If I were a rich man could I sell a pancreas? A study in the locus of oppression

Dan Brock argues that since the unexploitable rich could sell their kidneys too, exploitation could not be an essential feature of organ vending. This paper takes his claim as the point of departure for a discussion on the locus of organ vending-associated oppression. While it accepts Brock's conclusion, it explores the possibility that such oppression is invariably found rather outside the sphere of exchange. It then analyses the implications of this possibility for the discourse surrounding the ethics of organ vending.

Financial implications of pancreas transplant complications: a business case for quality improvement

We quantified the financial implications of surgical complications following pancreas transplantation. We reviewed medical and financial records of 49 pancreas transplant recipients at the University of Michigan Health System (UMHS) between 1/6/2002 and 11/22/2004. The association of donor, transplant recipient and financial variables was assessed. The median costs to UMHS of procedures and follow-up were $92,917 for recipients without surgical complications versus $108,431 when a surgical complication occurred, a difference of $15,514 (p = 0.03). Median reimbursement by the payer was $17,363 higher in patients with a surgical complication (p = 0.001). Similar trends (higher insurer costs) were noted when stratifying by payer (public and private) and specific procedure (SPK and PAK). All parties (patient, physician, payer and medical center) should benefit from quality improvement, with payers having a financial interest in pancreas transplant surgical quality initiatives.

Health insurance considerations for adolescent transplant recipients as they transition to adulthood

The advent of improved immunosuppression and enhanced allograft outcomes has resulted in a growing number of patients taking expensive immunosuppression medications for the rest of their lives. Healthcare costs for the majority of transplantation procedures in the USA currently are covered by Medicare, but coverage ends for outpatient immunosuppression medications 36-44 months after transplantation. Two or three immunosuppressive agents typically are included in post-transplant regimens with a total annual cost that can exceed 13,000 dollars. This represents a significant financial burden for families no matter if they have adequate health insurance coverage because of co-payment obligations. Evidence suggests that some patients have reduced immunosuppression doses because of an inability to afford their medication, increasing the risk of graft failure. The purpose of this article was to review these and other issues pertaining to medical insurance coverage and transplantation, particularly for adolescent recipients as they transition to adulthood.

The long-term management of pancreas transplantation

Diabetes mellitus (DM) is a major health problem worldwide, which affects 18.2 million individuals (6.3% of the population) in the United States. Currently, the prevalence of Type 1 DM in the United States is estimated to be 1,000,000 individuals, and 30,000 new cases are diagnosed each year. In addition to end-stage renal disease (ESRD), DM is associated with blindness, accelerated atherosclerosis, dyslipidemia, cardio- and cerebrovascular disease, amputation, poor quality of life, and overall lifespan reduction. It accounts for more than 160,000 deaths per year in the United States alone. In 2002, the annual national direct and indirect costs of Types 1 and 2 DM exceeded $130 billion, which included hospital and physician care, laboratory tests, pharmaceutical products, and patient workdays lost because of disability or premature death. Hyperglycemia alone or in concert with hypertension is the primary factor influencing the development of major diabetic complications. From 1990 to 2001, the number of existing ESRD cases to DM increased by more than 300%, while the rate per million populations increased from 167% to 491%. The number is expected to grow 10-fold by 2030 to 1.3 million accounting for 60% of ESRD population. To date, DM is the leading indication for transplantation and is the cause of ESRD in more than 40% of all transplant recipients each year.

Simultaneous pancreas and kidney transplantation for end-stage renal failure secondary to diabetic nephropathy : principles and practice

Diabetic nephropathy is the second most common cause of renal failure in the United Kingdom where majority of the patients were managed by renal transplantation and insulin therapy in the past. Over the last three decades, increasing number of patients are undergoing simultaneous pancreas and kidney transplantation (SPKT) because of its advantages, which renders the patient both dialysis and insulin-independent, halts the progression of complications of diabetes, thereby improves the quality of life, survival and has proven to be cost-effective. This article presents a review on the principles and contemporary practice of SPKT worldwide and highlights the future directions.

Transplantation for type I diabetes: comparison of vascularized whole-organ pancreas with isolated pancreatic islets

OBJECTIVE

We sought to compare the efficacy, risks, and costs of whole-organ pancreas transplantation (WOP) with the costs of isolated islet transplantation (IIT) in the treatment of patients with type I diabetes mellitus.

