Superior long-term results of simultaneous pancreas-kidney transplantation from pediatric donors

Poor utilization of deceased donor pancreata in the United States: Time for action

The number of solid organ pancreas transplants performed in the United States has declined over the past two decades despite improving outcomes and the known benefits associated with this procedure. Although the reasons are multifactorial, high rates of deceased donor pancreata nonrecovery and nonuse have at least in part contributed to the reduction in pancreas transplant activity. The pancreas has higher nonrecovery and nonuse rates compared to the kidney and liver because of more stringent donor selection criteria, particularly with respect to donor age and body mass index, although even marginally inferior donor pancreata likely still benefit some patients compared to alternative therapies. In this editorial, we present several donor-, candidate-, and center-specific factors that are either confirmed or suspected of being associated with inferior outcomes, which contribute to high pancreas nonrecovery and nonuse rates. In addition, we have discussed several measures to increase pancreas recovery and reduce pancreas nonutilization.

First World Consensus Conference on pancreas transplantation: Part II - recommendations

The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246.

Donor risk factors in pancreas transplantation

The aim of the work was to analyze and expose the donor and recipient risk factors in pancreas transplantation. In the following paper, we exposed the 2018 Spanish Consensus Document on Donor and Recipient Selection Criteria for Pancreas Transplantation. An assessment of the previous Selection Criteria for Donors and Recipients of Pancreas Transplantation, published in 2005 by the Spanish Pancreas Transplant Group (GETP) and the National Transplant Organization (ONT) was performed. A literature review was performed using Cochrane Library, PubMed and Google Scholar databases. Some of the following terms were used for the literature search: “Diabetes Mellitus,” “Pancreas Transplantation,” “Insulin-Secreting Cells,” “Pancreas Allograft Thrombosis,” “Allograft Pancreatitis,” “Donors’ Risk Factors,” “Recipients’ Risk Factors,” “Pancreas Allograft Rejection” and “Pancreas Allograft Survival.” After an extended search, different inclusion criteria were established. Articles and documents with abstracts of full text and in English or Spanish language were selected. Subsequently, different scientific meetings took place during 2015 and 2016 by the GETP. Finally, the updated criteria were published by the GETP and ONT in 2018. Several risk factors have been described in pancreas transplantation that can be divided into donor risk factors: Advanced age (> 50 years); high body mass index (BMI) (> 30 kg/m²); cause of death (e.g., stroke); previous hyperglycemia; hyperamylasemia; cold ischemia time (greater than 8 or 12 h, depending on the type of donation); the use of vasopressors in the intensive care unit or cardiac arrest; and the macroscopic aspect of the pancreas allograft. The following are recipient risk factors: Advanced age (> 50 years); active smoking; high BMI (> 30 kg/m²); and peripheral artery disease or sensorimotor polyneuropathy. Based on the aforementioned parameters, different selection criteria have been established for the recipients depending on the type of pancreas transplantation. Knowledge of the risk factors for pancreas transplantation allows the establishment of reliable selection criteria for choosing donors and recipients.

Pancreas transplants from small donors: are the outcomes acceptable? A retrospective study

Despite good organ quality, pancreata from extremely small pediatric donors (<30 kg) are generally avoided by many centers because of concerns of reduced islet cell mass and early technical failure. Therefore, we sought to compare the outcomes of small pancreas grafts (<30 kg) to those from higher weight donors from transplants performed between 1994 and 2015 (n = 1183). A total of 33 pancreata were from donors' ≤30 kg (3%), with a mean weight of 23.8 kg and mean age of 7.8 years. Patient survival was similar at 1, 5, and 10 years between recipients of ≤30 and >30 kg donors (≤30 kg: 96.8%, 86.8%, and 78.1% vs. >30 kg: 96.8%, 89.5%, and 79.1%, P = 0.5). Pancreas graft survival at 1, 5, and 10 years was also similar, ≤30 kg: 93.9%, 73.2%, and 61.0% vs. >30 kg: 87%, 73.3%, and 58.3% (P = 0.7). This graft survival pattern was also seen when comparing pancreata from ≤20 kg donors to those from >20 to 30 kg. Cause of graft loss, and metabolic and physiologic outcomes did not differ between the groups. After assessing the impact of donor weight as a continuous variable and calculating recipient-to-donor weight ratio (RDWR), we observed no effect of donor weight on patient and graft outcomes.

