Older patients receiving pancreas transplants have lower rates of acute rejection and total complications than their younger counterparts. 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 has changed the picture for the better for older patients, according to study results presented at the American Transplant Congress in Philadelphia in May.
Through a retrospective chart review of 139 consecutive pancreas transplant patients over a 15-year period at New York–Presbyterian Hospital/Weill Cornell Medical Center in New York City, investigators compared the outcomes in 19 patients 50 years old or older with outcomes in 120 patients younger than 50 years at the time of transplant.
The median age for the older cohort was 53 and for the younger cohort it was 37. Otherwise, the baseline demographic characteristics were not statistically different for the groups. All patients received maintenance triple immunosuppression therapy (calcineurin inhibitor, mycophenolate mofetil, and low-dose steroids). Approximately equivalent proportions of the older and younger groups were receiving hemodialysis preoperatively (74 percent and 83 percent, respectively) and underwent simultaneous pancreas and kidney transplants (58 percent and 67 percent, respectively). The remaining patients received a pancreas after kidney transplant or a pancreas transplant alone (42 percent of the older group and 33 percent of the younger group).
The investigators, led by Cheguevara Afaneh, MD, reported that long-term graft survival was equivalent for the two groups at about 77 percent for the older patients and 50 percent for the younger ones (p = 0.43). Patient survival was between 80 and 90 percent for the two groups.
Postoperative complication rates at 30 days were similar (47 percent versus 50 percent, respectively), but the older group experienced fewer major complications (36.4 percent versus 69.7 percent). Similarly, the older patients did better in terms of acute rejection at 1 year (5.3 percent versus 37.5 percent) and of overall acute rejection (10.5 percent versus 53.3 percent). There was no difference between the older and younger groups in the incidence of infections requiring hospitalization, cytomegalovirus infections, or posttransplant lymphoproliferative disorder.
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,” said 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.
Older data from the International Pancreas Transplant Registry suggest that pancreas recipients over 45 have problems of poorer graft survival and death, Brayman said. But over the past decade, pancreas transplantation has become more common for older patients. Several centers, including Brayman’s, have performed pancreas transplants in patients over 60 with good results.
For the future, Brayman foresees more pancreatic islet transplants. “The results for islet transplantation at 5 years are comparable to the results for a pancreas transplant alone,” he said. Currently, Medicare does not pay for islet transplants. He sees that as an impediment to the development of the procedure but said that efforts are under way to change the Medicare reimbursement policy.