History

Candidates for pancreas transplantation require evaluation for the following complications of diabetes:

Kidney disease
Retinopathy
Coronary artery, cerebral vascular, and peripheral vascular disease
Gastropathy
Neuropathy

Kidney disease

A significant number of pancreas transplantation candidates have preexisting advanced kidney disease. Therefore, coincident extrarenal disease should be assumed present. Candidates for PTA transplants must be evaluated for the likelihood of progression of kidney dysfunction once nephrotoxic immunosuppression is started, as these patients may eventually need a kidney transplant as well. Some of the relative benefits of SPK transplant (shorter waiting time for a kidney than for kidney alone candidates and improved pancreas graft function compared with PTA recipients) may warrant waiting for eventual SPK rather than proceeding with PTA.

Diabetic retinopathy

Diabetic retinopathy is a frequent finding in patients with diabetes and end-stage renal disease (ESRD). Significant vision loss may be observed. Also, patients may be overtly blind. Blindness is not an absolute contraindication to transplantation. However, it is essential to confirm that a patient with significant vision loss has an adequate support system to ensure help with travel and immunosuppressive medications.

Coronary artery disease

A significant comorbidity to consider in patients with type I diabetes with diabetic nephropathy is coronary artery disease (CAD). Patients with diabetes and ESRD are estimated to carry a nearly 50-fold greater risk of cardiovascular events than the general population. This type of patient may have several risk factors in addition to diabetes for the development of CAD, including hypertension, hyperlipidemia, and smoking. They may have asymptomatic myocardial ischemia because of neuropathy associated with diabetes. The prevalence of significant (> 50% stenosis) CAD in patients with diabetes who are starting treatment for ESRD is estimated to be 45-55%.^[18]

Cerebral vascular disease

Patients with ESRD and diabetes also experience an increased rate of strokes and transient ischemic attacks. Deaths related to cerebral vascular disease are approximately twice as common in patients with diabetes compared to patients without diabetes once ESRD has occurred. Patients with diabetes experience strokes more frequently and at a younger age than do age- and gender-matched nondiabetic patients with stroke.

Peripheral vascular disease

Lower extremity peripheral vascular disease is significant in patients with diabetes. Patients with ESRD are at risk for amputation of a lower extremity. These problems typically begin with a foot ulcer associated with advanced somatosensory neuropathy.

Gastroparesis

Impaired gastric emptying (gastroparesis) is an important consideration because of its significant implications in the posttransplantation course. Patients with severe gastroparesis may have difficulty tolerating oral immunosuppressive medications essential to prevent rejection of the transplants. Episodes of volume depletion with associated azotemia frequently occur in patients with simultaneous pancreas-kidney (SPK) transplants. Patients typically require careful treatment, including motility agents such as metoclopramide, cisapride, or erythromycin.

Autonomic neuropathy

Autonomic neuropathy is prevalent and may manifest as gastropathy, cystopathy, and orthostatic hypotension. The extent of diabetic autonomic neuropathy commonly is underestimated.

Neurogenic bladder dysfunction is an important consideration in patients undergoing bladder-drained pancreas-alone transplantation or SPK transplantation. Inability to sense bladder fullness and empty the bladder predisposes to high postvoid residuals and the possibility of vesicoureteral reflux and reflux into the donor duodenum. This may adversely affect renal allograft function, increase the incidence of bladder infections and pyelonephritis, and predispose to graft pancreatitis.

The combination of orthostatic hypotension and recumbent hypertension results from dysregulation of vascular tone. This has implications for blood pressure control following transplantation, especially in patients with bladder-drained pancreas transplants predisposed to volume depletion. Therefore, careful reassessment of the posttransplantation antihypertensive medication requirement is required.

Sensory and motor neuropathies

These conditions are common in patients with longstanding diabetes. This may have implications for rehabilitation after transplantation. It also indicates the potential risk of a foot injury and subsequent diabetic foot ulcers.

