despite improvement in insulin therapy , pancreas transplantation ( pt ) is currently the only treatment that restores normal glucose metabolism and substantially improves the quality of life in type 1 diabetes mellitus ( t1 dm ) patients . depending on donor characteristics and the clinical condition of the recipient , there are differences in both graft and patient survival . in diabetic patients with end - stage renal disease ( esrd ) , simultaneous pancreas - kidney transplantation ( spkt ) offers lower patient mortality than patients on the waiting list or deceased donor ( dd ) kidney transplant recipients [ 59 ] . the advantage in patient survival of pancreas after kidney ( pakt ) or pancreas transplantation alone ( pta ) over conventional therapy remains controversial . according to the international pancreas transplant registry ( iptr ) , at 31 december 2004 , > 23 000 pancreas transplants had been reported , with a higher proportion performed in usa ( n  =  17 132 ) than in non - usa countries ( n  =  5294 ) where 89% were performed in europe . moreover , between 2000 and 2004 , the annual number of pt reported in usa remained constant at ~1400 , while in non - usa countries , the number of reported cases decreased from > 450 to ~250 in the same period . the discrepancy in pt activity between usa and europe may be due , at least in part , to differences in the reporting registry . while the iptr has a relation with the united network for organ sharing ( unos ) of usa and transplant activity report to unos is mandatory , such reports from non - usa countries are voluntary . however other factors , such us decease organ donation , other deceased solid organ transplant ( dsot ) activity , waiting list inclusion criteria and prevalence of t1 dm or esrd secondary to t1 dm , may play a role in the differences of reported pt worldwide when adjusted to population . the primary objective of the present study was to compare the true incidence of pancreas transplant activity between usa and 13 selected european countries ( sec ) and secondly , to evaluate the relationship with deceased organ donation and other dsot activity during the period between 2002 and 2006 . for the period 200206 , we analysed databases from different national transplant organizations ( france , italy , spain , switzerland and united kingdom ) [ 1014 ] , other european countries included in organ exchange organizations , such as eurotransplant ( austria , belgium , germany and the netherlands ) , scandiatransplant ( denmark , finland , norway and sweden ) , and the unos from usa . in all cases , the annual report included the period between 1 january and 31 december , except for the united kingdom which analysed the financial year ( between 1 april and 31 march of the next year ) . for the purposes of this study , other european countries with > 105 million inhabitants had some pt activity , such as bulgaria , czech republic , croatia , poland , hungary , portugal , ireland and rumania , but we were unable to obtain any data from their national transplant organizations . in order to ensure the validity of the results from database reports , these were checked independently by the four authors ( jmgp , dm , lpt and pg ) and then compared with the results published every year by the council of europe in the transplant newsletter . in most cases , there were no differences or they were minimal and due to the inclusion of some islet cells transplantation activity ( see below ) ; in any case , the data reports from the different transplant organizations were taken as accurate . the number of dd , pt , deceased donor kidney transplantations ( ddkt ) , deceased donor liver transplantations ( ddlt ) and heart transplantations ( ht ) for each year was obtained . as the pancreas is the organ most frequently transplanted together with another organ , two categories of pt were considered according to the renal function of the recipient : spkt in patients with esrd and solitary pt in patients without current renal disease . likewise , we recorded the number of patients on the pancreas transplant waiting list at the end of each year . as pt from living donors is only exceptionally performed ; any transplant activity involving living donors was not included in the analysis . in order to take into account demographic differences between countries for comparative purposes , the total number of pt , dd and other dsot activity was calculated , and the rates were expressed as incidence per million population ( p.m.p . ) . the population of each european country in the different years was obtained from the statistical office of the european communities ( eurostat )   and the usa population from the us census bureau . the total number corresponding to dd , pt activity and pt active waiting list are shown in table 1 together with demographic changes in the different countries and years . in usa , the total number of pt decreased from 1460 in 2002 to 1386 in 2006 ( 5% ) and the rate from 5.08 p.m.p . in 2002 to 4.64 in 2006 ( 8.7% ) . by contrast , in sec , the total number increased from 591 in 2002 to 718 in 2006 ( 21.5% ) as well as the rate from 1.61 p.m.p . in 2002 to 1.91 p.m.p . in 2006 this increment was mainly due to increased pt activity rate in five countries ( france , italy , the netherlands , spain and especially united kingdom ) , which