The Outcomes of Pancreatic Transplantation from Pediatric Donors-A Single Institution Experience

OBJECTIVES

The aim of this study was to compare the outcomes of pancreatic transplantation from pediatric donors younger than 15 years of age to the outcomes of pancreatic transplantation from adult donors.

METHODS

Sixty patients underwent pancreatic transplantation in our facility from August 2012 to June 2019. These patients were divided into two groups according to the age of the donor: Cases in which the donor was younger than 15 years of age were classified into the PD group (n = 7), while those in which the donor was older than 15 years of age were classified into the AD group (n = 53). The outcomes of pancreas transplantation were retrospectively compared between the two groups.

RESULTS

Pancreatic graft survival did not differ between the PD and AD groups. Furthermore, there were no differences in the HbA1c and serum creatinine levels at three months, with good values maintained in both groups. The results of oral glucose tolerance tests (OGTTs) revealed that the blood glucose concentration did not differ between the two groups. However, the serum insulin concentration at 30 min after 75 g glucose loading was significantly higher in the PD group.

CONCLUSION

The outcomes of pancreatic transplantation from pediatric donors may be comparable to those of pancreatic transplantation from adult donors and the insulin secretion ability after transplantation may be better.

Simultaneous en-bloc pancreas and kidney transplantation from a small pediatric donor after circulatory death

Simultaneous pancreas and kidney transplantation (SPKT) is an effective treatment option for patients with type 1 diabetes and end stage renal disease. Increasing demands for organs for transplantation coupled with a rise in age and size of adult donors has led to greater utilization of pediatric donors, and with good outcomes. Nonetheless, there remains reticence among transplant surgeons to transplant pancreases from small pediatric donors despite the optimal characteristics and macroscopic features of the younger pancreas. We report a successful case of SPKT from a small pediatric donor and explore the aspects of potential concern that might have led some clinicians to decline these organs. We also discuss the measures taken to overcome potential obstacles to successful transplantation from this donor source, and the rationale behind them.

A steady decline in pancreas transplantation rates

BACKGROUND/OBJECTIVES

After years of growth in many pancreas transplant programs, UNOS has reported declining transplant numbers in the USA. This precipitating trend urges for an evaluation of the transplant numbers and scientific productivity in the Eurotransplant region and the UK.

METHODS

We performed a trend analysis of pancreas transplantation rates, between 1997 and 2016, adjusting for changes in population size, and an analysis of scientific publications in this field. We used information from the UNOS, Eurotransplant, and UK transplant registry and bibliometric information from the Web of Science database.

RESULTS

Between 2004 and 2016 there was an average annual decline in pancreas transplantation rates per million inhabitants of 3.3% in the USA and 2.5% in the Eurotransplant region. In the UK, transplant numbers showed an average annual decline of 1.0% from 2009 to 2016. Publications in Q1 journals showed an annual change of -2.1% and +20.1%, before 2004, and a change of -3.8% and -5.5%, between 2004 and 2016, for USA and Eurotransplant publications, respectively.

CONCLUSIONS

Adjusting pancreas transplantation rates for changes in population size showed a clear decline in transplant numbers in both the USA and Eurotransplant region, with first signs of decline in the UK. Following this trend, the number of scientific publications in this field have declined worldwide.

