Pancreas and pancreas-kidney transplantation are considered now an acceptable alternative for the treatment of Type I diabetic patients particularly if there is already significant diabetic nephropathy. Pancreas transplantation is also performed with less frequency to treat Type II diabetes (less than 4% of recipients). Diabetes mellitus is the major cause of end-stage renal disease and the secondary complications of diabetes (neuropathy, diabetic gastroparesis and retinopathy) have significant impact in the patients' quality of life. The objectives of pancreas transplantation are: a)normalize insulin production and glucose metabolism, and b) prevent and in some cases correct systemic and vascular complications of chronic hyperglycemia. A much more unusual indication for pancreas transplant is pancreas failure secondary to chronic pancreatitis.

Generalities of Pancreas Transplantation

As of October 2000, more than 15,000 pancreas transplants have been reported to the International Pancreas Transplantation Registry (>11,000 in the US, >4,000 outside the US). Simultaneous kidney-pancreas (SPK) transplantation is the treatment of choice in uremic type I diabetics. Both organs may originate from a cadaveric donor. Simultaneous cadaver pancreas living-donor kidney transplantation (SPLK) offers the potential benefits of living kidney donation (e.i. shorter waiting time, improved short term and long term renal graft outcome). Patients who have previously undergo a successful kidney transplant may receive a pancreas after kidney (PAK) transplantation. In patients in whom pancreas transplantation is indicated (e.g. brittle diabetes) but that have not yet developed advanced kidney disease the transplantation of a pancreas alone (PA) is considered the treatment of choice.

Overview of Surgical Approach

The most widely used surgical technique at the present time is whole-organ pancreas transplantation. The exocrine secretions are managed in different ways. Initially, polymer duct obliteration was widely practiced, however, this technique was associated with a high incidence of vascular thrombosis, pancreatitis and formation of fistulas. At this time intestinal and bladder drainage are mostly used.

Bladder drained pancreas transplants attained general acceptance in the 1990's (>80-90% in 1995,1996) however, complications such as hematuria, urine leaks, recurrent urinary tract infections, urethritis, and reflux pancreatitis have been described in about 25% of patients. After the first year more than 10% of patients require conversion to enteric drainage. With the bladder drainage technique (pancreaticoduodenocystostomy) the quantitative evaluation of exocrine secretions in urine was used for the diagnosis of rejection (decrease of urinary amylases and lipases). Insulin is systemically drained (iliac veins) in bladder drained pancreas and this may lead to hyperinsulinemia. In enteric drained grafts drainage of insulin can be done into the portal vein and this appears to be more physiologic. Enteric drainage consists of the anastomosis of the pancreas and attached duodenal segment into the small bowel. Currently the majority of pancreas transplants are enteric-portally drained. Recent comparative studies have shown that fewer readmissions occurred with this surgical technique and that there is overall decreased recipient morbidity with improvement of rehabilitation and quality of life. One study has shown decrease in the incidence and severity of rejection episodes with portal-enteric drainage. Incidence of infectious complications also have been reported to be lower with enteric versus bladder drainage.

Results

The first pancreas transplant was performed in 1966. Very poor graft survival was observed during the first two decades of pancreas transplantation. Progressive improvement in outcome have been seen for pancreas transplantation since the late 1980's. The best results are still obtained with simultaneous kidney-pancreas transplants (SPK) with a one year graft survival of 82%; however, good one year graft survivals are also obtained with PAK (74%) and PTA (76%). In all groups graft survival improvements have resulted from decrease in technical failures and decrease in immunological failures.
Overall one year patient survival is excellent being more than 94%.
It has been demonstrated that a better quality of life is obtained by patients with SPK when compared to patients with kidney transplants alone. Pancreas transplantation does not affect adversely the survival of the renal graft (overall one year kidney survival in SPK is more than >90%).

Grading of Acute Pancreas Allograft Rejection

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