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What about Pancreas transplantation? by edmund Sanchez, mD D IABETES MELLITUS AffECTS 8.3% of the United States population (25.8 million individuals), and 1.9 million new cases of diabetes mellitus were diagnosed in people 20 years and older in 2010. Diabetes cost was (in 2007) $174 billion ($116 in direct costs, $58 in indirect costs) in the U.S., based on the American Diabetes Association's recent 2011 report. There are many efforts directed at curing diabetes. Despite many breakthroughs in recent years, the mainstay is still directed at treatment and not cure. Insulin replacement therapy and insulin pumps are still the primary regimen for type I and some type II diabetics. The development of "closed loop" insulin delivery systems is looking promising in the preliminary stages of development. In a select percentage of type I diabetes mellitus and type II diabetes mellitus patients, pancreas transplantation is an option. Cell or Organ Transplantation? Pancreas transplantation was first performed successfully on Dec. 17, 1966, by Drs. Kelly and Lillehei at the University of Minnesota, as a result of a worldwide collaboration. Since then, the evolution of pancreas transplantation has followed surgical refinements and improvements in immunosuppressive medications. Islet cell replacement has been pursued as a possible alternative to whole organ transplantation. The insulin-producing cells (beta islets, or islets of Langerhans) of the pancreas are isolated from a donor pancreas through a complex process of purification. These islets are then injected into the patients portal blood supply to function and secrete insulin. The first successful report came out of Edmonton, Alberta in 1999 by Shapiro et. al. Whole Organ Pancreas Transplantation Data In 2011, a total of 1,051 pancreas transplants were performed. Of these, 791 were simultaneous pancreas and kidney (SPK), 149 pancreas after kidney (PAK), and 111 pancreas transplant alone (PTA). In years previous, the total number of pancreas transplants performed has ranged from 1,137–1,435 in the United States. 14 | Cleveland/Akron/Canton MD News ■ MDNEWS.COM ■ JULY-AUGUST 2013 Nationally, the pancreas transplant (graft) survival varies if it were transplanted as SPK, PAK or PTA. The graft survival and patient survival are in the following table: GrAFT FAIlurE 6M GrAFT FAIlurE 1yr GrAFT FAIlurE 3yr GrAFT FAIlurE 5yr SPK 5.6% 7.5% 13.3% 16.4% PAK 17.7 23.6 38.7 46.2 PAK LDK 16.4 21.6 37.5 43.5 PAK DDK 19.9 26.9 40.4 50.9 Successfully transplanted pancreata have also demonstrated improvements in kidney transplant graft survival when compared to diabetic individuals who received kidney transplants alone. Maintenance of Pancreas Transplant The evolution of pancreas transplantation into its current state was a result of improved surgical technique and immunosuppressive agents. The most current regimen involves the use of very potent antibodies to suppress the immune system at the time of transplantation. This is in addition to drugs tacrolimus, mycophenolic acid and prednisone. The overall effect of these agents is to suppress the individual's immune system in order to minimize the chances of rejection of the transplanted pancreas (and kidney). These medications are usually taken twice a day and are kept within a therapeutic range measured in the patient's routine blood work. The improvement in quality of life, near cessation of progressive diabetes-induced pathophysiologic changes and prolongation of kidney graft survival make whole pancreas transplantation a viable option in the treatment of diabetes mellitus. For more information regarding whole organ transplantation, contact your local transplant program. Dr. Edmund Sanchez is an associate professor of surgery at Case Western Reserve University and the Surgical Director of the Kidney and Pancreas Transplant Programs at the Transplant Institute of University Hospitals Case Medical Center. ■