Nutritional Risks in Patients Undergoing Total Pancreatectomy Islet AutoTransplantation in the POST Consortium

Islet Autoantibodies and Their Association With β-Cell Function and Diabetes Measures in Children With Acute Recurrent and Chronic Pancreatitis

OBJECTIVE

In children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP), circulating islet autoantibodies (auto-Ab) may influence β-cell function. This study reports Ab prevalence in youth with ARP or CP and investigates effects on indices of insulin secretion during mixed meal tolerance testing (MMTT) and diabetes status.

RESEARCH DESIGN AND METHODS

This was a retrospective cross-sectional analysis of 234 youth with ARP or CP who had islet Ab testing (Ab+ group, n = 28 [12%]; Ab- group, n = 206 [88%]). Fasting glucose and HbA1c were collected. MMTT was performed in 78% of participants (183 of 234). MMTT-derived indices were calculated and compared between groups.

RESULTS

The Ab+ and Ab- groups did not differ in age, sex, race, ethnicity, BMI percentile, or fasting glucose. Of Ab+ patients, 54% had one Ab+ islet and 46% had multiple Ab+ islets. Comparing the Ab+ to Ab- groups, HbA1c was higher (median 5.7 vs. 5.2%, P < 0.01), and C-peptide was lower (median 2.4 vs. 3.7 ng/mL, P = 0.01) in the Ab+ group. The Ab+ compared with the Ab- group had a higher proportion of prediabetes/diabetes (57% vs. 32%, P < 0.001). In survival analysis, the Ab+ group had significantly shorter time from first acute pancreatitis episode to diabetes development (P = 0.02).

CONCLUSIONS

In children with ARP or CP, Ab+ was associated with higher risk of diabetes/diabetes development and shorter time to diabetes development, suggesting that islet Ab+ is associated with β-cell dysfunction in this patient cohort. Islet Ab+ was also associated with higher HbA1c and lower C-peptide levels. Future studies are needed to validate the role of islet Ab positivity in pancreatitis.

Challenges of Managing Type 3c Diabetes in the Context of Pancreatic Resection, Cancer and Trauma

Type 3c diabetes mellitus (T3cDM), also known as pancreatogenic or pancreoprivic diabetes, is a specific type of DM that often develops as a result of diseases affecting the exocrine pancreas, exhibiting an array of hormonal and metabolic characteristics. Several pancreatic exocrine diseases and surgical procedures may cause T3cDM. Diagnosing T3cDM remains difficult as the disease characteristics frequently overlap with clinical presentations of type 1 DM (T1DM) or type 2 DM (T2DM). Managing T3cDM is likewise challenging due to numerous confounding metabolic dysfunctions, including pancreatic endocrine and exocrine insufficiencies and poor nutritional status. Treatment of pancreatic exocrine insufficiency is of paramount importance when managing patients with T3cDM. This review aims to consolidate the latest information on surgical etiologies of T3cDM, focusing on partial pancreatic resections, total pancreatectomy, pancreatic cancer and trauma.

Nutrition challenges following total pancreatectomy with islet autotransplantation

Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical treatment option for patients with chronic pancreatitis who have not responded to other therapies. TP offers pain relief whereas IAT preserves beta cell mass to reduce endocrine insufficiency. During the surgical procedure, the entire pancreas is removed. Islet cells from the pancreas are then isolated, purified, and infused into the liver via the portal vein. Successful TPIAT relieves pain for a majority of patients but is not without obstacles, specifically gastrointestinal, exocrine, and endocrine challenges. The postoperative phase can be complicated by gastrointestinal symptoms causing patients to have difficulty regaining adequate oral intake. Enteral nutrition is frequently provided as a bridge to oral diet. Patients undergoing TPIAT must be monitored for macronutrient and micronutrient deficiencies following the procedure. Exocrine insufficiency must be treated lifelong with pancreatic enzyme replacement therapy. Endocrine function must be monitored and exogenous insulin provided in the postoperative phase; however, a majority of patients undergoing TPIAT require little or no long-term insulin. Although TPIAT can be a successful option for patients with chronic pancreatitis, nutrition-related concerns must be addressed for optimal recovery.

Nutrition support in the pediatric total pancreatectomy with islet autotransplantation recipient

For children with diminished quality of life and chronic pain caused by acute recurrent or chronic pancreatitis who are undergoing total pancreatectomy with islet autotransplantation, postoperative nutrition support has several unique characteristics. Surgical complications may lead to delays in nutrition support initiation or require modifications to the regimen. Early postoperative dysmotility requires the use of temporary enteral nutrition until this improves. The resultant complete exocrine pancreatic insufficiency necessitates lifelong pancreatic enzyme replacement therapy and fat-soluble vitamin supplementation. A low-oxalate diet is recommended to prevent kidney stones. Carbohydrate counting is needed for the provision of short-term insulin dosing and possibly long-term as well, depending on the transplanted islet yield. Children should have careful nutrition assessment and monitoring at several follow-up visits during the first year, then annually, and at any time with concerns.