Pancreatic Grafts from Pediatric Donors Do Not Appear to Grow After Transplantation into Adults

Unlike pediatric kidney donors, there is no literature regarding the growth of pediatric donor pancreatic transplant grafts. Our center prospectively followed three pediatric donor grafts after transplant by measuring two dimensions of the graft at postoperative day one and then at one, two, and three months post-transplant surgery with the hypothesis that the grafted pancreas would not grow like pediatric kidney donors given the fundamental physiologic differences between these two organs. Two grafts were stable to minimally larger in size, the third case decreased in size. Interestingly, all patients had an excellent clinical response with normalization of HbA1c. Further study will be required to understand the natural history of pancreatic transplants from a pediatric donor. Volumetric assessment with magnetic resonance imaging (MRI) is proposed as the next step for better evaluation of graft size.

Donor Characteristics of Pancreas Transplantation in Australia and New Zealand: A Cohort Study 1984-2014

Background

The aim of this study was to audit the characteristics of pancreas donors over time in Australia and New Zealand. Pancreas transplantation was introduced in Australian and New Zealand in 1984.

Methods

We analyzed data from the Australia and New Zealand Islet and Pancreas Transplant Registry, 1984 to 2014. We investigated the variation of donor characteristics of sex, age, body mass index, smoking status, blood group, multiple organ donation, cytomegalovirus status, terminal creatinine, hypertension, and cause of death for pancreas transplantation over time. We used χ² test (Fisher test when necessary) or analysis of variance to test difference for categorical or continuous characteristics, respectively.

Results

There were 628 pancreas donors from 1984 to 2014. Donor body mass index (from 21.9 to 24.0, P < 0.001) and age (from 23.9 to 28.5, P = 0.02) have both increased while terminal creatinine has decreased (86.3 to 73.3, P = 0.01) from 1995 to 2014. In the meantime, the proportions of donors with hypertension (from 19% to 1%, P < 0.001) and who were smokers (from 54% to 15%, P < 0.001) have decreased. Profile of cause of donor death has also changed over time (P = 0.06) with increase in cerebral hypoxia/ischemia (from 3% to 17%) and reductions in intracranial hemorrhage (27% to 13%).

Conclusions

Many donor characteristics have changed over time. The most significant changes appear to reflect changes in the general population, rather than changes in donor selection.

Retrieval of the pancreas allograft for whole-organ transplantation

Proper pancreas retrieval during multi-organ recovery is one of the cornerstones of technically successful whole-organ pancreas transplantation. With evolving surgical approaches for organ retrieval and implantation, it has become standard to procure the pancreas in conjunction with other abdominal organs without compromising either vasculature, graft quality, or transplant outcomes. This review summarizes the major steps required for proper whole-organ retrieval of the pancreas allograft with suggestions and tips whenever alternative approaches are available.

Expanding the donor pool in pancreas transplantation

PURPOSE OF REVIEW

The current era of organ shortage has necessitated expansion of the currently available organ donor pool, to increase the number of pancreases available for transplant. This review summarizes the cumulative efforts of various centers in making this possible.

RECENT FINDINGS

Various centers are consistently reporting their experience with marginal donors; recent additions to the cohort have been increase in pancreases from donors after cardiac death (controlled and uncontrolled), update on long-term outcomes of live pancreas donors, as well as efforts at objectively assessing donor risk.

SUMMARY

It has become important for the transplanting surgeon to make difficult decisions on organ suitability and appropriateness depending upon the recipient's status. Further more, limiting further damage to these vulnerable grafts is important in improving utilization as well as successful transplantation.

Donor risk factors, retrieval technique, preservation and ischemia/reperfusion injury in pancreas transplantation

PURPOSE OF REVIEW

Pancreas transplantation is still hampered by a high incidence of early graft loss, and organ quality concerns result in high nonrecovery/discard rates. Demographic donor characteristics, surgical retrieval strategy, preservation fluid and ischemia time are crucial factors in the process of organ selection and are discussed in this review.

