Pankreas Transplantasyonu
Özet
Pankreas transplantasyonu, Tip 1 Diyabet hastalarında glukoz metabolizmasını düzenleyerek normoglisemi sağlayan ve yaşam kalitesini artıran en etkili tedavi yöntemidir. İlk kez 1966'da gerçekleştirilen bu prosedür; tek başına (PTA), böbrek nakli sonrası (PAK) veya eş zamanlı böbrek-pankreas nakli (SPK) şeklinde uygulanabilmektedir. Tedavinin temel hedefleri kan şekeri regülasyonu, sekonder komplikasyonların önlenmesi ve yeni renal greftin korunmasıdır. Donör seçiminde P-PASS ve pDRI gibi risk indeksleri kullanılırken, greftlerin genellikle kadavradan alınması tercih edilir. Cerrahi tekniklerdeki gelişmelerle birlikte ekzokrin drenaj için mesane veya enterik yöntemler kullanılmakta; immünsüpresif tedavilerdeki ilerlemeler ise akut rejeksiyon riskini yönetilebilir kılmaktadır. Teknik başarısızlıklar, vasküler tromboz ve enfeksiyonlar hala önemli risk faktörleri olsa da modern yaklaşımlarla bir yıllık sağkalım oranları %95-98 bandına ulaşmıştır. Gelecekte kök hücre temelli organoid üretiminin organ yetersizliği sorununa çözüm olması beklenmektedir. Multidisipliner bir yaklaşım gerektiren bu nakil süreci, ileri evre diyabet komplikasyonlarının yönetiminde hayati bir role sahiptir.
Pancreas transplantation is the most effective treatment for Type 1 Diabetes patients, providing normoglycemia and improving quality of life by regulating glucose metabolism. First performed in 1966, this procedure can be applied as pancreas transplant alone (PTA), pancreas after kidney (PAK), or simultaneous pancreas-kidney (SPK) transplantation. The primary goals are blood glucose regulation, prevention of secondary complications, and protection of the new renal graft. Risk indices like P-PASS and pDRI are used for donor selection, with grafts typically sourced from deceased donors. Advances in surgical techniques utilize bladder or enteric methods for exocrine drainage, while improvements in immunosuppressive therapies make acute rejection risks manageable. Although technical failures, vascular thrombosis, and infections remain significant risk factors, modern approaches have brought one-year survival rates to the 95-98% range. In the future, organoid production based on stem cells is expected to resolve organ shortage issues. Requiring a multidisciplinary approach, this transplantation process plays a vital role in managing advanced diabetes complications.
Referanslar
Herold K.C., Vignali D.A.A., Cooke A. Type 1 diabetes: Translating mechanistic observations into effective clinical outcomes. Nat. Rev. Immunol. 2013;13:243–256. doi: 10.1038/nri3422.
Nolan C.J., Damm P., Prentki M. Type 2 diabetes across generations: From pathophysiology to prevention and management. Lancet. 2011;378:169–181. doi: 10.1016/S0140-6736(11)60614-4.
Niclauss N, Meier R, Bédat B, Beta‐cell replacement: pancreas and islet cell transplantation. Endocr Dev 2016; 31: 146.
Lentine KL, Kasiske BL, Levey AS. KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation. 2017;101(8S Suppl 1):S1‐S109.
Sutherland DE, Goetz FC, Najarian JS. Living-related donor segmental pancreatectomy for transplantation. Transplant Proc. 1980;12(4 Suppl 2):19-25
Gruessner AC. 2011 update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the course of twenty-four years at the International Pancreas Transplant Registry (IPTR). Rev Diabet Stud. 2011; 8:6-16.
Tibell A, Solders G, Larsson M. Superior survival after simultaneous pancreas and kidney transplantation compared with transplantation of a kidney alone in diabetic recipients followed for 8 years. Transplant Proc. 1997;29(1–2):668.
Lee CM, Scandling JD, Krieger NR. Outcomes in diabetic patients after simultaneous pancreas‐kidney versus kidney alone transplantation. Transplantation. 1997;64(9):1288‐1294.
Rayhill SC, D’Alessandro AM, Odorico JS. Simultaneous pancreas‐kidney transplantation and living related donor renal transplantationin patients with diabetes: is there a difference in survival? Ann Surg. 2000;231(3):417‐423.
Nyqvist D, Köhler M, Wahlstedt H. Donor islet endothelial cells participate in formation of functional vessels within pancreatic islet grafts. Diabetes 2005; 54: 2287.
Gruessner AC, Gruessner RW. Long-term outcome after pancreas transplantation: a registry analysis. Curr Opin Organ Transplant. 2016;21:377–85.
Barton FB, Rickels MR, Alejandro R. Improvement in outcomes of clinical islet transplantation: 1999–2010. Diabetes Care 2012; 35: 1436.
