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Kidney/Pancreas & Islet Cell Transplant


                                               Kidney/Pancreas and Islet Transplantation: Version 7.0

Summary


Pancreas transplantation, either whole organ or islet transplantation alone, is the only known treatment that restores continuous euglycemic control in Type I diabetics, and recently has become a treatment available for the so-called Type 1-1/2 or “thin Type 2” patients. In spite of major advances in continuous infusion methods through implanted pumps, pancreas transplant, either alone or with a kidney remains a viable option for selected patients.
 
The incidence of kidney/pancreas and pancreas alone transplantation hovers around 2.78/1,000,000 population, with pancreas alone around 1 transplant/2,000,000. In 2015, 719 patients underwent kidney/pancreas, the 2nd lowest since 1993, and 228 pancreas-alone (PTA) transplants, the lowest PTA volume since 1997. Of the approximately 124 UNOS-approved centers in the United States, only 17 have performed more than 100 pancreas transplants since 1988. Kidney/pancreas (SPK) and pancreas transplantation (PAK & PTA) account for about 3.8% of the solid organ transplants performed in the United States. As of November, 2016 there are 1921 patients awaiting kidney/pancreas and 968 for pancreas alone transplantation. There is a growing discrepancy between those listed for pancreas transplant and the number of organs available. (Source: OPTN)

The pancreas is a very delicate organ taking very special handling from procurement to transplant. Because of widespread experience in early pancreas graft losses a decade or so ago, pancreas continues to hold its place as the organ with the highest non-acceptance rate and the widest variation of acceptance experience across organ procurement organizations of any organ. The decline in pancreas alone transplants from a high of 1484 in 2004 to the very low 228 stated above has led to several changes in allocation policy to gain more uniformity in organ acceptance criteria and reduce the very wide geographic variation.

There are two types of kidney/pancreas transplants: simultaneous pancreas kidney (SPK) and pancreas after kidney (PAK). They differ in the timing. With SPK, both organs are transplanted at the same time. With PAK, the pancreas is transplanted as a planned separate procedure that is usually done several months following a successful kidney transplant. Different centers have different philosophies on how kidney/pancreas transplantation is best managed. Historically, graft survival following SPK has been superior to PAK. The absence of a Donor Risk Index for pancreas transplants has made comparisons of outcome difficult. Many centers will determine whether they will do a SPK or PAK based on organ availability. Typically, SPK is done using a deceased donor kidney and pancreas from the same donor. Frequently, PAK is done using a living donor kidney. This has the advantage that it can be a scheduled procedure. A deceased donor pancreas is then used for the pancreas transplant. The timing of the pancreas transplant is dependent on the availability of the deceased donor pancreas. Pancreas transplant alone (PTA) is typically done for “brittle” diabetics without renal failure. (See “Indications for Pancreas Transplantation Alone (PTA)” later in this discussion). UNOS and OPTN report PAK along with PTA as “pancreas” transplants. They reserve the term “kidney/pancreas” for SPK. This is important to remember when looking at center specific data on graft and patient survival, wait times, etc.

The general interest in islet transplantation has waned over the past few years and is now confined to a few centers with interest in doing it. Islets are clusters of five different cell types. They are produced from partial digestion of the pancreas in the lab and then are commonly infused into the hepatic circulation where they take up residence to provide their endocrine functions of producing glucagon, insulin, somatostatin, a regulatory pancreatic polypeptide controlling both functions of the pancreas, and ghrelin which stimulates hunger. Islet transplantation has become more commonly covered by insurance carriers with the ongoing support of CMS for clinical trials (see below). The indications for islet cell transplantation are the same as for the other types of pancreas transplantation.