Donor Selection for Pancreas Transplantation?

Robert J. Stratta, MD

Disclosures

March 27, 2001

Question

What are the donor exclusion criteria, with special reference to fatty pancreas, for pancreas transplantation?

Santosh Potdar, MD

Response from Robert J. Stratta, MD

Donor selection and organ procurement are of paramount importance to the success of pancreas transplantation. Most heart-beating donors who have been declared brain-dead and are appropriate for kidney, liver, and heart donation are also suitable for pancreas donation. Although there is some evidence to suggest that donor hyperglycemia may have an adverse effect on initial and long-term allograft function, the presence of hyperglycemia or hyperamylasemia, as such, are not contraindications for pancreas donation. In general, ideal pancreas donors range in age from 15 to 40 years and range in weight from 30 to 80 kg. As the results of pancreas transplantation have improved and experience has increased, previous absolute contraindications for pancreas donation have become relative contraindications, and previous relative contraindications have become mere risk factors for a successful outcome.

Indications for cadaveric pancreas donation include:

  • Declaration of brain death with informed consent

  • Donor age 6-55 years (ideal is 15-40 years)

  • Weight 30-100 kg (ideal is 30-80 kg)

  • Hemodynamic stability with adequate perfusion and oxygenation

  • Normal glycohemoglobin level (only in cases of severe hyperglycemia, extreme obesity, or positive family history of diabetes mellitus)

  • Absence of infectious or transmissible diseases (ie, tuberculosis, syphilis, hepatitis A, B, or C virus, HIV) with negative serology

  • Absence of malignancy (except nonmelanoma skin cancer or low-grade brain cancer)

  • Absence of parenchymal/intrinsic pancreatic disease.

Contraindications for pancreas donation include:

  • History of diabetes mellitus (Type 1, Type 2, or gestational)

  • Previous pancreatic surgery or moderate-to-severe pancreatic trauma

  • Pancreatitis (active acute or chronic)

  • Significant intra-abdominal contamination

  • Major (active) infection

  • Chronic alcohol abuse

  • Recent history of IV drug abuse or high-risk sexual behavior (ie, heterosexual or homosexual promiscuous behavior)

  • Prolonged hypotension or hypoxemia with evidence of significant end-organ (kidney, liver) damage

  • Severe atherosclerosis, fatty infiltration, or pancreatic edema

  • Severe obesity (> 150% ideal body weight [IBW], body mass index [BMI] > 30)

  • Inexperienced organ retrieval team.

Pancreatic donor risk factors include:

  • History of massive transfusion

  • Prior splenectomy

  • Mild-to-moderate obesity (< 150% IBW, BMI > 27.5)

  • Aberrant hepatic arterial anatomy

  • Positive VDRL or RPR

  • Prolonged length of hospital stay

  • Donor age > 45 years

  • Cardiovascular death or cerebrovascular accident (CVA) as the cause of brain death

  • Mild-to-moderate fatty infiltration of the pancreas, pancreatic edema, or atherosclerosis

  • Donor instability

  • Mild pancreatic trauma.

According to United Network for Organ Sharing Registry data, the following variables are associated with an increased risk of pancreas allograft thrombosis:

  • Donor age > 40 years

  • Cardiovascular death or CVA as the cause of brain death

  • Pancreas preservation time >24 hours.

There is also anecdotal experience to suggest that:

  • >130% IBW or BMI > 30 may be associated with an increased risk of early pancreas graft loss (due to thrombosis, pancreatitis, infection, or primary nonfunction).

  • Donor liver biopsy with > 25% to 50% macrovesicular steatosis may be associated with a fatty pancreas leading to an increased risk of early graft loss.

  • Fatty infiltration of the pancreas (as opposed to peripancreatic fat) may be associated with an increased risk of early graft loss. Notably, pancreas grafts from female donors > 45 years of age appear to fare better than pancreas grafts from male donors > 45 years independent of age, cause of brain death, or body habitus.

I personally believe that donor obesity/fatty pancreas is an underappreciated cause of early graft loss following pancreas transplantation. However, some overweight donors may have little or no fatty infiltration of the pancreas, while some thin donors may have significant fatty infiltration of the pancreas. So the correlation is not absolute. It is also important to distinguish fatty infiltration of the pancreatic parenchyma from peripancreatic fat deposition. The latter is not uncommon, but is not associated with adverse outcomes. I believe that many pancreas grafts go unused because an inadequate dissection of the retroperitoneum is performed and peripancreatic fat or edema is mistakenly identified as intrinsic parenchymal disease. The only reliable way to make this distinction is to completely mobilize the spleen and body and tail of the pancreas up into the operative field so that the anterior and posterior aspects of the gland can be carefully visualized and palpated to determine the quality of the organ. There are no data currently available regarding the utility of donor pancreas biopsies, particularly with regard to steatosis.

In general, we try to avoid combining risk factors with regard to pancreas donation. For instance, a 49-year-old thin female who dies from head trauma probably is a good donor for the pancreas, whereas a 36-year-old obese male with hypertension who dies from a CVA probably is a marginal donor. By using donor age, weight, and cause of brain death as the 3 most important factors, one can usually make a rapid and accurate assessment of the quality of the donor pancreas prior to actual intraoperative assessment, which is the second most important factor.

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