Pancreas transplantation, the most effective method of normalizing glucose control in type 1 diabetes, is not commonly used in type 2 diabetes, although patient and graft survival rates are equivalent (1). We conducted a mail survey of American transplant programs on 15 September 2000 characterizing the approach to pancreas transplantation in type 2 diabetic end-stage renal disease (ESRD) patients.
A total of 44 (30.3%) centers responded. The mean center-specific cumulative volume was 70 ± 227 cases (0–1,300), with a total of 6,014 procedures. The collective experience of 872 cases in 1999 represents 71% of the 1,237 American pancreas transplants reported to the United Network for Organ Sharing.
Diabetes is classified at more programs (86% [38/44]) than renal transplantation (63.6% [28/44]). Of pancreas recipients in 1999, 1.8% (16/872) had type 2 diabetes; they were intentionally selected (87.5% [14/16]).
Age, associated with declining tissue strength and healing potential, and obesity, linked with increased anesthetic problems and wound failure, are key features of type 2 diabetes. The median age of 64 years for incident ESRD patients compels transplant consideration, even when life expectancy is shorter than that of an allograft. Advanced age absolutely precludes renal transplantation at only 3 of 44 (6.8%) centers and relatively at 28 of 44 (63.6%). For pancreas candidates, 14 of 44 (31.8%) centers view advanced age as an absolute contraindication and 35 of 44 (79.5%) as one that is relative. A few centers proffer either procedure to patients of virtually any age, but at all ages, there is a consistently lower acceptance rate for pancreas versus renal candidates. A 65-year-old candidate would be placed on the pancreas waiting list at only 14% (6/44) of centers, and even a 55-year-old candidate would be declined at 27% (12/44). Nine of 44 (22.7%) centers considered obesity an absolute contraindication to renal transplantation compared with 8 of 44 (18.2%) for pancreas transplantation, and a total of 32 of 44 (72.7%) centers considered obesity a relative contraindication for kidney transplantation compared with 39 of 44 (88.6%) for pancreas transplantation.
Pancreas transplantation is not immediately life saving. Few donors are available, and the use of less-than-ideal allografts is generally deferred. Candidate selection is similarly restrained. Currently representing 78% of incident diabetic ESRD patients in the U.S., type 2 diabetic patients are older (median age 65 vs. 54 years), less likely to undergo even renal transplantation (2% vs. 9%), and more likely to die (23% vs. 18%) than those with type 1 diabetes (2). Selection policies for pancreas transplantation corroborate a conservative approach that excludes most type 2 diabetic patients. This judicious strategy likely accounts for the small but encouraging results reported and seems unlikely to change without augmentation of the supply of good-quality cadaver donors.
References
Address correspondence to Amy L. Friedman, MD, Department of Surgery, Yale University School of Medicine, FMB 112, 333 Cedar St., New Haven, CT 06520. E-mail: [email protected].
