##common.pageHeaderLogo.altText##

Original article

Vol. 155 No. 9 (2025)

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

Cite this as:
Swiss Med Wkly. 2025;155:4382
Published
24.09.2025

Summary

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.

References

  1. 1. Husebye ES, Pearce SH, Krone NP, Kämpe O. Adrenal insufficiency. Lancet. 2021 Feb;397(10274):613–29. 10.1016/S0140-6736(21)00136-7
  2. 2. Husebye ES, Anderson MS, Kämpe O. Autoimmune Polyendocrine Syndromes. N Engl J Med. 2018 Mar;378(12):1132–41. 10.1056/NEJMra1713301
  3. 3. Barzilai D, Dickstein G, Kanter Y, Plavnick Y, Schramek A. Complete remission of Cushing’s disease by total bilateral adrenalectomy and adrenal autotransplantation. J Clin Endocrinol Metab. 1980 May;50(5):853–6. 10.1210/jcem-50-5-853
  4. 4. Hardy JD, Moore DO, Langford HG. Cushing’s disease today. Late follow-up of 17 adrenalectomy patients with emphasis on eight with adrenal autotransplants. Ann Surg. 1985 May;201(5):595–603. 10.1097/00000658-198505000-00008
  5. 5. Dong D, Ji Z, Li H. Autologous Adrenal Transplantation for the Treatment of Refractory Cushing’s Disease. Urol Int. 2019;103(3):344–9. 10.1159/000502345
  6. 6. Grodstein E, Hardy MA, Goldstein MJ. A case of human intramuscular adrenal gland transplantation as a cure for chronic adrenal insufficiency. Am J Transplant. 2010 Feb;10(2):431–3. 10.1111/j.1600-6143.2009.02929.x
  7. 7. Vouillarmet J, Buron F, Houzard C, Carlier MC, Chauvet C, Brunet M, et al. The first simultaneous kidney-adrenal gland-pancreas transplantation: outcome at 1 year. Am J Transplant. 2013 Jul;13(7):1905–9. 10.1111/ajt.12296
  8. 8. Dubernard JM, Cloix P, Tajra LC, Alduglihan W, Borson F, Lefrançois N, et al. Simultaneous adrenal gland and kidney allotransplantation after synchronous bilateral renal cell carcinoma: a case report. Transplant Proc. 1995 Feb;27(1):1320–1.
  9. 9. Siniscalchi C, Moretti V, Cataldo S, Rocci A, Basaglia M, Tassoni MI, et al. The Schmidt Syndrome. Acta Biomed. 2018 Jan;88(4):499–501. 10.23750/abm.v88i4.5117
  10. 10. Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, et al.; Chronic Kidney Disease Epidemiology Collaboration. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006 Aug;145(4):247–54. 10.7326/0003-4819-145-4-200608150-00004
  11. 11. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, et al.; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009 May;150(9):604–12. 10.7326/0003-4819-150-9-200905050-00006
  12. 12. Hardy JD, Langford HG. Adrenal Autotransplantation in Cushing’s disease. Ann N Y Acad Sci. 1964 Nov;120(1):667–8. 10.1111/j.1749-6632.1964.tb34760.x
  13. 13. Buron F, Vouillarmet J, Thaunat O, Thivolet C, Badet L, Morelon E. Autoimmune Recurrence as a Cause of Adrenal Gland Graft Loss? Am J Transplant. 2016 Jul;16(7):2235–6. 10.1111/ajt.13737
  14. 14. Gilabert R, Fernández-Cruz L, Real MI, Ricart MJ, Astudillo E, Montaña X. Treatment and outcome of pancreatic venous graft thrombosis after kidney—pancreas transplantation. Br J Surg. 2002 Mar;89(3):355–60. 10.1046/j.0007-1323.2001.02016.x
  15. 15. Troppmann C. Complications after pancreas transplantation. Curr Opin Organ Transplant. 2010 Feb;15(1):112–8. 10.1097/MOT.0b013e3283355349
  16. 16. Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab. 2024 Jun;109(7):1657–83. 10.1210/clinem/dgae250
  17. 17. Citterio F. Steroid side effects and their impact on transplantation outcome. Transplantation. 2001 Dec;72(12 Suppl):S75–80.
  18. 18. Freise CE, Kang SM, Feng S, Posselt A, Hirose K, Hirose R, et al. Experience with steroid-free maintenance immunosuppression in simultaneous pancreas-kidney transplantation. Transplant Proc. 2004 May;36(4):1067–8. 10.1016/j.transproceed.2004.04.017
  19. 19. Shapiro AM, Lakey JR, Ryan EA, Korbutt GS, Toth E, Warnock GL, et al. Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med. 2000 Jul;343(4):230–8. doi: https://doi.org/10.1056/NEJM200007273430401
  20. 20. Occhipinti M, Lampasona V, Vistoli F, Bazzigaluppi E, Scavini M, Boggi U, et al. Zinc transporter 8 autoantibodies increase the predictive value of islet autoantibodies for function loss of technically successful solitary pancreas transplant. Transplantation. 2011 Sep;92(6):674–7. 10.1097/TP.0b013e31822ae65f
  21. 21. Vendrame F, Pileggi A, Laughlin E, Allende G, Martin-Pagola A, Molano RD, et al. Recurrence of type 1 diabetes after simultaneous pancreas-kidney transplantation, despite immunosuppression, is associated with autoantibodies and pathogenic autoreactive CD4 T-cells. Diabetes. 2010 Apr;59(4):947–57. 10.2337/db09-0498
  22. 22. Nankivell BJ, Borrows RJ, Fung CL, O’Connell PJ, Allen RD, Chapman JR. The natural history of chronic allograft nephropathy. N Engl J Med. 2003 Dec;349(24):2326–33. 10.1056/NEJMoa020009
  23. 23. Oka K, Shimodaira H, Hirano T, Sakurai E, Tamaki T, Kozaki M. Comparison of adrenal functions in kidney transplant recipients with different long-term immunosuppressive treatments—prednisolone and azathioprine versus prednisolone and cyclosporine. Transplantation. 1993 Sep;56(3):603–9. 10.1097/00007890-199309000-00020
  24. 24. Stock PG, Mannon RB, Armstrong B, Watson N, Ikle D, Robien MA, et al. Challenges of calcineurin inhibitor withdrawal following combined pancreas and kidney transplantation: results of a prospective, randomized clinical trial. Am J Transplant. 2020 Jun;20(6):1668–78. 10.1111/ajt.15817