RECENT FINDINGS

The donor shortage is driving an increasing utilization of nonideal organs which would previously have been identified as unsuitable. Recent literature suggests that organs from extended criteria donors - older (>45 years), BMI >30  kg/m(2), and donation after cardiac death (DCD) - can achieve the same graft and patient survival as those from standard criteria donors, with the proviso that the accumulation of risk factors and long ischemic times should be avoided. Visual assessment of the pancreas is advisable before declining/accepting a pancreas. University of Wisconsin represents the gold standard solution; however, histidine-tryptophan-ketoglutarate and Celsior result in equal outcomes if cold ischemia time (CIT) is less than 12  h. Currently in pancreas transplantation, there is no proven effective ischemia/reperfusion injury prophylaxis than trying to keep CIT as short as possible.

SUMMARY

Demographic risk factors, inspection of the pancreas by an experienced surgeon and predicted CIT are crucial factors in deciding whether to accept a pancreas for transplantation. However, there is a need for an improved evidence base to determine where to set the 'cut-off' for unsuitable pancreatic grafts.

The potential benefit of non-purified islets preparations for islet transplantation

Since the advent of islet transplantation, there has been a significant emphasis on the importance of islet purity despite an inevitable associated loss of islet mass during the purification process. One of the key elements of the 'Edmonton Protocol' for islet transplantation published in 2000 was an emphasis on the need for sequential transplants of highly purified islets (averaging 24% beta cell purity) and the close correlation between the numbers of islets transplanted and the success of the procedure. However, the emphasis on islet purity may warrant further consideration as auto transplantation of non-purified islets currently provides the most successful insulin independence rates within the field of islet transplantation. While the role of auto and allo immunity could contribute to the differences in the success rates it is clear that within the clinical setting, significant acinar and ductal contamination is well tolerated. However, one could go further and hypothesize that extra-insular tissue including acinar tissue, ductal tissue, peri-pancreatic lymph nodes and vascular tissue actually confer an advantage to islet survival/function and may even contribute to the insulin secreting capacity of the graft post transplant. As such this review will assess the influence of extra-insular pancreatic tissue on the results of islet transplantation based on published evidence and will also explore the possibility that non-islet pancreatic cells are capable of differentiating into a beta cell phenotype in vivo contributing to an ongoing regeneration of endocrine mass during the period following transplantation.

Donor-dependent risk factors for early surgical complications after simultaneous pancreas-kidney transplantation

INTRODUCTION

The success of simultaneous pancreas-kidney transplantation (SPK) depends in a large degree on avoidance of surgical complications in the early postoperative period. The aim of the study was to analyze the Pre-procurement Pancreas Allocation Suitability Score (P-PASS) and the deceased donor parameters included within it as risk factors for early surgical complications after SPK.

MATERIAL AND METHODS

Forty-six consecutive donors whose kidney and pancreas were simultaneously transplanted were included in the study.

RESULTS

Donor age was older among recipients who lost their pancreatic grafts: 30.4±6.9 versus 24.1±6.9 years. Donor age was also older among recipients who lost their pancreatic grafts or died compared with those discharged with a functioning graft: 29.3±5.7 versus 24.0±6.9 years. Donor body mass index (BMI) was higher among patients who died compared with those who were discharged: 25.3±1.1 versus 23.2±2.5 kg/m2. P-PASS was higher in patients who lost their pancreatic grafts (17.6±2.1 vs 15.2±1.8) or died (15.3±1.9 vs 17.2±1.9), or lost pancreatic graft or died (15.2±1.8 vs 17.0±2.2) or with intra-abdominal infections (IAI; 17.1±1.7 vs 15.0±1.8). The incidence of donors≥30 years old was higher among recipients with IAI (45.4% vs 14.3%; P=.04). An higher rate of donors with P-PASS>16 was revealed among patients who lost their pancreatic grafts (26.7% vs 3.2%), died (26.7% vs 3.2%), lost the pancreatic graft or died (33.3% vs 6.4%), or experienced IAI (46.7% vs 9.7%). Multivariate logistic regression analysis revealed P-PASS (odds ratio 2.57; P=.014) and serum sodium (odds ration, 0.91; P=.048) to be important predictors of IAI development.

