Pancreas transplantation in the United States as reported to the United Network for Organ Sharing (UNOS) and analyzed by the International Pancreas Transplant Registry

D E Sutherland, A Gruessner
Clinical Transplants 1995, : 49-67
As of 1995, more than 7,500 pancreas transplants had been reported to the International Pancreas Transplant Registry. More than 5,300 were performed in the United States, including more than 4,000 since the inception of the UNOS Registry in October, 1987. The bladder drainage (BD) technique has been the most widely used duct management technique since 1987 with 93% of all cases. In the overall analysis of US BID cadaveric pancreas transplants reported to the registry, patient survival and pancreas functional graft survival rates were 91% and 75% respectively, at one year, 88% and 72% at 2 years, and 85% and 67% at 3 years. When the 1987-95 US data for primary BID cases was analyzed according to the three major recipient categories [simultaneous pancreas/kidney transplants (SPK) (n=3,539); pancreas after kidney transplants (PAK) (n=238); and pancreas transplants alone (PTA) (n=175)], patient survival rates were no different (91%, 92% and 91% at one year, respectively), but pancreas graft survival rates were significantly higher in the SPK than in the PAK and PTA categories (78%, 56%, and 55%, at one year, respectively). In the SPK group, kidney graft survival rates at one year were 86%. An improvement of the graft survival could be shown over the analyzed time period for all categories. Outcomes were also compared according to whether induction immunotherapy in recipients included ALG/ATG/ATS, OKT3 or neither. In the primary SPK category, patients who received OKT3 (n=1,416) showed the best outcome with one-year graft survival rates of 83% followed by ALG/ATG/ATS (n=1,559) with 78%. Patients that received neither (n=410) had a significantly lower graft survival rate. In the primary PAK category, the use of OKT3 (n=49) was associated with lower graft survival rates than when ALG/ATG/ATS (n=143) or neither (n=40) were given, 51%, 66%, and 55% at one-year, respectively. In the PTA category, the use of ALG/ATG/ATS (n=93) was associated with significantly higher graft survival rates than when OKT3 (n=62) or neither (n=9) were used, being 63%, 58%, and none, respectively, at one-year. No negative impact of longer preservation time could be found in the univariate analysis. The effect of HLA-A, B and DR mismatching on outcome for primary US cases was also determined. Again the results differed according to recipient category. For SPK cases, there was only a beneficial effect of a perfect 6 antigen match (n=21) compared to 1 and 2-6 mismatches being 85%, 73% and 78% at one-year. In the primary PAK category, graft survival rates were significantly higher in those mismatched for 0 (n=6) and one (n=25) than for 2-6 (n=195) HLA antigens, being 100%, 76% and 58% at one year. In the primary PTA category there were no zero mismatch, technically successful cases. One-year graft survival rates were 70% (n=10) for the category with one mismatch and 55% (n=157) in the 2-6 antigen mismatch group. Cox multivariate analyses of the US data base showed that, overall, recipient category was the most significant factor (relative risk for graft loss being significantly lower for SPK than for PAK and PTA cases). Other variables also had an impact on results depending on the recipient category. Recipient age has an impact on patient survival as well as graft survival. It was most influential in the SPK and PAK category, but an effect was not seen in the PTA category. In both the PAK and PTA categories, minimizing HLA mismatches was associated with a significantly lower risk for graft loss. In the SPK and PTA category, anti-T-cell therapy significantly lowered the risk of graft loss. In the PAK and SPK category the transplant outcome improved significantly over the analyzed time period. Patient survival also improved overtime.

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