The prevalence of type 2 diabetes mellitus (T2DM) among patients with kidney failure is nearly 40%. The therapeutic paradigm for the management of T2DM in the setting of chronic kidney disease (CKD) has undergone a dramatic evolution in recent years. Progressive CKD decreases the need for exogenous insulin, allowing noninsulin treatments to be more effective in controlling serum glucose levels. Although diet, exercise, weight loss, and behavioral therapy are important factors in diabetes management, several noninsulin alternatives have risen to the forefront, including glucagon-like peptide 1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, and dual glucose-dependent insulinotropic polypeptide/glucagon-like peptide 1 receptor agonists, particularly in patients with cardiovascular risk factors. Consequently, many patients with T2DM and stage 4/5 CKD previously taking insulin no longer require it at transplant referral and are not considered for simultaneous kidney-pancreas transplant (SKPT). Given the diabetogenic effects of calcineurin inhibitors and steroids, coupled with the more rapid elimination of endogenous insulin associated with improved renal function posttransplant, many patients are denied access to SKPT although they will predictably become insulin-requiring after kidney transplant alone. To be, or not to be, on insulin should no longer be the key question in the evaluation of patients with CKD and T2DM for SKPT.

INTRODUCTION:Rural residents with end-stage kidney disease have lower access to kidney transplantation, especially in later stages. We examined the impact of rurality on initiation of transplant evaluation and whether this varies by region. METHODS:We conducted a retrospective cohort study of 86,839 adults (18-80 years) referred for kidney transplantation between 2015 and 2023 in the Early Steps to Transplant Access Registry, linked to United States Renal Data System (USRDS). Rurality was defined using the USRDS variable based on the ZIP code using rural-urban commuting area codes. The primary outcome was evaluation initiation within 6 months of referral. Fine and Gray competing risk models estimated the time to evaluation start, accounting for death as a competing event, with multivariable adjustment and interaction by geographic region; sub-analyses were stratified by the end-stage renal disease (ESRD) network. RESULTS:Median time to evaluation was longer for rural patients (166 days) than urban patients (106 days), a pattern consistent across all ESRD networks. The largest rural-urban time gaps were observed in New York and the Ohio River Valley. Rural residence was associated with an 11% lower likelihood of evaluation initiation (adjusted subdistribution hazard ratio [aSHR] [95% CI]: 0.89 [0.86, 0.92]). The strongest disparities were in New York (aSHR [95% CI]: 0.56 [0.50, 0.62]) and New England (aSHR [95% CI]: 0.76 [0.69, 0.83]). The Southeast (aSHR [95% CI]: 0.90 [0.87, 0.94]) and Ohio River Valley (aSHR [95% CI]: 0.92 [0.85, 0.99]) showed similar associations. CONCLUSION:Rural residents were less likely to initiate transplant evaluation compared to urban residents. These findings suggest that rural disparities exist in the early steps of the transplant process, highlighting the need for targeted interventions, especially in regions with lowest access.

Background. Pancreas transplantation (PT), historically limited to patients with type 1 diabetes (T1D), is currently performed successfully in selected patients with type 2 diabetes (T2D). However, contemporary practice patterns and eligibility criteria for PT in T2D remain incompletely characterized. Methods. The International Pancreas and Islet Transplant Association Pancreas Transplant Interest Group developed an electronic survey to assess center-level approaches to patient phenotyping, candidacy, and peri- and posttransplant management for PT in patients with T2D. The survey was distributed to international transplant professionals during an International Pancreas and Islet Transplant Association Pre-Congress meeting on June 15, 2025. Results. Thirty-seven participants completed the survey. Most respondents’ programs offer PT for T2D only when a kidney transplant is also indicated. Fewer respondents’ programs also offer PT alone (10%), evaluate T2D candidates on a case-by-case basis (3%), or do not offer PT to patients with T2D (10%). Total daily insulin requirement and body mass index (BMI) were the most selected factors in determining eligibility. Considerable variability existed in metabolic thresholds: 62% of programs reported no C-peptide cutoff, whereas nearly half required a BMI of <30 kg/m2 for C-peptide-positive candidates. Respondents frequently recommend weight-optimization strategies, including lifestyle modification, glucagon-like peptide-1 receptor agonists, and bariatric surgery for candidates exceeding acceptable BMI thresholds. Surgical technique, induction, and maintenance immunosuppression and early posttransplant glycemic management were largely uniform between T2D and T1D recipients. Conclusions. International practice reflects broad but heterogeneous adoption of PT for T2D, with most participants restricting its use to candidates requiring kidney transplantation and emphasizing integrated clinical phenotyping approaches.

