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Guidance on the Benefits of Pancreas After Kidney (PAK) Transplantation

This proposal aims to address the decline in pancreas transplants and the underutilization of Pancreas After Kidney (PAK) transplants. By providing a guidance document with evidence supporting PAK transplantation, this proposal advocates offering PAK transplants as an alternative to simultaneous pancreas-kidney (SPK) transplants for uremic diabetic candidates with a waiting time of more than 1 year. Analysis of a large cohort of SPK, PTA, and PAK candidates/recipients from 1995-2010 will be conducted to examine kidney and pancreas graft survival, waitlist and recipient mortality, and hazard ratio of patient recipient survival compared to SPK waitlist survival.

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Guidance on the Benefits of Pancreas After Kidney (PAK) Transplantation

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  1. Guidance on the Benefits of Pancreas After Kidney (PAK) Transplantation Pancreas Transplantation Committee

  2. What problem will the proposal solve? • Decline in pancreas transplants, and substantial decline in PAKs Stratta, Robert J., Jonathan A. Fridell, Angelika C. Gruessner, Jon S. Odorico, and Rainer W.g. Gruessner. Pancreas transplantation: A Decade of Decline. Current Opinion in Organ Transplantation 21, no. 4 (August 2016): 386-92. doi:10.1097/mot.0000000000000319.

  3. What problem will the proposal solve? • PAKs are underutilized: • Many uremic diabetic patients who receive a kidney transplant are not offered a subsequent pancreas transplant and miss the potential benefits: • PAK transplant recipients have survival advantage to SPK waiting list candidates • Receiving a pancreas after a kidney increases kidney graft survival • 2003 JAMA paper • Compared PAK patient survival to uremic diabetic patients waiting for a PAK who received a kidney alone, not to SPK waitlist candidate survival (as in current analysis)

  4. What are the proposed solutions? • Provide a guidance document with evidence in support of offering PAK transplants • Guidance document recommends PAK transplantation as an alternative to SPK transplants for diabetic uremic candidates, particularly if the SPK waiting time is > 1 year

  5. Data Analysis • Cohort: 28699 SPK, PTA, PAK candidates/recipients from 1995-2010 • Allows for long term follow up • larger cohort than 2003 JAMA paper • Does not exclude patients with reported creatinine > 2 mg/dl • Contrast with 2003 JAMA paper, which did exclude these patients • Analysis examined: • Kidney and pancreas graft survival across transplant type • Waitlist and recipient mortality by PAK, SPK • Hazard ratio of SPK and PAK patient recipient survival compared to SPK WL survival

  6. Supporting Evidence

  7. SPK WL Survival, Post Tx PAK, SPK Survival

  8. How will members implement this proposal? • Transplant hospitals may use this guidance as a resource for staff, for discussions with patients and when considering organ offers • Guidance documents are for voluntary use by members and are not prescriptive of clinical practice

  9. How will the OPTN implement this proposal? • Anticipated Board date: December 3-5, 2017 • Committee will monitor and annually review the number of PAKs performed • UNOS will create an educational component on how to use the guidance

  10. Questions? Jon Odorico, MD Committee Chair jon@surgery.wisc.edu Abigail Fox, MPA Committee Liaison Abigail.fox@unos.org

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