Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of May 2003.
As of December 31, 2003, more than 21,000 pancreas transplants had been reported to the IPTR, >15,000 in the US and >5,000 outside the US. An era analysis of US cases from 1987 to May 15, 2003 showed a progressive improvement in outcome (p<0.04), with pancreas transplant graft survival rates (GSRs) going from 76% at one year for 1987-92 to 85% for 2001-2003 SPK cases, from 57%-79% for PAK cases, and from 55%-76% for PTA cases. The improvements were due both to decreases in technical failure rates (from 15%-10% in SPK, 21%-13% in PAK, and 24%-8% in PTA) and immunological failure rates (going from 6%-1% for SPK, from 23%-4% for PAK, and from 28%-7% for PTA cases). The proportion of recipients >45 years old increased from 11% in all 3 recipient categories in 1987-92 to 32-36% for 2001-2003 cases, and the improved outcomes encompassed the older patients as well. Contemporary pancreas transplant outcomes were calculated separately for January 1, 1999- May 15, 2003 US and non-US cases. The results of the US analysis are summarized first. US patient survival rates at one year were >95% in each recipient category, with one-year primary pancreas GSRs of 85% for SPK (n=3,775), 79% for PAK (n=951), and 78% for PTA (n=403) (p<0.0001). The immunological graft failure rates for 1996-2002 technically successful SPK, PAK and PTA cases were 2% (n=3,437), 5% (n=854), and 7% (n=356) at one year (p=0.0001). There was a progressive increase in the use of ED (as opposed to BD) for duct management. For 1999-2003 US primary pancreas transplants, ED was used in 78% of SPK, 60% of PAK and 49% for PTA cases. Of the ED transplants, venous drainage via the portal system was used for 23% of SPK, 27% of PAK and 44% of PTA cases. Pancreas GSRs were nearly identical for 1999-2003 ED (n=2,898) and BD (n=798) SPK transplants (85% for both at one year), nor was there a significant difference (p>0.17) in pancreas GSRs for systemic (n=2,218) versus portal (n=680) venous drained ED SPK transplants (84% vs 87% at one year). Kidney GSRs were not significantly different for ED versus BD SPK cases, 93% and 92% at one year (p=0.24). Pancreas GSRs for PAK transplants were 82% at one year for BD (n=360; all systemic venous drainage) versus 77% for ED with systemic (n=398) versus 74% for ED with portal (n=150) venous drainage (p=0.03 overall, and 0.02 for ED portal vs ED systemic). For PTA cases, one-year GSRs were 81% with BD (n=196; all systemic venous drainage) versus 69% for ED with systemic (n=99) versus 80% for ED with portal (n=90) venous drainage (p > or = 0.08 overall, and 0.11 for ED portal vs ED systemic). BD transplants were associated with a 12-14% conversion rate to ED by 2 years after transplantation in the 3 recipient categories. The age of US pancreas transplant recipients made little difference for outcome in the SPK category, with one-year pancreas GSRs ranging from 80-85% for patients grouped by age in decades from 10-19 to 60-69 years. In the PAK category, one-year GSRs tended to increase with age, going from 71% for those 20-29 to 89% for those 60-69 years old. Likewise, in the PTA category one-year GSRs were higher in older than younger donors, age, being only 50% in 10-19 year-old and 87% in 40-49 year-old recipients. Pancreas GSRs were identical (85% at one year) for 1999-2003 US SPK recipients reported to have Type 1 (n=3,479) or Type 2 (n=231) diabetes (6% classified as Type 2). TAC+MMF was the dominant maintenance immunosuppressant for 1999-2003 US cases (approximately two-thirds) and with this regime one-year GSRs were >81% in all 3 recipient categories. The results were very similar (> or = 79% one-year GSR) in patients (approximately 10%) treated with sirolimus under various protocols. HLA-B locus matching had a significant effect on pancreas transplant outcome in the PTA category. For 1999-2003 cases the one-year rejection loss rate was 15% in recipients mismatched for 2 B-locus antigens (n=28) versus 3% and 4% for those mismatched for one (n=114) or zero (n=82) antigens. The proportion of 1999-2003 US pancreas grafts that were retransplants was <2% in the SPK and only 9% in the PTA categories, but 23% in the PAK category. The majority of the latter were done after isolated failure of a pancreas graft in SPK recipients. Pancreas retransplant GSRs at one year were 69% in the SPK (n=60), 77% in the PAK (n=288) and 73% in the PTA (n=39) categories, significantly lower than for primary grafts only in the SPK category (p=0.001). In regard to non-US pancreas transplants, even in 1999-2003 the overwhelming majority were in the SPK category (n=1,833), with one-year patient, kidney and pancreas survival rates of 98%, 94% and 89%, slightly but significantly higher than those for US cases done during the same period. Non-US PAK (n=55) GSR at one year was 88%, similar to that for US cases done during this period, but the non-US PTA (n=80) GSR at one year was lower at 66%. In summary, with modern immunosuppression (TAC + MMF for maintenance) 1999-2003 US pancreas transplant graft survival rates were > or = 80% at one year in all categories of recipients (SPK, PAK, PTA), as was the case for non-US SPK and PAK transplants.
Gruessner
Angelika C
AC
IPTR, Diabetes Institute for Immunology and Transplantation, Department of Surgery University of Minnesota, Minneapolis, USA.
Sutherland
David E R
DE
D003710:Demography; D005060:Europe; D006084:Graft Rejection / Q000453:epidemiology / Q000517:prevention & control; D006085:Graft Survival; D006801:Humans; D007165:Immunosuppression Therapy; D015994:Incidence; D016035:Pancreas Transplantation / Q000706:statistics & numerical data; D012042:Registries; D009927:Tissue and Organ Procurement; D016896:Treatment Outcome; D014481:United States