Older Patients Do Well With Pancreas Transplants


May 6, 2011 (Philadelphia, Pennsylvania) — Older patients receiving
pancreas transplants experience lower rates of acute rejection episodes
and total complications compared with their younger counterparts,
according to a study presented here at the American Transplant Congress
(ATC) 2011. With improvements in the management of diabetes, more older
patients are presenting for transplantation of pancreases and kidneys.
Previous registry data suggested that older patients did not do as well
as younger ones, but modern induction and maintenance immunosuppressive
therapy have changed the picture for older patients.
In a retrospective chart review study of 139 consecutive pancreas
transplant patients during a 15-year period from New York-Presbyterian
Hospital/Weill Cornell Medical Center in New York City, researchers
compared outcomes for patients 50 years old and older (n = 19) with
outcomes for patients younger than 50 years (n = 120) at the time of
transplant.
In addition to age, the baseline demographic characteristics were the
same for the groups. The median age for the older cohort was 53 years
(range, 50 - 61 years), and for the younger cohort it was 37 years
(range, 19 - 49 years; P < .001). All patients were
maintained on triple immunosuppression (calcineurin inhibitor,
mycophenolote mofetil, and low-dose steroids). Equivalent proportions of
the older and younger groups were receiving hemodialysis preoperatively
(74% and 83%, respectively; P = .36) and underwent simultaneous pancreas and kidney transplants (58% and 67%, respectively; P = .41).
Investigators led by Cheguevara Afaneh, MD, showed that long-term
graft survival was equivalent for the 2 groups, at about 77% for the
older patients and 50% for the younger ones (P = .43). Patient survival was between 80% and 90% (P = .79) for the 2 groups.
Postoperative complication rates at 30 days were similar (47% vs 50%, respectively; P = .83), but the older group experienced fewer major complications (36.4% vs 69.7%; P = .03). Similarly, the older patients did better in terms of acute rejection at 1 year (5.3% vs 37.5%; P = .004), as well as for overall acute rejection (10.5% vs 53.3%; P
< .001). The older and younger groups did not differ in the
incidence of infections requiring hospitalization, cytomegalovirus
infections, or posttransplant lymphoproliferative disorder.
Kenneth Brayman, MD, PhD, professor of surgery and director of
transplantation services and of the Kidney and Pancreas Transplant
Program at the University of Virginia in Charlottesville, told Medscape Medical News
that in this study and others, "It does seem like the incidence of
acute rejection is lower in older patients so they require less vigorous
induction and maintenance immunosuppression...because their immune
systems are not quite as robust."
Dr. Brayman, who was not involved with the New York study, noted that
data from about 20 years ago from the International Pancreas Transplant
Registry implied that pancreas recipients older than 45 years had
problems, with poorer graft survival and death. In the past decade,
however, it has become more common to transplant older patients.
Consistent with the present findings, he said, a number of centers,
including his own, have done pancreas transplants in patients older than
60 years, with good results.
The future probably will involve more pancreatic islet transplants.
"The results for islet transplantation at 5 years are comparable to the
results for a pancreas transplant alone," Dr. Brayman said. At this
time, Medicare does not pay for islet transplants, which is an
impediment to the development of the procedure. Efforts are underway to
change the Medicare reimbursement policy, he noted.
Dr. Afaneh has disclosed no relevant
financial relationships. Dr. Brayman had no disclosures relevant to this
discussion. He has received research support from Wyeth/Pfizer,
Novartis, and Quark Pharmaceuticals.

American Transplant Congress (ATC) 2011: Concurrent Session 19. Presented May 1, 2011.