SUMMARY BACKGROUND DATA

A striking improvement has taken place in the results of IIT with regard to attaining normoglycemia and insulin independence of type I diabetic recipients. Theoretically, this minimally invasive therapy should replace WOP because its risks and expense should be less. To date, however, no systematic comparisons of these 2 options have been reported.

METHODS

We conducted a retrospective analysis of a consecutive series of WOP and IIT performed at the University of Pennsylvania between September 2001 and February 2004. We compared a variety of parameters, including patient and graft survival, degree and duration of glucose homeostasis, procedural and immunosuppressive complications, and resources utilization.

RESULTS

Both WOP and IIT proved highly successful at establishing insulin independence in type I diabetic patients. Whole-organ pancreas recipients experienced longer lengths of stay, more readmissions, and more complications, but they exhibited a more durable state of normoglycemia with greater insulin reserves. Achieving insulin independence by IIT proved surprisingly more expensive, despite shorter initial hospital and readmission stays.

CONCLUSION

Despite recent improvement in the success of IIT, WOP provides a more reliable and durable restoration of normoglycemia. Although IIT was associated with less procedure-related morbidity and shorter hospital stays, we unexpectedly found IIT to be more costly than WOP. This was largely due to IIT requiring islets from multiple donors to gain insulin independence. Because donor pancreata that are unsuitable for WOP can often be used successfully for IIT, we suggest that as IIT evolves, it should continue to be evaluated as a complementary alternative to rather than as a replacement for the better-established method of WOP.

[Pancreatic transplantation: 1. Indications and results]

In the face of a rising incidence of diabetes, pancreatic transplantation seems to be the only treatment capable of normalizing glycosylated hemoglobin and stabilizing or improving the complications of diabetes. To date, more than 19,000 pancreatic transplantations have been done worldwide. Surgical indications must take into account the constraints and risks specific to the diabetic illness, the risks of a complex surgical procedure, and the absolute necessity for long term immunosuppression. Combined kidney/pancreas transplantation is the most common procedure (90% of cases) and is the most effective treatment for renal insufficiency due to diabetes. Results have improved significantly over the last ten Years due to improvements in the surgical technique and to improvement of immunosuppressive regimens. Results are at least as good and perhaps better than those achieved in the transplantation of other solid organs; patient survival, renal graft survival, and pancreatic graft survival are respectively 95%, 92%, and 85% at one Year. Results of pancreatic transplantation alone have improved and now seem equal to those of combined organ transplantation. Transplantation seems to be cost-effective in the overall care of advanced diabetes, particularly in those patients on chronic dialysis or having degenerative complications.

Preparation of candidates for renal transplantation: cost analysis

While the costs of renal transplantation are lower than those of dialysis, little is known about the costs of managing the waiting list. We performed a cost analysis of admission and clinical management of a waiting list for renal and pancreas-kidney transplantation. Admission to the waiting list included (1) renal graft from cadaver: minimum cost Euros () 1784.56 for men < 55 years, maximum 2127.85 for women >/= 55 years; (2) pancreas-kidney transplantation: minimum 2475.50 for men, maximum 2540.10 for women >/= 35 years. Check of suitability state on waiting list after 2 and 5 years: minimum 1400.15 for men >/= 55 years (check every 2 years), maximum 1467.07 for women >/=40, <55 years (every 5 years). The differences are related to the imaging techniques: from 43.90 (Doppler ultrasonography) to 283.28 (coronary angiography). Maintenance of the waiting list: minimum cost 1885.21 in the first year and 3187.02 in the (fifth year) for men < 55 years; maximum 2228.50 (first year) and 5116.70 (fifth year) for women >/= 55 years. These results show different costs for recipients on the basis of sex and age ranges, due to the different requirements for imaging tests such as cardiac scintiscan at age >/= 55 years) and economic charges that increase with age. Reduced waiting times allow lowered total costs. This evaluation allowed us to calculate for our region (Piemonte, Northern Italy), the management costs of the patients presently on our waiting list (369 patients at December 31, 2002) from preparation to transplantation as 959,179.18.

Pancreas transplantation in Ohio: a 15-year outcomes analysis

BACKGROUND

Beginning in 1984, all pancreas transplantations performed in the state of Ohio have been tracked by the Ohio Solid Organ Transplantation Consortium (OSOTC). In this study the outcomes of these transplantations were compared across 3 eras to determine whether increasing experience has been beneficial.

