TABLE 7.
Expert panel recommendations on recipient selection for pancreas transplantation
| Query | Recommendation | GRADE | Quality score | Agreement | Proposed action |
|---|---|---|---|---|---|
| 4.1 – “Is there a higher risk of post‐transplant renal failure in potential PTA recipients with normal (eGFR ≥90 ml/min/1.73 m2) or mildly decreased (eGFR 60–89 ml/min/1.73 m2) renal function and nephrotic syndrome when compared to recipients without nephrotic syndrome?” | In patients referred for PTA with normal or mildly decreased (eGFR 60–89 ml/min/1.73 m2) renal function and nephrotic syndrome, the benefits of insulin independence should be balanced against the possible risk of accelerated renal failure. | NG | 70% | 88.2% | Retrospective and prospective studies on PTA in patients with normal or mildly decreased renal function and nephrotic syndrome are very much needed. |
| 4.2 – “Is there a higher risk of post‐transplant renal failure in potential PTA recipients with normal (eGFR ≥90 ml/min/1.73 m2) or mildly decreased (eGFR 60–89 ml/min/1.73 m2) renal function and proteinuria (without nephrotic syndrome) when compared to recipients without proteinuria?” | In PTA recipients, with normal or mildly decreased (eGFR 60–89 ml/min/1.73 m2) renal function and proteinuria (without nephrotic syndrome), the benefits of insulin independence should be balanced against the potential risk of worsening of nephropathy. | 2C | 74% | 90.6% | Specific registry analysis and prospective studies are both needed to further clarify the possible increase in the risk of renal failure in PTA recipients with normal or mildly decreased renal function with proteinuria, but without nephrotic syndrome. |
| 4.3 – “Does PTA improve the course of chronic diabetic complications as compared to state‐of‐the‐art medical therapies?” | Successful PTA is associated with an improved course of chronic complications of diabetes as compared to current therapies. | 2C | 83% | 90.6% | A prospective observational or randomized trial should probably be the next action to take. |
| 4.4 – “Are the results of PAK transplants performed in recipients with a creatinine clearance or eGFR ≤45 ml/min inferior to the results of PAK transplants performed in patients with higher creatinine clearance or eGFR levels?” | PAK transplantation in diabetic patients with a functioning kidney graft and a creatinine clearance or eGFR ≤ 45 ml/min could be performed after careful risk‐benefit analysis in the individual patient. Immunosuppression should be optimized to protect renal function. | NG | 82% | 90.6% | Ad hoc registry analysis as well as prospective studies are required to clarify if recipients with a creatinine clearance ≤45 ml/min are exposed to undue risk of renal graft failure when undergoing PAK transplant. |
| 4.5 – “Are the results of PAK transplants performed in recipients with a history of renal rejection inferior to the results of PAK transplants performed in patients without a history of renal rejection?” | Patients with history of renal allograft rejection should be selected very carefully for PAK transplantation. Optimal HLA matching and avoidance of donor‐specific antibodies are both expected to mitigate the risk of post‐PAK rejection. | NG | 84% | 90.6% | Further retrospective and prospective observational studies are both needed. |
| 4.6 – “Are the results of PAK transplants performed within 6 months from renal transplantation inferior to the results of PAK transplants performed after this time interval?” | PAK transplantation performed within 6 months of renal transplantation is associated with similar outcomes when compared to PAK transplantation performed after this time point. PAK transplantation provides better results when performed within 1 year after kidney transplantation. | 2C | 88% | 96.4% | Further retrospective and prospective observational studies are both needed. |
| 4.7 – “Are the results of preemptive SPK transplants superior to those of SPK transplants performed in patients undergoing dialysis?” | Preemptive SPK transplant is associated with improved outcomes when compared to SPK transplant performed in patients undergoing dialysis. | 2B | 98% | 100% | Further studies should define the level of renal function at which SPK transplantation becomes preferred as compared to PTA. |
| 4.8 – “Are the results of SPK transplants in obese patients inferior when compared to the results of SPK transplants in non‐obese patients?” | Obese patients undergoing SPK transplant may face a higher rate of early complications when compared to nonobese recipients. | 2B | 95% | 91.4% | The value of bariatric procedures and/or minimally invasive transplantation in obese SPK candidates should be explored to improve the outcome of SPK transplantation in obese recipients. |
| 4.9 – “Are the results of SPK transplants in patients with a lower limb amputation inferior to the results of SPK transplants in patients without history of lower limb amputation?” | Pre‐SPK transplant lower limb amputation, in the context of cardiovascular disease, may be a risk factor for inferior transplant results. | 2C | 85% | 94.3 | None. |
| 4.10 – “Are the results of SPK transplants in patients with an history of coronary heart disease inferior to the results of SPK transplants in patients without an history of coronary heart disease?” | History of treated coronary heart disease is associated with an increased risk of post‐SPK transplant cardiovascular events and inferior long‐term results. | 2C | 97% | 94.3% | Report outcomes of SPK transplantation based on severity of coronary heart disease. |
Abbreviations: eGFR, estimated glomerular filtration rate; HLA, human leukocyte antigen; NG, not graded; PAK, pancreas after kidney; PTA, pancreas transplantation alone; SPK, simultaneous pancreas kidney.