The review examines national trends in pancreas transplant activity, the workforce currently in place, and the fellowship training exposure available to the next generation of transplant specialists. Its central conclusion is stark: declining procedure numbers have undermined surgical and medical training opportunities in a field that is among the most technically complex in all of transplantation. The consequences are visible at every stage of the process, from the recovery of the donor organ in the operating room of a donor hospital to the backbench preparation of the organ and finally the implantation surgery itself. Fewer transplants mean fewer opportunities for trainees to develop and maintain the skills the operation demands.

The numbers tell a story of sustained contraction. Pancreas transplantation in the United States peaked in the mid-2000s, when more than 1,400 procedures were performed annually, and has declined markedly and persistently at both the national and programmatic levels since then. The OPTN/SRTR 2024 Annual Data Report, cited in the review, documents the continued erosion of activity. Multiple centers have abandoned their pancreas programs entirely, concentrating what remains of the national volume into a small number of high-volume institutions. This concentration may preserve outcomes at those centers, but it hollows out the training ecosystem elsewhere, leaving many transplant surgery fellows with little or no hands-on pancreas experience during their formal education.

The authors trace the decline to a convergence of systemic drivers rather than a single cause. Shifts in allocation policy, evolving practice patterns, perceptions of risk relative to benefit, and competition from emerging therapies have all played a role. A 2024 Delphi survey and US conference report published in the American Journal of Transplantation, led by Robert F. Parsons and including Dunn among its authors, gathered experts to generate strategies for a national comeback in pancreas transplantation, reflecting growing alarm within the field. Earlier analyses, including a widely discussed 2016 paper titled Pancreas Transplantation: An Alarming Crisis in Confidence, had already documented the erosion and warned of its downstream consequences.

At the same time, the demand side of the equation has not disappeared. Recent survey data published in Diabetes Care found a persistent burden of severe hypoglycemia and impaired awareness of hypoglycemia among people with type 1 diabetes, even among those using modern diabetes technology. Continuous glucose monitors and automated insulin delivery systems have transformed daily management for many patients, but they do not eliminate the most dangerous complications of the disease for everyone. Consensus reports from the American Diabetes Association and the European Association for the Study of Diabetes continue to identify pancreas transplantation as the definitive option for selected patients with severe, unstable diabetes. The clinical need, in other words, remains robust even as the surgical capacity to meet it withers.

The evidence base supporting the procedure is also stronger than the declining volumes might suggest. A 30-year follow-up of a nationwide Dutch cohort published in Diabetes Care demonstrated superior long-term survival for simultaneous pancreas-kidney transplantation compared with kidney transplantation alone as renal replacement therapy for diabetic patients. A propensity-matched global cohort study published in 2025 in Transplantation International compared simultaneous pancreas-kidney transplantation with kidney transplant alone in real-world conditions. Long-term single-center data from Canada, published in The Lancet Diabetes & Endocrinology, documented two decades of durable outcomes for pancreatic islet transplantation, a related cell-based therapy. Together these studies reinforce that replacing or supplementing the diabetic pancreas delivers measurable, lasting benefit.

Paradoxically, two developments that should be good news for the field are compounding the training crisis. The first is the dramatic rise in donation after circulatory death, or DCD, organ recovery in the United States, documented in a 2026 analysis in JAMA. DCD donors now represent a substantial and growing share of deceased organ donation, and pancreata from these donors present unique technical challenges during recovery and preservation. The second is the rapid adoption of perfusion technologies, machine-based systems that circulate preservation fluid through recovered organs to assess and improve their viability. Both developments add layers of complexity to organ recovery and evaluation that trainees must master, precisely as the overall volume of pancreas transplants available for hands-on learning continues to shrink.

The mechanics of organ recovery deserve particular attention. In the current US system, organ procurement organizations coordinate donation, and the recovery surgeon’s skill heavily influences whether a pancreas is ultimately transplanted or discarded. Studies have shown that dedicated recovery surgeons and full-time organ recovery teams can reduce the discard of marginal organs, and the review’s authors point to the effect of less training being evident in both the recovery and transplant settings. A surgeon who has never been taught to meticulously dissect the pancreatic vessels and avoid injury to the organ’s delicate vascular supply may inadvertently render an otherwise usable pancreas untransplantable. Research on pancreata recovered for research purposes, published in the American Journal of Transplantation in 2024, examined whether the growing diversion of recovered pancreata to research has further affected transplantation availability. Every discarded or diverted organ represents not only a lost opportunity for a patient but also a lost training case for a fellow.

The training infrastructure itself is fragmented. Pancreas transplant training in the United States occurs largely within abdominal transplant surgery fellowships accredited under requirements developed by the Transplant Accreditation & Certification Council, but the actual exposure a fellow receives depends heavily on the volume and composition of cases at their home program. Parallel concerns have been raised in transplant nephrology, where published surveys of program directors and debates over whether the subspecialty should pursue formal recognition from the Accreditation Council for Graduate Medical Education reveal similar anxieties about inconsistent training exposure. Some innovators have responded with creative solutions, including a hands-on training course for pancreas allograft procurement, backbench preparation, and transplantation described in Global Surgical Education in 2023, designed to supplement the clinical experience that declining volumes can no longer guarantee.