METHODS

Between July 1984 and December 1999, 765 kidney-pancreas (KPTx) and 76 pancreas only (Ptx) transplantations were performed. Outcomes measures for these 841 pancreas transplantations were compared over 3 eras, 1984 to 1989, 1990 to 1994, and 1995 to 1999.

RESULTS

One-year patient survivals for KPTx patients were 87%, 92%, and 94% in the 3 eras, respectively. Graft survival at 1 year was also markedly improved between era 1 and era 3, increasing for PTx patients from 21% to 85% and for KPTx patients from 68% to 85%. Average waiting time increased from 132 to 318 days between era 1 and era 3. Conversely, average length of stay in hospital was significantly decreased from 34 to 18 days. The cost of the procedure, as measured by hospital charges, also decreased when compared in 1985 dollars as a technique to control for inflation.

CONCLUSIONS

These data suggest that pancreas transplantation in Ohio has become a very successful and cost-effective therapeutic intervention for patients with type I diabetes with or without concomitant end-stage renal failure.

Pancreas after kidney transplants

BACKGROUND

For certain uremic diabetic patients, a sequential transplant of a kidney (usually from a living donor) followed by a cadaver pancreas has become an attractive alternative to a simultaneous transplant of both organs. The purpose of this study was to compare outcomes with simultaneous pancreas-kidney (SPK) versus pancreas after kidney (PAK) transplants to determine advantages and disadvantages of the two procedures.

METHODS

Between January 1, 1994, and June 30, 2000, we performed 398 cadaver pancreas transplants at our center. Of these, 193 were SPK transplants and 205 were PAK transplants. We compared these two groups with regard to several endpoints, including patient and graft survival rates, surgical complications, acute rejection rates, waiting times, length of hospital stay, and quality of life.

RESULTS

Overall, surgical complications were more common for SPK recipients. The total relaparotomy rate was 25.9% for SPK recipients versus 15.1% for PAK recipients (P = 0.006). Leaks, intraabdominal infections, and wound infections were all significantly more common in SPK recipients (P = 0.009, P = 0.05, and P = 0.01, respectively, versus PAK recipients). Short-term pancreas graft survival rates were similar between the two groups: at 1 year posttransplant, 78.0% for SPK recipients and 77.9% for PAK recipients (P = not significant). By 3 years, however, pancreas graft survival differed between the two groups (74.1% for SPK and 61.7% for PAK recipients), although this did not quite reach statistical significance (P = 0.15). This difference in graft survival seemed to be due to increased immunologic losses for PAK recipients: at 3 years posttransplant, the incidence of immunologic graft loss was 16.2% for PAK versus 5.2% for SPK recipients (P = 0.01). Kidney graft survival rates were, however, better for PAK recipients. At 3 years after their kidney transplant, kidney graft survival rates were 83.6% for SPK and 94.6% for PAK recipients (P = 0.001). The mean waiting time to receive the pancreas transplant was 244 days for SPK and 167 days for PAK recipients (P = 0.001).

CONCLUSIONS

PAK transplants are a viable option for uremic diabetics. While long-term pancreas graft results are slightly inferior to SPK transplants, the advantages of PAK transplants include the possibility of a preemptive living donor kidney transplant, better long-term kidney graft survival, significantly decreased waiting times, and decreased surgical complication rates. Use of a living donor for the kidney transplant expands the donor pool. Improvements in immunosuppressive regimens will hopefully eliminate some of the difference in long-term pancreas graft survival between SPK and PAK transplants.

Response shift and adaptation in chronically ill patients

The purpose was to explore the impact of response shift on quality-of-life measurement and consequently on cost-effectiveness analysis. This was done by using data from an earlier study. Adaptation to illness provides a probable explanation for the occurrence of response shift. In the case of proxy respondents, it is likely that the adaptation effect is absent. Therefore, two hypotheses were tested: 1) retrospective quality-of-life measurement does not differ from ratings given by proxies; and 2) proxy ratings differ from prospectively assessed pretreatment quality-of-life scores. Quality of life was assessed using a visual analog scale (VAS), time tradeoff (TTO), and the standard gamble (SG). Analyses revealed that neither hypothesis could be rejected, indicating that prospectively assessed pretreatment quality of life is enhanced by adaptation to the imperfect health state during the pretreatment period. Consequently, the cost-effectiveness ratio is different when using proxy measures or retrospective assessments of pretreatment quality of life, compared with using assessments of the quality of life in currently ill patients.

