Preoperative risk evaluation: Where is the limit for recipients of a pancreatic graft?

aClinical Division of Nephrology, Department of Internal Medicine bDivision of Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.
Current opinion in organ transplantation (Impact Factor: 2.88). 12/2012; 18(1). DOI: 10.1097/MOT.0b013e32835c9666
Source: PubMed


PURPOSE REVIEW: Pancreas transplantation is an accepted treatment strategy that can result in normalization of blood glucose, but this must be weighed against the risks of a surgical procedure and subsequent immunosuppression. To improve the risk/benefit ratio, pancreas transplantation is typically performed in end-stage renal disease patients who are undergoing simultaneous kidney transplantation or who previously received a renal transplant and are obligated to the use of immunosuppressive medications. As diabetic patients are at high risk for the development of cardiovascular disease, intensive evaluation before transplantation is necessary to minimize the perioperative and postoperative risk.

Recent findings:
The field of pancreas transplantation has been limited by a lack of randomized controlled trials not only on the procedure of transplantation itself, but also on the preoperative evaluation of the patients. The data regarding pretransplant evaluation are scarce including its usefulness of tumor screening and cardiovascular evaluation, as well as its effectiveness.

Evaluation for pancreas transplantation is an important issue to minimize the risk of the patients for perioperative and postoperative complications. This is especially important in transplant recipients with a diabetic background, who are by definition 'high-risk patients' for transplantation.

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    ABSTRACT: For patients with diabetes and progressive chronic kidney disease, kidney transplantation is the optimal mode of renal replacement therapy, with or without a pancreas transplant. Additional benefits of pancreas transplant have become increasingly apparent due to advances in surgical outcomes and immunosuppression, and may be reasonably considered even in selected patients with type 2 diabetes. In general, pancreas transplantation is associated with long-term survival advantages despite an increased short-term morbidity and mortality risk. This is true with simultaneous pancreas kidney transplantation or pancreas after kidney transplantation compared to kidney transplantation alone, regardless of kidney donor status (living or deceased). Individual patient preferences, comorbidities, and expected waiting time influence selection of transplant modality, rather than a clear survival benefit of one strategy versus the other. In selected patients with type 2 diabetes, recent outcomes data support cautious utilization of simultaneous pancreas kidney transplantation when a living kidney donor transplant is not an option. The purpose of this review is to summarize current data regarding kidney and pancreas transplant treatment options in patients with both type 1 and 2 diabetes and the influence of current organ allocation policies to better understand the advantages and disadvantages of each of these strategies.
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    ABSTRACT: Over the last decade, islet transplantation has gained clinical acceptance as a definitive treatment for the cure of Type 1 diabetes. However its widespread applicability is hindered by the shortage of donor pancreata, innate and alloimmune graft rejection, the recurrence of autoimmunity, the deleterious side-effects of chronic immunosuppressive therapy and a lack of funding to support the procedure as an alternative to chronic insulin therapy. Existing methodologies often require multiple islet infusions to ensure long-term likelihood of complete insulin independence, a decided disadvantage given the inadequate supply of donor organs. Ideally, it may be possible to achieve permanent glycometabolic control following β-cell replacement through islet transplantation by adopting an integrated multimodal approach, such as combining immunomodulatory therapies that restored tolerance to both allo- and autoantigens with strategies that provided a limitless, expandable source of insulin-producing cells for transplantation. In this review, we discuss strategies to overcome the barrier of inadequate donor-tissue supply, such as improving single donor islet transplantation outcomes, utilizing islets from donors after cardiac death, employing living donor islet transplantation or porcine islet xenotransplantation and adopting stem cell-based strategies for β-cell regeneration. Strategies promoting longitudinal graft survival and function are also discussed in detail, including those targeting the innate non-antigen specific immune response as well as immunosuppressive, immunomodulatory and tolerance-inducing methodologies that improve islet transplantation outcomes. We also address other avenues that promote graft survival and function such as immunoisolation of islets, transplantation to alternative sites, overcoming metabolic stress, promotion of vasculogenesis and reduction of hypoxia to enable successful engraftment. The progress achieved in these areas and in autologous islet transplantation is extremely promising and has drawn us a step closer to achieving widespread application of islet transplantation as a cure for type 1 diabetes.
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    ABSTRACT: The increasing rate of societal obesity is also affecting the transplant world through obesity in candidates and donors as well as its posttransplant repercussions. Being overweight and obese has been shown to have significant effects on both short- and long-term complications as well as patient and graft survival. However, much of the comorbidity can be controlled or prevented with careful patient selection and aggressive management. A team approach to managing obesity and its comorbidities both pre- and posttransplant is essential for successful transplant outcomes. Complicating understanding the results of obesity research is the inclusion different weight categories, use of listing vs transplant weights, patient populations large enough for statistical power, and changes in transplant management, especially immunosuppression protocols, anti-infection protocols, and operative techniques. Much more research is needed regarding many elements, including safe weight loss before transplantation, prevention of weight gain after transplant, genomic influences, and the role of bariatric surgery in the transplant process.
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