Editorial
The odd situation of pancreas transplantation in Spain
La extraña situación del trasplante de páncreas en España
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"Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Salamanca, Universidad de Salamanca, Salamanca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La extraña situación del trasplante de páncreas en España" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1454 "Ancho" => 2500 "Tamanyo" => 216836 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pancreas transplant rate PMP in different countries in recent years.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This year marks the 35th anniversary of the first pancreas transplant performed in Spain under the leadership of professors Laureano Fernández Cruz and Salvador Gil Vernet at Hospital Clinic in Barcelona.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Since then, more than 1700 procedures have been performed in Spain, mainly simultaneous pancreas-kidney (SPK) transplants.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Pancreas transplantation has taken a long time to reach maturity as compared to the transplant of other solid organs, but the huge advances in recent years in both the surgical technique and the management of these patients have lead to excellent outcomes. Nowadays, five year patient survival is over 90%, the decrease in surgical complications is reflected by only 6% pancreas graft losses in the first 90 days after transplantation,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> and pancreas graft survival is above 85% at one year and 74% at five years, respectively.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> It has to be said, however, that there is still no standard method for assessing graft function and so the different series have tended to use different methods.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Moreover, long-term results show that the SPK transplant is superior to an isolated kidney transplant, especially when compared with patients under 50 and in kidney transplants with cadaveric donors.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The uncertainty arises when comparing the SPK transplant with the isolated kidney transplant from a living donor in patients with type 1 diabetes and end-stage renal failure; in this case not only are there improvements in relation to quality of life,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> but also in patient survival after 20 years<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> and in the control of cardiovascular disease.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">These data support our criterion that every patient with type 1 diabetes mellitus and end-stage renal failure, on dialysis or pre-dialysis, who meets the appropriate requirements, should be a candidate for SPK transplantation. In parallel, the latest available data from the American registry show an increase in pancreas transplants of the SPK type, with figures at their highest since 2013.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In light of this evidence, the pancreas transplant situation in Spain is paradoxical, with a declining activity. We could argue that it is declining worldwide, but in our case the rate of transplants per million population (PMP) is significantly lower than in a number of different countries in Europe, and in Australia, Canada and the USA, despite being Spain's world leadership in donation and in the transplantation of other solid organs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">One reason for this situation could be the under-use of the available pancreas grafts; 40% of the pancreases offered for transplantation are not accepted and 50% of those removed are rejected, mainly due to the macroscopic appearance of the organ.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We also have practically no experience in the use of pancreases from donors in asystole; despite this being common in USA and United Kingdom, in Spain, it is still only in the very beginnings, even though these donors currently constitute 26% of the total.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Lastly, another variable that may have an impact on pancreas transplantation activity could be the very strict donation criteria.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This situation has been debated, both within the <span class="elsevierStyleItalic">Grupo Español de Trasplante de Páncreas</span> (GETP) [Spanish Pancreas Transplant Group] and jointly with the <span class="elsevierStyleItalic">Organización Nacional de Trasplantes</span> (ONT) [Spanish National Transplant Organisation], culminating in the ONT publishing a consensus document on criteria for the pancreas donor and the recipient in June 2018.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">To the above reasons we could add as a hypothesis the small number of patients on the waiting lists, secondarily causing better selection of donors by the different transplant groups, looking for the best organ for their few recipients.</p><p id="par0055" class="elsevierStylePara elsevierViewall">It is obvious that waiting lists, whether long or short, are a direct consequence of the indications that we set as healthcare professionals. I think it is worth to think about the indication of transplant data by each autonomous region (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In 2017, the autonomous region of Extremadura reached the highest rate of indications with 3.7 PMP, followed by Cantabria, Castilla-La Mancha and Castilla-León. In contrast, there were regions that did not indicate any cases. It is true that during the last four years it is observed a great variability, with regions changing from a of zero to more than 3 PMP indications depending on the year.