CONCLUSION

Older age and higher BMI among deceased donors increased the risk of IAI, pancreatic graft loss, or recipient death after SPK. Transplantation of a pancreas from a donor with a low P-PASS score was associated with a lower risk of surgical complications after SPK.

Improvement in Short-Term Pancreas Transplant Outcome by Targeted Antimicrobial Therapy and Refined Donor Selection

Graft thrombosis and infectious complications are the main early causes of pancreatic allograft loss in recipients of whole vascularized pancreas transplants, resulting in loss rates up to 10 per cent in the first post transplant week. In this study we sought to determine if initiation of a standardized selection criteria and posttransplant chemoprophylaxis regimen could reduce the rate of early allograft loss; we compared the rate of early allograft loss after introduction of these changes. Of the 61 diabetic recipients who underwent these protocols, 50.8 per cent were female. Average age was 42.9 ± 7.4 years of age, average length of stay was 12.7 ± 8.7 days, with all transplants performed heterotopic to the right lower quadrant with venous drainage to the proximal external or common iliac vein. Organ donors were 21.4 ± 4.8 years of age, body mass index was 23.9 ± 2.8 kg/m2, with a length of stay of 3.7 ± 1.6 days. One-week pancreatic allograft survival for the protocolized versus nonprotocolized patients was 100 per cent versus 96.7 per cent, 1 month was 98.4 per cent versus 93.4 per cent, and 1 year was 96.7 per cent versus 88.5 per cent, respectively. In the protocolized group there were two graft losses due to infectious complications and none due to thrombosis. Before initiation of the protocols patient survival at 1 year was 91.8 per cent and after was 100 per cent. Pancreas transplantation is arguably the most technically demanding organ transplant from a complication and loss standpoint. However, highly successful outcomes can be obtained with standardized protocols beginning pretransplant to reduce the incidence of posttransplant complications.

Stereological evaluation of the kidneys of anencephalic and normal fetuses

The aim of this study is to test the glomerular and other quantitative parameters of kidneys of anencephalic fetuses and comparing those to "normal" fetuses. In this study, 20 kidneys of human fetuses (5 boys and 5 girls of anencephalic fetus, and 5 boys and 5 girls of normal fetus), at gestational ages of 25-30 weeks, were examined. This study is based on two basic research methods: one is a conventional anatomical measurement at the macroscopical level; the other is a design-biased stereological method at the microscopical level. Physical dissector and Cavalieri principle were used to estimate the total and numerical density of glomerulus and the volume of kidney, respectively. The results of the two types of investigation were compared based on anencephalic/normal and boy/girl kidneys at both the macroscopical and microscopical levels. There was no significant difference found between the quantitative features of kidneys (volume of kidneys and mean number and/or height of glomerulus) belonging to anencephalic and normal fetuses. The results of this study suggest that anencephalic fetuses did not differ from normal fetuses in respect of kidneys.

Pancreas transplantation: lessons learned from a decade of experience at Wake Forest Baptist Medical Center

This article reviews the outcome of pancreas transplantations in diabetic recipients according to risk factors, surgical techniques, and immunosuppression management that evolved over the course of a decade at Wake Forest Baptist Medical Center. A randomized trial of alemtuzumab versus rabbit anti-thymocyte globulin (rATG) induction in simultaneous kidney-pancreas transplantation (SKPT) at our institution demonstrated lower rates of acute rejection and infection in the alemtuzumab group. Consequently, alemtuzumab induction has been used exclusively in all pancreas transplantations since February 2009. Early steroid elimination has been feasible in the majority of patients. Extensive experience with surveillance pancreas biopsies in solitary pancreas transplantation (SPT) is described. Surveillance pancreas biopsy-directed immunosuppression has contributed to equivalent long-term pancreas graft survival rates in SKPT and SPT recipients at our center, in contrast to recent registry reports of persistently higher rates of immunologic pancreas graft loss in SPT. Furthermore, the impact of donor and recipient selection on outcomes is explored. Excellent results have been achieved with older (extended) donors and recipients, in recipients of organs from donation after cardiac death donors managed with extracorporeal support, and in African-American patients. Type 2 diabetics with detectable C-peptide levels have been transplanted successfully with outcomes comparable to those of insulinopenic diabetics. Our experiences are discussed in the light of findings reported in the literature.