Originally exclusively considered for patients with type 1 diabetes, expansion of combined pancreas and kidney transplantation to select patients with type 2 diabetes (T2DM) has become more common internationally. It has become clear that the pancreas transplant community is grappling with a definition of "type 2 diabetes" in this context. Specifically, it is imperative that a definition be established to communicate uniformly and consistently about these patient populations as we develop policies, study outcomes, and compare pancreas transplantation to alternative therapies. As the pancreas transplant physicians and endocrinologists strive to characterize various forms of diabetes, the field seeks to identify the potential candidates among those with features of T2DM, and other forms of diabetes who can safely undergo pancreas transplantation and who would benefit from this procedure and be rendered normoglycemic, as is the expectation for successful pancreas transplantation in recipients with type 1 diabetes. To this end, the International Pancreas and Islet Transplantation Association Pancreas Transplant Interest Group organized a pre-Congress meeting before the 20th World Congress, held in Pisa, Italy, in the summer of 2025, titled "Definition and listing guidelines for pancreas transplantation in type 2 diabetes mellitus: don't hype the type." An international panel was invited to present on several topics related to the definition of T2DM in the context of pancreas transplantation. This review summarizes the presentations and follow-up discussion regarding pancreas transplantation for T2DM from the meeting.

Enteric leaks following pancreas transplant cause significant morbidity and may result in allograft loss. The proximal duodenal staple line is particularly susceptible. We describe a novel technique utilizing omentopexy to mitigate proximal duodenal staple line leaks. This was a single center, retrospective analysis of all pancreas transplants performed from 10/01/2014-7/31/2024. The omentopexy technique was introduced in 10/2019. A piece of donor omentum is mobilized and retained during procurement, then used to buttress the proximal duodenal staple line after implantation. Recipients were identified as concerning for leak if they underwent percutaneous drainage or reoperation for peripancreatic fluid collections, and those with leaks as intraoperative confirmation or radiographic evidence of fistula to the donor duodenum. In total, 263 pancreas transplants were included - 155 prior to (pre) and 108 following (post) implementation of the omentopexy technique. Potential proximal duodenal leak was identified in 16(10.3%) pre versus 7(6.5%) post introduction, with confirmed proximal duodenal leaks in 7(4.5%) pre versus 1(0.9%) post. Management of leaks was with percutaneous drainage for 5 and operative intervention for 3 recipients. Omentopexy to the donor duodenal staple line is simple to perform and reduced the relative risk of proximal duodenal staple line leak by 78.7%.

Background:Gastroparesis (GP) is a chronic disorder of the stomach characterized by delayed gastric emptying and frequently associated with longstanding diabetes. This is a single-center retrospective analysis designed to establish the prevalence and assess the impact on posttransplant outcomes of GP among pancreas transplant recipients. Methods:Medical records for all recipients of pancreas transplants performed between January 2003 and December 2023 were reviewed. GP was defined by abnormal gastric-emptying scintigraphy or other motility study or a history of symptoms. Primary outcomes included graft loss and patient death. Clinical outcomes included length of stay after transplant and readmissions, including specifically for GP symptoms. Results:Of 731 recipients, 156 (21%) were diagnosed with GP before transplant. Patients with GP were younger and more likely to be female individuals. Posttransplant, there was no difference in length of stay, graft survival, or patient survival. Patients with GP were more likely to be readmitted and to be specifically admitted for GP symptoms. Requirement for interventions was more common in patients with GP. Conclusions:GP is identified with increased frequency among the specific patient population referred for pancreas transplant, and although it does not seem to affect allograft or patient survival, it does seem to have an impact on readmissions and the need for interventions.