Cost-utility analysis of living-donor kidney transplantation followed by pancreas transplantation versus simultaneous pancreas-kidney transplantation

For a type I diabetic with end-stage renal disease, the choice between a kidney-alone transplant from a living-donor (KA-LD) and a simultaneous pancreas kidney (SPK) transplant remains a difficult one. The prevailing practice seems to favor KA-LD over SPK, presumably due to the superior long-term renal graft survival in KA-LD and the elimination of the lengthy waiting time on the cadaver transplant list. In this study, two treatment options, KA-LD followed by pancreas-after-kidney (PAK) and SPK transplant, are compared using a cost-utility decision analysis model. The decision tree consisted of a choice between KA-LD + PAK and SPK. The analysis was based on a 5-yr model and the measures of outcome used in the model were cost, utility and cost-utility. The expected 5-yr cost was $277,638 for KA-LD + PAK and $288,466 for SPK. When adjusted for utilities, KA-LD + PAK at a cost of $153,911 was less cost-effective than SPK at a cost of $110,828 per quality-adjusted year. One-way sensitivity analyses were performed by varying patient and graft survival probabilities, utilities and cost. SPK remained the optimal strategy over KA-LD + PAK across all variations. Two-way sensitivity analysis showed that in order for KA-LD + PAK to be at least as cost-effective as SPK, 5-yr pancreas and patient survival rates following PAK would need to surpass 86 and 80%. In conclusion, according to the 5-yr cost-utility model presented in this study, KA-LD followed by PAK is less cost-effective than SPK as a treatment strategy for a type I diabetic with end-stage renal disease. For patients interested in the benefits of a pancreas transplant, it would be reasonable to offer SPK as the optimal treatment, even if a living kidney donor is available.

Quality of life after pancreas transplantation: a review

For persons with diabetes and end stage renal disease, successful combined or sequential pancreas/kidney transplant is an attractive therapeutic alternative to insulin and dialysis. There is considerable controversy regarding pancreas transplantation (p Tx), however, as some recent reviews have concluded, p Tx results in at most only modest reductions in secondary complications and has increased morbidity and costs compared with kidney transplant alone. While the impact on patients' quality of life (QOL) is a major consideration for p Tx, the literature on this topic has not been carefully considered. The purpose of this review is to evaluate studies of QOL after p Tx and identify well-validated findings. Comparative cross-sectional and longitudinal studies have shown that the QOL outcomes of p Tx recipients who achieve insulin-independence are better than those of candidates or of recipients with pancreas graft loss. More positive health perceptions, improved social interaction and increased vitality/energy are significantly associated with successful p Tx. Researchers have found few areas where the QOL benefits of p Tx significantly exceed or differ from those that occur with kidney transplant alone. A consistent finding across studies is that p Tx improves patient perceptions about diabetes-specific issues such as satisfaction with diet flexibility and health management, while kidney transplant does not. Future studies should attempt to accrue sufficient sample sizes to permit statistical adjustment for selection biases; follow patients for several years to permit differences in rates of progression of secondary complications to impact QOL; and use current graft loss and morbidity statistics to estimate any added risks of p Tx over kidney-only transplant. It is still an open question as to whether or not there are sufficient QOL benefits from p Tx long-term to out-weigh added risks, and this needs to remain an active area of investigation.

Treatment strategies for insulin-dependent diabetics with ESRD: a cost-effectiveness decision analysis model

