Lessons learned from more than 1,000 pancreas transplants at a single institution

Objective To determine outcome in diabetic pancreas transplant recipients a ccording to risk factors and the surgical techniques and immunosuppressive protocols that evolved during a 33-year period at a single institution. Summary Background Data Insulin-dependent diabetes mellitus is associated w ith a high incidence of management problems and secondary complications. Cl inical pancreas transplantation began at the University of Minnesota in 196 6, initially with a high failure rate. but outcome improved in parallel wit h other organ transplants. The authors retrospectively analyzed the factors associated with the increased success rate of pancreas transplants. Methods From December 16, 1966, to March 31, 2000, the authors performed 1, 194 pancreas transplants (111 from living donors; 191 retransplants): 498 s imultaneous pancreas-kidney (SPK) and 1 simultaneous pancreas-liver transpl ant; 404 pancreas after kidney (PAK) transplants; and 291 pancreas transpla nts alone (PTA). The analyses were divided into five eras: era 0, 1966 to 1 973 (n = 14), historical; era 1, 1978 to 1986 (n = 148), transition to cycl osporine for immunosuppression, multiple duct management techniques, and on ly solitary (PAK and PTA) transplants; era 2, 1986 to 1994 (n = 461), all c ategories (SPK, PAK, and PTA), predominately bladder drainage for graft duc t management, and primarily triple therapy (cyclosporine, azathioprine, and prednisone) for maintenance immunosuppression; era 3, 1994 to 1998 (n = 28 6), tacrolimus and mycophenolate mofetil used; and era 4, 1998 to 2000 (n = 275), use of daclizumab for induction immunosuppression, primarily enteric drainage for SPK transplants, pretransplant immunosuppression in candidate s awaiting PTA. Results Patient and primary cadaver pancreas graft functional (insulin-inde pendence) survival rates at 1 year by category and era were as follows: SPK , era 2 (n = 214) versus eras 3 and 4 combined (n = 212), 85% and 64% versu s 92% and 79%, respectively; PAK, era 1 (n = 36) versus 2 (n = 61) versus 3 (n = 84) versus 4 (n = 92), 86% and 17%, 98% and 59%, 98% and 76%, and 98% and 81%, respectively; in PTA, era 1 (n = 36) versus 2 (n = 72) versus 3 ( n = 30) versus 4 (n = 40), 77% and 31%, 99% and 50%, 90% and 67%, and 100% and 88%, respectively. In eras 3 and 4 combined for primary cadaver SPK tra nsplants, pancreas graft survival rates were significantly higher with blad der drainage (n = 136) than enteric drainage (n = 70), 82% versus 74% at 1 year (P =.03). Increasing recipient age had an adverse effect on outcome on ly in SPK recipients. Vascular disease was common (in eras 3 and 4, 27% of SPK recipients had a pretransplant myocardial infarction and 40% had a coro nary artery bypass); those with no vascular disease had significantly highe r patient and graft survival rates in the SPK and PAK categories. Living do nor segmental pancreas transplants were associated with higher technically successful graft survival rates in each era, predominately solitary (PAK an d PTA) in eras 1 and 2 and SPK in eras 3 and 4. Diabetic secondary complica tions were ameliorated in some recipients, and quality of life studies show ed significant gains after the transplant in all recipient categories. Conclusions Patient and graft survival rates have significantly improved ov er time as surgical techniques and immunosuppressive protocols have evolved . Eventually, islet transplants will replace pancreas transplants for suita ble candidates, but currently pancreas transplants can be applied and shoul d be an option at all stages of diabetes. Early transplants are preferable for labile diabetes, but even patients with advanced complications can bene fit.