Increasingly, patients with forms of diabetes other than Type I diabetes (T1D) are being offered pancreas transplantation and the results are excellent and nearly equivalent to the results in patients with T1D.
Traditional indications for pancreas transplantation are T1D patients who have chronic kidney disease (CKD) or those without kidney failure but who have hypoglycemia unawareness. But more and more, patients with either Type 2 diabetes (T2D), the most common form of diabetes, or pancreticogenic diabetes, such as those who have lost pancreatic endocrine and exocrine function due to trauma, surgery, chronic pancreatitis or a combination, are receiving pancreas transplantation in the US and around the world. While pancreas transplantation for T2D is still being practiced at selected centers, over the last decade, the number of T2D patients receiving pancreas transplants has risen steadily in the US and now accounts for approximately 9-10% of all pancreas transplants.1
In the past, pancreas transplantation was not commonly offered to patients with T2D because it was thought that the metabolic state involving insulin resistance and high insulin requirements could not be overcome by the insulin output from the graft resulting in a lower success rate as defined by the achievement of insulin independence. However, it became evident first through anecdotal experiences and later through reports from single centers that insulin independence could be achieved in many insulin-dependent T2D patients despite high insulin requirements and measurable insulin resistance.2,3
A number of factors leading to improved success rates as well as less toxic immunosuppression developed over the years now allows more favorable risk-benefit ratios for not only T1D and T2D patients, but also those with brittle pancreaticogenic diabetes.
The efficacy of pancreas transplantation in T2D, C-peptide+ patients with CKD is now well established. Several single center retrospective studies indicate excellent outcomes for patients with T2D undergoing simultaneous pancreas-kidney (SPK) transplantation.2-6 All of these studies suggest nearly equivalent patient and graft survival rates of SPK transplants in T1D vs. T2D patients. Light and colleagues published an initial report of their experience with SPK transplants in selected C-peptide + T2D patients and showed similar 20-year pancreas and kidney graft survival rates.2,3 Other groups, including UW-Madison, have outstanding pancreas transplant outcomes in selected T2D patients (unpublished results).4,6Retrospective national registry studies corroborate the results of single centers. Sampaio et al. also conducted a retrospective analysis of the national UNOS database of over 6000 SPKtransplants and showed nearly equivalent patient, kidney graft, and pancreas graft survival between T1D and T2D SPK recipients after adjusting for recipient risk factors.7 Based on these outstanding results, we now routinely offer selected patients with T2D and CKD an SPKtransplant.
Thus, for the uremic T2D patient who does not have a living kidney donor available, an SPKtransplant, if the patient meets eligibility criteria (see below), is an excellent option. This patient group has other options including a deceased donor kidney transplant for treatment of their CKD, yet the kidney graft outcomes of an SPK transplant are generally better than that of a deceased donor kidney alone.8,9
Major advantages for the T2D patient with CKD to receive an SPK transplant, as compared to receiving a cadaver kidney transplant alone, include a much shorter waiting time (due to shorter waiting list) and a better quality kidney. These are two very impactful reasons why if patients are eligible for a pancreas transplant and don’t have a living donor kidney available, an SPK should be considered. If a patient has a suitable living donor, then this is a very good option as well and is associated with excellent kidney graft results and similar to those of an SPK.
Eligibility criteria in the patient with T2D and CKD for an SPK transplant are:
- CKD stage IV or V
- Insulin-dependent diabetes (i.e. generally not indicated for diabetes controlled by diet or pills)
- If fasting C-peptide > 2.0 ng/ml then BMI must be ≤ 30 kg/m2; if fasting C-peptide < 2.0 ng/ml then BMI ≤ 35 kg/m2
- Insulin requirements generally < 75 U/day
- Mild or corrected cardiac disease
- Minimal to mild iliac artery vascular disease
- No active cancer and infection
- Demonstrated compliance with medical care
- Non-smoking status
Eligibility criteria in the patient with T2D for Pancreas transplant alone are the same as above except there must be no CKD present and there are no absolute C-peptide and BMI cutoff criteria although patients generally have a BMI ≤35 kg/m2.
In summary, excellent and nearly equivalent results of pancreas transplantation can be achieved in T2D patients compared with T1D patients. Improving risk-benefit ratios provide excellent rationale for broadening indications and being able to offer pancreas transplantation to greater numbers of patients.
For more information
The UW Health pancreas transplant program has performed more than 1,600 transplant procedures since its inception in 1982, making it one of the largest and most active in the nation. For questions about a patient or a referral, call the UW Health Pancreas Transplant Clinic at (608) 262-5420.
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2 Light JA, Barhyte DY. Simultaneous pancreas-kidney transplants in type I and type II diabetic patients with end-stage renal disease: similar 10 –yr outcomes. Transplant Proc. 2005, 37:1283-
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5 Orlando G, Stratta RJ, Light J. Pancreas transplantation for type 2 diabetes mellitus. Curr Opin Organ Transplant. 2011, 16:110-5.
6 Shin S, Jung CH, Choi JY, Kwon HW, Jung JH, Kim YH, Han DJ. Long-term metabolic outcomes of functioning pancreas transplants in type 2 diabetic recipients. Transplantation 2016 Jun 22 [Epub ahead of print].
7 Sampaio MS, Kuo H-T, Bunnapradist S. Outcomes of Simultaneous Pancreas-Kidney Transplantation in Type 2 Diabetic Recipients. Clin J Am Soc Nephrol. 2011, 6:1198-1206.
8 Wiseman AC, Gralla J. Simultaneous pancreas kidney transplant versus other kidney transplant options in patients with type 2 diabetes. Clin J Am Soc Nephrol. 2012 7:656-64.
9 Wiseman AC. Kidney transplant options for the diabetic patient. Transplant Rev 2013, 27:112-6.