Clinical decision analysis has become an important tool for evaluating specific clinical scenarios and exploring public health policy issues. A decision analysis model that incorporates patient preferences regarding various outcomes, as well as cost, may be particularly informative in patients with type I diabetes and end-stage renal disease (ESRD). Such a model that includes pancreas transplantation as a treatment choice has not been performed and is presented in this study. The decision tree consisted of a choice between four possible treatment strategies: dialysis, kidney-alone transplant from a cadaver (KA-CAD) or living donor (KA-LD), and simultaneous pancreas-kidney (SPK) transplant. The analysis was based on a 5-year model, and the measures of outcome used in the model were cost and cost adjusted for quality of life. The measure of preference for quality of life was obtained using the "Standard Reference Gamble" method in 17 SPK transplant recipients who underwent transplantation between January, 1992 and June, 1996 at our center. The measures for various outcome states (mean +/- 1 SD) were dialysis-free/insulin-free = 1, dialysis-free/insulin-dependent = 0.6 (0.4 to 0.8), dialysis-dependent/insulin-free = 0.5 (0.36 to 0.64), dialysis-dependent/insulin-dependent = 0.4 (0.21 to 0.59), and death = 0. The expected 5-year costs for each of the treatment strategies in the model were dialysis, $216,068; KA-CAD transplant, $214,678; KA-LD transplant, $210,872; and SPK transplant, $241,207. The expected cost per quality-adjusted year for each of the treatment strategies in the model were dialysis, $317,746; KA-CAD transplant, $156,042; KA-LD transplant, $123,923; and SPK transplant, $102,422. SPK transplantation remained the optimal strategy after varying survival probabilities, costs, and utilities over plausible ranges by means of one-way sensitivity analysis. In conclusion, according to the 5-year cost-utility model presented in this study, SPK transplantation is the most cost-effective treatment strategy for a patient with type I diabetes and ESRD. From a policy standpoint, looking at the cost alone of pancreas transplantation is deceiving. In these patients, who may view various outcome states differently, it would be important to take into account cost adjusted for quality of life when evaluating this procedure.

In vitro amylase release of preserved pancreas: a simple test to assess the viability of pancreatic allograft during preservation in the pigs

To determine an in vitro marker of viability during pancreatic preservation, 12 pigs underwent total pancreas harvesting, and graft were stored in Euro-Collins or Belzer perfusion solution for up to 24 hours. Amylase concentration of the storage solution was analyzed in regular periods and tissue samples were taken for acridine-orange histochemical evaluation of viability in the same time. In vitro pancreatic amylase release (IU/g pancreas tissue) was calculated from the volume of solution and the weight of graft. A significant increase of amylase release was found in the course of preservation in both media. Comparing amylase release in different solutions we found significant difference between Euro-Collins and Belzer media (4 hours: 6.45 IU/g vs. 2.2 IU/g, 8 hours: 11.5 vs. 3.58, 24 hours: 8.7 vs. 42.8, respectively). Comparison of amylase release with histochemical evaluation of viability showed strict correlation. We concluded that amylase release is a good marker for exocrine tissue destruction as well as viability of preserved pancreas. Our data confirms that Belzer solution is superior in pancreatic preservation. It is suggested that after adaptation into human model in vitro pancreatic amylase release could be a time- and cost-saving, useful method in predicting pancreatic transplant function prior graft implantation.

Design, development, and implementation of a critical pathway in simultaneous pancreas-kidney transplant recipients

The purpose of this study was to assess the effect of implementation of a critical pathway after simultaneous pancreas-kidney transplantation on length of stay and hospital charges. Two well-matched groups were compared: 10 patients who received transplants in 1991 (before implementation of the critical pathway) and 10 patients who received transplants in 1995 (after implementation). For the initial transplant hospitalization, the critical pathway was associated with significant reductions in length of stay, total number of laboratory tests, clinical laboratory charges, and total inpatient charges with organ acquisition charges excluded. Despite the rising costs of medical care, we have designed and implemented a critical pathway for simultaneous pancreas-kidney transplantation that has stabilized hospital charges by decreasing length of stay and the number of clinical laboratory tests.

Primary enteric drainage of the pancreas allograft revisited

BACKGROUND

Historically, primary enteric drainage (ED) of exocrine secretions in pancreas allografts was associated with a poor outcome, mostly as a result of infectious complications. On the other hand, bladder drainage (BD), which is presently used in the majority of institutions, is associated with substantial urologic morbidity. The aim of this study is to reassess the role of primary ED by reviewing our experience with ED versus BD in simultaneous pancreas-kidney transplantations.

STUDY DESIGN

The records of all pancreas-kidney transplantations performed between October 1990 and September 1996 were reviewed (n = 42). Enteric drainage was used in the last 16 (38%) and BD in the first 26 (62%). The BD and ED groups were comparable with respect to donor and recipient characteristics.

