Superior Long-Term Results of Simultaneous Pancreas Kidney
The shortage of cadaveric donors for simultaneous pancreas-kidney transplantation has prompted the use of cadaveric organs from pediatric donors. The long-term outcome and its impact on overall long-term survival are unknown. A total of 680 recipients receiving cadaver Simultaneous pancreas-kidney (SPK) transplantation from pediatric and adult donors between July 1986 and September 2001 were analyzed and compared. Ten-year kidney and pancreas graft survival for SPK transplantation from donors aged <18 years (n = 142) were 80% and 72%, respectively, compared to 61% pancreas and kidney graft survival from donors ≥18 years of age (n = 538; p = 0.03 and 0.05, respectively). Five years post-transplant, blood glucose, HbA1c and creatinine clearance were significantly better in recipients from pediatric donors (85.3 ± 13 mg/dL, 5.5 ± 3.5% and 65.6 ± 16 mL/min, respectively), compared to recipients from adult donors (95.1 ± 29 mg/dL, 5.9 ± 3.5% and 58.3 ± 17 mL/min; p = 0.001, 0.01 and 0.002, respectively). Causes of graft failure for kidney and pancreas transplants were similar between the two groups. No statistically significant difference was observed in patient survival between recipients from pediatric donors compared to adult donors (85% vs. 76%, p = 0.29). When recipients of SPK from pediatric donors were stratified according to age (3-11 years and 12-17 years) and compared, no difference in kidney or pancreas graft survival was observed (kidney 76.4% vs. 81.3%, p = 0.15; pancreas 75% vs. 76%, p = 0.10, respectively). Pediatric donors represent a valuable source of organs, providing excellent short- and long-term outcomes. Wide utilization of pediatric organs will substantially increase the donor pool.
The annual incidence of type I diabetes mellitus (DM) continues to steadily rise as the number of individuals in the United States affected by this disease is estimated to number nearly 800 000, with comparable statistics in Europe. Diabetes mellitus afflicts 6% of the general population and is currently the third most common disease and the fourth leading cause of death by disease in the United States. Despite insulin therapy, it remains the most common cause of blindness in people of working age and is intimately related with long-term complications such as nephropathy, vasculopathy, retinopathy and neuropathy. Among the most significant of these complications is nephropathy, as diabetic renal disease is the most common cause of end-stage renal disease (ESRD). Moreover, diabetic patients with ESRD exhibit the highest mortality rates when compared to all other groups of ESRD patients.
Simultaneous pancreas-kidney (SPK) transplantation is a well-established treatment for patients with insulin-dependent DM complicated by ESRD. Simultaneous pancreas-kidney transplantation reverses the destructive effects of diabetes with the restoration of normoglycemia and renal function. In addition, attenuation of diabetic nephropathy, retinopathy and cardiovascular disease has also been reported. Unfortunately, the number of diabetic patients on the waiting list for pancreas transplantation continues to be greater than the number of available donor organs. Given this disparity, it has become clear that alternative solutions for donors must be identified.
Pediatric donor organs have long been considered a potential source of organs. Pediatric kidneys have cautiously been utilized in many transplant centers as an additional source of organs for adult recipients. The use of pediatric kidney donors is controversial based on several reports demonstrating poor functional outcome, a higher incidence of rejection, worse graft and patient survival rates and a higher incidence of surgical complications including vascular thrombosis, renal artery stenosis, hydronephrosis and urinary leak.
However, recent studies have reported good long-term results utilizing pediatric kidneys in adult recipients. Improvement in surgical technique and optimization of immunosuppression has led several retrospective analyses to report minimal differences in serum creatinine, patient survival and graft survival between recipients of adult and pediatric donor organs.
Pediatric donors are rarely used for pancreas transplantation due to concerns about islet cell mass, increased technical demands and the possible risks of vascular thrombosis. To date, only short-term data are available regarding the use of pediatric donors in pancreas transplantation and little information has been published on the fate of very young donor pancreata. In the present study, we sought to compare the long-term outcome of SPK transplants from pediatric donors versus adult donors, focusing on patient and graft survival, long-term diabetes control and long-term renal function. In addition, causes of graft loss were compared and analyzed between the two groups.