Surgeons Advise More Pancreas Transplants to Treat Diabetes

Pancreas transplantation should be considered more often for people with diabetes who meet eligibility criteria, a group of transplant surgeons argues in a new mini-review.

By providing complete beta-cell replacement, pancreas transplantation "frees the patient with diabetes from the need to monitor serum glucose and administer exogenous insulin," write Jonathan A. Fridell, MD, professor of surgery and director of pancreas transplantation at the Indiana University School of Medicine, and colleagues, in their mini-review published online November 15 in the Journal of Clinical Endocrinology & Metabolism.

Fridell and colleagues also point out that pancreas transplantation is "the single most effective method of achieving sustained euglycemia while preventing hypoglycemia and ketoacidosis, normalizing A1c levels, and optimizing time in range."

At the same time, "the trade-off...is that it entails a major surgical procedure and requisite long-term immunosuppression," and thus, is most often reserved for people already committed to immunosuppression, most commonly for kidney transplantation.

However, pancreas transplant alone may be appropriate for individuals who have extreme glycemic lability due to hypoglycemic unawareness, recurrent ketoacidosis, or progressive nonrenal complications, say Fridell and colleagues.

Thus, they argue, "Pancreas transplantation should be featured more prominently in the management algorithms for patients with insulin-requiring diabetes who are failing exogenous insulin therapy or experiencing progressive diabetic complications regardless of diabetes type. Furthermore, all patients with diabetes and chronic kidney disease should undergo consideration for [simultaneous pancreas and kidney] transplantation independent of geography or location."

Procedure Has Been Declining but TransplantWait Lists Are Long

In their mini-review, entitled, "Pancreas transplantation: Current challenges, considerations, and controversies," Fridell and coauthors point out that pancreas transplants have been declining despite "steadily improving outcomes in each successive era coupled with expansion of recipient selection criteria to include [insulin-requiring] patients with type 2 diabetes."

In 2021, approximately 920 pancreas transplants were performed in the United States, including 818 simultaneous pancreas-kidney (SPK) transplants, 50 pancreases after kidney (PAK) transplants, and 49 pancreas transplants alone (PTA).

That overall number of pancreas transplants represents a large decline from the nearly 1500 performed in 2004, a drop they attribute to a lack of primary referral source and general acceptance by the diabetes care community, absence of consensus criteria, and "access, education, and resource issues within the transplant community."

Asked to comment, endocrinologist M. Sue Kirkman, MD, professor of medicine at the University of North Carolina, Chapel Hill, points out that an algorithm on when to consider pancreas transplantation is included in a statement on type 1 diabetes treatment in adults by the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) published in 2021.

The ADA/EASD criteria there are similar to those that Fridell and colleagues suggest in their review, such as "failure" of medical therapy and recurrent severe hypoglycemia.

However, noted Kirkman, who is a co-author of the ADA/EASD statement: "Waiting lists for pancreas transplants are already several years long, yet the authors suggest that more people should be referred for transplants. It is unclear how healthcare systems and transplant systems would handle an increase in the number of people on the waiting lists with presumably ongoing limitations on the number of donor organs."

"Diabetes care providers should learn more about the benefits and risks of pancreas transplantation so that people with diabetes can be informed about all options for therapy," she continued.

Conversely, "the transplant community may also need to learn more about the rapidly changing landscape in nonsurgical treatments of diabetes," she urged.

For type 1 diabetes, "we know that rates of end-stage complications continue to fall and the differential in life expectancy between those with and without diabetes continues to narrow. But too many people still do not have access to optimal therapy."

"One philosophical question would be: Where do we put resources — into markedly expanding access to optimal medical and technological management, or into referring more people for pancreas transplantation?"

The authors and Kirkman have reported no relevant financial relationships.

J Clin Endocrinol Metab. Published online November 15, 2022. Abstract

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

For more diabetes and endocrinology news, follow us on Twitter and Facebook.

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.