RESULTS

Length of stay for the transplantation (mean +/- standard deviation) was significantly shorter with ED than with BD (12.9 +/- 5.6 versus 20.4 +/- 9.6 days, p = 0.007). The total number of readmissions (1.7 +/- 1.5 versus 1.2 +/- 1.2 days, p = 0.2) and the length of hospital stay in the first 6 months after discharge (13.7 +/- 16.2 versus 10 +/- 11.3 days, p = 0.4) were similar between BD and ED. Complications requiring admission were distributed as follows in BD and ED recipients: recurrent/persistent urinary complications (46% versus 6%, p = 0.01), dehydration (27% versus 6%, p = 0.05), symptomatic graft pancreatitis (8% versus 6%, p = 0.9), gastrointestinal disturbance (27% versus 12%, p = 0.1), and wound infection (12% versus 19%, p = 0.5). The duration of the operative procedure was shorter in ED than in BD (4.3 +/- 0.9 versus 5.4 +/- 0.8 hours, p = 0.01). Reoperation during the initial transplantation stay was necessary in 23% of the patients having BD, compared with none having ED (p = 0.04). Similarly, fewer ED patients underwent reoperations compared with BD patients in the first 6 months after discharge (38% versus 69%, p = 0.04). Hospital charges for ED were lower than for BD for the initial admission ($73,458 +/- 17,103 versus $107,193 +/- 32,965, p = 0.001). Actuarial patient (96% versus 94%, p = 0.6), kidney (85% versus 87%, p = 0.9), and technically successful pancreas (90% versus 85%, p = 0.6) survival rates at 1 year were similar for BD and ED.

CONCLUSIONS

Our results indicate that, compared with BD, ED is associated with less morbidity and shorter hospitalization without compromising outcome. Primary ED is a viable alternative to BD in simultaneous pancreas-kidney transplantation. More clinical experience with careful cost-effectiveness analysis is needed to better assess the implications of primary ED.

Analysis of hospital charges after simultaneous pancreas-kidney transplantation in the era of managed care

BACKGROUND

The purpose of this study was to analyze and compare hospital charges in simultaneous pancreas-kidney transplant (SPKT) recipients before and after implementation of managed care principles.

METHODS

Two groups were compared: 14 consecutive SPKT patients transplanted in 1991 vs. 15 consecutive SPKT patients transplanted in 1995. All patients underwent whole organ pancreas transplantation with bladder drainage and received quadruple immunosuppression with OKT3 induction. The two groups were well-matched; outliers were excluded (four in 1991 and five in 1995), and no attempt was made to convert 1991 to 1995 dollars. Patient and graft survival rates were 100%, and no major early complications occurred. All SPKTs were performed in a single hospital setting, and all inpatient charges for the initial hospitalization were analyzed retrospectively and itemized by service.

RESULTS

Pharmacy, organ acquisition, and clinical laboratory services accounted for nearly 80% of charges in each group. For the initial transplant hospitalization, the 1995 group experienced significant reductions in: (1) length of stay (16.3+/-1.4-135+/-3.5 days, P=0.03); (2) total number of laboratory tests (392+/-15-224+/-60, P<10(-3)); (3) clinical laboratory charges ($23,623+/-$1,780-$11,165+/-$3,091, P<10(-6)); and (4) total inpatient charges with organ acquisition charges excluded ($87,815+/-$8,678-$75,152+/-$16,871, P=0.049). However, these potential savings were offset by a nearly 47% increase in organ acquisition charges and a 38% increase in medical/surgical supplies. Consequently, total hospital charges for SPKT were no different in 1991 and 1995.

CONCLUSIONS

Despite the rising costs of medical care, we have implemented managed care principles after SPKT that were successful in stabilizing hospital charges by decreasing length of stay and clinical laboratory tests during the study period. However, escalating charges related to organ acquisition and medical/surgical supplies remain a problem.

[Combined kidney-pancreas transplantation: what are the costs and benefits, who are the recipients?]

