Pancreas Transplant Candidate Evaluation

The emphasis of the pretransplantation evaluation should be to identify and treat all coexisting medical problems that may increase the rate of morbidity and mortality of the surgical procedure and adversely impact the posttransplantation course. In addition to a thorough medical evaluation, the social issues of the patient should be evaluated to determine conditions that may jeopardize the outcome of transplantation, such as financial and travel restraints or a pattern of noncompliance.

Pretransplant cardiac risk screening is needed in all pancreas transplant candidates. At a minimum, a 12-lead electrocardiogram and ECHO are required. Given risk factors for CAD, most patients will require stress testing or anatomic study of potential coronary lesions. Such studies may include stress echocardiogram, stress nuclear medicine studies, coronary C.T., or cardiac catheterization. Appropriate testing is often made in conjunction with cardiology and center-specific protocols.

Laboratory studies should include blood chemistries, liver function tests, CBC count, coagulation profile, urinalysis, urine culture, and cytospin (when indicated). A C-peptide level may distinguish if the candidate has type I or type II diabetes. In addition, test for the following infections:

Hepatitis B and C serologies
Cytomegalovirus (CMV) serologies (immunoglobulin M/immunoglobulin G [IgM/IgG])
Epstein-Barr virus serologies (IgM/IgG)
Varicella-zoster serologies (IgM/IgG)
Rapid plasma reagent (syphilis)
HIV serology
Purified protein derivative (tuberculosis skin test with anergy panel, when indicated)

Imaging studies performed in the pre-transplantation evaluation are chest radiography and potentially ultrasound or computed tomography (CT) evaluation of target (iliac) vessels to look for vascular calcification or narrowing.

Determining donor human leukocyte antigen (HLA) typing, presence of anti-HLA donor-specific antibodies, serologies, and crossmatch results with patients on the pancreas transplantation waiting list will permit the ideal situation of allocating the cadaveric pancreas (plus kidney, with simultaneous pancreas-kidney [SPK] transplantation) prior to procurement of the organs.

The timing of allocation of the pancreas to a specific patient relative to the procurement of the organ has important implications. Early allocation allows the transplantation center performing the pancreas transplantation the choice to arrange for organ recovery and transportation. It will enable recipients to be admitted to the hospital and be prepared for surgery prior to organ recovery, thus avoiding last-minute reallocation of organs and minimizing the cold-ischemia time of the pancreas prior to implantation. Pancreas allografts do not tolerate cold ischemia as well as kidney allografts.

Ideally, the pancreas should be revascularized within 12 hours after cross-clamping at procurement. Finally, early allocation also allows identification of highly matched (zero-mismatch) donor-recipient pairs or highly sensitized recipients before procurement, minimizing cold-ischemia time if the organs need to be transported across the country.

Treatment & Management

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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.