Modelling donor factors influencing pancreas transplant utilization and evolution of decision-making over time

Background: Pancreas transplantation remains the only definitive treatment for diabetes mellitus. However, the global number of pancreas transplants and utilisation of pancreas grafts is declining. We aimed to identify significant donor factors associated with pancreas non-use. Methods: Population-cohort study using United States (US) data from the Organ Procurement and Transplant Network (OPTN) registry (2010-2024). Multivariable regression models were constructed to assess associations between donor characteristics and pancreas utilisation. Restricted cubic splines were used to preserve non-linear relationships and interaction terms with donation date were performed, to capture evolving decision-making behaviours. Results: We identify 23 donor factors significantly associated with utilisation (n = 14,612 transplants from 133,986 donors). The most important continuous donor factors are age, BMI and peak creatinine; all showing significant non-linear relationships with utilisation (all P < 0.001). Donor type is the most important categorical variable, with donation after circulatory death (DCD) having 92% lower odds of utilisation (aOR=0.078, 95% CI = 0.070 to 0.087, P = < 0.001). Interaction analyses reveal increasing reluctance to use DCD donors or older donors over the study period (both interaction P < 0.001). Conversely, clinicians have become more comfortable transplanting pancreases from Hepatitis C positive donors and IV drug use (IVDU) donors over time (both interaction P < 0.001). Conclusions: This large population cohort study demonstrates significant shifts in utilisation decision-making over time. Growing reluctance to use DCD, despite evidence of favourable outcomes, highlights a valuable area to focus US pancreas utilisation efforts. Meanwhile, previously underused groups such as Hepatitis C positive and IVDU donors show growing acceptance, supporting expansion of these donor populations globally.