Robert J. Stratta, MD

Disclosures

November 21, 2005

Question

What is your opinion about the modality of pancreas alone (PA) transplantation?

Response from Robert J. Stratta, MD

Indications for PA transplantation include the presence of insulin-requiring, "complicated" diabetes despite the administration of conventional antidiabetic therapies. Diabetic patients must demonstrate a consistent failure of exogenous insulin therapy, defined as either (1) glucose hyperlability with frequent episodes of diabetic ketoacidosis or hypoglycemia unawareness causing a significant impairment in quality of life, or (2) evidence for 2 or more progressive diabetic complications, such as proliferative retinopathy, nephropathy, or symptomatic peripheral or autonomic neuropathy.

In potential candidates for PA transplantation, a creatinine clearance above 60-70 mL/min is usually required because immunosuppression can cause accelerated deterioration of native renal function in patients with a lower creatinine clearance. In patients with borderline renal function or significant proteinuria (> 1 g/24 hrs), a trial of a calcineurin inhibitor may be indicated prior to transplantation to assess renal reserve and determine whether or not the patient would benefit from a simultaneous kidney-pancreas transplant.

Standard eligibility guidelines for pancreas transplantation include the predicted ability to withstand the operative procedure and possible associated complications, the predicted ability to tolerate (and comply with) the requisite chronic immunosuppression, and the absence of any exclusion criteria, such as insufficient cardiovascular reserve, active infection (acute or chronic), recent malignancy, positive HIV or hepatitis B surface antigen serology, ongoing substance abuse, major ongoing untreated psychiatric illness, recent history of medical noncompliance, inadequate social support, inability to provide informed consent, significant irreversible hepatic or pulmonary dysfunction, morbid obesity, severe untreatable vascular disease, or any other systemic illness that would severely limit life expectancy or compromise recovery.

PA transplantation is restricted by necessity to diabetic patients who have demonstrated a propensity to progressive diabetic complications that are (or predictably will be) worse than the potential side effects of chronic immunosuppression. In addition, diabetic patients with repeated episodes of ketoacidosis, hypoglycemia unawareness, or glucose hyperlability may benefit from PA transplantation because achieving an insulin-free state would immediately enhance their quality of life. Ideally, pancreas transplantation should be performed before diabetic complications become irreversible and before the need for a kidney transplant arises.

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