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Simultaneous pancreas and kidney transplantation: current trends and future directions.

Redfield RR, Scalea JR, Odorico JS - Curr Opin Organ Transplant (2015)

Bottom Line: Rates of pancreas transplantation have declined, despite improved pancreatic graft outcomes.Rejection of the pancreas may be discordant with the kidney after SPK and there is a greater appreciation of antibody-mediated rejection of the pancreas allograft.SPKs are being performed with greater frequency in type 2 diabetes mellitus patients and in patients of advanced age, with exemplary results.

View Article: PubMed Central - PubMed

Affiliation: Division of Transplantation, Department of Surgery, University of Wisconsin -Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA *Joseph R. Scalea and Robert R. Redfield contributed equally to the writing of this article.

ABSTRACT

Purpose of review: Important trends are being observed in pancreas transplantation in the USA. We will describe recent trends in simultaneous pancreas kidney (SPK) transplantation related to immunosuppression, treatment of rejection, and transplantation for patients of advanced age and C-peptide positive diabetes.

Recent findings: Rates of pancreas transplantation have declined, despite improved pancreatic graft outcomes. Regarding immunosuppression, trends in SPK transplantation include T-cell depletion induction therapy, waning mammalian target of rapamycin inhibitor use and steroid use in greater than 50% of pancreas transplant recipients with few patients undergoing late steroid weaning. Rejection of the pancreas may be discordant with the kidney after SPK and there is a greater appreciation of antibody-mediated rejection of the pancreas allograft. De-novo donor-specific antibody without graft dysfunction remains an active area of study, and the treatment for this condition is unclear. SPKs are being performed with greater frequency in type 2 diabetes mellitus patients and in patients of advanced age, with exemplary results.

Summary: The current state of the art in SPK transplantation is yielding superb and improving results.

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Related in: MedlinePlus

Improving results of SPK transplantation in the USA. The half-life for an SPK is now approximately 14 years. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas. Reproduced with permission from [6].
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Figure 1: Improving results of SPK transplantation in the USA. The half-life for an SPK is now approximately 14 years. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas. Reproduced with permission from [6].

Mentions: Owing to a variety of factors including improved surgical technique, immunosuppression, donor and recipient selection, and graft surveillance – with greater reliance on pancreas biopsy – the half-life for an SPK pancreatic graft (Fig. 1) has steadily increased to over 14 years [7]. Registry data suggest that the majority of the improvement in long-term graft survival is because more grafts survive the first year posttransplantation, which is in part because of fewer early technical graft losses. Of the various forms of pancreas transplantation (solitary pancreas transplant [SPT] vs. SPK), SPK has historically been associated with better pancreatic graft survival [8]. Between 1988 and 1998 rates of pancreas transplantation increased markedly worldwide, with SPK representing the vast majority of transplants. However, since the early 2000s, rates of pancreas transplantation have stabilized and even declined in the USA (Fig. 2). The reason(s) for this decline are not well understood [9]. The most pronounced decrease in volume was observed in pancreas after kidney (PAK) transplants, which may be due to changes in referral patterns. SPK transplant volume saw a plateauing or slight decline recently compared with the dramatic increases observed in the prior decade. The reason for the decline in SPK transplant volume is not precisely clear but is likely multifactorial. An analysis of the United Network for Organ Sharing/Scientific Registry of Transplant Recipients (UNOS/SRTR) database suggests that fewer patients are being placed on the SPK waiting list [10▪]. It has been suggested that decreased rates of SPK waitlisting may be related to changes in the rates of diabetic nephropathy development or delayed progression to later-stage CKD [11]. In this regard, greater availability of better insulin delivery systems and diabetes education are probably having a beneficial impact. However, regional waiting list rules may also be contributory. Declining rates of pancreas transplantation may also be reflective of more stringent donor selection and greater scrutiny of center outcomes. Finally, it is very likely that changes in the donor population are adversely affecting allocation of suitable pancreata. Only approximately 15% of US deceased donors in 2013 donated a pancreas for transplantation. This is not a surprising trend given that the US donor population is becoming increasingly old, obese, and diabetic [11]. Undoubtedly, some transplantable pancreata are also being allocated for islet transplantation and research. It would be of interest to understand whether other countries are observing similar trends to those occurring in the USA, alas these data are not readily available.


