Expanding the Pancreas Donor Pool: Reassessing the Impact of Donor Body Mass Index on Transplant Outcomes

Pancreas transplantation in the United States has declined over the past 20 years, in part because restrictive donor selection practices, particularly around obesity, contribute to high organ turndown rates. This retrospective study used data from the Organ Procurement and Transplantation Network (OPTN) to assess whether donor body mass index (BMI) affects outcomes after primary simultaneous pancreas-kidney transplantation. The analysis included 9519 adult recipients transplanted from 2010 through 2022. Donors were categorized by BMI as underweight, normal weight, overweight, or obese. Kaplan-Meier analysis, Cox proportional hazards models, and restricted cubic spline modeling were used to compare outcomes across groups. Donor BMI was not associated with significant differences in one- or three-year patient survival or death-censored pancreas and kidney graft survival, and multivariable Cox regression analysis found donor BMI to not be an independent predictor of graft loss. Instead, factors associated with one-year graft failure included donor age over 45 years, cerebrovascular accident as the cause of death, and cold ischemia time longer than 12 h. These findings indicate that carefully selected pancreata from donors with higher BMI can achieve outcomes comparable to those from normal-weight donors, supporting reconsideration of BMI-based exclusion criteria to expand the donor pool and increase pancreas transplantation rates.