Improvement in pancreas transplant evaluation and surgical volume using a multidisciplinary approach

To the Editor: Pancreas numbers are down: Pancreas transplantation is the only long-term treatment for diabetes that restores glucose homeostasis, without the risks of hypoglycemia.1Stratta RJ Gruessner AC Odorico JS Fridell JA Gruessner RW Pancreas transplantation: an alarming crisis in confidence.Am J Transplant. 2016; 16: 2556-2562Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 2Margreiter C Resch T Oberhuber R et al.Combined pancreas-kidney transplantation for patients with end-stage nephropathy caused by type-2 diabetes mellitus.Transplantation. 2013; 95: 1030-1036Crossref PubMed Scopus (36) Google Scholar, 3Scalea JR Redfield 3rd, RR Arpali E et al.Pancreas transplantation in older patients is safe, but patient selection is paramount.Transpl Int. 2016; 29: 810-818Crossref PubMed Scopus (33) Google Scholar Further, receiving a simultaneous pancreas kidney (SPK) transplant improves life expectancy over kidney transplantation alone.4Morath C Zeier M Dohler B et al.Transplantation of the type 1 diabetic patient: the long-term benefit of a functioning pancreas allograft.Clin J Am Soc Nephrol. 2010; 5: 549-552Crossref PubMed Scopus (49) Google Scholar,5Dholakia S Mittal S Quiroga I et al.Pancreas transplantation: past, present, future.Am J Med. 2016; 129: 667-673Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Despite this, the total number of pancreas transplants in the United States has decreased since 2006. Experts in the field recently reported that, while this drop in volume is multifactorial, the lack of a steady referral source is partly to blame.1Stratta RJ Gruessner AC Odorico JS Fridell JA Gruessner RW Pancreas transplantation: an alarming crisis in confidence.Am J Transplant. 2016; 16: 2556-2562Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Having observed a similar trend at our institution, we sought to assess the effectiveness of our SPK screening process. To do so, we reviewed our center’s kidney transplant waiting list with the goal of identifying patients who may also be candidates for SPK. Informed by that analysis, we assembled a multidisciplinary team of surgeons, endocrinologists, nephrologists, and transplant coordinators, to develop criteria for pancreas transplant candidacy. Our multidisciplinary team produced simple criteria (diabetics aged <65, on insulin, BMI<30 with end-stage renal disease [ESRD]) and recommendations in order to optimize treatment options. A pilot study using these new criteria to “internally convert” kidney alone to SPK candidates was undertaken. What we found: The kidney transplant (only) list included 1191 active patients (Figure 1A). Of these, 642 (53.9%) were diabetic, and 157 patients (24.5%) met the criteria for SPK evaluation. Potential SPK candidate mean wait-time was 898 days (2.4 years). Of the SPK candidates, 19 patients (12.1%) were type I and the remainder (n = 138; 87.9%) were type II diabetics. All type I and 72 type II patients (52.2%) required insulin (mean dose 31 units/d). After pilot study implementation, pancreas transplant evaluation rates increased from 0.71 to 3.54 per month (Figure 1B, P < .001). These results were driven by internal conversion of kidney transplant alone candidates to SPK. Pancreas transplantation rates also increased from 0.85 to 2.30 per month (Figure 1C; P = .012), with a current rate of 3.00 per month (P = .035). Our multidisciplinary pilot program led also to a subjective increase in enthusiasm for SPK as the treatment of choice for diabetics with ESRD. Indeed, the standardization and inclusive nature of our protocol appears to have brought a “unifying” or “team” feel to the care of the severely diabetic. Teamwork is the answer: Despite improvement in clinical outcomes over the last 2 decades, rates of pancreas transplantation have trended down in the United States.1Stratta RJ Gruessner AC Odorico JS Fridell JA Gruessner RW Pancreas transplantation: an alarming crisis in confidence.Am J Transplant. 2016; 16: 2556-2562Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar According to the United Network for Organ Sharing, 798 SPKs were performed in 2016, compared with 924 SPKs in 2006. A modest increase in SPK volume was observed from 2014 to 2016. Stratta et al suggested that decreased pancreas transplant volumes are multifactorial, but that a “pipeline” problem may be partly to blame.1Stratta RJ Gruessner AC Odorico JS Fridell JA Gruessner RW Pancreas transplantation: an alarming crisis in confidence.Am J Transplant. 2016; 16: 2556-2562Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar It is possible that over the last decade, fewer referring physicians (and surgeons) have been trained to determine which patients are indeed SPK candidates. The failure to offer diabetic patients an SPK has potentially damaging implications. Firstly, kidney transplant alone patients are likely to wait much longer on the list. Secondarily, not being offered an SPK may reduce access to higher-quality kidneys. Although surgeons are historically responsible for identifying patients appropriate for kidney versus pancreas transplantation in the outpatient setting, a team approach appears more effective. Based on our most recent data, it appears that the rate of internal conversion will stabilize at approximately 5 conversions per month, or 60 SPKs per year. By implementing a team-based approach to the evaluation process, we observed that more patients were given an opportunity to undergo SPK. JRS developed strategy, implemented strategy, collected data, analyzed data, wrote the paper, edited the paper, and submitted the paper. SS co-implemented strategy and edited the paper. EL partnered with transplantation, co-developed strategy, and analyzed the data. STB co-developed strategy, implemented strategy, analyzed data, and edited the paper. RNB co-developed strategy, implemented strategy, analyzed data, and edited the paper. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.