Report of the first five DCDD pancreas transplants within the Eurotransplant region; excellent results with prolonged first warm ischemia times

Dear Sirs, The success of pancreas transplantation has led to an increased number of pancreas transplantations, which again has led to an increased need for suitable pancreas allografts. This initiated a search for alternative ways to increase the number of pancreas donors. Donation-aftercirculatory-determination-of-death (DCDD) is such an alternative and is a recognized form of transplantation with regard to kidney, liver, and lung transplantation. However, there is limited experience with DCDD in pancreas transplantation [1–6]. A large study with Scientific Registry of Transplant Recipients (SRTR) data showed DCDD-status to have a marginally significant risk (HR 1.39; P = 0.10) compared with a donation-after-brain-death (DBD)-donor [1]. Nevertheless, similar patient survival and graft survival rates between DBD and DCDD-groups at 1-year, 5-years [2,3,6], and even 10-years follow-up [5] have been reported. Results describe higher rate of renal complications such as delayed graft function (DGF) or urinary tract infections [2,3] after DCDD transplantation, however, there were no higher rates in pancreas-related complications [2,5]. Interestingly, these reports are always with rather short 1st warm ischemia times (WITs), ranging from 14 min [4] to 21 min [5]. Within the Eurotransplant region DCDD is only performed in Austria, Belgium, and The Netherlands. In February 2011, the first DCDD pancreas transplantation within the Eurotransplant region was performed in our center. Since then four more DCDD pancreas transplantations were performed. All five allografts were procured from DCDD-donors in The Netherlands. Pancreas allografts were matched and offered via Eurotransplant. Donor, transplant, and recipient characteristics are shown in the Table 1. HTK perfusion-fluid was used in all procedures. All patients were treated with alemtuzumab (Campath) induction-therapy and maintained on duo therapy, consisting of tacrolimus and mycophenalate mofetil. At 1-year follow-up all recipients are alive with optimally functioning pancreas and kidney allografts. There were no perioperative complications. Three pancreas allografts were enteric-drained and two were initially bladder-drained and converted to enteric drainage afterward, according to a two-step protocol [7]. All patients had immediate pancreas function, measured as peroperative lowering of the blood glucose levels, and, except for the fourth recipient, all SPKpatients had immediate kidney function, measured as peroperative diuresis. There were a few long-term complications: the first patient developed moderate interstitial and vascular rejection after 3 months, which was treated with antirejection therapy consisting of methylprednisolone. The third recipient developed a hematoma near the pancreas allograft, for which he was reoperated twice. After 2 months this recipient developed acute kidney insufficiency because of a ureteral stricture caused by a renal BK-infection, for which he was reoperated and reinsertion of the ureter to the bladder was performed. After lowering the immunosuppressive therapy, this recipient developed an interstitial rejection episode of the kidney, which was treated with methylprednisolone. The fourth recipient had a DGF of the kidney, for which he was treated with dialysis on days 2, 3, 4, and 6 postoperatively. After 6 weeks, a CT-scan showed a distal, partial venous thrombosis in the splenic vein, for which anticoagulant therapy (coumarine) was started liberally. The fifth recipient showed acute respiratory insufficiency because of a rhinovirus-infection 2 days after the operation, for which he was shortly admitted to the intensive care unit (ICU). HbA1c-values at 3-months follow-up were normal (mean of 32.6 mmol/mol) and most recent values are still within the normal ranges for all patients. Most of the postoperative complications our recipients experienced are not necessarily directly related to DCDD-allografts. Only DGF of the kidney in the fourth recipient is seen more often after DCDD transplantation [2,3,5]. Although DCDD pancreas transplantation is not a new concept worldwide, only few reports of pancreas transplantation using allografts from DCDD-donors have been published [1–5]. Within Europe, UK-Transplant has the largest series of DCDD pancreas transplantation [8], with