The pancreas allograft donor: current status, controversies, and challenges for the future

The pancreas allograft is a scarce resource that is currently underutilized. The selection of appropriate deceased donors for pancreas procurement is of paramount importance for minimizing technical failure and optimizing long-term outcomes in pancreas transplantation. Despite the increasing demand for pancreas transplantation, increases in overall organ donation rates and the evolution of criteria that constitute an "acceptable" pancreas donor, the number of deceased donor pancreas transplants being performed in the United States has actually declined in recent years. Although there are many factors that must be considered during evaluation of the potential pancreas allograft donor to minimize morbidity and graft loss, it is evident that there are transplantable organs that are not used. In this review, deceased donor pancreas identification, management, selection, allocation, assessment, preservation, and the problem of pancreas underutilization will be discussed.

Donor pancreata: evolving approaches to organ allocation for whole pancreas versus islet transplantation

As islet transplantation increasingly enters the clinical arena, its coexistence with vascularized pancreas transplantation makes it necessary to reassess the questions of donor selection and allocation. In answering these questions, one must put in the balance the short-term morbidity of pancreas transplantation with the long-term attrition of islet grafts. The preferential allocation of pancreases from obese and older donors for islet isolation has been based on their association with worse pancreas transplant outcomes and better islet isolation results in islet yields. In this overview, we show that transplanted islet mass does not necessarily correlate with graft function and make the case that donor selection criteria for islet transplantation, and hence allocation rules, may need to be redefined.

Combined pancreas and en bloc kidney transplantation using a bladder patch technique from very small pediatric donors

Very small pediatric donors are underutilized for pancreas and kidney transplantation for the fear of inadequate islet mass and higher incidence of technical complications, and the lower age limit for such donors is not well defined. We present here two cases of combined pancreas and en bloc kidney transplantation from very small pediatric donors (14 and 18 months old) to adult type 1 diabetic and uremic patients. The conventional surgical procedure for simultaneous pancreas and kidney transplantation with systemic venous and bladder exocrine drainage was successfully applied to very small organs. For both, we utilized the recently described bladder patch technique for ureteral reconstruction. One patient developed venous thrombosis (partial thrombosis of the splenic and mesenteric veins) and the other urine leak (from a midportion of the medial ureter without compromising the bladder patch) after the transplants; both were successfully managed and the patients demonstrated immediate and sustained pancreas and kidney graft functions for 12 and 2 months posttransplantation. These cases illustrate the feasibility of combined pancreas and en bloc kidney transplantation from very small pediatric donors using a bladder patch technique to avoid small ureteral anastomosis.

Surgical techniques for pancreas transplantation

PURPOSE OF REVIEW

Pancreas transplantation reproducibly induces insulin independence in beta-cell penic diabetic patients. The difference between full insulin independence, partial graft function, and graft loss, mostly results from technical failure, graft rejection, and patient death with function graft. The purpose of this review is to examine recent surgical advances and discuss their contribution to improved graft function.

RECENT FINDINGS

Few actual surgical innovations were described in the period reviewed. Duodenoduodenostomy is an interesting option for drainage of digestive secretions, when the pancreas is placed behind the right colon and is oriented cephalad. The main advantage of this technique is easy endoscopic assessment of donor duodenum but, when allograft pancreatectomy is necessary, repair of native duodenum may be troublesome. Selective revascularization of the gastroduodenal artery, at the back-table, possibly improves blood supply to the head of the pancreas graft and duodenal segment. There is no proof that this additional maneuver is always beneficial, although it can be graft saving in case of poor segmental graft perfusion.

