A team from Minneapolis, Minnesota, USA, determined outcome in diabetic pancreas transplant recipients, according to risk factors and the surgical techniques and immunosuppressive protocols that evolved during a 33-year period at a single institution.
Clinical pancreas transplantation began at the University of Minnesota in 1966, initially with a high failure rate, but outcome improved in parallel with other organ transplants.
The authors retrospectively analyzed the factors associated with the increased success rate of pancreas transplants.
The surgeons performed 1,194 pancreas transplants (111 from living donors; 191 re-transplants) between 1966 and 2000. Of these, 498 were simultaneous pancreas-kidney (SPK) and 1 was a simultaneous pancreas-liver transplant. 404 were pancreas after kidney (PAK) transplants; and 291 were pancreas transplants alone (PTA).
The analyses were divided into five eras, depending on the type of immunosuppression and surgical technique used within the time periods: Era 0 (1966 to 1973), historical; Era 1 (1978 to 1986); Era 2 (1986-1994); Era 3 (1994-1998); and Era 4 (1998-2000).
In Era 1 patients underwent solitary (PAK and PTA) transplants involving multiple duct management techniques, and received cyclosporine for immunosuppression.
In Era 2, all varieties of pancreatic transplantation were performed (SPK, PAK, and PTA) with bladder drainage for graft duct management. Cyclosporine, azathioprine, and prednisone were used for immunosuppression.
In Era 3, tacrolimus and mycophenolate mofetil replaced the standard immunosuppressive regime of the previous era.
The surgical technique of Era 4 was primarily enteric drainage for SPK transplants. Daclizumab was used for induction immunosuppression; pre-transplant immunosuppression was used in candidates awaiting PTA.
|Pancreas transplant should be an option at all stages of diabetes.
|Annals of Surgery|
One-year patient and graft survival rates were calculated for each category and era.
The patient survival following SPK transplant was 85% in Era 2, compared to 92% in Eras 3 and 4 combined. Graft survival was 64% and 79%, respectively.
In Era 1, patient and graft survival rates, following PAK transplants, were 86% and 17%, respectively. In Era 4 these figures were 98% and 81%.
PTA transplant patient and survival rates were 77% and 31%, and 100% and 88%, for Eras 1 and 4 respectively.
SPK graft survival rates were significantly higher with bladder drainage (82%) than enteric drainage (74%) at 1 year.
Increasing recipient age had an adverse effect on outcome only in SPK recipients. Vascular disease was found to be common; those with no vascular disease had significantly higher patient and graft survival rates in the SPK and PAK categories.
Living donor segmental pancreas transplants were associated with higher technically successful graft survival rates in each era.
The researchers found that pancreatic transplants reduced diabetic secondary complications in some recipients. Quality of life was improved in all patients.
Dr David Sutherland, of the University of Minnesota, said on behalf of the group, "Patient and graft survival rates have significantly improved over time as surgical techniques and immunosuppressive protocols have evolved.
"Eventually, islet transplants will replace pancreas transplants for suitable candidates, but currently pancreas transplants can be applied, and should be an option at all stages of diabetes. Early transplants are preferable for labile diabetes, but even patients with advanced complications can benefit," he concluded.