Importantly. ATP and GTP content were lower in the DCD islets which correlated inversely to longer warm ischemia times. This has led to concerns that DCD islets possibly engraft more poorly in portal vein transplantation103. The proportion of category 5 DCD versus category 3 DCD has been steadily rising in the Netherlands: from 0.6% of all DCD procedures in 2014 to 4% in 2018. Out of all allocated DCD pancreas for islet isolation to our center the proportion of category 5 DCD pancreas has increased from 2.5% in 2014 to almost 18% in 2018104. There has been concern that the use of rocuronium as a muscle relaxant in the euthanasia procedure may interact with paracrine signaling in islets cells for maintaining glucose homeostasis105,106. We presented that islet yield in terms of IEQ and IEQ/gram pancreas was similar between category 5 DCD (n=16) and category 3 DCD pancreas (n=48). However, preliminary data indicate that insulin release from category 5 DCD islets after a glucose challenge is impaired in vitro104. Clinical outcome of islet transplantation using DCD pancreas Controlled DCD islet transplantation was first reported in 200351. Immediate graft function was observed with a reduction in daily insulin requirement, improved glycemic control, absence of hypoglycemic events, and a normal C-peptide level. Insulin independence followed at day 52. Since then the scarce reports on clinical outcome of DCD islet transplantations showed no obvious difference. One study examined insulin independence and the decrease in insulin requirement at 1-month post-transplantation. No difference was found for the DCD group (n=9) compared to the DBD group (n=196)82. In the Netherlands, three months post- transplantation mixed meal tests were given to recipients receiving a single or combined (single DBD, single DCD, double DBD, double DCD, or combined DBD and DCD, n=29). No differences in C-peptide production or blood glucose level during the mixed meal test were found among the groups88. With only controlled category 4 DCD pancreas used in the Japanese Islet Transplantation Registry, 18 recipients received DCD islet infusions94. Ten of these recipients received more than one islet infusions. After three years, 33.6% maintained a C-peptide level more than or equal to 0.3 ng/mL. All recipients remained free of severe hypoglycemic events and three achieved insulin independence for 14, 79, and 215 days. There is no data on clinical outcome of uncontrolled DCD islet transplantation. Future P...
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