INTRODUCTION:Individuals with end-stage kidney disease face barriers and delays in access to kidney transplantation, but little is known about access before waitlisting due to the lack of national data on pre-waitlisting measures. The Early Steps to Transplant Access Registry (E-STAR) captures referral and evaluation data in four US regions, including the Ohio River Valley, and this study utilizes E-STAR data to describe sociodemographic factors associated with starting the transplant evaluation and waitlisting in this region. METHODS:Adults referred to a transplant center for evaluation within the Ohio River Valley during 2015-2021 and captured within E-STAR were included. Linked E-STAR, US Renal Data System, and American Community Survey data were used to assess the association between sociodemographic (age, sex, race or ethnicity, insurance status), clinical, and neighborhood factors and time from referral to evaluation start and time from evaluation start to waitlisting by Cox proportional hazards analyses. RESULTS:Among 15,673 referred adults, the mean age was 55 years, and the majority were male (61.4%) and had public insurance (56.6%), while 21.3% were preemptively referred. Compared to individuals aged 18-29, all other age groups had a lower likelihood of starting the evaluation in the adjusted model. Black adults (vs. White; adjusted hazard ratio: 0.89 [95% CI: 0.81-0.98]), and those with Medicaid or Medicare were less likely to start the evaluation (vs. employer-sponsored, 0.58 [0.50-0.66]; 0.66 [0.66-0.82], respectively). Among individuals who started the evaluation, those with Black (vs. White) race, and Medicaid or Medicare (vs. employer-sponsored) were less likely to be waitlisted in the adjusted analysis. CONCLUSION:Associations between age, sex, race, and economic characteristics and access to evaluation start and waitlisting were observed. Future research investigating underlying causes and points of intervention in this region is warranted.

PURPOSE OF REVIEW:For those with insulin dependent diabetes mellitus and renal failure, both simultaneous pancreas and kidney (SPK) and pancreas after kidney (PAK) transplant can free the recipient of renal replacement and insulin therapies and provide survival advantage over ongoing dialysis and diabetes. Yet, pancreas transplants are notably declining in the United States, particularly for PAK. RECENT FINDINGS:Pancreas transplant continues to provide better glycemic control than all present medical therapies. Outcomes for both SPK and PAK also continue to improve, and overall patient survival for both SPK and PAK are similar, excellent, and superior to all other transplant or medical options. SPK is associated with better pancreas allograft survival, but this gap is narrowing for PAK, and the best kidney allograft survival is achieved with living donor renal transplant (LDRTx) and PAK. SUMMARY:PAK remains a viable and successful treatment for uremia and insulin dependent diabetes, and, particularly when following a LDRTx, can confer the additional benefits associated with LDRTx and preemptive transplant. To achieve insulin and dialysis independence, either LDRTx followed by PAK (if a living donor is available) or SPK should be offered to candidates with appropriate indications.

Background. In 2020, liver allocation policy in the United States was changed to allow for broader organ sharing, which was hypothesized to reduce patient incentives to travel for transplant. Our objective was to describe patterns of travel for domestic liver transplant pre- and post–acuity circle (AC) implementation. Methods. Incident adult liver transplant listings between August 16, 2016, and February 3, 2020 (pre-AC) or June 13, 2020, and December 3, 2023 (post-AC) were obtained from the Scientific Registry of Transplant Recipients. We used previously defined geographic catchment areas to classify patients as (1) no travel, (2) travel to a neighboring region, and (3) travel beyond a neighboring region. We used multinomial logistic regression to identify characteristics associated with travel and cause-specific hazards modeling to estimate the association between travel and time to deceased donor transplant, stratified by model for end-stage liver disease (MELD) score and AC era. Results. Among 83 033 liver candidates, 76% were listed in their home region. Black race, lower educational attainment, increased neighborhood social deprivation, and Medicaid were significantly associated with decreased odds of traveling beyond a neighboring region. After AC, traveling beyond a neighboring region was associated with an increased hazard of transplant for patients with a MELD score <15 (cause-specific hazard ratio [csHR]: 1.25; 95% confidence interval [CI], 1.11-1.40), MELD score 15–24 (csHR: 1.19; 95% CI, 1.07-1.31), and MELD score 25–34 (csHR: 1.15; 95% CI, 1.01-1.32). Conclusions. Travel frequency, geographic patterns of travel, and characteristics associated with travel were largely unchanged after AC. Changes to allocation policy alone may not equalize patient means or desire to travel for transplant care.

