Is Extending Criteria for Pancreas Donor Programs the Best Way to Shorten Waiting Lists?

The growing waiting list for pancreas transplantation both in USA and in Eurotransplant countries reflects the critical need for new strategies for the management of patients affected by type 1 diabetes mellitus with indication for transplantation. As well as other solid organs, the extension of the donor selection criteria for pancreas transplantation was proposed in the last decades, but only few studies have been published about this issue to date. Indeed, in a period in which donor age of 45 years or more was considered a relative contraindication for pancreas transplantation, in 2005 one of the first studies about the extended donor criteria1 reported on pancreas transplantation from donors with a mean age > 45 year. The 1-and -5-years survival rates of patients (87,5% at both time points) and grafts survival rates (81,2% and 67,7% respectively), were comparable to the current literature data, underlining the importance of an appropriate general donor assessment evaluation more than the age parameter alone. A local allocation policy in order to reduce the ischemia time also played and more recently continues to play a pivotal role in this context. Only after more than ten years, the prospective “EXPAND study” by Proneth et al.2 confirmed these results, achieving a 1-year graft survival rate of 83,3% after transplants using extended donor criteria (EDC) on age (between 50 and 60), which was equal to the rate attained using standard criteria (83.5%) with donor age averaging 31,7 years). These results can give a new impulse to the application of donor extension criteria for pancreas transplantation. However, it is mandatory to underline that, due to the very delicate nature of both diabetic patients and of pancreas graft, strongly prone to complications and to long term high failure rate, the importance to obtain the 5-year’s results after pancreatic transplant from EPD as well as of the graft should be stressed, in order to establish if an extended pancreas deceased donors program could really represent the best option to increase life expectancy and improve the quality of life for many patients with juvenile diabetes. Indeed, although the importance of this work is that it represents the first prospective multicenter study on this issue, the results are not so different from the past, despite the progress of the surgical technique and of the immunosuppressant therapies in the last years, and other strategies such as the islet transplantation and living donor pancreas transplantation have been improved, amplifying the question of which option really represents the best way to shorten the waiting list for pancreas transplantation. Without a doubt, while living donor still raise ethical and results concerns, clinical pancreatic islet transplantation is becoming a more widely available option for patients with type 1 diabetes mellitus and eventually a potential cure, being considered one of the safest and least invasive transplant procedures. With more than 1500 patients treated since 2000, remarkable progress has occurred in both the technical aspects of islet cell processing and the outcomes of clinical islet transplantation, so that this therapeutic strategy has moved from a curiosity to a realistic treatment option for selected patients with type 1 diabetes3. In conclusion, the continuously growing demand of pancreas transplantation and the concomitant lack of ideal donors induce surgeons and clinicians to make more and more efforts to find new strategies to shorten the waiting lists. However, the question whether or not the extension of the donor criteria for solid organ transplantation really represents today the best option to follow still remains “a question” unsolved.