A patient is listed for live donor kidney transplantation followed by pancreas transplantation. If a pancreas is available and the kidney transplant cannot be done simultaneously, can the pancreas transplant be done first followed by the kidney transplant?
Response from Robert J. Stratta, MD
If the patient is not yet on dialysis, I think that the pancreas transplant could be done "first," particularly if the living donor kidney transplant could be performed soon thereafter. Requisite immunosuppression for the pancreas transplant would probably accelerate deterioration of renal functional resulting in the need for dialysis sooner rather than later, and it would be preferable to perform the living donor kidney transplant prior to initiating dialysis. Hemodialysis in the setting of a recent pancreas transplant is a bad combination, since the pancreas is at risk for either hemorrhage or thrombosis because of the hemodynamic and coagulation effects of dialysis (peritoneal dialysis would not be a reasonable option because of the intraperitoneal location of the pancreas allograft and the risk of infection). Moreover, patients with advanced renal insufficiency usually do not tolerate immunosuppression particularly well, and dose-limiting side effects would be a problem. This underscores the importance of minimizing the time between the pancreas and kidney transplants.
If the patient is already on dialysis (either peritoneal or hemodialysis), I would not advise "pancreas before kidney" transplantation because of the same risks of either hemorrhage or thrombosis associated with hemodialysis (again, peritoneal dialysis would not be an appropriate option because of the potential risk of intra-abdominal infection associated with the pancreas allograft). Dosing immunosuppression in the setting of renal failure would again be difficult, particularly with regard to tolerability.
In summary, my (limited) experience with dialysis in the setting of a recent pancreas transplant (ie, acute tubular necrosis following simultaneous kidney-pancreas transplantation) has not been favorable, and my anecdotal experience with induction immunosuppression in the setting of ongoing renal failure has likewise been negative. Unless the patient was receiving a 6-antigen match pancreas, I would probably pass on the pancreas offer and wait for either a simultaneous living donor kidney/cadaver donor pancreas or perform a living donor kidney followed by a sequential pancreas after kidney transplant soon thereafter.
Medscape Transplantation. 2002;3(1) © 2002 Medscape
Cite this: Robert J Stratta. Live Donor Kidney Transplantation Followed by Pancreas Transplantation? - Medscape - Jun 18, 2002.