Author(s): Gruessner AC, Sutherland DE
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Abstract As of December 31, 2003, more than 21,000 pancreas transplants had been reported to the IPTR, >15,000 in the US and >5,000 outside the US. An era analysis of US cases from 1987 to May 15, 2003 showed a progressive improvement in outcome (p<0.04), with pancreas transplant graft survival rates (GSRs) going from 76\% at one year for 1987-92 to 85\% for 2001-2003 SPK cases, from 57\%-79\% for PAK cases, and from 55\%-76\% for PTA cases. The improvements were due both to decreases in technical failure rates (from 15\%-10\% in SPK, 21\%-13\% in PAK, and 24\%-8\% in PTA) and immunological failure rates (going from 6\%-1\% for SPK, from 23\%-4\% for PAK, and from 28\%-7\% for PTA cases). The proportion of recipients >45 years old increased from 11\% in all 3 recipient categories in 1987-92 to 32-36\% for 2001-2003 cases, and the improved outcomes encompassed the older patients as well. Contemporary pancreas transplant outcomes were calculated separately for January 1, 1999- May 15, 2003 US and non-US cases. The results of the US analysis are summarized first. US patient survival rates at one year were >95\% in each recipient category, with one-year primary pancreas GSRs of 85\% for SPK (n=3,775), 79\% for PAK (n=951), and 78\% for PTA (n=403) (p<0.0001). The immunological graft failure rates for 1996-2002 technically successful SPK, PAK and PTA cases were 2\% (n=3,437), 5\% (n=854), and 7\% (n=356) at one year (p=0.0001). There was a progressive increase in the use of ED (as opposed to BD) for duct management. For 1999-2003 US primary pancreas transplants, ED was used in 78\% of SPK, 60\% of PAK and 49\% for PTA cases. Of the ED transplants, venous drainage via the portal system was used for 23\% of SPK, 27\% of PAK and 44\% of PTA cases. Pancreas GSRs were nearly identical for 1999-2003 ED (n=2,898) and BD (n=798) SPK transplants (85\% for both at one year), nor was there a significant difference (p>0.17) in pancreas GSRs for systemic (n=2,218) versus portal (n=680) venous drained ED SPK transplants (84\% vs 87\% at one year). Kidney GSRs were not significantly different for ED versus BD SPK cases, 93\% and 92\% at one year (p=0.24). Pancreas GSRs for PAK transplants were 82\% at one year for BD (n=360; all systemic venous drainage) versus 77\% for ED with systemic (n=398) versus 74\% for ED with portal (n=150) venous drainage (p=0.03 overall, and 0.02 for ED portal vs ED systemic). For PTA cases, one-year GSRs were 81\% with BD (n=196; all systemic venous drainage) versus 69\% for ED with systemic (n=99) versus 80\% for ED with portal (n=90) venous drainage (p > or = 0.08 overall, and 0.11 for ED portal vs ED systemic). BD transplants were associated with a 12-14\% conversion rate to ED by 2 years after transplantation in the 3 recipient categories. The age of US pancreas transplant recipients made little difference for outcome in the SPK category, with one-year pancreas GSRs ranging from 80-85\% for patients grouped by age in decades from 10-19 to 60-69 years. In the PAK category, one-year GSRs tended to increase with age, going from 71\% for those 20-29 to 89\% for those 60-69 years old. Likewise, in the PTA category one-year GSRs were higher in older than younger donors, age, being only 50\% in 10-19 year-old and 87\% in 40-49 year-old recipients. Pancreas GSRs were identical (85\% at one year) for 1999-2003 US SPK recipients reported to have Type 1 (n=3,479) or Type 2 (n=231) diabetes (6\% classified as Type 2). TAC+MMF was the dominant maintenance immunosuppressant for 1999-2003 US cases (approximately two-thirds) and with this regime one-year GSRs were >81\% in all 3 recipient categories. The results were very similar (> or = 79\% one-year GSR) in patients (approximately 10\%) treated with sirolimus under various protocols. HLA-B locus matching had a significant effect on pancreas transplant outcome in the PTA category. For 1999-2003 cases the one-year rejection loss rate was 15\% in recipients mismatched for 2 B-locus antigens (n=28) versus 3\% and 4\% for those mismatched for one (n=114) or zero (n=82) antigens. The proportion of 1999-2003 US pancreas grafts that were retransplants was <2\% in the SPK and only 9\% in the PTA categories, but 23\% in the PAK category. The majority of the latter were done after isolated failure of a pancreas graft in SPK recipients. Pancreas retransplant GSRs at one year were 69\% in the SPK (n=60), 77\% in the PAK (n=288) and 73\% in the PTA (n=39) categories, significantly lower than for primary grafts only in the SPK category (p=0.001). In regard to non-US pancreas transplants, even in 1999-2003 the overwhelming majority were in the SPK category (n=1,833), with one-year patient, kidney and pancreas survival rates of 98\%, 94\% and 89\%, slightly but significantly higher than those for US cases done during the same period. Non-US PAK (n=55) GSR at one year was 88\%, similar to that for US cases done during this period, but the non-US PTA (n=80) GSR at one year was lower at 66\%. In summary, with modern immunosuppression (TAC + MMF for maintenance) 1999-2003 US pancreas transplant graft survival rates were > or = 80\% at one year in all categories of recipients (SPK, PAK, PTA), as was the case for non-US SPK and PAK transplants.
This article was published in Clin Transpl
and referenced in Journal of Clinical Research & Bioethics