Clevers H. Modeling development and disease with organoids. Cell 2016; 165: 1586
Sneddon JB, Tang Q, Stock P. Stem cell therapies for treating diabetes: progress and remaining challenges. Cell Stem Cell 2018; 22: 810.
Franz C, Görtz M, Wührl M. The Role of Pre-Procurement Pancreas Suitability Score (P-PASS) and Pancreas Donor Risk Index (PDRI) in the Outcome of Simultaneous Pancreas and Kidney or Pancreas After Kidney Transplantation. Ann Transplant. 2019 Jul 26;24:439-445.
Boggi U, Vistoli F, Del Chiaro M. Simultaneous cadaver pancreas-living donor kidney transplantation. Transplant Proc. 2004;36:577–9.
Boggi U, Amorese G, Marchetti P. Segmental live donor pancreas transplantation: review and critique of rationale, outcomes, and current recommendations. Clin Transplant. 2011;25:4–12.
Luis M-B and Jaime L-S, Donor risk factors in pancreas transplantation, World J Transplant. 2020 Dec 28; 10(12): 372–380, doi: 10.5500/wjt.v10.i12.372
Krieger NR, Odorico JS, Heisey D.M. Underutilization of pancreas donors. Transplantation . 2003;75:1271–1276.
Kapur S, Bonham CA, Dodson SF. Strategies to expand the donor pool for pancreas transplantation. Transplantation. 1999;67:284–290.
Humar A. Pancreas donors. Curr Opin Organ Transplant. 2007;12:73–76.
Humar A, Ramcharan T, Kandaswamy R. Technical failures after pancreas transplants: why grafts fail and the risk factors--a multivariate analysis. Transplantation . 2004;78:1188–1192.
Rudolph EN, Dunn TB, Sutherland DER. Optimizing outcomes in pancreas transplantation: impact of organ preservation time. Clin Transplant. 2017;31(9):e13035.
Gruessner RW, Sutherland DE. Simultaneous kidney and segmental pancreas transplants from living related donors-the first two successful cases. Transplantation. 1996;61:1265–1268. doi: 10.1097/00007890-199604270-00025.
Zielinski A, Nazarewski S, Bogetti D. Simultaneous pancreas-kidney transplant from living related donor: a single-center experience. Transplantation. 2003;76(3):547–552. doi: 10.1097/01.TP.0000076624.79720.14.
Pieroni E, Napoli N, Lombardo C. Duodenal graft complications requiring duodenectomy after pancreas and pancreas-kidney transplantation. Am J Transplant. 2018 Jun;18(6):1388-1396.
Redfield RR, Scalea JR, Odorico JS. Simultaneous pancreas and kidney transplantation: current trends and future directions. Curr Opin Organ Transplant. 2015 Feb;20(1):94-102.
Kopp WH, Verhagen MJ, Blok JJ. Thirty Years of Pancreas Transplantation at Leiden University Medical Center: Long-term Follow-up in a Large Eurotransplant Center. Transplantation. 2015 Sep;99(9):e145-51.
Kotton CN, Kumar D, Caliendo AM. The third international consensus guidelines on the management of cytomegalovirus in solid‐organ transplantation. Transplantation. 2018;102(6):900‐931.
Benedetti E, Gruessner AC, Troppmann C. Intra‐abdominal fungal infections after pancreatic transplantation: incidence, treatment, and outcome. J Am Coll Surg. 1996;183(4):307‐316.
Smets YFC, Van Der Piji JW, Van Dissel JT. Infectious disease complications of simultaneous pancreas kidney transplantation. Nephrol Dial Transplant. 1997;12(4):764‐771.
Danziger‐Isakov L, Kumar D; AST ID Community of Practice . Vaccination of solid organ transplant candidates and recipients: guidelines from the American society of transplantation infectious diseases community of practice. Clin Transplant. 2019;33(9):e13563.
Syeda G.B , Pavan D , Pancreas Transplantation, In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. 2021 Sep 18.
Dholakia S, Oskrochi Y, Easton G. Advances in pancreas transplantation. J R Soc Med. 2016 Apr;109(4):141-6.
Mittal S, Johnson P, Friend P. Pancreas transplantation: solid organ and islet. Cold Spring Harb Perspect Med. 2014 Apr 01;4(4):a015610.
Taihei I, Takashi K, Naohiro A. Impact of Pancreas Transplantation on the Patient Survival—An Analysis of the Japanese Pancreas Transplants Registry, J Clin Med. 2020 Jul; 9(7): 2134.
Stephanie B, Toshiaki S, Annelore V.M. Towards a Functional Cure for Diabetes Using Stem Cell-Derived Beta Cells: Are We There Yet? Cells 2021 Jan 19;10(1):191.
Jonathan A.F, Silke N , Michael C . The survival advantage of pancreas after kidney transplant, Am J Transplant. 2019 Mar;19(3):823-830.
