Canadian Diabetes Assocation Clinical Practice Guidelines Pancreas and Islet Cell Transplant Chapter 20 Breay W. Paty, Angela Koh, Peter Senior

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 Key Points 1.Simultaneous pancreas-kidney transplant in T1DM and ESRD can improve kidney graft survival 2.Successful pancreas or islet allotransplantation may result in insulin independence in patients with T1DM and potential macro- and microvascular benefits 3.There are risks associated with these procedures and thus the risk-benefit ratio must be weighed for each patient individually

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Co-existing Renal Disease Simultaneous kidney-pancreas transplant in patients with T1DM and ESRD can improve renal graft survival If considered for renal transplant Consider for simultaneous pancreas transplant

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Pancreatic or Islet Transplant may Restore Endogenous Insulin Secretion Reduction of diabetes related complications Islet cell transplant May stabilize microvascular disease Pancreatic Transplant Improved microvascular outcomes, lipids, blood pressure & carotid intimal media thickness Restoration of endogenous insulin secretion Improvement in A1C Reduction/elimination of hypoglycemia Pancreatic transplant/islet auto-transplant NOTE: Insufficient data on overall patient survival with transplant.

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Pancreas Graft Survival Based on Type of Transplant 1 Transplant Type1 year5 years10 years15 years Simultaneous pancreas kidney 83%69%51%33% Pancreas after kidney74%45%24%13% Pancreas alone78%54%28%9% 1.Waki K, Kadowaki T. An analysis of long-term survival from the OPTN/UNOS Transplant Registry. Clin Transplant. 2007: Ryan EA, Paty BW, Senior PA, et al. Five year follow-up after clinical islet transplantation. Diabetes. 2005;54: Islet Transplantation: Insulin Independence Rate 2 Transplant Type1 year5 years10 years15 years Islet allotransplantation70%10%NA

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association RisksIsletPancreas ProceduralMinor Procedural Risk (<10%): Intraperitoneal hemorrhage Partial portal vein thrombosis Gallbladder puncture Major Surgical Risk: Graft Thrombosis Hemorrhage Pancreatitis Wound Infection Peripancreatic abscess Duodenal stump leakage ImmunosuppressionLifelong Risks Associated with Procedures

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1. Individuals with T1DM and ESRD who are being considered for kidney transplantation, should also be considered for simultaneous pancreas transplantation [Grade D, Level 4] Recommendation 1

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 2.Individuals with T1DM and preserved renal function, or who have undergone successful kidney transplantation, but have persistent metabolic instability characterized by severe glycemic lability and/or severe hypoglycemia despite best efforts to optimize glycemic control, may be considered for pancreas or islet allotransplantation [Grade D, Consensus]

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 Recommendation 3 3.Individuals undergoing total pancreatectomy for benign pancreatic disease may be considered for islet auto-transplantation, but only in an experienced islet transplantation centre [Grade D, Consensus]

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines – for professionals BANTING ( ) – for patients