes but mainly failures were discussed which precluded the onset of IPITA (International Pancreas and Islet Transplantation Association), EuroSPK (European Study Group for simultaneous Pancreas and Kidney Transplantation) and EPITA (European Pancreas and Islet Transplantation Association).During one of the Spitzingsee meetings, participants had the idea to renew the urinary drainage technique of the exocrine secretion of the pancreatic graft with segmental graft and eventually with whole pancreaticoduodenal transplant. That was clinically achieved during the mid 80’s and remained the mainstay technique during the next decade. In parallel, the Swedish group developed the whole pancreas transplantation technique with enteric diversion. It was the onset of the whole pancreas reign. The enthusiasm for the technique was rather moderated in its early phase due to the rapid development of liver transplantation and the need for sharing vascular structures between both organs, liver and pancreas. During the modern era of immunosuppression, the whole pancreas transplantation technique with enteric diversion became the gold standard for simultaneous pancreas and kidney transplantation (SPK), with portal drainage of the venous effluent of the pancreas, even for pancreas after kidney (PAK) or pancreas transplantation alone (PTA). Today, there remains room for improvement: safety of using the duodeno-duodenal anastomosis technique must be confirmed by prospective analysis while preventing ischemic reperfusion injuries, using specific drugs; that must be assessed in new trials.

Long-Term Results After Pancreas Transplantation

With the advances in technique and immunosupression, not only the short- but the long-term outcomes of pancreas transplantation have improved significantly. This retrospective study describes the long-term outcomes of simultaneous pancreas and kidney (SPK) transplants, pancreas after kidney (PAK), and pancreas transplants alone (PTA). An overall analysis was performed for all deceased donor (DD) primary pancreas transplants performed in the United States between 1988 and 1999. In addition, the long-term outcome for pancreas transplants performed at the University of Minnesota (UM) was analyzed. For SPK transplants performed in the United States between 1998 and 1999, the half-life of the pancreas was almost 12 years, and was 12.5 years for kidneys. For SPK cases where the pancreas was functioning at 1 year, the half-lives of both the pancreas and the kidney grafts extended more than 14 years. The half-lives of solitary pancreas transplants were between 7 years for PAK and 9 years for PTA cases. For US solitary transplants with at least 1 year of graft function, the half-lives extended to almost 9 years. Pancreas transplants performed at the UM showed the same significant improvements over time. Of special interest is the excellent long-term graft function of pancreas transplants from a living donor, which in the early years clearly surpassed that of solitary DD pancreas transplants. A multivariate analysis showed that the factor with the highest impact on long-term graft function in all three transplant categories was the use of a young donor. In SPK cases, the most frequent reason for late graft loss was death with a functioning graft. In solitary pancreas transplants, most late graft losses were still due to immunological reasons.

Early steroid withdrawal in solitary pancreas transplantation results in equivalent graft and patient survival compared with maintenance steroid therapy

Although steroid withdrawal in simultaneous kidney pancreas transplantation has been shown to be feasible, the results of early steroid withdrawal in immunologically solitary pancreas transplantation are not well known. This study evaluated an early steroid withdrawal protocol in this group. The results of steroid withdrawal at 21 d post-transplant in solitary pancreas transplant recipients was compared with a control group consisting of solitary pancreas transplant recipients maintained on steroids (MG). Additional immunosuppression consisted of rabbit anti-thymocyte globulin induction followed by tacrolimus and mycophenolate mofetil in both groups. The withdrawal group (WG, n = 22) consisted of 11 pancreas transplant alone (PTA), six pancreas after kidney (PAK), and five simultaneous cadaveric pancreas living kidney (SPLK) recipients. The steroid maintenance group (MG, n = 32) consisted of 8 PTA, 11 PAK, and 13 SPLK recipients. Recipient and donor demographic characteristics were similar. Seventy eight percent of MG patients had infection-related complications in the first year compared with 50% of the WG patients (p = 0.04). The one-yr rejection, pancreas graft, and patient survival rates were 27.3% 95.5%, and 100% in the WG, and 37.5%, 81.3%, and 93.8% in the MG respectively and not significantly different. We conclude that early corticosteroid withdrawal in isolated pancreas transplantation results in fewer infections and can be achieved without an increased risk of rejection or graft loss over the first year.