As the requirement for immunosuppressive therapy after pancreas transplantation for insulin-dependent diabetes, which has compromised its use in non-uremic patients, cannot be avoided in uremic patients undergoing kidney transplantation, the benefits of combined kidney-pancreas transplantation might be sufficient to counterbalance the risks of the procedure. The International Pancreas Transplant Registry has collected data on over 7000 combined transplantations, allowing evaluation of the risks involved, assessment of patient benefit and identification of indications. Compared with renal graft alone, survival after combined transplantation is equivalent in patients under 45 years of age, but decrease in older patients and those with a history of heart failure. Actuarial survival of the pancreas graft, defined as absence of insulinotherapy, is currently 78% at 1 year and 65% at 5 years. Although combined transplantation may not reach early expectations regarding its affect on the progression of diasets complications patients quality of life is greatly improved after successful grafting as the daily constraints of regular meals, insulin injections and glycemia controls disappear at the same time as the burden of dialysis treatment. Combining a pancreas graft with a kidney graft inevitably increases morbidity during the post-operative months, but experience has shown that many young patients are very willing to pay the price in order to benefit from a combined graft. We currently propose combined transplantation in patients under 45 who are free of severe cardiovascular disease and accept to reconsider candidates after myocardial revascularization. The recent introduction of new immunosuppressive drugs such as tacrolimus and mycophenolate offer hope for further improvement in success rates. Despite currently disappointing clinical results, pancreatic islet-cell transplantation provides excitivy perspectives.

Pancreas transplantation for diabetes mellitus

Pancreas transplantation has become a viable option for the patient wi th insulin-dependent diabetes mellitus with progressive renal failure. The most common type of pancreas transplantation is a simultaneous pancreas and kidney transplantation performed from a single cadaver donor (SPK). The next most common is pancreas transplantation after successful kidney transplantation (PAK). A few centers are performing pancreas transplantation alone (PTA) in diabetic recipients without renal disease but who have significant complications from their diabetes. Pancreas transplantation is associated with a higher morbidity than kidney transplantation alone. Most pancreas transplantation centers report a significant increase in acute rejection, which can lead to increased hospitalization and risk of opportunistic infection. In addition, the early era of pancreas transplantation was associated with significant surgical complications. However, with bladder drainage of the pancreas exocrine secretions, the surgical complication rate has decreased significantly. Despite medical and surgical complications, the overall results for pancreas transplantation are excellent, with 1 -year graft survival of 75% for SPK transplantations and 48% for PAK and PTA transplant recipients. The effects of a pancreas transplantation on the secondary complications of diabetes have been studied extensively. Most studies have shown a modest improvement in secondary complications with the exception of diabetic retinopathy. The major benefit of pancreas transplantation appears to be enhanced quality of life for patients successfully transplanted. For these reasons, the Kidney-Pancreas Committee of the American Society of Transplant Physicians believes the current results of pancreas-kidney transplantation justify its use as a valid option for insulin-dependent diabetic transplant recipients.

Simultaneous pancreas-kidney and sequential pancreas-after-kidney transplantation

Simultaneous pancreas-kidney (SPK) or pancreas-after-kidney (PAK) transplantation has been advocated as an alternative to kidney transplant alone (KTA) for type 1 diabetics with end-stage renal disease. Advocates of combined transplant assert that the procedure reduces, prevents, or mitigates secondary complications of diabetes and improves the quality of life (QOL) of recipients. The combined procedures may be accomplished with a relatively low mortality, but the morbidity significantly exceeds that of KTA. The published data did not provide unambiguous support for the contention that SPK or PAK improved or ameliorated the secondary diabetic complications of retinopathy, neuropathy, and nephropathy, and it cannot be reasonably concluded that such benefit is likely to result. The majority of studies of QOL subsequent to combined transplant had significant methodologic deficiencies which made generalizations problematic. Notwithstanding, improvements in objective measures, such as return to employment or school, reduction in medical care requirements, days spent in hospital, social or physical activity, etc, have not been demonstrated for combined transplant; improvements in subjective measures were inconsistently reported. The United Network for Organ Sharing (UNOS) registry indicated that SPK represents 83 percent, and PAK about 8 percent of all pancreas transplants in the United States. Pancreas graft survival data are limited; UNOS reported 3-year survival rates of approximately 65 percent following SPK, and 35 percent after PAK. Renal graft survival following SPK appears comparable to that reported for most cadaver KTA. However, selection of SPK in lieu of KTA with a living-related donor or HLA-matched cadaver kidney may result in significant reduction in expected renal graft survival, in the range of 40-70 percent to as much as 350 percent. A cost-effectiveness analysis (CEA) model compared SPK with KTA and continued insulin therapy. The model employed a wide range of reported charges/payments, and postulated that SPK would provide significant improvements in quality of life. Sensitivity analyses indicated that SPK was equal in cost effectiveness to KTA only in patients who incurred very high annual costs for the treatment of hyper- or hypoglycemia. The literature does not indicate that such patients comprise the majority of SPK recipients. Additional evidence is necessary to unequivocally demonstrate the risks, costs, and ultimate benefits of combined transplant. Such information should include detailed and unambiguous patient selection criteria, prospective comparative studies of the effects of SPK/PAK upon secondary complications and quality of life, and accurate cost data for the transplant procedures and required followup care.