</p><p id="par0065" class="elsevierStylePara elsevierViewall">However, there is not only variability in the indications according to the year analysed, but also between the different regions. According to ONT data, during the last four years Andalusia, Castile-La Mancha, Castile-León and Extremadura are the only regions with a mean number of indications PMP above 2.5.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Other regions such as La Rioja, Madrid, the Basque Country, Cantabria and Asturias remain below the mean of 1.5 indications PMP.</p><p id="par0075" class="elsevierStylePara elsevierViewall">From these data it could assumed that there are fewer patients with type 1 diabetes in end-stage renal failure with indication for SPK transplantation in these regions.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The reasons for this variability are many and heterogenous, and often difficult to determine, but we can mention the following: differences in the incidence of type 1 diabetes according to region; lack of pancreas transplant team in some regions; distrust of the results obtained by the reference group; uncertainty about current outcomes and about the advantages of the combined transplant for the patient; or even apathy towards the preparation and follow-up of a patient who will be transplanted outside our hospital.</p><p id="par0085" class="elsevierStylePara elsevierViewall">We have demonstrated over the years that our transplant system is exceptional. We therefore have the obligation to encourage the appropriate training, provide educational and organisational measures to correct this anomalous situation, so patients can receive what today is considered the best therapeutic option for their type 1 diabetes with end-stage renal disease.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Muñoz-Bellvís L. La extraña situación del trasplante de páncreas en España. Nefrología. 2019;39:455–457.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1454 "Ancho" => 2500 "Tamanyo" => 216836 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pancreas transplant rate PMP in different countries in recent years.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2847 "Ancho" => 2521 "Tamanyo" => 334361 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ONT (<span class="elsevierStyleItalic">Organización Nacional de Trasplantes</span> [Spanish National Transplant Organisation]) report for 2017 on waiting list inclusions for pancreas transplantation and transplant rate PMP in the different autonomous regions.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trasplante de páncreas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L. 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Gustafson" 3 => "M.A. Skeans" 4 => "M.A. Curry" 5 => "M.A. Prentice" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Transplant" "fecha" => "2018" "volumen" => "18" "numero" => "Suppl. 1" "paginaInicial" => "S114" "paginaFinal" => "S171" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Documento de consenso sobre criterios de selección de donante y receptor en trasplante de páncreas. Actualización del documento de consenso sobre Trasplante de Páncreas e Islotes 2005. Grupo Español de Trasplante de Páncreas y Organización Nacional de Trasplantes. Available from: <a target="_blank" href="http://www.ont.es/infesp/Paginas/DocumentosdeConsenso.aspx">http://www.ont.es/infesp/Paginas/DocumentosdeConsenso.aspx</a> [accessed 1.01.18]." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003900000005/v1_201912172106/S2013251419301452/v1_201912172106/en/main.assets" "Apartado" => array:4 [ "identificador" => "38706" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003900000005/v1_201912172106/S2013251419301452/v1_201912172106/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251419301452?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 41 | 31 | 72 |
| 2024 September | 50 | 18 | 68 |
| 2024 August | 74 | 72 | 146 |
| 2024 July | 39 | 28 | 67 |
| 2024 June | 64 | 49 | 113 |
| 2024 May | 45 | 45 | 90 |
| 2024 April | 40 | 28 | 68 |
| 2024 March | 39 | 22 | 61 |
| 2024 February | 37 | 36 | 73 |
| 2024 January | 35 | 18 | 53 |
| 2023 December | 28 | 27 | 55 |
| 2023 November | 40 | 39 | 79 |
| 2023 October | 34 | 19 | 53 |
| 2023 September | 34 | 23 | 57 |
| 2023 August | 29 | 27 | 56 |
| 2023 July | 51 | 21 | 72 |
| 2023 June | 40 | 20 | 60 |
| 2023 May | 39 | 25 | 64 |
| 2023 April | 20 | 14 | 34 |
| 2023 March | 53 | 21 | 74 |
| 2023 February | 63 | 17 | 80 |
| 2023 January | 40 | 21 | 61 |
| 2022 December | 70 | 26 | 96 |
| 2022 November | 46 | 24 | 70 |
| 2022 October | 59 | 30 | 89 |
| 2022 September | 61 | 29 | 90 |
| 2022 August | 33 | 43 | 76 |
| 2022 July | 31 | 41 | 72 |
| 2022 June | 44 | 42 | 86 |
| 2022 May | 50 | 22 | 72 |
| 2022 April | 56 | 42 | 98 |
| 2022 March | 54 | 38 | 92 |
| 2022 February | 48 | 45 | 93 |
| 2022 January | 40 | 31 | 71 |
| 2021 December | 37 | 47 | 84 |
| 2021 November | 35 | 35 | 70 |
| 2021 October | 37 | 38 | 75 |
| 2021 September | 28 | 39 | 67 |
| 2021 August | 51 | 38 | 89 |
| 2021 July | 43 | 25 | 68 |
| 2021 June | 42 | 33 | 75 |
| 2021 May | 65 | 43 | 108 |
| 2021 April | 112 | 44 | 156 |
| 2021 March | 74 | 39 | 113 |
| 2021 February | 66 | 21 | 87 |
| 2021 January | 37 | 15 | 52 |
| 2020 December | 23 | 11 | 34 |
| 2020 November | 25 | 16 | 41 |
| 2020 October | 23 | 24 | 47 |
| 2020 September | 26 | 9 | 35 |
| 2020 August | 18 | 9 | 27 |
| 2020 July | 15 | 11 | 26 |
| 2020 June | 18 | 10 | 28 |
| 2020 May | 16 | 14 | 30 |
| 2020 April | 14 | 10 | 24 |
| 2020 March | 14 | 6 | 20 |
| 2020 February | 22 | 15 | 37 |
| 2020 January | 65 | 27 | 92 |
| 2019 December | 37 | 13 | 50 |
| 2019 November | 16 | 12 | 28 |
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