Kidney/Pancreas Transplant Program
Indications and Contraindictions - Kidney/Pancreas
Indications for Simultaneous Pancreas-Kidney (SPK) Transplantation
Patients with insulin dependent (Type 1, juvenile diabetes) diabetes who have
end stage renal disease (ESRD) and require dialysis or expect to require
dialysis in the next 12 months may be considered for SPK transplantation.
Patients may be evaluated for transplantation prior to the
institution of dialysis. Patients are eligible for SPK transplantation if their
creatinine clearance (Clcr) calculated by the Cockcroft-Gault formula is less
than 20 ml/min. The Cockcroft-Gault formula for calculation of Clcr is now
considered to be superior to actual measured creatinine clearance as determined
by a 24-hour urine collection, due to inherent inaccuracies and collection
The formula is as follows:
Clcr (ml/min) = (140-age)(wt. kg)
creatinine (mg/dl) x72
For women, the result is multiplied by 0.85
Patients referred for SPK transplantation, who are
acceptable candidates by all criteria, are counseled about possible living donor
kidney transplantation. Since there is an extreme shortage of cadaver kidneys in
the United States and because living donor kidneys have a survival
advantage over cadaver kidneys, diabetic patients with ESRD referred for SPK
transplantation should consider living donor kidney transplant alone (LDKTA)
followed by a pancreas after kidney (PAK) procedure.
The University of Maryland is the world leader in
performing laparoscopic living donor nephrectomy, markedly reducing the cost and
morbidity of living kidney donation. Furthermore, the University of Maryland has
become the largest and most successful center in the United States in performing
solitary pancreas transplants (PAK). Thus for patients referred for SPK
transplantation, we offer the option of LDKTA plus a pancreas after kidney (PAK)
procedure at a later date.
The LDKTA and PAK option carries equal pancreatic
transplant success as SPK transplantation (see accompanying article; Bartlett
ST, et al., Ann Surg,224:440-452,1996) combined with the added survival
advantage of LDKTA. Patients presenting for SPK transplantation with no living
donor options will wait for cadaveric SPK transplantation. Those with living
donor options are offered the choice of cadaveric SPK or LDKTA plus PAK
SPK Transplantation can be considered in Type 1 diabetic patients with ESRD when the patient has:
- Documented Type 1 diabetes. (Special consideration is given to selected recipients
with Type 2 diabetes.) Candidates with a strong family history, or late age
or gestational onset, have a C-peptide level determined after glucose loading.
- Evidence of at least one type of progressive secondary diabetic complication
- diabetic retinopathy
- diabetic neuropathy
- diabetic gastroparesis
- accelerated atherosclerosis
- A rare indication for pancreas transplantation is extremely
brittle diabetes. These patients may not have secondary complications.
However, these individuals have frequent hypoglycemic episodes, with evidence of
impairment of employability or the safety of the patient or children in their
care. Usually there is evidence of frequent emergency room visits for
hypoglycemia or diabetic ketoacidosis.
Contraindications for Simultaneous Pancreas-Kidney (SPK) Transplantation
There are certain absolute contraindications to SPK transplantation:
- HIV infection
- Disseminated or untreated cancer
- Severe psychiatric disease
- Unresolvable psychosocial problems
- Persistent substance abuse
- Severe mental retardation
- Un-reconstructable coronary artery disease or refractory congestive heart failure
Relative Contraindications to SPK transplantation:
- Cardiovascular disease. All Type 1 diabetic patients require dobutamine
stress echocardiography or exercise or pharmacologic stress scintigraphy prior
to consideration. Candidates with positive stress testing will require consultation
with a cardiologist prior to transplantation. Candidates with a positive stress
test usually will require cardiac catheterization and possible angioplasty or bypass.
- Treated malignancy. The cancer-free interval required will vary depending on
the stage and type of cancer. Consultation with a board-certified oncologist is
required in most cases.
- Substance abuse history. Patients must present evidence of involvement
in drug free rehabilitation. This includes written documentation
of participation in rehabilitation including negative random toxicologic screens.
- Liver Cirrhosis. Candidates with chronic hepatitis B or C or
persistently abnormal liver function testing will have specialized testing prior to
- Structural genitourinary abnormality or recurrent urinary tract infection.
Urologic consultation is required prior to consideration.
- Past psychosocial abnormality. Master of Social Work (MSW) or psychiatry
evaluation, as appropriate.
- Aortoiliac disease. Patients with abnormal
femoral pulses or disabling claudication, rest pain or gangrene will require
evaluation by a board-certified vascular surgeon prior to consideration.
Patients with significant aortoiliac occlusive disease may require angioplasty
or aortoiliac grafting prior to transplantation. Patients with significant
aortoiliac occlusive disease may require angioplastyor aortoiliac grafting
prior to transplantation.
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February 21, 2011.