Solid pancreas transplant: Pushing forward

Abstract

Pancreas transplant has evolved significantly in recent years. It has now become a viable treatment option on type 1 diabetic patients with poorly controlled diabetes on conventional treatment, insulin intolerance, hypoglycaemia unawareness, brittle diabetes and/ or end-stage kidney disease. The purpose of this review is to provide an overview of pancreas transplant historical origins and current barriers to broader utilization of pancreata for transplant, with a focus on areas for future improvement to better pancreas transplant care. Donor pancreata remain underutilized; pancreatic allograft discard rates remain close to 30% in the United States. Donations after cardiac death (DCD) pancreata are seldom procured. Study groups from Europe and the United Kingdom showed that procurement professionalization and standardization of technique, as well as development of independent regional procurement teams might increase organ procurement efficiency, decrease discards and increase pancreatic allograft utilization. Pancreas transplant programs should consider exploring pancreas procurement opportunities on DCD and obese donors. Selected type 2 diabetics should be considered for pancreas transplant. Longer follow-up studies need to be performed in order to ascertain the long-term cardiovascular and quality of life benefits following pancreas transplant; the outcomes of which might eventually spearhead advocacy towards broader application of pancreas transplant among diabetics.

Hypertension, but not body mass index, is predictive of increased pancreatic lipid content and islet dysfunction

“…Statistically, discard rates steadily rise as donor age and BMI increase, with discard of >80% from donors with a BMI >35 kg/m 2 and 72% of donors above age 50 . Though the reasons for organ discard are myriad, major concerns arise related to steatosis‐associated inflammation and ischemia–reperfusion injury, leading to subsequent thrombosis and graft failure . Pancreatic steatosis is the accumulation of fat specifically within the parenchyma of the organ; however, the ability to determine whether a graft is suitable for transplant and to qualify the degree of steatosis in pancreata before transplant is highly subjective.…”

“…6 Though the reasons for organ discard are myriad, major concerns arise related to steatosis-associated inflammation and ischemia-reperfusion injury, leading to subsequent thrombosis and graft failure. [7][8][9] Pancreatic steatosis is the accumulation of fat specifically within the parenchyma of the organ; however, the ability to determine whether a graft is suitable for transplant and to qualify the degree of steatosis in pancreata before transplant is highly subjective. Thus, assessment based on visualization and unclear relationships between BMI and pancreatic steatosis may result in the unnecessary discard of otherwise healthy organs.…”

Pancreas Transplantation from Donors after Circulatory Death: an Irrational Reluctance?

“…Despite a growing incidence in type 1 DM worldwide, pancreas transplant numbers in the USA and Eurotransplant region are decreasing, whereas numbers in the UK remain practically stable [6]. The main reasons for this are the lack of good-quality donor grafts and improvement in DM treatment, even though pancreas transplantation leads to more stable glycated hemoglobin (HbA1c) levels compared with strict insulin regimens [7], and long-term results of simultaneous pancreas-kidney (SPK) transplantation demonstrate a clear survival benefit as compared with patients who remain on the waiting list [8]. Forced by donor shortage, nowadays, more extended criteria donors (ECD) are used for transplantation, i.e., donation after brain death donation after brain death donors (DBD) of higher age and BMI, or donation after circulatory death donors (DCD).…”

Machine Perfusion and the Pancreas: Will It Increase the Donor Pool?

“…In the USA where the majority of pancreas transplants are from DBD donors and there is a 20% discard rate [76–78], a decline in this figure by a modest 25% would result in 70 more transplants a year a 7% increase overall. Furthermore, if there is also renewed acceptance of DCD donor pancreata increasing from 3% at present closer to the rates in the UK or Europe (approximately 20% [77]), such an expansion could equate to 200 more transplants per year. In both situations, the availability of more suitable donors determined by objective measures during dynamic preservation and optimisation does need to be matched by clinicians and patients who are willing to accept the recent successful results and proven benefits of a pancreas transplant on both survival and quality of life.…”