Analyses of pancreas transplant outcomes for United States cases reported to the United Network for Organ Sharing (UNOS) and non-US cases reported to the International Pancreas Transplant Registry (IPTR).
As of September 1999, almost 13,000 pancreas transplants had been reported to the IPTR, > 9,000 in the US and > 3,000 outside the US. An era analysis of US cases from 1987 to 1997 showed a progressive improvement in outcome (p < 0.04), with pancreas transplant graft survival rates (GSRs) going from 74% to 85% at one year for SPK cases, from 56% to 75% for PAK cases, and from 50% to 69% for PTA cases. The improvements were due both to decreases in technical failure (TF) rates (overall from 16% to 8%) and immunological failure rates (going from 6% to 2% for SPK, from 23% to 7% for PAK, and from 35% to 9% for PTA cases). The proportion of recipients > 44 years old increased from 5% to 24%, and the improved outcomes encompassed the older patients as well. In patients > 44 years old, SPK pancreas GSRs at one year increased from 69% for 1987-89 cases to 79% for 1996-97 cases (p < 0.03). Pancreas GSRs were also similar for recipients reported to have Type I or Type II diabetes (at 1 year, 84% and 81%, respectively, for 1994-99 SPK transplants), the latter designated in 3% of the recipients. Contemporary pancreas transplant outcomes were calculated separately for 1996-99 US and non-US cases. US patient survival rates at one year were > or = 95% in each recipient category, with one year pancreas GSRs of 84% for SPK (n = 2,502), 76% for PAK (n = 404), and 72% for PTA (n = 176) (p = 0.0001). The immunological graft failure rates for 1996-99 US SPK, PAK and PTA cases were 2%, 6%, and 10% at one year (p = 0.001). There was a progressive increase in the use of ED (as opposed to BD) for duct management, up to nearly 60% of US pancreas transplants by 1998. Approximately 18% of SPK ED transplants had venous drainage via the portal system. Pancreas GSRs were not significantly different for 1996-99 ED (n = 1,170) and BD (n = 1,203) US SPK transplants (84% and 85%, respectively, at 1 year), nor was there any difference in pancreas GSRs for systemic (n = 437) versus portal (n = 194) venous drained ED SPK transplants (84% and 83%, respectively, at 1 year). Interestingly, kidney GSRs were significantly higher for ED versus BD US SPK cases, 93% versus 84% at one year (p = 0.003). Duct management did matter for solitary (PAK and PTA) pancreas transplants. PAK pancreas GSRs were 80% at one year for BD (n = 238) versus 68% for ED (n = 156) US transplants. PTA pancreas GSRs were 78% at one year for BD (n = 98) versus 63% for ED (n = 73) US transplants. However, BD transplants were associated with a 12% conversion rate to ED by 2 years after transplantation. Analyses of outcome by immunosuppression for US cases showed pancreas GSRs to be higher in SPK recipients given MMF (87% at 1 year) than in those who were not (76% at 1 year). For PAK and PTA recipients, those given anti-T cell for induction and TAC and MMF for maintenance immunosuppression had the highest GSRs: 86% and 83%, respectively, at one year for BD pancreas transplants; not significantly different from the pancreas GSR (87% at 1 year) in BD SPK recipients also given anti-T cell for induction and TAC and MMF for maintenance immunosuppression. Analyses of US pancreas transplant outcome according to HLA matching showed no effect at all in the SPK category, while for PAK and PTA transplants an effect was seen at the A and B loci, strongest at the B loci. Matching for at least one antigen at both loci was associated with one-year pancreas GSRs of 85% for PAK and 74% for PTA, versus 70% and 60%, respectively, at one year for those who were not matched for at least one antigen at both the A and B loci. In regard to non-US cases, the overwhelming majority were in the SPK category (n = 528 for 1996-99), with one-year pancreas GSR of 79%, not significantly different from US cases. Approximately 40% of non-US SPK cases were ED (n = 204), and, as in the US, the pancreas GSRs were similar for ED and BD transplants in this category. (ABSTRACT TRUNCATED)
Gruessner
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IPTR, Department of Surgery, University of Minnesota, Minneapolis, USA.
Sutherland
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D000328:Adult; D003922:Diabetes Mellitus, Type 1 / Q000601:surgery; D006085:Graft Survival; D006650:Histocompatibility Testing; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods; D007390:International Agencies; D008875:Middle Aged; D016035:Pancreas Transplantation / Q000401:mortality / Q000502:physiology / Q000706:statistics & numerical data*; D012042:Registries; D012086:Reoperation / Q000706:statistics & numerical data; D015996:Survival Rate; D014019:Tissue Donors / Q000706:statistics & numerical data; D009927:Tissue and Organ Procurement / Q000458:organization & administration* / Q000706:statistics & numerical data; D017211:Treatment Failure; D016896:Treatment Outcome; D014481:United States