**4.2. Inclusion on the waiting list**

**4. Waiting list for pancreas transplantation**

266 Organ Donation and Transplantation - Current Status and Future Challenges

living kidney donor and a preemptive kidney transplant.

Evaluation of the candidates for pancreas transplantation should be performed as early as possible, in order to identify those who would benefit the most from the procedure. In patients with chronic kidney disease, we recommend referral to a pancreas transplant center as soon as glomerular filtration rate (GFR) falls below 25–30 ml/min. This early referral offers precious time for patient evaluation and possible inclusion on the waiting-list pre-dialysis. Additionally, and depending on transplant center policies, this allows the study of a possible

Patient evaluation and clinical workup is similar to that performed for kidney transplantation, such as complete medical history, immunological study, uremic state, liver disease, cancer and infection screening, with some additional particularities related to diabetic disease: hormonal study, β cell autoantibodies, as well as study of the main diabetic complications.

• Hormonal assessment: the main purpose is to determine whether or not the patient has endogenous insulin secretion. For this, it is sufficient to determine the fasting plasma levels

• Autoantibodies: the main objective of pre-transplant quantification of β cell autoantibodies (IAA, GAD, ZnT8A, IA2) is to establish a baseline. These tend to be negative after years of evolution of DM, and therefore negative at the time of transplantation. Their presence does not represent a contraindication for pancreas transplantation. During follow-up, nonethe-

• Diabetic retinopathy is present in up to 90% of of all transplant candidates, with varying

• Diabetic polyneuropathy is also present in majority of patients but rarely contraindicates the transplant. However, it is advisable to take into account the severe dysfunction of the autonomic nervous system, due to post-transplant complications and the negative impact on patient survival. Diabetic neuropathy can often affect the urinary bladder leading to incontinence or incomplete bladder emptying. If urinary exocrine drainage is used, a urinary urethrocystography is recommended to rule out pathology of the bladder and urethra, as

• Cardiovascular evaluation is the most important due to the impact of cardiovascular disease on post-transplant mortality and morbidity. Previous history of myocardial infarction, angioplasty, or coronary bypass should not necessarily be a contraindication to transplantation. Workup should be exhaustive before including the patient on the waiting list. It is advisable to perform an electrocardiogram (EKG) and a pharmacological stress test with MIBI-dipyridamole, as well as an echocardiography to evaluate ventricular ejection fraction and exclude motility disorders. If any of these tests are pathological, coronary angiography should be performed to identify more accurately the existing lesions and

of C-Peptide. Its negativity indicates the absence of insulin secretion.

well as a cystomanometry to study and evaluate bladder function.

less, its reappearance is associated with an increased risk for disease relapse.

degrees of severity. It is not considered an exclusion criteria for transplantation.

**4.1. Evaluation of candidates**

At the time of inclusion on the waiting list, a checklist should be performed to ensure all pretransplant studies have been completed, and revised by the medical team. It is important to ensure that the patient has received a clear and comprehensible information regarding the advantages, as well as of the possible complications of the transplant, so that he can decide to freely choose this form of treatment.

Logistical issues should also be discussed in advance with the patient, in order to minimize the time from patient contact to the surgical procedure (hence cold ischemia time). The patient and his closest relatives should be aware of the expected duration of the intervention, median hospital stay, and most important post-transplant cares and outpatient visits.

Also, and for as long as they remain on the waiting list, the patient should be made aware of the importance of maintaining regular communication with the transplant center. The high incidence of complications that may occur in these diabetic patients, especially if they are affected by chronic renal failure and are also waiting for a simultaneous kidney transplant, requires strict monitoring and follow-up as long as they are not transplanted. Ideally, they should be visited by a member or collaborating doctor of the transplant team every 3–4 months. Only in this way, it is possible to detect possible events that may represent a temporary contraindication for the intervention.
