Optimizing outcomes in pancreas transplantation: Impact of organ preservation time

Abstract

Recent changes to pancreas graft allocation policy have increased the number of organs available for regional and distant sharing, which results in a corresponding increase in preservation time. We sought to systematically assess the impact of cold ischemia time (CIT) on outcomes post-transplant. A retrospective review of 1253 pancreas transplants performed at a single transplant center was performed to correlate CIT to transplant outcomes. The rate of technical failure (TF) increased with 20+ hours of CIT, with a 2.7-fold to 6.2-fold increased rate of TF for pancreas after kidney (PAK), simultaneous pancreas and kidney (SPK), and pancreas transplants overall. Long-term graft survival was best with <12 hours of CIT; graft failure increased 1.2-fold to 1.4-fold with 12-24 hours of CIT and 2.2-fold with 24+ hours. CIT had less influence on the pancreas transplant alone category than either SPK or PAK and had markedly more influence on grafts from older (age >25 years) and overweight (body mass index >25) donors. In the final analysis, grafts with <12 hours of CIT performed the best overall, and strategies that reduce CIT (such as early allocation, pre-recovery cross-matching, and chartered flights for organs) should be considered whenever possible.

Improving pancreas graft utilization through importation

“…The 14‐hour mean CIT of the imported group in our series is within acceptable standards for pancreas transplantation . Our CIT is well below the upper limit of 24 hours, at which point graft failure increases by 2.2‐fold.…”

Early protocol computer tomography and endovascular interventions in pancreas transplantation

“…It is possible that this survival advantage is due to significantly shorter mean cold ischemic time (no protocol CTA = 887 ± 195 mins vs protocol CTA = 659 ± 178 min) and younger donor age (no protocol CTA = 44 ± 11 years vs protocol CTA = 36 ± 14 years), both of which have been shown to improve graft survival 32 . However, there was a significantly lower rate of graft failure (all‐cause) in patients where thrombosis was present after the introduction of early protocol CTA (23.4% before vs 5.6% after, p = .02).…”

“…After instituting the protocol change, we have found that many patients (41.7%) have graft thrombosis of varying severity without evidence of dysfunction. The retrospective nature of our study does limit our insight into whether these thromboses identified would have had any effect on the graft function if they received no intervention, although there was a significant improvement in graft survival after the introduction of protocol CTA (p = .04).It is possible that this survival advantage is due to significantly shorter mean cold ischemic time (no protocol CTA = 887 ± 195 mins vs protocol CTA = 659 ± 178 min) and younger donor age (no protocol CTA = 44 ± 11 years vs protocol CTA = 36 ± 14 years), both of which have been shown to improve graft survival 32. However, there was a significantly lower rate of graft failure (all-cause) in patientswhere thrombosis was present after the introduction of early protocol CTA (23.4% before vs 5.6% after, p = .02).…”

Donor risk factors in pancreas transplantation

“…However, other authors have reported an increase in the incidence of complications such as anastomotic leaks, thrombosis, pancreatitis and infections, and they recommended to not exceed the limit of 20 h[ 35 - 38 ]. Recent studies showed a higher rate of graft failure when the cold ischemia time increased[ 39 ].…”