PANCREAS RETRANSPLANTS COMPARED WITH PRIMARY TRANSPLANTS

The improved results with pancreas transplantation in general, and the emerging evidence that the procedure favorably influences the course of secondary diabetic complications, given an impetus to retransplant patients whose initial graft has failed. In order to determine whether a pancreas retransplant policy is justified, we analyzed the results at our own institution. From 1978 through 1989, 327 pancreas transplants were performed in 261 patients, including 259 primary (79%) and 68 retransplants (21%) after a previous one failed (including 2 primary transplants performed elsewhere), with 48 second (15%), 18 third (5%), and 2 fourth (1%) transplants. The surgical techniques used in the 261 primary PxTxs were open-duct free drainage into the peritoneal cavity in 15 recipients, of whom 3 (20%) were retransplanted; duct occlusion in 34, of whom 9 (26%) were retransplanted; intestinal drainage in 78, of whom 23 (29%) were retransplanted; and bladder drainage in 134, of whom 13 (10%) were retransplanted. The surgical techniques used for the 68 pancreas retransplants were duct occlusion in 11 (10 second, 1 third), intestinal drainage in 12 (9 second, 3 third), and bladder drainage in 45 (29 second, 14 third, and 2 fourth); bladder drainage has been used nearly exclusively for the most recent pancreas retransplants. The recipient categories in the 261 primary transplants were pancreas alone in 115, of whom 29 (25%) were retransplanted, pancreas after kidney in 81, of whom 17 (21%) were retransplanted, and simultaneous pancreas and kidney transplants in 63, of whom 2 (3%) were retransplanted. Of the 68 pancreas retransplants, 32 (47%) were pancreas alone (26 second, 6 third), 24 (35%) were pancreas after kidney (17 second, 6 third, 1 fourth), and 12 (18%) were simultaneous pancreas and kidney (5 second, 6 third, 1 fourth). Overall patient survival rates were similar (P = 0.48), at 1 month (actual [98% after primary and 94% after retransplantation]) and at 1 year (actuarial [91% vs. 89%]). Overall graft functional rates were also similar, at 1 month (actual [76% for all primary and 79% for all retransplants-P = 0.9]), and at 1 year (actuarial [46% vs. 43%-P = 0.9]). Causes of graft losses at 1 month were similar for primary (18% were technical failures, 6% were rejected) and retransplant (16% were technical failures, 3% were rejected) cases. For technically successful primary (n = 191) and retransplant (n = 57) cases, at 1 month 92% and 85% were functioning, respectively; at 1 year, 61% and 49% (P > 0.2). Within the different duct management categories, there were no differences in function rates for primary vs. retransplant cases: at 1 year 18% vs. 10% for duct occluded, and 42% vs. 39% for intestinal drainage. But for both groups the results were better with the bladder drainage technique: at 1 year 60% for primary vs. 53% for retransplant cases. Within the pancreas transplant alone and pancreas after kidney categories, there were also no significant differences in graft function rates for primary vs. retransplant cases (P > 0.6): at 1 year 41% vs. 48% for all pancreas alone and 35% vs. 40% for all pancreas after kidney, and 54% vs. 68% for bladder-drained pancreas alone and 53% vs. 50% for bladder-drained pancreas after kidney transplants. However, for simultaneous pancreas and kidney (all bladder-drained), the results with primary transplants were significantly better than with retransplants (P = 0.05), with 1-year pancreas graft function rates of 68% vs. 32%. Except for those who require a kidney, pancreas retransplantation can be performed without penalty in terms of complication or overall success rate compared with primary transplants. We conclude that pancreas retransplantation should be applied in selected diabetic patients after failure of a previous graft.