Simultaneous adrenal gland and pancreas-kidney transplantation and associated hormonal challenges

Adrenal gland transplantation has only been performed in rare cases, with variable results in terms of functional activity. Consequently, there is a lack of evidence in endocrine management and tapering hormone replacement therapy after such transplantations. We report on a simultaneous pancreas-kidney and adrenal gland allotransplantation in a 48-year-old female patient with type 1 diabetes and severe autoimmune adrenal insufficiency. Surgery was uneventful, without major surgical morbidity. Pancreas and kidney graft function were excellent from the beginning. Adrenal graft function was difficult to assess and steroid tapering was not well tolerated and hampered clinical recovery. Despite the evidence of adequate graft perfusion and initially even measurable levels of cortisol production, persistent adrenal graft function was not obtained, and the patient remained on hormone replacement therapy. Simultaneous pancreas-kidney and adrenal gland transplantation is technically safe, without the need for major surgical modifications or adjustments in immunosuppression. However, it should only be performed in combination with a kidney or pancreas-kidney transplant, which justifies the lifelong immunosuppression. The major challenge remains the postoperative endocrine management, with steroid tapering and adequate assessment of adrenal graft function. Patients should be followed by an interdisciplinary team involving endocrinologists, nephrologists and transplant surgeons.