outweighed the decreases recorded in six other countries ( austria , belgium , germany , norway , sweden and switzerland ) . in two sec ( denmark and finland ) , there was no reported pt activity during the period analysed ( table 1 and figure 1 ) . only two sec ( austria and belgium ) showed a higher rate of pt activity than usa for any of the 5 years analysed . surprisingly , in belgium , this rate decreased from 6.21 p.m.p . in 2002 to 2.47 p.m.p . in 2006 ( 60.2% ) . the pt rate was at least 2.4 times higher in usa than in sec for any of the 5 years analysed ( figure 1 ) . in usa , the total number of spkt increased from 905 in 2002 to 924 in 2006 ( 2% ) representing 62 and 66.5% , respectively , of all pt activity . in sec , the total number of spkt increased from 457 in 2002 to 605 in 2006 ( 32.4% ) , representing 77 and 84.5% , respectively , of all pt activity . only italy showed a similar percentage of spkt than usa , while austria and belgium showed a lower percentage than the sec median ( data not shown ) . population , total number of pancreas transplants , pancreas waiting list and dd in usa and 13 european countries dd  =  deceased donors . pancreas transplant activity rate ( incidence per million population ) in usa and 13 european countries considered together ( sec ) and individually during the period 200206 . in usa , although the number of patients on the active waiting list for pt at the end of each year decreased from 2835 in 2002 to 1984 in 2006 ( 30% ) ( table 1 ) , the number of candidates awaiting pt that remained inactive increased from 753 in 2002 to 1970 in 2006 ( 162% ) ( data not shown ) . the number of patients on the active waiting list in sec increased from 897 in 2002 to 1009 in 2006 ( 12.5% ) . in five sec countries ( austria , belgium , france , italy and sweden ) , it decreased ; in another five ( germany , the netherlands , spain , switzerland and united kingdom ) , it increased , while in norway this number did not change . in denmark and finland , there were no patients on the active waiting list during the period analysed ( table 1 ) . deceased donation increased in usa from 6190 in 2002 to 8024 in 2006 ( 26% ) and in sec from 6422 in 2002 to 7340 in 2006 ( 14.3% ) ( table 1 ) . the dd rate was higher in usa ( 21.52 p.m.p . in 2002 and 26.89 p.m.p . in 2006 ) than in sec ( 17.51 in 2002 and 19.56 in 2006 ) , but the differences were not as high as in pt activity , only 1.21.38 times higher during the period analysed . three sec countries ( austria , belgium and spain ) showed similar or higher dd activity rate than usa , while france , finland and italy showed a higher activity rate than the sec median ( figure 2 ) . dd activity rate ( incidence per million population ) in usa and 13 european countries considered together ( sec ) and individually during the period 200206 . from 2002 to 2006 , the total number of ddkt increased in both usa ( from 8593 to 10 659 ; 24.8% ) and sec ( from 10 736 to 11 955 ; 11.3% ) . accordingly , ddkt activity rate was slightly higher in usa , but five sec ( austria , belgium , finland , france and spain ) showed higher activity rate than usa ( figure 3 ) . deceased kidney transplant activity rate ( incidence per million population ) in usa and 13 european countries considered together ( sec ) and individually during the period 200206 . the total number of ddlt increased in usa from 4969 in 2002 to 6362 in 2006 ( 28% ) , whereas a lower increase was observed in sec ( from 4757 in 2002 to 5536 in 2006 ; 16.4% ) . ddlt activity rate was higher in usa ( 17.2721.32 p.m.p . ) than in sec ( 12.9714.75 p.m.p . ) between 2002 and 2006 , but the differences were not as high as in pt ( only 1.31.44 times higher ) . only two sec countries ( belgium and spain ) showed a higher ddlt activity rate than usa ( figure 4 ) . deceased liver transplant activity rate ( incidence per million population ) in usa and 13 european countries considered together ( sec ) and individually during the period 200206 . the total number of ht was similar between 2002 and 2006 in usa ( 21552192 ; 1.7% ) and sec ( 19702011 ; 2.1% ) , with a higher activity rate in usa . nevertheless , four sec ( austria , belgium , norway and spain ) showed a similar or higher ht activity rate than usa ( figure 5 ) . heart transplant activity rate ( incidence per million population ) in usa and 13 european countries considered together ( sec ) and individually during the period 200206 . the percentage of pancreata recovered and transplanted from dd was higher in usa ( 23.6% in 2002 and 17.3% in 2006 ) than in sec ( 9.2% in 2002 and 9.9% in 2006 ) , but overall , this percentage decreased in usa with respect to sec . however , five sec ( austria , belgium , germany , norway and switzerland ) showed an important decrease in this percentage , while in four ( france , the netherlands , spain and specially united kingdom ) , it increased ( figure 6 ) . number of pancreata recovered and transplanted from every 100 dd in usa and 13 european countries considered together ( sec ) and individually during the period 200206 . firstly , a large number of pt performed in non - usa countries are not reported to the iptr . secondly , thirdly , there was great variability between sec countries in pt activity not related to the number of dd or other organ transplant activity . finally , despite