Intra portal Islet auto transplantation (IAT) independently improves quality of life in patients after Total Pancreatectomy (TP) and IAT in patients with chronic refractory pancreatitis
Srinath Chinnakotla2, Gregory Beilman1, David Vock1, Martin Freeman3, Varvara Kirchner1, Timothy Pruett1, Stuart Amateau3, Guru Trikudanathan3, Elissa Downs4, Sarah Jane Schwarzenberg4, Matthew Armfeild4, Karthik Ramanathan1, David Sutherland1, Melena Bellin4
1Surgery, University of Minnesota, Minneapolis, Minnesota, United States, 2Surgery, University of Minnesota, Minneapolis, Minnesota, United States, 3Medicine, University of Minnesota, Minneapolis, Minnesota, United States, 4Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
Objective: TPIAT is increasingly utilized for the management of intractable chronic-pancreatitis (CP).TP removes the source of pain and the addition of an islet auto transplant (IAT) minimizes the risk for deleterious effect of brittle diabetes. However, little is known about the impact of IAT on long-term islet function and quality of life (QoL). Furthermore, some payers cover TP but do not cover IAT because of lack of such long-term outcome data. In particular, IAT is not covered by Medicare or by some states' Medicaid plans resulting in inequity access to care for patients in US. The aim of this study was to evaluate the long-term impact of IAT on QoL in patients undergoing TP for CP.
Methods: Included were patients >1 year post- TPIAT at our center with >1 Short Form-36 (SF-36) completed post-TPIAT; we excluded those with partial pancreatectomy only, subsequent pancreas transplant, or no QoL data. QoL measures derived from SF-36 included physical component summary (PCS) and mental component summary (MCS) scores and 8 subscale scores. Patients were classified as insulin independent or dependent at time of QoL assessment, and as having islet graft function or graft failure (meal stimulated C-peptide <0.6 ng/mL). Data were analyzed using a linear mixed model with a term for on or off insulin, with a natural cubic spline basis for time since transplant to account for temporal trends, and a random subject-specific effect to account for within-person correlation. This modelling was repeated for islet graft function.
Results: Among 815 patients who have received islet autografts at our center since 1977, 564 met criteria for inclusion with 2,161 total QOL surveys. Patients had a mean age of 33.1 years (SD 15.5 yrs, 23% children); 70% were female. Most recent QoL survey for each participant was collected at a median of 4.0 years (IQR 1.6 - 7.2 years), with 42.7% with QoL data >5 years and 17.3% with data >10 years post-TPIAT. In the linear mixed model accounting for time since transplant and within-person correlations, insulin independent patients exhibited higher QoL in every subscale domain (magnitude between 0.15-0.3 population SD scores) and for PCS and MCS (p<0.05 for all, Table 1). PCS was 3.04 (SE 0.57) higher in insulin independent vs those on insulin (p<0.001). Among 429 participants who had C-peptide data, only 15% had islet graft failure as defined by endogenous C-peptide. No differences in QoL were observed by graft failure vs graft function but this may be due to inadequate power given the rarity of islet graft failure.
Conclusions: Islet graft function is preserved long-term in the majority of TPIAT recipients. QoL is significantly higher when insulin independence is present. These data support offering IAT with TP, rather than just performing TP and treating with exogenous insulin.
Table 1: QoL in TPIAT
|Domain||Average Difference [Insulin Independent- Using Insulin] (SE)||p-value|
|Subscale, SF-36 Domains, Z-scores|
|Physical Function||0.29 (0.05)||<0.001|
|Role Physical||0.31 (0.07)||<0.001|
|Bodily Pain||0.25 (0.06)||<0.001|
|General Health||0.25 (0.06)||<0.001|
|Social Function||0.23 (0.07)||0.001|
|Role Emotional||0.15 (0.07)||0.042|
|Mental Health||0.19 (0.07)||0.004|
|Component Summary Scores, Standardized|
|Physical Component Summary||3.04 (0.57)||<0.001|
|Mental Component Summary||1.62 (0.7)||<0.001|
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