Robert J. Stratta, MD

Disclosures

September 09, 2004

Question

What are the acceptable donor criteria for cadaveric pancreas donation?

F.R. Calder, Mb ChB

Response from Robert J. Stratta, MD

Donor selection and organ procurement are paramount to the success of pancreas transplantation. Most heart-beating multiorgan donors without pancreatic trauma or diabetes, age 6-55 years, with a body mass index (BMI) < 30 kg/m2 are considered for pancreas donation. Although there is some evidence to suggest that donor hyperglycemia may have an adverse effect on initial and possibly long-term allograft function, the presence of hyperglycemia or hyperamylasemia, as such, are not contraindications to pancreas donation.

In general, ideal pancreas donors range in age from 10 to 40 years, range in weight from 30 to 80 kg, and have sustained brain death due to a traumatic etiology. As the results of pancreas transplantation have improved and experience has increased, previous contraindications for pancreas donation have become mere risk factors for a successful outcome. According to International Pancreas Transplant Registry data, the following variables are associated with an increased risk of pancreas allograft thrombosis: (1) donor age above 40 years; (2) cardiovascular or cerebrovascular cause of brain death; and (3) pancreas preservation time greater than 24 hours.

The results of anecdotal experience suggest that: (1) donor BMI > 30 kg/m2 may be associated with an increased risk of early pancreas graft loss due to thrombosis, pancreatitis, infection, or primary nonfunction; (2) a donor liver biopsy showing greater than 25% to 30% macrovesicular steatosis may be associated with a fatty pancreas leading to an increased risk of early graft loss; and (3) fatty infiltration of the pancreas (as opposed to peripancreatic fat) may be associated with an increased risk of early graft loss. The presence of donor obesity or a fatty pancreas may be an underappreciated cause of early graft loss. There are no data currently available regarding the utility of donor pancreas biopsies, particularly with regard to steatosis. In addition, there are few studies that have objectively addressed the risks associated with fatty infiltration of the pancreas. Obesity appears to be less predictive of a fatty pancreas if the donor is young (< 25 years of age) or if the donor is female.

Organs demonstrating gross fibrosis, with a firm or "woody" texture of the parenchyma, typically are not accepted. Few data are available regarding pancreatic edema, which often may respond to colloid and mannitol administration in combination with dissection and surgical elevation of the spleen, body, and tail of the pancreas. In general, persistent severe parenchymal edema is a contraindication to pancreas utilization. Other organ-specific contraindications include severe hypernatremia (>160 mg/dL), hemodynamic instability, positive hepatitis serology, active acute or chronic pancreatitis, history of diabetes, previous pancreatic surgery, significant intra-abdominal contamination, moderate-to-severe atherosclerosis, and the lack of an experienced pancreas retrieval team.

Risk factors for pancreas donation include massive transfusions, need for multiple vasopressor agents, previous splenectomy, BMI > 30 kg/m2, aberrant hepatic artery anatomy, prolonged length of hospital stay, chronic alcohol abuse, simultaneous small bowel retrieval, and donor age above 45 years. Pancreas donors can be easily categorized as ideal, good, or marginal. By using donor age, weight/BMI, 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 next most important factor. If either the donor or recipient is marginal, there is a greater likelihood of a poor outcome. Global assessment of donor stability, anatomy, and organ quality by an experienced pancreas retrieval surgeon coupled with aggressive and appropriate donor management (hormonal and physiologic resuscitation) are pivotal to the success of pancreas transplantation.

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