the increase in the number of patients on the pt waiting list in some countries , a high percentage of pancreata are not recovered from dd . the latest report of the iptr , published in 2005 , estimated that < 10% of non - usa pt activity was not captured by the registry , with < 250 cases reported in 2004 . however in that year , our analysis showed that , in the 13 sec analysed , the total number of pt performed were 657 cases . moreover , according to other sources , in 2004 , > 200 pt cases were performed in australia , new zealand , canada , turkey , argentina , uruguay , republic of korea , japan , saudi arabia and other european countries ( czech republic , poland , bulgaria , hungary , portugal , ireland and romania ) . additionally , in brazil , with no data for 2004 , a total of 173 cases were reported in 2006 to the global observatory on donation and transplantation . according to these data , recent pt activity from non - usa countries may be higher than 1000 cases per year , with no > 30% being reported to the iptr . mandatory reporting of all pt activity from national registries to the iptr is needed to allow worldwide comparisons . we found important differences between countries in pt activity rate not related to dd or other dsot activity . although in usa , the dd and other dsot activity rates were higher than in sec , the differences were much higher in pt . moreover , while dd and other dsot activity rate increased in most countries , pt activity showed important variability regardless of the evolution in dd or other transplant activity . furthermore , the differences observed between countries in the same year and in the same country in different years did not show a similar evolution in dd and other dsot activity rate . another important difference between usa and sec is the higher percentage of spkt in sec due to a lower proportion of solitary pt performed in most sec . it is plausible that in usa , with a higher living donor kidney transplantation rate than sec , the high percentage of pakt in which the kidney came from a living donor ( > 60% )   may help to explain this difference . it decreased in usa and increased in sec despite the inverse evolution in pt activity . the waiting list increase in sec was mainly due to the increment of candidates for pt in the netherlands , spain and especially united kingdom ; however , these countries together with france and italy are the ones that contribute to the overall increase in pt activity in sec . paradoxically , the number of candidates on the active waiting list at the end of 2006 was almost 2-fold higher in usa with a lower population than in sec . however , this may be due to different criteria for registration on the waiting list ( older candidates ) and different allocation policies as has been observed in usa . in addition , the gap between the demand ( number of candidates on the active waiting list ) and the number of pt performed is higher in usa and again , important differences were found between countries . it increased in belgium , germany , the netherlands , norway and switzerland but dropped in usa , austria , france , italy , sweden and united kingdom . negative ( the number of pt performed per year was higher than the number of waiting list candidates at the end of the year ) , only occasionally in austria , belgium , germany , the netherlands and more frequently in norway , spain and switzerland . in general , a very large gap may indicate the need for greater pt activity . pancreas underutilization is another important challenge and has been considered an important issue in usa . when comparing practises in sec , we found variable proportions of dd from whom pancreata were recovered and transplanted . this proportion shows important changes between countries and years , varying from < 5 to > 25% . this may reflect the increased number of older donors , although the lack of experience in some recovery teams has been also considered . pt activity actually decreased during the period analysed in most countries and only increased in france , the netherlands , spain and especially in the united kingdom . it may also be speculated that the option of maintaining the patient with insulin therapy plays a role in pancreas underutilization and most transplant teams only accept ideal organs . in this respect , studies from usa showed that the non - recovery rate and the discard rate among recovered pancreata increased in recent years . taking into account these data , important efforts must be made to improve the underutilization of pancreata from dd , especially in those countries with a long waiting list . however , according to the international diabetes federation and the diabetes mondiale project group , the incidence of t1 dm in children ( 014 age range ) is higher in europe than in north - america , with a very high incidence ( > 20/100 000 per year ) observed in finland , norway , sweden and united kingdom . more important than the incidence of t1 dm in children is , in this case , the incidence of esrd , at any age , secondary to t1 dm . however , we found a very limited number of studies analysing this issue in recent scientific literature [ 2831 ] . this incidence varies in europe in 19992000 , between 16.3 cases p.m.p . in denmark , ~13 cases p.m.p . in finland , sweden and united kingdom ( scotland ) , 8.3 cases