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The 50-Year Evolution of Pancreas Transplantation at a Single High-Volume Institution
*Abraham Matar1, *Erik Finger1, Ty Dunn2, Abhinav Humar3, Angelika Gruessner4, *Rainer Gruessner4, *Karthik Ramanathan1, *Vanessa Humpreville1, Arthur Matas1, David Sutherland1, Raja Kandaswamy1
1Transplantation Surgery, University of Minnesota, Minneapolis, MN.; 2Transplantation Surgery, Medical College of Wisconsin, Milwaukee, WI.; 3Transplantation Surgery, University of Pittsburgh, Pittsburgh, PA.; 4Surgery, SUNY Downstate Medical Center, Brooklyn, NY.

Objective: As the prevalence of insulin dependent diabetes mellitus (DM) increases in the United States, pancreas transplantation (PTx) remains the most viable option with the potential to offer long term glycemic control. We aimed to assess the historical evolution of PTx and outcomes at a high-volume institution over 50 years.

Methods: Between 1966-2016 (minimum 7 yr follow-up), 856 deceased donor simultaneous pancreas kidney (SPK), 805 pancreas after kidney (PAK), and 610 pancreas transplant alone (PTA) were performed (n = 2271). Patients were stratified into six different β€œerasβ€? which corresponded to the dates that the predominant immunosuppressive protocols changed over the study period (Table 1). 14 transplants between 1966-1978 were excluded from analysis (era 0).

Results: Of the 2,257 pancreas transplants analyzed, 95.5% were for type 1 DM, with an increase in type 2 DM as the indication for PTx over time. Median patient survival (PS) improved over time regardless of transplant category (Fig 1A). For the entire cohort, median PS did not differ by transplant category - 16.0 yrs for SPK, 14.0 yrs for PAK, and 18.9 yrs for PTA (p = 0.21). Similarly, median pancreas graft survival (GS) and median death-censored graft survival (DC-GS) (Fig 1B) rates improved with era. Median GS differed by PTx category: SPK recipients had the best results (10.9 yrs) followed by PAK recipients (5.4 yrs), and PTA recipients (2.6 yrs) (p < 0.0001). Median DC-GS was further improved for all PTx categories – SPK 25.0 years, PAK 15.1 years, and PTA 9.4 years (p < 0.0001). The most recent era – era 6 – demonstrated significantly improved rates of PS, GS, and DC-GS compared to prior eras. By multivariate Cox regression analysis, improved pancreas graft survival rates were associated with primary transplants, bladder drainage of exocrine secretions, shorter graft preservation time and the use of younger, female, and leaner donors. Death with a functional graft (DwF) was the most common cause of graft loss – accounting for 49.3%, 27.9%, and 15.8% of graft loss for SPK, PAK, and PTA recipients, respectively. The most common cause of DwF was infection, followed by cardiovascular disease. The most common cause of DC-graft loss was technical failure (TF), followed by immune-mediated graft loss. The incidence of both TF and immune-mediated graft loss decreased with time from initial rates of 24.6% and 80.5%, respectively, to the most current era rates of 10.6% and 4.8%.

Conclusion: This represents the largest single center PTx experience. PS and GS rates have improved over time due to advances in surgical technique, immunosuppressive protocols, and careful selection of both donors and recipients. Although historically reserved for type 1 DM, PTx has become an option for selective patients with type 2 DM, markedly expanding the number of patients that may benefit. Current results support PTx as an excellent treatment option for patients with insulin-dependent DM.

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