Mental or emotional illnesses

Mental illnesses, including neuroses and depression, are common. Diagnosis and appropriate treatment of these illnesses is an essential pretransplantation consideration, with important implications for ensuring a high degree of medical compliance.

Workup

Kandaswamy R, Stock PG, Miller J, White J, Booker SE, Israni AK, et al. OPTN/SRTR 2020 Annual Data Report: Pancreas. Am J Transplant. 2022 Mar. 22 Suppl 2:137-203. [QxMD MEDLINE Link]. [Full Text].
United Network for Organ Sharing (UNOS). Data. UNOS. Available at https://unos.org/data/. March 31, 2022; Accessed: April 12, 2022.
Gruessner RW, Gruessner AC. Pancreas After Islet Transplantation: A First Report of the International Pancreas Transplant Registry. Am J Transplant. 2016 Feb. 16 (2):688-93. [QxMD MEDLINE Link]. [Full Text].
Demartines N, Schiesser M, Clavien PA. An evidence-based analysis of simultaneous pancreas-kidney and pancreas transplantation alone. Am J Transplant. 2005 Nov. 5(11):2688-97. [QxMD MEDLINE Link].
Burke GW 3rd, Vendrame F, Virdi SK, Ciancio G, Chen L, Ruiz P, et al. Lessons From Pancreas Transplantation in Type 1 Diabetes: Recurrence of Islet Autoimmunity. Curr Diab Rep. 2015 Dec. 15 (12):121. [QxMD MEDLINE Link].
Kerr HR, Hatipoglu B, Krishnamurthi V. Pancreas transplant for diabetes mellitus. Cleve Clin J Med. 2015 Nov. 82 (11):738-44. [QxMD MEDLINE Link].
Ziaja J, Bozek-Pajak D, Kowalik A, Krol R, Cierpka L. Impact of pancreas transplantation on the quality of life of diabetic renal transplant recipients. Transplant Proc. 2009 Oct. 41(8):3156-8. [QxMD MEDLINE Link].
Decker E, Coimbra C, Weekers L, et al. A retrospective monocenter review of simultaneous pancreas-kidney transplantation. Transplant Proc. 2009 Oct. 41(8):3389-92. [QxMD MEDLINE Link].
Becker LE, Hallscheidt P, Schaefer SM, Klein K, Grenacher L, Waldherr R, et al. A Single-center Experience on the Value of Pancreas Graft Biopsies and HLA Antibody Monitoring After Simultaneous Pancreas-Kidney Transplantation. Transplant Proc. 2015 Oct. 47 (8):2504-12. [QxMD MEDLINE Link].
Redfield RR, Scalea JR, Odorico JS. Simultaneous pancreas and kidney transplantation: current trends and future directions. Curr Opin Organ Transplant. 2015 Feb. 20 (1):94-102. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Atlanta, GA: U.S. Department of Health and Human Services; 2020. [Full Text].
Schenker P, Vonend O, Krüger B, Klein T, Michalski S, Wunsch A, et al. Long-term results of pancreas transplantation in patients older than 50 years. Transpl Int. 2011 Feb. 24(2):136-42. [QxMD MEDLINE Link].
Mora M, Ricart MJ, Casamitjana R, Astudillo E, López I, Jiménez A, et al. Pancreas and kidney transplantation: long-term endocrine function. Clin Transplant. 2010 Nov. 24(6):E236-40. [QxMD MEDLINE Link].
McCullough KP, Keith DS, Meyer KH, Stock PG, Brayman KL, Leichtman AB. Kidney and pancreas transplantation in the United States, 1998-2007: access for patients with diabetes and end-stage renal disease. Am J Transplant. 2009 Apr. 9(4 Pt 2):894-906. [QxMD MEDLINE Link].
Ojo AO, Meier-Kriesche HU, Hanson JA, et al. The impact of simultaneous pancreas-kidney transplantation on long-term patient survival. Transplantation. 2001 Jan 15. 71(1):82-90. [QxMD MEDLINE Link].
Orloff MJ, Greenleaf G, Girard B. Reversal of diabetic somatic neuropathy by whole-pancreas transplantation. Surgery. 1990 Aug. 108 (2):179-89; discussion 189-90. [QxMD MEDLINE Link].
Kim YJ, Shin S, Han DJ, Kim YH, Lee JY, Yoon YH, et al. Long-term Effects of Pancreas Transplantation on Diabetic Retinopathy and Incidence and Predictive Risk Factors for Early Worsening. Transplantation. 2018 Jan. 102 (1):e30-e38. [QxMD MEDLINE Link].
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[Guideline] Loupy A, Haas M, Solez K, et al. The Banff 2015 Kidney Meeting Report: Current Challenges in Rejection Classification and Prospects for Adopting Molecular Pathology. Am J Transplant. 2017 Jan. 17 (1):28-41. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Simultaneous pancreas-kidney transplantation with enteric drainage. Illustrated by Simon Kimm, MD. Image courtesy of Landes Bioscience.
Solitary pancreas transplantation with enteric drainage. Illustrated by Simon Kimm, MD. Image courtesy of Landes Bioscience.
Solitary pancreas transplantation with bladder drainage. Illustrated by Simon Kimm, MD. Image courtesy of Landes Bioscience.

