Pancreas transplantation

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Pancreas transplantation
Intervention

Pancreas transplant ex-situ prepared with reconstruction of arteries and lengthening of the portal vein
ICD-9-CM 52.8
MeSH D016035
MedlinePlus 003007

A pancreas transplant is an organ transplant that involves implanting a healthy pancreas (one that can produce insulin) into a person who usually has diabetes. Because the pancreas is a vital organ, performing functions necessary in the digestion process, the recipient's native pancreas is left in place, and the donated pancreas is attached in a different location. In the event of rejection of the new pancreas which would quickly cause life-threatening diabetes, the recipient could not survive without the native pancreas still in place. The healthy pancreas comes from a donor who has just died or it may be a partial pancreas from a living donor.[1] At present, pancreas transplants are usually performed in persons with insulin-dependent diabetes, who can develop severe complications. Patients with the most common- and deadliest- form of pancreatic cancer (pancreatic adenomas- which are usually always malignant, with a poor prognosis and high risk for metastasis- as opposed to more treatable pancreatic neuroendocrine tumors or pancreatic insulinomas) are usually not eligible for valuable pancreatic transplantations, since the condition usually has a very high mortality rate and the disease, which is usually highly malignant and detected too late to treat, could and probably would soon return.

Types

There are four main types of pancreas transplantation:

  • Pancreas transplant alone, for the patient with type 1 diabetes who usually has severe, frequent hypoglycemia, but adequate kidney function.
  • Simultaneous pancreas-kidney transplant (SPK), when the pancreas and kidney are transplanted simultaneously from the same deceased donor.
  • Pancreas-after-kidney transplant (PAK), when a cadaveric, or deceased, donor pancreas transplant is performed after a previous, and different, living or deceased donor kidney transplant.
  • Simultaneous deceased donor pancreas and live donor kidney (SPLK) has the benefit of lower rate of delayed graft function than SPK and significantly reduced waiting times, resulting in improved outcomes.[2]

Indications

In most cases, pancreas transplantation is performed on individuals with type 1 diabetes with end-stage renal disease. The majority of pancreas transplantation (>90%) are simultaneous pancreas-kidney transplantation.[3] It may also be performed as part of a kidney-pancreas transplantation.

Preservation until implantation

Standard practice is to replace the donor's blood in the pancreatic tissue with an ice-cold organ storage solution, such as UW (Viaspan) or HTK until the allograft pancreatic tissue is implanted.

Complications

Complications immediately after surgery include thrombosis, pancreatitis, infection, bleeding and rejection. Rejection may occur immediately or at any time during the patient's life. This is because the transplanted pancreas comes from another organism, thus the recipient's immune system will consider it as an aggression and try to combat it. Organ rejection is a serious condition and ought to be treated immediately. In order to prevent it, patients must take a regimen of immunosuppressive drugs. Drugs are taken in combination consisting normally of cyclosporine, azathioprine and corticosteroids. But as episodes of rejection may reoccur throughout a patient's life, the exact choices and dosages of immunosuppressants may have to be modified over time. Sometimes tacrolimus is given instead of cyclosporine and mycophenolate mofetil instead of azathioprine.

Prognosis

The prognosis after pancreas transplantation is very good. Over the recent years, long-term success has improved and risks have decreased. One year after transplantation more than 95% of all patients are still alive and 80-85% of all pancreases are still functional. After transplantation patients need lifelong immunosuppression. Immunosuppression increases the risk for a number of different kinds of infection[4] and cancer.

History

The first pancreas transplantation was performed in 1966 by the team of Dr. Kelly, Dr. Lillehei, Dr. Merkel, Dr. Idezuki Y, & Dr. Goetz, three years after the first kidney transplantation.[5] A pancreas along with kidney and duodenum was transplanted into a 28-year-old woman and her blood sugar levels decreased immediately after transplantation, but eventually she died three months later from pulmonary embolism. In 1979 the first living-related partial pancreas transplantation was done.

References

  1. ↑ Type 1 cures - pancreas transplants
  2. ↑ Farney, Alan; Cho E, Schweitzer EJ, Dunkin B, Philosophe B, Colonna J, Jacobs S, Jarrell B, Flowers JL, Bartlett ST (November 2000). "Simultaneous cadaver pancreas living-donor kidney transplantation: a new approach for the type 1 diabetic uremic patient.". Annals of Surgery 232 (5): 696–703. PMC 1421224. PMID 11066142. 
  3. ↑ Gruesomer AC, Sutherland DE (2005). "Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNIS) and the International Pancreas Transplant Registry (SCRIPT) as of June 2004". Clint Transplant 19 (4): 433–55. doi:10.1111/j.1399-0012.2005.00378.x. PMID 16008587. 
  4. ↑ Fishman JA, Rubin RH (1998). "Infection in organ-transplant recipients". N Engl J Med 338 (24): 1741–51. doi:10.1056/NEJM199806113382407. PMID 9624195.  Full text
  5. ↑ Kelly WD, Lillehei RC, Merkel FK, Idezuki Y, Goetz FC (1967). "Allotransplantation of the pancreas and duodenum along with the kidney in diabetic nephropathy". Surgery 61 (6): 827–37. PMID 5338113. 

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