The implications extend well beyond the operating room. If the current trajectory continues, the review suggests, the United States could face a self-reinforcing spiral: fewer trained surgeons lead to fewer programs, fewer programs lead to fewer transplants, and fewer transplants leave even fewer opportunities to train the next cohort. Meanwhile, cell-based alternatives are advancing rapidly, including stem cell-derived islet therapies reported in the New England Journal of Medicine in 2025 and chemically induced pluripotent stem cell-derived islets transplanted in a patient with type 1 diabetes, described in Cell in 2024. These advances offer hope but do not yet replace whole-organ transplantation for the broad population of patients who could benefit from it. The authors frame their analysis as a call to action: without deliberate national strategies to revitalize pancreas transplantation and safeguard its training pathways, a therapy that offers genuine insulin independence risks becoming available to only a fortunate few, delivered by a workforce that is aging out faster than it can be replaced.

Subject of Research: Trends in pancreas transplantation activity and surgical training in the United States

Article Title: Pancreas Transplant Training in the United States: Trends and Implications

Article References: Nagaraju, S., Harris, M. K., & Dunn, T. B. (2026). Pancreas Transplant Training in the United States: Trends and Implications. Current Transplantation Reports, 13(1), Article 33. https://doi.org/10.1007/s40472-026-00529-4

Image Credits: AI Generated

DOI: 10.1007/s40472-026-00529-4

Keywords: pancreas transplantation, surgical training, transplant workforce, donation after circulatory death, organ perfusion, type 1 diabetes, simultaneous pancreas-kidney transplant, organ procurement, fellowship training, islet transplantation, organ discard, transplant policy

The most fundamental shift is in who the donors are. For decades, the typical deceased donor was a young person declared dead by neurological criteria, a donation after brain death, or DBD, donor whose heart was still beating and whose organs could be recovered in a relatively controlled operating room environment. That profile has eroded. Driven partly by the decline of the drug overdose epidemic that had supplied a tragic stream of young donors, and partly by the deliberate expansion of eligibility criteria, donation has shifted toward older, medically complex individuals. In parallel, donation after circulatory death, or DCD, has grown dramatically. In DCD, death is declared after the heart stops, which means the organs endure a period of warm ischemia, deprived of oxygenated blood at body temperature, before recovery begins. That physiological insult makes DCD organs riskier to use and far more demanding to preserve, but the review notes that DCD has become an increasingly dominant share of deceased donation in the United States.

This changing donor phenotype collides with a stubborn biological constraint: ischemic time, the interval during which an organ sits without adequate blood flow between recovery and transplantation. Every hour of cold ischemia, the period when an organ is flushed with cold preservation solution and stored on ice, inflicts cumulative injury on delicate tissue such as the cells lining blood vessels and the energy-hungry mitochondria of kidney and liver cells. Traditional static cold storage was adequate for young, robust DBD organs traveling short distances. It is far less forgiving for an older DCD liver or a marginal kidney that must now cross a much larger geographic footprint to reach its recipient. The mismatch between a more fragile organ supply and a more dispersed allocation system is, in the authors’ framing, one of the central engineering problems of modern transplantation.

The technological response has been a rapid migration toward machine perfusion. Instead of passive storage on ice, machine perfusion devices pump preservation fluid through the organ, either chilled, as in hypothermic machine perfusion and hypothermic oxygenated perfusion, known as HOPE, or at body temperature, as in normothermic machine perfusion, NMP. Normothermic systems go further, delivering oxygenated blood or blood substitutes so the organ remains metabolically active, allowing clinicians to assess viability in real time and even to recondition organs that would otherwise be discarded. For lungs, ex vivo lung perfusion has enabled longer travel distances and ischemic times in the composite allocation score era, and clinical trials have shown that lungs can be preserved for up to 24 hours at 10 degrees Celsius without compromising outcomes after transplantation. For livers, normothermic machine perfusion has been shown to transform the logistics of transplantation, extending viable preservation windows and reducing the pressure of the race against the clock.

But this technological rescue comes with a bill. Machine perfusion devices, disposable perfusion circuits, and the trained personnel required to run them are expensive, and their use has grown alongside the shift toward DCD and marginal organs. National analyses of liver transplantation document a steep rise in ex situ machine perfusion use, and studies of cost reveal that these technologies add substantially to the standard acquisition cost of each organ. Compounding the problem, the review highlights troubling center-level variability in who actually receives perfused organs: research has found associations between a transplant center’s use of normothermic machine perfusion and the insurance status of its recipients, raising equity concerns about whether the benefits of expensive technology are distributed fairly. Meanwhile, organ acquisition charges, the costs transplant programs pass on to insurers and Medicare, have been climbing for years, with analyses of organ procurement organization cost reports showing that the price of procuring a kidney or liver has risen well beyond general medical inflation.