SUMMARY

Transplant surgeons should be familiar with all techniques for pancreas transplantation. Long-term graft function is possible only after technically successful pancreas transplantation. There is clearly a need for more objective assessment and standardization of surgical techniques for pancreas transplantation.

Toward improving human islet isolation from younger donors: rescue purification is efficient for trapped islets

Several reports suggest that islets isolated from younger donor pancreata are of better quality for clinical islet transplantation. The relative inefficiency of the continuous gradient purification process (CGP) is one of the major obstacles to the utilization of these younger donor pancreata. This study demonstrates the benefits of utilizing an additional purification step, rescue gradient purification (RGP), to recover trapped islets and examines the possible superiority of these rescued islets. Seventy-three human islet isolations purified by RGP following CGP were divided into two groups based on age, and the isolation results were retrospectively analyzed (group I: age < or = 40, group II: age > 40). The quality of islets from both CGP and RGP were assessed by beta-cell fractional viability (beta FV) and ADP/ATP ratio. Significant increases in the percent islet recovery from RGP and the percent trapped islets in group I compared to group II were observed. Donor age correlated negatively to the percent islets recovered from RGP (R = 0.440) and to the percent of trapped islets (R = 0.511). RGP islets had higher beta FV and better ADP/ATP ratio compared to CGP islets. In conclusion, RGP improved the efficiency in the purification of trapped islets, which often come from younger donor pancreata. The better quality of beta-cells in RGP islets encourages us to perform RGP, considering the higher quality as well as the quantity of remaining islets.

Can 'extreme' pancreas donors expand the donor pool?

PURPOSE OF REVIEW

The present review investigates donor qualities that impact pancreas and islet transplantation, with a focus on donors that have been historically underutilized, including those of extreme age, extreme size, and donors after cardiac death.

RECENT FINDINGS

The increasing waiting time caused by the shortage of available pancreata and the growing number of patients with uncontrolled diabetes has led to the expansion of acceptance criteria for transplantable pancreata. The possible increased perioperative risks and/or foreshortened graft survival associated with the use of 'extreme' donors should be weighed against the mortality of uremic diabetics on the waiting list and the risk of dying from a hypoglycemic-unawareness episode. Current data have shown that pediatric pancreas donors are associated with excellent outcomes. Selected donors up to 50 years of age are suitable for both islet and pancreas transplantation. Obese donors are more appropriate as islet donors, and donors after cardiac death provide an underutilized source of pancreata for transplantation, with clinical results that are identical to those observed from ideal donors.

SUMMARY

Donor selection in pancreas transplantation significantly impacts outcome, yet the use of extended criteria donors can provide results comparable with those of ideal donors.

Pancreas-kidney and pancreas transplantation for the treatment of diabetes mellitus

Kidney transplantation is the treatment of choice for end-stage diabetic nephropathy, but the ultimate treatment today for type 1 diabetes mellitus is the whole vascularized pancreas transplant. Although its use is increasing, pancreas transplantation remains an uncommonly used therapeutic option that normalizes glucose levels and results in stabilization or improvement in secondary complications far better than any other strategy available for treatment of type 1 diabetes. These documented benefits of a simultaneous kidney and pancreas transplant are the basis for its acceptance as an appropriate therapy for patients who have type 1 diabetes mellitus and end-stage renal disease.

Transplantation for type 1 diabetes: whole organ pancreas and islet cells

Beta-cell transplantation can be either a whole organ pancreas transplant or an islet cell transplant; both have resulted in restoration of a normoglycemic state. These transplants can be performed in conjunction with kidney transplants or as solitary grafts. In general, whole organ transplants have more sustained and durable function and are more widely available than their islet counterparts, but entail a much more invasive procedure. Beta-cell transplantation continues to evolve, with considerable improvement in results over the past two decades, and is a cost-effective option for select patients with type 1 diabetes.