*3.1.2. Pancreas after kidney transplantation (PAK)*

and chronic pancreatitis, cystic fibrosis, and trauma). According to data obtained from the last US Pancreas Transplant Registry (OPTN/SRTR), pancreas transplantation in type 2 diabetes is increasing worldwide [6], representing up to 8% of all transplants performed in the US [7]. The most recent report demonstrates a 3-year graft survival of 83.3%. Indication in these patients is not consensual. At our center, we indicate in patients <50 years, body mass index (BMI) <30, at least 5 years of insulin therapy, C-Peptide <3.0 ng/mL, and daily insulin at <0.5 U/kg/day. Larger cohorts, standardized inclusion criteria, and long-term

**b.** Age: an age limit is not established. Though it is usual to accept candidates up to the age of 50 and assessing individually those aged between 50 and 55 years, some groups accept

**c.** Diabetic complications: the presence and severity of these complications, at the time the patient is studied for transplantation, is another parameter to assess. Successful pancreas transplantation requires suitable vascular permeability for arterial and venous anastomosis. Presence of severe calcifications in the iliac vessels, where the vascular anastomoses of the organs are usually performed, as well as the existence of a severe peripheral vascular disease, can technically allow the implantation of a graft, but it is inadvisable to implantboth organs. In these cases, priority is given to kidney transplantation. Coronary heart disease is also a frequent contraindication for pancreas transplantation. The implantation of two organs requires a major surgery with longer anesthesia time and a greater probability of presenting some type of complication or surgical re-intervention. Other secondary diabetic complications, such as retinopathy and neuropathy, rarely represent by themselves as a contraindication for the transplant, but due consideration should be given to the pa-

Pancreas transplantation can be performed individually or simultaneously with kidney transplantation in patients with ESRD. Each type of transplant has certain characteristics that must

Simultaneous kidney-pancreas transplantation (SPK) is the most common type of pancreas transplant, representing over 98% of all pancreas transplants performed in the US [7]. It is currently the best treatment alternative to patients with ESRD who are candidates to a kidney transplant. In addition to the demographic and clinical parameters previously described, immunological and waiting-list vintage should be considered when proposing a patient to an SPK. The presence of HLA alloantibodies reduces the probability of finding a suitable donor and increases waiting-list vintage. In moderate (cPRA > 50%) and highly sensitized (cPRA > 90%) patients, an individual approach is advised

results are warranted.

patients who are >60 years old [8].

262 Organ Donation and Transplantation - Current Status and Future Challenges

tient during pre-transplant evaluation.

be highlighted.

**3.1. Indications according to transplant modality**

*3.1.1. Simultaneous transplantation of pancreas and kidney (SPK)*

This type of transplant is considered for those patients who are candidates for a kidney and pancreas transplant and who have an available living kidney donor or where waiting-list vintage is significantly shorter to kidney when compared to pancreas transplant. The major benefit of PAK is reducing, or avoiding, time on dialysis while waiting for pancreas transplantation. Restoration of kidney function may reduce uremia-induced anticoagulation and possibly reduce bleeding during surgical complications. This approach implies, nonetheless, two different surgical procedures. Moreover, up-to-date results are somewhat poorer for patients who have undergone PAK transplant, with an inferior pancreas graft survival and higher acute rejection incidence [10]. The decision to perform a PAK (live donor kidney) or an SPK will depend fundamentally on the characteristics of the living donor (age, HLA compatibility), the possibility of performing a preventive transplant, the expected time on the waiting list, as well as the patient's expectations (**Table 2**).


immunosuppression to which the patient must be subjected for life does not always justify the

Pancreas Transplantation

265

http://dx.doi.org/10.5772/intechopen.76667

The results obtained with the PTA are somewhat worse than those of the PAK and SPK. The incidence of technical complications (mainly graft thrombosis) and acute rejection is some-

It is performed to patients with brittle diabetes and normal renal function, who require repeated hospital admissions due to metabolic decompensation and/or severe hypoglycemic unawareness. These should be confirmed during a hospital stay following treatment optimization using insulin pump and/or continuous glycemic control monitors. It may also be performed to patients with the brittle diabetes and incipient diabetic complications, in order

The main indications, as well as the absolute and relative contraindications for pancreas trans-

• Failure to achieve glycemic control using other alternatives—such as insulin pump and/or continuous glycaemic

hypothetical advantages of the transplant.

what higher to the other types of transplant.

to reduce progression of secondary complications.

PAK: diabetes mellitus and functioning kidney transplant

• Not aware of severe hypoglycemia (life threatening) • Frequent hospital admission due to metabolic complications

control monitors—during a hospital admission

**Absolute contraindications**

Active infection

Chronic liver or pulmonary disease

Morbid obesity (BMI >35 kg/m2

Active gastrointestinal bleeding **Relative contraindications** Age: <18 and >55 years old Obesity (BMI < 30 kg/m2

Recent acute coronary heart disease

Recent retinal hemorhage

Active smoking

SPK: diabetes mellitus and end-stage renal disease (GFR <20 ml/min or dialysis)

Severe untreatable coronary heart disease; severe left ventricular disfunction

Severe psycologic or psychiatric disease; drug and alchool abuse

)

Symptomatic cerebrovascular or peripheral vascular diseases Severe autonomic neuropathy or diabetic gastropathy

**Table 3.** Indications and contraindications to pancreas transplantation.

)

PTA: Type 1 diabetes with normal renal function (GFR >60 ml/min; proteinuria <1 g/day), and:

Active or past cancer without adequate remission period (excluded in situ and skin epitheliums)

plantation, are presented in **Table 3**.