Policy changes have poured fuel on this fire. The Organ Procurement and Transplantation Network, operating under federal oversight, has spent the past decade dismantling the old donation service area boundaries that historically gave local patients first claim on local organs. First acuity-based liver allocation and then the composite allocation score, a continuous distribution framework, replaced geographic priority with a points-based system balancing medical urgency, waiting time, and travel-related logistics. The stated goal is laudable: organs should flow to the sickest patients wherever they live, not to whoever happens to be nearest the donor hospital. Kidney allocation moved to a circle-based system, and lung allocation adopted continuous distribution. The consequences for logistics, however, are measurable. Studies have documented a large increase in the volume of organ offers that transplant centers must evaluate, decreased efficiency in kidney placement, and longer travel distances and ischemic times for lungs, all of which multiply the coordination burden on procurement teams and add cost at every step.

Federal pressure has also targeted the performance of the organ procurement organizations themselves, the 50-odd nonprofit entities that hold exclusive contracts to coordinate donation within their territories. The Centers for Medicare and Medicaid Services has tightened its conditions of participation and performance evaluations for OPOs, and the Health Resources and Services Administration launched a modernization initiative for the OPTN aimed at increasing accountability. More recently, the CMS Increasing Organ Transplant Access model, or IOTA, is designed to push transplant hospitals to perform more transplants. Analyses of procurement activity following CMS performance evaluations suggest these interventions are reshaping OPO behavior. The cumulative effect is a system in which every participant, from the OPO to the transplant surgeon, faces intensifying metrics-driven pressure to recover and place more organs, including organs that a more conservative era would have declined.

The result, the review argues, is an industry straining against an architecture designed for a different time. Organ procurement remains vertically integrated: the OPO coordinates the donor, dispatches surgical teams, arranges preservation, and manages transport, while transplant centers absorb the acquisition costs through a reimbursement structure, the standard acquisition cost framework, that has not kept pace with modern practice. The authors point to emerging alternatives, including dedicated procurement entities and on-demand organ recovery services that decouple the surgical recovery step from the local OPO monopoly. Evidence from individual centers suggests that specialized donor surgeon involvement can reduce discards of marginal liver allografts, hinting that professionalized, high-volume procurement teams might extract more usable organs from the same donor pool. Normothermic regional perfusion, an alternative to super-rapid recovery in DCD that restores circulation to abdominal organs before retrieval, illustrates how technique choice at the donor hospital ripples through cost and quality downstream, and it remains a subject of active regulatory debate at HRSA.

What would redesign look like? The authors sketch a future in which procurement, preservation, and transport are disaggregated and each is optimized independently. Dedicated procurement organizations could concentrate surgical expertise and standardize recovery quality. Regional perfusion and preservation hubs, analogous to central laboratories, could receive organs, assess them on machine perfusion platforms, and hold them in extended preservation, using technologies like 10-degree lung storage or overnight normothermic liver perfusion to convert the frantic overnight transplant into a scheduled daytime operation. Modernized reimbursement would need to pay transparently for these services rather than burying them in acquisition charges, and quality metrics would need to align across OPOs, preservation centers, and transplant programs so that no participant is rewarded for shifting cost or risk onto another. The review is careful to note the goal: improved efficiency, cost control, and organ utilization without reducing patient access.

The stakes of getting this right are enormous. More than one hundred thousand Americans remain on transplant waiting lists, and every discarded organ represents a life not saved. Xenotransplantation looms on the horizon as a potential additional supply, but as the review’s own financial analysis of procurement suggests, even pig organs will flow through the same procurement, preservation, and allocation infrastructure, inheriting its inefficiencies unless the system is reformed first. The changing landscape of organ recovery is, at its core, a story about a public trust, the gift of donated organs, being handled by a logistics network that was never designed for older donors, warmer perfusion machines, and continent-wide allocation. Fleischer and Sheetz make the case that the coming decade will decide whether that network is deliberately re-engineered, or whether it simply continues to absorb complexity and cost until something gives.

Subject of Research: Trends in US deceased donor organ procurement, preservation technology, allocation policy, and costs

Article Title: The Changing Landscape of Organ Recovery: Recent Trends and Future Predictions

Article References: Fleischer, C. M., & Sheetz, K. H. (2026). The Changing Landscape of Organ Recovery: Recent Trends and Future Predictions. Current Transplantation Reports, 13(1), Article 32. https://doi.org/10.1007/s40472-026-00530-x

Image Credits: AI Generated

DOI: 10.1007/s40472-026-00530-x

Keywords: organ procurement, deceased donation, donation after circulatory death, machine perfusion, organ allocation, composite allocation score, organ procurement organizations, transplantation policy, ischemic time, organ acquisition costs, normothermic perfusion, health policy