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Beatrice P. Concepcion @KidneyBea_N

Beatrice P. Concepcion is a transplant nephrologist and Associate Professor at the University of Chicago in the Department of Medicine, Section of Nephrology. She also serves as the Medical Director of the kidney and pancreas transplant program. Her research interests include increasing access to kidney and pancreas transplantation and improving clinical and patient-centered outcomes of kidney and pancreas transplant recipients.

Competitors for the Dual-Organ Transplant Region

Team 1: Simultaneous Liver-Kidney Transplantation vs Team 2: Simultaneous Pancreas-Kidney Transplantation

Image generated by Evan Zeitler using Image Creator from Microsoft Designer, accessed via https://www.bing.com/images/create, January, 2024. After using the tool to generate the image, Zeitler and the NephMadness Executive Team reviewed and take full responsibility for the final graphic image.

I was a transplant nephrology fellow when I met Ms. J. She was a young 30+ year old, diagnosed with type 1 diabetes at age 5, and ultimately developed kidney failure at age 30. She received a simultaneous pancreas-kidney transplant (SPK) a month prior and was admitted to the hospital with abdominal pain and elevated pancreatic enzymes.  Unfortunately, imaging revealed that the pancreas had thrombosed and the next day, she underwent an allograft pancreatectomy. This led to a prolonged hospital stay which included wound complications and infection, but thankfully she ultimately recovered. When I saw her during one of her clinic follow-up appointments months later, I asked her how she was coping with the loss of her pancreas allograft. I was struck by her response: “That month off insulin was the best month of my life. I would do it all over again… to have a chance at not having to be on insulin.”

This encounter left a huge impression and made me appreciate the impact that a successful pancreas transplant can have on a patient’s life. Despite the hurdles, challenges, and potential complications, SPK is undoubtedly an excellent option for the appropriately selected recipient. When a pancreas transplant works, it not only provides euglycemia and freedom from insulin but also stabilizes or improves diabetic complications, increases life expectancy, and improves quality of life compared to remaining on dialysis or undergoing kidney-alone transplantation. In addition, the current organ allocation scheme in the United States allows for shorter waiting times for an SPK transplant (and earlier kidney transplantation compared to waiting for a kidney-alone transplant), not to mention that SPK’s usually come with “high-quality” kidneys.

Despite these benefits, it is undeniable that SPK transplantation seems to have had a scoring drought lately and is arguably falling behind other organ counterparts. There has been a steady decline in the number of SPK transplants performed over the last 20 years. The reason for this is likely multifactorial:

• From a transplant provider perspective, surgical and medical care is complex and requires training, experience, and expertise. It is not surprising that pancreas transplant outcomes are better at high-volume centers compared to low-volume centers. Due to the limited number of high-volume pancreas transplant centers in the country, there are definite challenges in training the next generation of surgeons and nephrologists and gaining appropriate experience and expertise. For example, not all centers associated with a transplant nephrology fellowship routinely perform pancreas transplants therefore not all transplant nephrology fellows receive the training needed to care for pancreas transplant recipients (a role that the specialty has historically taken on).
• From a referring provider perspective, there may be gaps in knowledge regarding who is appropriate for SPK transplant thus patients may not be referred for pancreas transplant or receive the appropriate education. For example, providers may not know that some patients with type 2 diabetes may be good candidates for SPK.
• From a patient perspective, there may be hesitation in pursuing a pancreas transplant due to the availability of newer glucose monitoring and insulin delivery devices. There may also be barriers in accessing a transplant center that offers SPK. Indeed, geographic disparities in access to SPK exist in the US.

In 2022, the American Society of Transplantation convened a Pancreas Workshop to identify the barriers to pancreas transplantation and propose potential solutions. The workgroup recently published a manuscript entitled “Generating Strategies for a National Comeback in Pancreas Transplantation: A Delphi Survey and U.S. Conference Report” which outlines the steps for a national comeback in pancreas transplantation. These include improving referral and candidate selection, donor pancreas utilization, collaboration among different stakeholders, and training, education and research in pancreas transplantation.

Back to Ms. J: She received a second pancreas transplant a year after the first one failed. Last I checked, she was doing well, free from insulin and dialysis. There are undoubtedly many patients just like her who would want to pursue an SPK transplant if given the option. I firmly believe that our community is working hard to ensure that SPK transplantation is an available and accessible option for those who would benefit. Please don’t miss reading the excellent dual-organ transplant region scouting report for additional discussion of the nuances and current state of SPK transplantation.

To conclude, despite all the challenges faced, I am fully expecting a dramatic comeback from SPK transplantation in the coming years. It is undoubtedly an excellent option for the appropriately selected recipient. With teamwork, determination, and perseverance, we can assist patients through a successful SPK transplant, blocking complications when they arise while always keeping our eyes on the ball. I am picking SPK as my #NephMadness 2024 champion, and so should you!

Copyright: BigBlueStudio/Shutterstock

– Guest Post written by Beatrice P. Concepcion @KidneyBea_N

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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