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)

Division of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin, Tucson AZ 85724, USA.
The Review of Diabetic Studies 01/2011; 8(1):6-16. DOI: 10.1900/RDS.2011.8.6
Source: PubMed


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.

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Available from: Angelika C Gruessner
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    • "In the 2011 Update on Pancreas Transplantation by A.C. Gruessner, the best graft function occurred in patients who had SPK transplants compared to patients who underwent PAK, or PTA, and decreased graft survival in solitary pancreas transplantation was attributed to immunologic graft loss [13]. The graft and subsequent patient survival advantage in the steroid maintenance group compared to the induction only group may be attributable to the high percentage of SPK patients (80.4%), and the low percentage of PTA patients (5.4%) in the former vs. 65.2% and 17.0% respectively in the latter group. "
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    ABSTRACT: The appropriateness of steroid maintenance in pancreas transplantation is unproven. The current literature is insufficient due to small numbers, short follow-up and sparse data. Data from the UNOS database on adults ≥18 years old, who received pancreas and kidney-pancreas transplants between January 1996 and March 2014 were analyzed (n = 27,077). Two groups were evaluated: (a) Steroids Induction only (n = 4391) and (b) Steroid maintenance (n = 22,686). One-, 3-, 5-, 10-, and 15-year unadjusted patient and graft survival rates were compared. A Cox proportional hazards model was used to determine what patient factors were associated with these outcomes. There were differences in patient survival at 1 and 3 years and in graft survival at 3 and 5 years. There was a higher rate of infectious complications in the maintenance group, but after controlling for several recipient factors, whether a patient received steroid maintenance or not, was not significantly associated with the risk of death or graft failure. The use of maintenance steroids is significantly associated with an increased risk of infectious complications, but no difference in patient death or graft failure after controlling for multiple recipient factors. There is also no benefit with the use of steroid maintenance after pancreas transplantation. Copyright © 2015 IAP and EPC. Published by Elsevier B.V. All rights reserved.
    Full-text · Article · Aug 2015 · Pancreatology
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    • "Antithymocyte globulin (depleting antibodies, thymoglobulin) or antieinterleukin-2 (nondepleting antibodies, Simulect) was used; however, comparisons have not been conducted between modalities. Organ Procurement and Transplantation Network data (2008) show that 52.9% of patients were induced with these drugs, whereas 33% received no induction therapy [19]. The literature recommends the use of these agents to produce a more effective immunosuppression and give rise to the withdrawal or phasing out of corticosteroids, as well as the reduction in the dosages of calcineurin inhibitors. "
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    ABSTRACT: Simultaneous pancreas/kidney transplants require a long graft survival and the recipient to present with more benefits than risks. We evaluated the risk factors of receptor's death and pancreatic graft loss on 2 occasions (3 and 12 months' postoperatively) in 292 transplants in whom 22 variables were evaluated. Variables were selected, 9 receivers, 8 donors, and 5 variables related to the surgical procedure. All independent variables were compared with the dependent variables of pancreatic graft losses and patient deaths. Those considered significant according to univariate analysis were analyzed by using multiple logistic regression techniques in an attempt to develop a mathematical model capable of predicting both pancreatic graft and patient losses. Lastly, based on the resulting models with all significant variables, scores were created to determine the risk of patient death and pancreatic graft loss. In the adjusted multivariate analysis, the significant variables were donor age, receiver's body mass index, initial pancreas implant, iliac venous drainage, and use of induction therapy related to pancreatic loss within 3 months after transplantation. Independent risk factors regarding the loss of patients within 12 months were body mass index and receptor induction therapy. The variables related to pancreatic graft loss within 3 months were donor age, receiver body mass index, initial use of pancreatic graft, iliac venous drainage, and induction therapy; these variables can be used for creating a risk score. The donor body mass index and the induction therapy were independently related to patient loss within 12 months after the transplant.
    Full-text · Article · Jul 2014 · Transplantation Proceedings
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    • "Although type II diabetes was a contraindication to pancreas transplantation, initial intentional SPK transplantation with type II diabetes showed that augmentation of endogenous insulin secretion from pancreas allograft in patients with C-peptideÀpositive, insulin-requiring diabetes resulted in insulin independence, improved glucose metabolism, and enhanced quality of life [14] [15]. The operative procedure changes, optimizing immunosuppression, careful pretransplantation evaluation, and improved graft monitoring have become standard in the last decade and resulted in excellent 5-year patient, kidney, and pancreas graft survival [2] [16]. However, technical failure and immunological graft loss is still a problem in pancreas transplantation and requires further investigation. "
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    ABSTRACT: BK polyomavirus-associated nephropathy (BKVAN) is an important cause of renal allograft loss. Immunosuppression therapy in renal transplant recipients can lead to the reactivation of latent BK polyomavirus (BKV) infection, leading to BK viruria and viremia. This single-center study aimed to clarify the association between quantitative measurement of BKV DNA and the progression of BKV infection, and secondly to identify the risk factors associated with the evolution of viruria to viremia. We retrospectively analyzed 266 patients who underwent renal transplantation in our center from October 2006 to February 2013. We examined the viral loads of BKV in urine and plasma by quantitative real-time polymerase chain reaction assay after screening all of the recipients by urinary sediment examination. BKVAN was diagnosed by histological examination with immunohistochemistry of the large T antigen in biopsy specimens. Overall, 22 recipients showed BK viruria alone, whereas 22 progressed to BK viremia, of which 6 patients were diagnosed with BKVAN. Among BKVAN patients, 2 cases progressed to graft loss at 59 months and 31 months after diagnosis, respectively. In BKVAN group, the plasma viral loads were significantly higher than those in viremia without nephropathy (P < .001). Multivariate analysis revealed that the evolution of viruria to viremia was associated with recipient age over 55 years (odds ratio, 32.08; 95% confidence interval, 2.1-489.5) and tacrolimus exposure (odds ratio, 11.98; 95% confidence interval, 1.34-107.04). The progression from viremia to BKVAN was strongly associated with increasing plasma viral loads for BKV DNA. The cutoff value of 1 × 10(4) copies/mL for plasma viral loads could differentiate between BKVAN and viremia alone. Further, recipient age over 55 years and tacrolimus exposure were independently associated with the evolution of viruria to viremia.
    Full-text · Article · Mar 2014 · Transplantation Proceedings
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