Pancreas

Pancreas transplantation is a treatment option usually for type 1 diabetes patients. Four different procedures are available:

  • simultaneous pancreas–kidney transplantation
  • pancreas transplant alone
  • pancreas-after-kidney transplantation
  • islet cell transplantation.

Single-organ pancreas transplant, or combined pancreas and kidney transplantation, is a common procedure in many countries (Mitta & Gough, 2014).

The most common indication for pancreas transplantation (pancreas alone, simultaneous pancreas–kidney and pancreas-after-kidney transplant) in the US for 2015 was type 1 diabetes (82.4%), followed by type 2 diabetes (8.1%) and other (9.5%). Type 1 diabetes (84.0%) and type 2 diabetes (9.7%) were also the most common indications for combined pancreas and kidney transplantation (SPK) in the US during 2015 (Kandaswamy et al., 2017).

Allogeneic pancreatic islet cell transplantation is another treatment option for type 1 diabetes (National Institute for Health and Care Excellence [NICE] [IPG257], 2008; Health Quality Ontario, 2015). Currently, very few centres worldwide perform islet cell transplantation. This is likely to change with the development of alternative transplant sites and new cell sources, such as porcine islet cells and embryonic stem/induced pluripotent stem (CESiPS)-derived beta cells, with their potential for ‘on-demand’ and ‘unlimited’ cell therapy for type 1 diabetes (Anazawa et al., 2018).

In response to the lack of strategies in the literature for beta-cell replacement, a national French expert panel has published recommendations on the different kinds of beta-cell replacement, their benefit-risk ratios and indications for each type of transplantation, according to the type of diabetes and its control and association with end-stage renal disease. Allotransplantation requires immunosuppression, a risk that should be weighed against the risks of poor glycaemic control, diabetic lability and severe hypoglycaemia, especially in cases of unawareness. Pancreas transplantation is associated with improvement in diabetic micro- and macro-angiopathy, but has the associated morbidity of major surgery.

Islet transplantation is a minimally invasive radiological or mini-surgical procedure involving infusion of purified islets via the hepatic portal vein, but needs to be repeated two or three times to achieve insulin independence and long-term functionality. Simultaneous pancreas-kidney and pancreas after kidney transplantations are proposed for kidney recipients with type 1 diabetes with no surgical, especially cardiovascular, contraindications. In cases of high surgical risk, islet after or simultaneously with kidney transplantation may be proposed. Pancreas, or more often islet, transplantation alone is appropriate for non-uraemic patients with labile diabetes (Wojtusciszyn A et al. 2018).

In addition, autologous pancreatic islet cell transplantation after pancreatectomy can improve glycaemic control in patients with chronic pancreatitis or benign pancreatic endocrine tumours (National Institute for Health and Care Excellence (NICE) [IPG274], 2008).