Simultaneous pancreas and kidney transplantation: current trends and future directions.

Redfield RR, Scalea JR, Odorico JS - Curr Opin Organ Transplant (2015)

Improving results of SPK transplantation in the USA. The half-life for an SPK is now approximately 14 years. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas. Reproduced with permission from [6].
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4286161&req=5

Figure 1: Improving results of SPK transplantation in the USA. The half-life for an SPK is now approximately 14 years. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas. Reproduced with permission from [6].
Mentions: Owing to a variety of factors including improved surgical technique, immunosuppression, donor and recipient selection, and graft surveillance – with greater reliance on pancreas biopsy – the half-life for an SPK pancreatic graft (Fig. 1) has steadily increased to over 14 years [7]. Registry data suggest that the majority of the improvement in long-term graft survival is because more grafts survive the first year posttransplantation, which is in part because of fewer early technical graft losses. Of the various forms of pancreas transplantation (solitary pancreas transplant [SPT] vs. SPK), SPK has historically been associated with better pancreatic graft survival [8]. Between 1988 and 1998 rates of pancreas transplantation increased markedly worldwide, with SPK representing the vast majority of transplants. However, since the early 2000s, rates of pancreas transplantation have stabilized and even declined in the USA (Fig. 2). The reason(s) for this decline are not well understood [9]. The most pronounced decrease in volume was observed in pancreas after kidney (PAK) transplants, which may be due to changes in referral patterns. SPK transplant volume saw a plateauing or slight decline recently compared with the dramatic increases observed in the prior decade. The reason for the decline in SPK transplant volume is not precisely clear but is likely multifactorial. An analysis of the United Network for Organ Sharing/Scientific Registry of Transplant Recipients (UNOS/SRTR) database suggests that fewer patients are being placed on the SPK waiting list [10▪]. It has been suggested that decreased rates of SPK waitlisting may be related to changes in the rates of diabetic nephropathy development or delayed progression to later-stage CKD [11]. In this regard, greater availability of better insulin delivery systems and diabetes education are probably having a beneficial impact. However, regional waiting list rules may also be contributory. Declining rates of pancreas transplantation may also be reflective of more stringent donor selection and greater scrutiny of center outcomes. Finally, it is very likely that changes in the donor population are adversely affecting allocation of suitable pancreata. Only approximately 15% of US deceased donors in 2013 donated a pancreas for transplantation. This is not a surprising trend given that the US donor population is becoming increasingly old, obese, and diabetic [11]. Undoubtedly, some transplantable pancreata are also being allocated for islet transplantation and research. It would be of interest to understand whether other countries are observing similar trends to those occurring in the USA, alas these data are not readily available.

Bottom Line: Rates of pancreas transplantation have declined, despite improved pancreatic graft outcomes.Rejection of the pancreas may be discordant with the kidney after SPK and there is a greater appreciation of antibody-mediated rejection of the pancreas allograft.SPKs are being performed with greater frequency in type 2 diabetes mellitus patients and in patients of advanced age, with exemplary results.

View Article: PubMed Central - PubMed

Affiliation: Division of Transplantation, Department of Surgery, University of Wisconsin -Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA *Joseph R. Scalea and Robert R. Redfield contributed equally to the writing of this article.

ABSTRACT

Purpose of review: Important trends are being observed in pancreas transplantation in the USA. We will describe recent trends in simultaneous pancreas kidney (SPK) transplantation related to immunosuppression, treatment of rejection, and transplantation for patients of advanced age and C-peptide positive diabetes.

Recent findings: Rates of pancreas transplantation have declined, despite improved pancreatic graft outcomes. Regarding immunosuppression, trends in SPK transplantation include T-cell depletion induction therapy, waning mammalian target of rapamycin inhibitor use and steroid use in greater than 50% of pancreas transplant recipients with few patients undergoing late steroid weaning. Rejection of the pancreas may be discordant with the kidney after SPK and there is a greater appreciation of antibody-mediated rejection of the pancreas allograft. De-novo donor-specific antibody without graft dysfunction remains an active area of study, and the treatment for this condition is unclear. SPKs are being performed with greater frequency in type 2 diabetes mellitus patients and in patients of advanced age, with exemplary results.

Summary: The current state of the art in SPK transplantation is yielding superb and improving results.

Show MeSH
Related in: MedlinePlus