**Indications**

**Table 2.** Pancreas after kidney transplantation: pros and cons compared to SPK.

This alternative has been gaining increasing interest in recent years due to the current shortage of cadaveric organs from young donors and the consequent increase in waiting-list time for kidney-pancreas transplantation. In some centers, PAK represents up to 50% of pancreas transplants, most of them having received a kidney transplant from a previously living donor.

The indications regarding age, type of DM, and vascular status of the recipient would be the same as in the case of SPK. However, a functioning kidney graft with good and stable renal function (glomerular filtration rate—GFR > 40 ml/min) is recommended prior to inclusion on the waiting list, due to the risk of acute kidney injury following the pancreas transplantation surgery and the increase in doses of immunosuppressors.

One of the issues raised in this type of transplant has been on when to perform pancreas transplantation after the kidney transplantation. There is no established time limit, and it depends on the progression of each patient following the kidney transplant. However, it seems that a better survival of the pancreatic graft has been observed when the interval between both transplants is less than 12 months. For some authors, the optimal interval between both procedures should be less than 4 months.

#### *3.1.3. Pancreas transplant alone*

Isolated pancreas transplantation in diabetics without documented kidney disease, and with little or no other secondary complication, would theoretically be the ideal transplant. These would be the ones who could benefit the most from the positive effects of this transplant, by being able to prevent the appearance of secondary complications, thanks to an early metabolic control. However, it is considered that the risk of the intervention, as well as the risk of immunosuppression to which the patient must be subjected for life does not always justify the hypothetical advantages of the transplant.

The results obtained with the PTA are somewhat worse than those of the PAK and SPK. The incidence of technical complications (mainly graft thrombosis) and acute rejection is somewhat higher to the other types of transplant.

It is performed to patients with brittle diabetes and normal renal function, who require repeated hospital admissions due to metabolic decompensation and/or severe hypoglycemic unawareness. These should be confirmed during a hospital stay following treatment optimization using insulin pump and/or continuous glycemic control monitors. It may also be performed to patients with the brittle diabetes and incipient diabetic complications, in order to reduce progression of secondary complications.

The main indications, as well as the absolute and relative contraindications for pancreas transplantation, are presented in **Table 3**.

#### **Indications**

This alternative has been gaining increasing interest in recent years due to the current shortage of cadaveric organs from young donors and the consequent increase in waiting-list time for kidney-pancreas transplantation. In some centers, PAK represents up to 50% of pancreas transplants, most of them having received a kidney transplant from a previously living donor. The indications regarding age, type of DM, and vascular status of the recipient would be the same as in the case of SPK. However, a functioning kidney graft with good and stable renal function (glomerular filtration rate—GFR > 40 ml/min) is recommended prior to inclusion on the waiting list, due to the risk of acute kidney injury following the pancreas transplantation

**SPK PAK**

**a.** Minimizes or avoids the need for

**c.** Avoids uremia-asociated

**d.** Time to pancreas transplantation usually shorter than for SPK

**b.** Two cycles of induction

**c.** Higher incidence of acute rejection

**d.** Inferior pancreas graft survival

dialysis (in LDKT)

complications

**b.** Shorter surgical procedure

**a.** Two surgical procedures

immunosuppression

**b.** Single cycle of induction

**b.** Lower probability of receiving kidney transplant preemptively

immunosuppression

**c.** Better graft survival

Advantages **a.** Single surgical procedure

264 Organ Donation and Transplantation - Current Status and Future Challenges

Disadvantages **a.** Longer waiting-list time

One of the issues raised in this type of transplant has been on when to perform pancreas transplantation after the kidney transplantation. There is no established time limit, and it depends on the progression of each patient following the kidney transplant. However, it seems that a better survival of the pancreatic graft has been observed when the interval between both transplants is less than 12 months. For some authors, the optimal interval between both pro-

Isolated pancreas transplantation in diabetics without documented kidney disease, and with little or no other secondary complication, would theoretically be the ideal transplant. These would be the ones who could benefit the most from the positive effects of this transplant, by being able to prevent the appearance of secondary complications, thanks to an early metabolic control. However, it is considered that the risk of the intervention, as well as the risk of

surgery and the increase in doses of immunosuppressors.

**Table 2.** Pancreas after kidney transplantation: pros and cons compared to SPK.

cedures should be less than 4 months.

*3.1.3. Pancreas transplant alone*

SPK: diabetes mellitus and end-stage renal disease (GFR <20 ml/min or dialysis)

PAK: diabetes mellitus and functioning kidney transplant

PTA: Type 1 diabetes with normal renal function (GFR >60 ml/min; proteinuria <1 g/day), and:


#### **Absolute contraindications**

Severe untreatable coronary heart disease; severe left ventricular disfunction

Chronic liver or pulmonary disease

Active infection

Active or past cancer without adequate remission period (excluded in situ and skin epitheliums)

Severe psycologic or psychiatric disease; drug and alchool abuse

Morbid obesity (BMI >35 kg/m2 )

Active gastrointestinal bleeding

#### **Relative contraindications**

Age: <18 and >55 years old

Obesity (BMI < 30 kg/m2 )

Recent acute coronary heart disease

Recent retinal hemorhage

Symptomatic cerebrovascular or peripheral vascular diseases

Severe autonomic neuropathy or diabetic gastropathy

Active smoking

**Table 3.** Indications and contraindications to pancreas transplantation.
