*Purpose: Organ donors frequently develop hyperglycaemia in intensive care, which is managed with insulin. In islet and solid pancreas transplantation (PT) we reported that Donor Insulin Use (DIU) predicts worse beta cell function. Here, we aimed to: a) determine relationships between DIU and graft failure in PT; and b) describe donor phenotypes related to DIU predicting optimal outcomes.

*Methods: In data from the UK PT programme, regression models determined: a) associations between DIU and graft failure; and, b) the relationship between several donor phenotypes and graft failure, relative to an optimal donor phenotype. Net Reclassification Improvement assessed the added value of DIU as a predictor of graft failure.

*Results: In 2168 PTs (mean [SD] age: 42 [8] years; BMI: 23.5 [3.4]) kg/m²), 1112 (51%) donors were insulin-treated. DIU was associated with a lower risk of graft loss (hazard ratio, 95% CI: 0.72 [0.53-0.96], p=0.026) at 3 months post-transplantation. Other significant predictors of graft loss included older donor age (1.02, 1.01-1.03, p<0.001), higher body mass index (BMI) (1.06, 1.01-1.10, p=0.009), and donor type (DCD vs. DBD) (1.47 [1.03-2.09], p=0.032). DIU led to a significant improvement in outcome discrimination and risk reclassification (aROC [se] improvement: 0.09 [0.03], p=0.003); NRI: 0.16, p-value=0.032). The optimal donor phenotype was identified as: age ≤40 years; BMI ≤25 kg/m2 and receiving insulin (failure rate 27/494 [5.5%]). After adjusting for donor type and cold ischaemic time, the worst donor phenotype was age >40 years, BMI >25 kg/m2 and not receiving insulin (failure rate 24/152 [16%], OR (95% CI): 3.2 (1.8-5.8), p=<0.001: failure risk, worst vs. optimal).

*Conclusions: Contrary to prior data on beta cell function, DIU predicts better graft survival in PT recipients. If validated, use of DIU to classify donor phenotypes could improve organ selection and allocation processes leading to better outcomes.

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