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Table 1. Characteristics of adult recipients of pancreas transplantation, United States, 2019^[1]

Table 1. Characteristics of adult recipients of pancreas transplantation, United States, 2019 ^[1]

Patient Characteristic	All Candidates		PAK		PTA		SPK
	Number	PCT	Number	PCT	Number	PCT	Number	PCT
Age 18-34 y	226	22.7%	4	9.1%	20	24.7%	202	23.2%
Age 35-49 y	520	52.3%	30	68.2%	34	42.0%	520	52.3%
Age 50-60 y	213	21.4%	9	20.5%	20	24.7%	213	21.4%
Age > 60 y	35	3.5%	1	2.3%	7	8.6%	27	3.1%
Male	606	61.0%	26	59.1%	37	45.7%	543	62.5%
Female	388	39.0%	18	40.9%	44	54.3%	326	37.5%
White	519	52.2%	27	61.4%	66	81.5%	426	49.0%
Black	271	27.3%	8	18.2%	9	11.1%	254	29.2%
Hispanic	157	15.8%	7	15.9%	6	7.4%	144	16.6%
Asian	43	4.3%	2	4.5%	0	0%	41	4.7%
Other	4	0.4%	0	0%	0	0%	4	0.5%
All recipients	1015	100%	44	4%	99	10%	872	86%

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Author

Joseph Sushil Rao, MD Post-Doctoral Associate, Division of Solid Organ Transplantation, Department of Surgery, Schulze Diabetes Institute, University of Minnesota School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Erik B Finger, MD, PhD Associate Professor of Surgery, Division of Solid Organ Transplantation, University of Minnesota School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, American Gastroenterological Association

Disclosure: Received grant/research funds from Novartis for other; Received grant/research funds from Bayer for other; Received grant/research funds from Otsuka for none; Received grant/research funds from Bristol Myers Squibb for other; Received none from Scynexis for none; Received grant/research funds from Salix for other; Received grant/research funds from MannKind for other.

Chief Editor

Ron Shapiro, MD Professor of Surgery, Surgical Director, Kidney/Pancreas Transplant Program, The Recanati/Miller Transplantation Institute at Mount Sinai Hospital

Ron Shapiro, MD is a member of the following medical societies: American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, American Surgical Association, Association for Academic Surgery, Central Surgical Association, International Pancreas and Islet Transplant Association, International Pediatric Transplant Association, Society of University Surgeons, Transplantation Society

Disclosure: Nothing to disclose.

Additional Contributors

Dixon B Kaufman, MD, PhD, FACS Ray D Owen Professor and Chief, Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health

Dixon B Kaufman, MD, PhD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Transplant Surgeons, American Surgical Association, Association for Academic Surgery, Central Surgical Association, Society of University Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: MEDEOR Therapeutics; eGenesis; Opsis<br/>Received research grant from: NIH.