BACKGROUND:Organ allocation has recently changed to acuity circle (AC)-based policies. This study aimed to quantify changes in travel distance and potential environmental impacts of AC policies. METHODS:Data were obtained from the Scientific Registry of Transplant Recipients for each solid organ for an equidistant window before and after AC implementation. We calculated the distance between the donor and recipient hospital for each organ. We used an interrupted time series model to calculate excess travel distance after AC along with associated carbon emissions. RESULTS:We analyzed travel distance for 226 731 deceased donor organs. There was a significant increase in total excess distance traveled: 1.5 × 106 miles for lung, 3.1 × 106 for heart, 2.2 × 106 miles for liver, and 3.2 × 106 miles for kidney. This led to increased estimated carbon emissions associated with transport ranging from: 175.7 to 193.4 kg CO2e per lung, 291.7 to 312.5 kg CO2e per heart, 114.9 to 131.7 kg CO2e per liver, and 0.2 to 5.3 kg CO2e per kidney. CONCLUSIONS:Our findings quantify an increase in total distance traveled and potential carbon emissions after AC implementation. Environmental impacts of allocation policies should be considered, especially with upcoming continuous distribution.

Belatacept may be used to spare or replace calcineurin inhibitors (CNI) to preserve renal function. Use in pancreas transplant (PTx) is limited by increased risk of pancreas rejection. This retrospective analysis included all PTxs performed between 2004 and 2023. A 1:2 case/control analysis was performed to identify predictors of belatacept use and compare allograft and patient survival. Of 731 PTxs, 21 (3%) started belatacept (eight simultaneous pancreas and kidney (SPK), three pancreas after kidney (PAK), and 10 pancreas transplant alone (PTA). At 1 year, Δ estimated glomerular filtration rate (eGFR) was +7% SPK, -15% PAK, and +32% PTA. Case-control analysis found no demographic predictors for belatacept except older recipient age for PTA. No difference in median kidney, pancreas, or patient survival was observed compared to control. Pancreas rejection occurred in two SPKs. There were two death censored pancreas allograft failures, both PTAs. Kidney allografts failed in two SPK and one PAK. Eight patients died. Six were still receiving belatacept at time of death with functioning allografts. Belatacept use after PTx is safe and can provide some renal recovery. Belatacept was initiated with eGFR approaching 20 mL/min/1.73m2. Earlier introduction may result in better outcomes.

INTRODUCTION:With the growing population of pancreas transplant recipients followed long-term, some female recipients are going to require surgical intervention for gynecologic symptoms and pathologies. Currently, there is a lack of literature describing how to approach this population and whether pelvic gynecologic procedures (GYN) can be performed safely given the proximity of the pancreatic (and possibly renal) allograft. In this single-center retrospective analysis, all pancreas transplant recipients that subsequently underwent GYN were reviewed. METHODS:Subjects were identified by cross-referencing all pancreas transplants performed between January 2003 and December 2022 for any subsequent GYN. Demographics at transplant and GYN, indications and procedure performed, operative time, presence and involvement of a transplant surgeon, complications length of stay, and readmissions were reviewed. RESULTS:Seventeen patients who underwent a total of 19 GYN after pancreas transplantation were identified. Operations performed included tubal ligation (n = 2), total abdominal hysterectomy with (n = 6) or without bilateral salpingectomy (n = 2), oophorectomy versus cyst drainage (n = 2), bilateral oophorectomy (n = 1), and unilateral (n = 4) versus bilateral (n = 2) salpingectomy. Four were performed through an open laparotomy and 15 were performed laparoscopically. In 11 cases, a transplant surgeon was involved intra-operatively. Eight of the 17 patients developed post-operative complications including post-operative fevers, fluid overload, neutropenia, elevated creatinine (n = 2), nephrolithiasis, urinary tract infection, and incisional hernia. Five required readmission. CONCLUSION:GYN can be performed safely following pancreas transplantation, but careful planning and the involvement of the transplant surgery team are advised.

