Pancreas Transplantation

Whole-organ pancreas transplantation is a major surgical procedure with a significant rate of morbidity and the need for immunosuppression. However, it improves the patient's quality of life and reverses some diabetic complications, and up to 82% insulin independence at 1 year is reported.82 Pancreas transplantation can be performed simultaneously with kidney transplantation (SPK), as occurs in approximately 90% of patients, or after kidney transplantation (4%) and in specialized enters in nonuremic patients as pancreas transplantation alone (6%).82 Survival rates are better for SPK because acute rejection can be treated earlier, coinciding with the simultaneous rise in serum creatinine that is indicative of acute rejection of the kidney. Pancreas transplantation in a nonuremic patient is performed more rarely. These patients have "brittle" (labile) diabetes or hypoglycemic unaware-ness that is regarded as potentially more harmful than the combined risk of the immunosuppression and surgical risks. The University of Minnesota has the largest experience (.n = 225), with acceptable rates of graft survival (80% at 1 year) and survival of patients (90% at 1 year).84

A combination of long waiting lists and restrictions dictated by organ allocation policies has prompted many pancreas transplantation centers to encourage initial kidney transplantation using a living donor kidney and follow-up with a cadaver pancreas as a separate procedure.83 The University of Maryland has taken this option one step further by offering simultaneous living kidney (using laparoscopic nephrectomy for the donor nephrectomy) and cadaver pancreas transplantation (SPLK) when a donor pancreas becomes available.85 With this single recipient surgical procedure, they reported 1-year actuarial survival of 94% and 86% for the kidney and pancreas, respectively. As a result, they noted that the waiting time for SPK at their center has been reduced by 45%. The group in Minneapolis also continues to promote living donation of both pancreas and kidney (SLPK) and have reported 115 procedures.86 However, there is a long learning curve and the need for meticulous donor evaluation to minimize the metabolic and surgical complications for the donor.

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