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Consensus criteria, education could boost pancreas transplantation uptake in diabetes

December 16, 2022

6 min read


Source/explanations


Source: Healio Interviews


disclosures: Fridell does not report relevant financial disclosures.


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The chances of a successful pancreas transplant for people with diabetes have increased in recent years, but the number of adults undergoing the procedure is declining, according to a review article.

A study published in American Journal of Transplantation in 2016 detailed a steady increase in the survival rate of people undergoing simultaneous pancreas and kidney transplants and those undergoing pancreas transplants after a kidney transplant. The proportion of those with a functioning pancreas after any type of transplant also increased from 1999-2003 to 2009-2013.



Jonathan A. Fridell, MD, FACS



Pancreas transplant success rates have increased over the past 20 years, but the number of adults undergoing the procedure in the US has declined. A report published in Current opinion on organ transplantation in 2016 found that the number of pancreas transplants taking place in the US peaked in 2003, before declining steadily from 2004 to 2013.

The decline in the number of surgeries has continued in recent years. In a review published in The Journal of Clinical Endocrinology & Metabolism, Jonathan A. Fridell, MD, FACS, professor of surgery, chief of abdominal transplant surgery and director of pancreas transplantation at Indiana University School of Medicine, and colleagues wrote that from 2005 to 2021 in the U.S., the number of simultaneous kidney and pancreas transplants decreased by 9%, pancreas transplants after kidney transplantation decreased by 85%, and pancreas transplants alone fell by 63%. Similar declines have also been observed in other countries.

“Kidney and pancreas transplantation has been a recognized standard of care for certain patient populations for more than 20 years, pancreas transplantation only for slightly less than that,” Fridell told Healio. “There is no therapy that competes with them for patients with the right indications. But when looking at guidelines for the management of patients with diabetic nephropathy and guidelines for patients with diabetes, these treatment routes are usually not explored. I think it’s because there’s hope that something better is coming, there’s a belief that insulin therapy should be able to work, and there’s a concern that this is a potentially morbid surgery.

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Healio spoke with Fridell about the benefits and risks of pancreas transplantation for people with diabetes, factors behind the decline in transplant rates in recent years, and reasons why health care professionals are considering people with type 1 or type 2 diabetes who may be candidates for the procedure, should teach better .

helio: Can you provide some background on pancreas transplantation in people with diabetes? What are some of the benefits and risks of this method?

Fridell: Pancreas transplantation is not new. The first pancreas transplant was performed at the University of Minnesota in the late 1960s. In surgery you add an extra pancreas, you don’t take out the original pancreas, you give them a second one. The thing is, if someone doesn’t make enough insulin to regulate their glucose, if you give them an extra pancreas, they have to make the insulin they need. It’s very similar to the way we add a kidney when someone doesn’t make enough or well enough urine; that way we can get them out of kidney failure and dialysis.

The risks are that it is major abdominal surgery. Any time you have an organ transplant, there is a risk that the blood supply will clot. For pancreas transplants, it is probably slightly more common than for other types of transplants. Also, the pancreas is attached to the intestine, very rarely to the bladder, so there is a risk of the attachments leaking. But these are all unusual complications.

Complications are usually graft-threatening, meaning you could lose the pancreas as a Result. They can, but are usually not life-threatening. And then there are the risks of lifelong immunosuppression. So instead of the risk of diabetes, where the patients can get vision loss or limb loss or loss of their kidney function, they trade that for immunosuppression, which is toxic and puts patients at risk for opportunistic infections and cancers.

Most of the time, we do pancreas transplants along with another organ, with the logic that since they’re committed to lifelong immunosuppression for the other organ, they might as well not be diabetic. The vast majority of those are kidney transplants for diabetic nephropathy or diabetic kidney disease. The very select group of patients eligible for a transplant are those in need of a kidney, or patients with life-threatening complications of diabetes, the most common of which is hypoglycaemia. In that group of patients, we would also include patients who have had their pancreas removed for non-cancerous reasons, such as chronic pancreatitis.

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helio: Can pancreas transplantation be performed in a wider population of people with diabetes?

Fridell: Originally, this operation was reserved for patients with specific type 1 diabetes, due to the risk of technical complications. We also used to limit it to fairly simple candidates – so younger recipients with not much vascular disease and not very overweight.

Recently we have expanded the number of people suitable for this operation. We offer it to elderly patients, which is good because our recipient population is aging. Most programs offer ages 50 to 59, many programs age 60 to 69, and very few, but some programs age 70 and older. Patients with a higher BMI are also offered transplants.

What’s really interesting is that today we’re also offering it to patients with type 2 diabetes. That’s actually becoming a common reason to get a kidney and pancreas transplant together for type 2 diabetes.

helio: Is there a reason why diabetes care professionals are hesitant to recommend a pancreas transplant to patients?

Fridell: There is a long memory of the early history of pancreas transplantation from when this surgery was first introduced. At that time, there were problems and complications in the period when we were figuring out how to perform the surgery and fine-tuning the surgical techniques, preservation solutions, postoperative treatment and immunosuppression, as was the case with every other type of transplant we’ve done . There’s a period of learning and figuring out steps, and there’s a long memory of what pancreas transplants looked like in these early years and probably into the late 1990s. But we have changed the technical aspects of the operation. We have better preservation solutions, immunosuppression has evolved and we have gained more experience. We are better at understanding complications and therefore predicting and preventing complications. Graft survival has improved significantly and technical graft loss has dropped significantly.

helio: Why has the number of pancreas transplant procedures declined over the past 20 years??

Fridell: There are many reasons, but probably the most prominent of them is that we are very tightly regulated, and the expectation is that we will have excellent results with every transplant that we do. As a field, we’ve become a little bit more cautious and a little bit more risk averse, which has resulted in better outcomes, but less organs getting used to.

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There are some misconceptions about what combinations of organs you should do. There are certainly some problems with references. For the kidney and pancreas patients, we usually catch those in transplant centers who perform pancreas transplants when they come in for their kidney, but there are many programs that don’t offer pancreas transplants, or only offer them with very narrow criteria, so those patients may not be captured. Also, the patients who would benefit from getting only a pancreas due to their life-threatening complications remain in the care of the diabetologists with optimized medical therapy, which is not as good as a pancreas transplant.

helio: What changes need to be made to increase acceptance of pancreas transplantation for people with diabetes?

Fridell: As a medical community, we need to identify the patients who are suitable candidates for this, think about it at the right time, and refer the patients. We need to educate the patients with diabetes because patients are allowed to refer themselves to transplant hospitals and if they know this is an option, almost all pancreatic transplant centers would welcome them. If they’re not a candidate, they can at least have the conversation about what’s involved. Maybe some of the patients that we’re seeing aren’t candidates for pancreas transplantation, but once it’s approved, they could be candidates for islet transplantation.

In transplant hospitals, there should be a pathway that when a patient is referred for a kidney transplant, if they are a good candidate for a pancreas transplant, there should be a mechanism for consultation or referral to a consignor who performs pancreatic transplants. so that patients are informed and can decide which procedure they want.

References:

  • Fridell JA, et al. J Clin Endocrinol Metab. 2022;doi:10.1210/clinem/dgac644.
  • Stratta RJ, et al. Ben J Transplant. 2016;doi:10.1111/ajt.13890.
  • Stratta RJ, et al. Curr Opin Organ Transplantation. 2016;doi:10.1097/MOT.0000000000000319.

For more information:

Jonathan A. Fridell, MD, FACScan be reached at jfridell@iupui.edu.

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