Two hundred consecutive simultaneous pancreas-kidney transplants with bladder drainage

BACKGROUND

Since 1982, 288 pancreas transplantations have been performed at the University of Wisconsin. This report reviews our experience with 200 consecutive simultaneous pancreas-kidney (SPK) transplantations during a 7-year period.

METHODS

Two hundred consecutive SPK transplantations were performed between December 1985 to October 1992. Immediate posttransplant function and surgical and infectious complications were evaluated. Frequency of rejection episodes were analyzed, as was 5-year patient and graft survival.

RESULTS

All but four pancreas transplants functioned immediately after transplantation. Three pancreas transplants failed because of thrombosis and one from primary nonfunction. Five-year patient survival was 90.2%, kidney survival 80.3%, and pancreas survival 78.6%. There were 54 surgical complications. Fifteen patients have died since 1985. The most frequent cause of death was infection (three patients). A total of 678 infectious episodes were recorded. Urinary tract infection (n = 344) was the most frequent type of infection. Enteric conversion was necessary in 35 patients, with the most frequent indication being a leak of the duodenal segment.

CONCLUSIONS

We concluded from this series that SPK transplantation is associated with higher cost and morbidity as compared with kidney transplantation alone. However, excellent long-term survival in combination with the clearly demonstrated benefits for secondary diabetic complications indicate that SPK transplantation is the procedure of choice for carefully selected patients with diabetes.

Organ procurement expenditures and the role of financial incentives

OBJECTIVES

To evaluate the billed charges for organ procurement and to consider the role of financial incentives to encourage organ donation.

DESIGN

Observational study. Data were obtained on donor organ acquisition charges from a random sample of kidney, heart, liver, heart-lung, and pancreas transplants.

SETTING

The data were based on 28.7% of all transplants performed in the United States in 1988.

MAIN OUTCOME MEASURE

Total charges for donor organ acquisition.

RESULTS

The median charges (1988 dollars) for donor organs were as follows: kidney, $12,290; heart, $12,578; liver, $16,281; heart-lung, $12,028; and pancreas, $15,400. Since 1983, kidney acquisition charges have increased by 12.9%, heart charges by 64.1%, and liver charges by 61.8%, after adjusting for inflation. Between 9% and 31% of total transplant procedure-specific charges were associated with donor organ acquisition.

CONCLUSIONS

There is wide unexplained variation in organ procurement charges. Data on actual costs are required to establish the appropriateness of current charges. Prevailing billing and payment methods should be reevaluated in an effort to address a variety of issues related to reimbursement. Current payment methods may actually contribute to cost inefficiency. Finally, while financial incentives may enhance the efficiency of organ procurement efforts, they will adversely affect the cost-effectiveness of transplantation.

An economic analysis of pancreas transplantation: costs, insurance coverage, and reimbursement

Since 1988 the demand for the pancreas transplantation has continued to increase. This has been accompanied by a growth in the number of centers offering the procedure, and an increase in the number of transplants performed. The National Cooperative Transplantation Study was undertaken to document the costs of all transplants, including pancreas transplantation. Data on transplantation procedure charges, from date of transplant to discharge, were obtained from 66.7% of all pancreas transplantation programs active in 1988. These programs accounted for 72% of all transplants performed that year. Valid sample survey data (no more than 25 transplants per center) were obtained for 133 randomly selected patients. This constituted 54% of all procedures done in the United States in 1988. Detailed data were also collected on sources of payment and amount reimbursed. Due to outlier data, we report statistical medians, rather than means, as our measure of central tendency. The median charge for a pancreas transplant with or without a kidney was $66917, with a hospital length of stay of 21 days, compared with a kidney transplant alone at $39625 and a hospital length of stay of 14 days. Total pancreas transplant charges fell between $45260 and $105375 for 50% of the cases studied. Half of the patients had a hospital length of stay between 16 and 33. Due to the small number of cases available for analysis, it was not meaningful to cross-classify the data according to various prognostic variables.(ABSTRACT TRUNCATED AT 250 WORDS)