Allocation of deceased donor renal allografts for transplant is complicated by the competing interests of multiorgan transplants (MOT) that include a kidney as a secondary organ (with a liver, lung or heart as the primary organ), simultaneous pancreas and kidney (SPK) transplants (that remove a patient from the kidney waiting list), and high priority kidney alone candidates such as prior living donors, pediatric recipients, and highly sensitized individuals. Furthermore, there are more than 80,000 candidates waiting for a kidney transplant alone without such priority. In the case of SPK transplant, the kidney is the primary organ transplanted and the pancreas is the accompanying organ, requiring candidates to be subject to the same listing criteria as kidney alone candidates. In comparison, candidates for other MOTs that include the kidney are not placed on the kidney waiting list and subject mainly to the listing criteria of the primary organ. This report will present how SPK transplant should be considered in the context of kidney allocation and outline the rationale as to why an SPK transplant should not be batched with other MOTs in allocation decisions. SPK transplants should rightfully continue to be regarded as a kidney transplant of the upmost priority secondary to the higher mortality of these candidates on the kidney waitlist, the demonstrated survival advantage of the combined transplant, and the unavoidable increased non-utilization of suitable pancreas allografts if it does not accompany a kidney.

Pancreas transplantation is currently the only available therapy capable of reliably reestablishing normal glucose homeostasis independent of exogenous insulin in patients with diabetes. Historically, this procedure was reserved exclusively for suitable candidates with Type 1 diabetes mellitus (T1DM). Indications for pancreas transplantation have been liberalized to include patients with T1DM that were previously not considered suitable, select candidates with Type 2 DM, and rarely for less common forms of diabetes. This review examines standard indications and contraindications for pancreas transplantation including expansion of criteria for candidates who are older, have obesity, or are medically or surgically complex. It remains unclear whether pancreas transplant is appropriate for most candidates with diabetes, particularly those with uremia, irrespective of age, size, diabetes type, or insulin need/dose, or if it remains appropriate only for a select group of patients.

In the United States, potential transplant candidates with insulin-dependent diabetes mellitus are inconsistently offered pancreas transplantation (PTx), contributing to a dramatic decline in pancreas allograft utilization over the past 2 decades. The American Society of Transplantation organized a workshop to identify barriers inhibiting PTx and to develop strategies for a national comeback. The 2-day workshop focused on 4 main topics: (1) referral/candidate selection, (2) organ recovery/utilization, (3) program performance/patient outcomes, and (4) enhanced education/research. Topics were explored through expert presentations, patient testimonials, breakout sessions, and strategic planning, including the identification of tasks for immediate focus. Additionally, a modified-Delphi survey was conducted among workshop members to develop and rate the importance of barriers, and the impact and feasibility of workgroup-identified improvement strategies. The panelists identified 16 barriers to progress and 44 strategies for consideration. The steps for a na- tional comeback in PTx involve greater emphasis on efficient referral and candidate se- lection, better donor pancreas utilization practices, eliminating financial barriers to procurement and transplant, improving collaboration between transplant and diabetes so- cieties and professionals, and increasing focus on PTx training, education, and research. Partnership between national societies, patient advocacy groups, and professionals will be essential to realizing this critical agenda.