Older Patients Do Well With Pancreas TransplantsMay 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 a
t 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.