Pancreas transplant alone has beneficial effects on retinopathy in type 1 diabetic patients

The effects of successful pancreas transplant alone (PTA) on chronic complications of diabetes, in particular diabetic retinopathy, remain disputed. We prospectively studied the course of diabetic retinopathy in PTA recipients and in non-transplanted (non-PTA) type 1 diabetic patients. The PTA and non-PTA groups consisted respectively of 33 (follow-up: 30 +/- 11 months) and 35 patients (follow-up: 28 +/- 10 months). Best corrected visual acuity, slit lamp examination, intraocular pressure measurement, ophthalmoscopy, retinal photographs, and in selected cases angiography were performed. Diabetic retinopathy and its improvement/deterioration were assessed according to criteria proposed by the Eurodiab Study. At baseline, 9% of PTA and 6% of non-PTA patients had no diabetic retinopathy, 24 and 29% had non-proliferative diabetic retinopathy (NPDR), whereas 67 and 66% had laser-treated and/or proliferative diabetic retinopathy (LT/PDR), respectively. No new case of diabetic retinopathy occurred in either group during follow-up. In the NPDR PTA group, 50% of patients improved by one grading, and 50% showed no change. In the LT/PDR PTA, stabilisation was observed in 86% of cases, whereas worsening of retinopathy occurred in 14% of patients. In the NPDR non-PTA group, diabetic retinopathy improved in 20% of patients, remained unchanged in 10%, and worsened in the remaining 70%. In the LT/PDR non-PTA group, retinopathy did not change in 43% and deteriorated in 57% of patients. Overall, the percentage of patients with improved or stabilised diabetic retinopathy was significantly higher in the PTA group. No differences were found between the two groups with regard to cataract lesions and intraocular pressure values. Despite a relatively short follow-up, our study shows that successful PTA can positively affect the course of diabetic retinopathy.

Influence of Pancreas Transplantation Alone on Native Renal Function

Pancreas transplantation alone (PTA) has become an accepted treatment of nonuremic diabetic patients, when the risks of secondary complications of diabetes mellitus are greater than those of the surgical procedure and the posttransplant immunosuppression. As a decrease in native renal function is expected, we followed this parameter among patients who underwent PTA. From January 1997 through January 2005, we performed 69 PTA in 66 patients. All patients showed glucose hyperlability with hypoglycemic unawareness, or two or more diabetic complications as well as creatinine clearance (CrCl) ≥ 45 mL/min. Immunosuppression was based on tacrolimus, mycophenolate mofetil and prednisone. Twenty-four hour CrCl were performed after all successful PTA. We divided patients in two groups according to the pretransplant CrCl: group 1, CrCl ≤ 70 mL/min ( n = 20) and group 2, CrCl > 70 mL/min ( n = 25). The data were analyzed using Student’s t-test ( P ≤ .05 was considered significant). Twenty-one patients were excluded from the analysis because of death ( n = 5) or graft loss ( n = 8) during the first year or follow-up shorter than 1 year ( n = 8). The mean value of CrCl decreased 28.8% (85.0 ± 31 versus 60.5 ± 36 mL/min; P < .001). There was also a 39.3% reduction among group 1 subjects ( P = .003), including 10 who displayed CrCl ≤ 30 mL/min. There was also a 24.4% reduction among group 2 ( P = .008), but no patient developed end-stage renal disease. In conclusion, native renal function decreased significantly after PTA, but was well tolerated among patients with CrCl > 70 mL/min. Patients with CrCl < 70 mL/min show a significant risk of worsened renal function.