2011 update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the course of twenty-four years at the International Pancreas Transplant Registry (IPTR)

Abstract

Aim: This study aimed to analyze the outcome of pancreas and pancreas-kidney transplantations based on the comprehensive follow-up data reported to the International Pancreas Transplant Registry (IPTR).

Methods: As of December 2010, more than 35,000 pancreas transplantations have been reported to the IPTR: more than 24,000 transplantations in the US and more than 12,000 outside the US. Cases with follow-up information until March 2011 were included in the analysis.

Results: Pancreas transplantations in diabetic patients were divided into 3 categories: those performed simultaneously with a kidney (SPK) (75%), those given after a previous kidney transplantation (PAK) (18%), and pancreas transplantation alone (PTA) (7%). The total number of pancreas transplantations steadily increased until 2004 but has since declined. The largest decrease was seen in PAK, which decreased by 50% from 2004 through 2010. Comparatively, the number of SPK decreased by 7% during this time. Era analysis of US transplantations between 1987 and 2010 showed changes in recipient and donor characteristics. Recipient age at transplantation increased significantly as well as transplantations in type 2 diabetes patients. The trend over time was towards tighter donor criteria. There was a concentration on younger donors, preferable trauma victims, with short preservation time. Surgical techniques for the drainage of the pancreatic duct changed over time, too. Now enteric drainage is the predominantly used technique in combination with systemic drainage of the venous effluent of the pancreas graft. Immunosuppressive protocols developed towards antibody induction therapy with tacrolimus and MMF as maintenance therapy. The rate of transplantations with steroid avoidance increased over time in all 3 categories. These changes have led to improved patient and graft survival. Patient survival now reaches over 95% at one year post-transplant and over 83% after 5 years. The best graft survival was found in SPK with 86% pancreas and 93% kidney graft function at one year. PAK pancreas graft function reached 80%, and PTA pancreas graft function reached 78% at one year. In all 3 categories, early technical graft loss rates decreased significantly to 8-9%. Likewise, the 1-year immunological graft loss rate also decreased: in SPK, the immunological 1-year graft loss rate was 1.8%, in PAK 3.7%, and in PTA 6.0%.

Conclusions: Patient survival and graft function improved significantly over the course of 24 years of pancreas transplantation in all 3 categories. With further reduction in surgical complications and improvements in immunosuppressive protocols, pancreas transplantation offers excellent outcomes for patients with labile diabetes.

Figures

Figure 1

Annual number of US pancreas transplantations reported to UNOS/IPTR, 1966-2010.

Figure 2

Annual number of US pancreas transplantations for the major recipient categories, 1988-2010.

Figure 3

Annual number (A) and rates (B) of US pancreas retransplantations, 1988-2010.

Figure 4

Box plots of patient age at the time of transplantation for all 3 transplant categories (simultaneous pancreas kidney (SPK), pancreas after kidney (PAK), and pancreas alone (PTA) transplantation) 1988-2010. 25th and 75th percentiles are at the ends of the box and the median is shown as the horizontal line inside the box. ° describes outlier.

Figure 5

Annual rates of US pancreas transplantations in patients with type 2 diabetes, 1994-2010.

Figure 6

Donor age for simultaneous pancreas kidney (SPK) and solitary transplantations (PAK & PTA), 1988-2010. 25th and 75th percentiles are at the ends of the box and the median is shown as the horizontal line inside the box. ° describes outlier.

Figure 7

Preservation time in hr for simultaneous pancreas kidney (SPK) and solitary transplantations 1988-2010. 25th and 75th percentiles are at the ends of the box and the median is shown as the horizontal line inside the box. ° describe outliers.

Figure 8

Rates of 5 and 6 HLA-A, -B, -DR mismatches, 1988-2010.

Figure 9

Rate of enteric drainage in pancreas transplantations in the US, 1988-2010. ED: enteric drainage.

Figure 10

Rate of portal vein drainage in enteric drained pancreas transplantations in the US, 1988-2010.

Figure 11

Rate of antibody induction therapy in pancreas transplantations in the US, 1988-2010.

Figure 12

Primary deceased donor graft function over 5 eras for simultaneous pancreas kidney (SPK) pancreas graft (A), SPK kidney graft (B), pancreas after kidney (PAK) pancreas graft (C), and pancreas transplant alone (PTA) pancreas graft (D).

Figure 13

Primary deceased donor (DD) graft function for recipients who reached the 1-year mark with a functioning graft over 5 eras for simultaneous pancreas kidney (SPK) pancreas graft (A), SPK kidney graft (B), pancreas after kidney (PAK) pancreas graft (C), and pancreas transplant alone (PTA) pancreas graft (D).

Figure 14

Rate of early technical graft failure in primary deceased donor (DD) transplantations, 1988-2010.

Figure 15

One-year immunological graft loss technically successful in primary deceased donor (DD) transplantations, 1988-2010.