p.m.p . in austria , ~6 cases p.m.p . in spain ( catalonia ) , norway and the netherlands and 3.8 cases p.m.p . in belgium ( french - speaking ) although this incidence has increased in most countries with respect to the period 199192 , it decreased in austria and especially in belgium , and in more recent years , it stabilized in denmark   and decreased in the netherlands . on the other hand , according to reports of the united states renal data system , it can be calculated that the incidence of esrd secondary to t1 dm decreased in usa from ~16 cases p.m.p . in the period 19972001 to 13 cases . the higher incidence of esrd secondary to t1 dm in usa compared with sec with a lower incidence of t1 dm may be due to an increased risk of this complication among ethnic minorities ( blacks and hispanics ) in usa , although the role of disparities in access to health care ( universal in europe and mostly private in usa ) , especially for chronic disease such as t1 dm , requiring prolonged and regular treatment , should also be considered . other potential explanations for the observed discrepancies in pt may include different insurance reimbursement policies and attitudes regarding the indication for pt , as reflected by the different statements issued by scientific societies [ 3639 ] . however , these factors may play a minor role because pt is covered by the different national health systems or private insurance in most sec or by medicare in usa ( except for pta in usa which has only been covered since april 2006 ) . moreover , similar specific recommendations for pt in diabetic patients have been published by the american diabetes association , the national kidney foundation and the american society of transplantation [ 3638 ] as well as the european renal association and the european society for transplantation . finally , it is plausible that the clinical criteria for inclusion on a pt waiting list vary between countries and even between different teams in the same country , as previously reported for spkt in the netherlands . as an example , spkt is not indicated for esrd diabetic patients in countries with a high incidence of this complication ( denmark and finland ) , where kidney transplant alone ( kta ) with more intensive treatment is the therapeutic option used with improved results in patient survival in recent years . in addition , in usa , ~7% of all spkt are performed in type 2 diabetic patients , while there are no comparable data from sec . although in a single - centre study from spain , this percentage was similar ( 5.2% ) , specific studies in the different sec are needed in order to determine whether there are differences in this attitude . the development of pt has been historically limited by the lack of randomized , controlled trials and relatively poor survival but currently , surgical and immunosuppressive advances have improved the results . although kta is clearly associated with a significant increase in life expectancy when compared with diabetic patients remaining on the waiting list , there is controversy as to whether adding a pancreas contributes independently to patient survival . while large population multi - centre and single - centre studies comparing spkt versus kta have found longer patient survival for spkt recipients , registry - based analysis showed contradictory results [ 9,4446 ] , probably limited to the information available in the database from registries . in addition , the clear and significantly lower mortality risk , after the 3 months post - transplantation period , in spkt as compared with patients who remained on the waiting list , is less evident for pakt and pta . these discrepancies may be a reason for the differences in prevailing attitudes in the medical community worldwide . a future survey of practitioners in europe and perhaps in usa will better delineate the current position regarding the utility of pt . although a decade ago , spkt was considered as optimal and the treatment of choice for juvenile diabetic patients with esrd for an increasing number of centres in europe , currently this approach remains uncommon and even inexistent in some european countries . due to the high mortality , while on dialysis , of this population , a debate is needed about the reasons of disparities in pt activity in europe . in conclusion , pt activity rate and active waiting list candidates were higher in usa than in sec countries . the differences were not related to deceased donation or other deceased transplant activity and are likely to be multifactorial . future analyses are needed to determine whether these results are due to differences in clinical indication for pt , higher incidence of diabetic nephropathy secondary to t1 dm or other unknown reasons .
background . 
 although pancreas transplantation ( pt ) is the treatment of choice in selected diabetic patients , the international pancreas transplant registry ( iptr ) has reported important differences in activity between usa and europe . of all cases 
 reported , 75% are from usa and only 23% from europe . therefore , an analysis of pt activity in selected european countries ( sec ) and usa was performed.materials and methods . 
 we compared national data reports ( 200206 ) of deceased donors ( dd ) and deceased solid organ transplantation ( dsot ) , with special attention to pt activity from 13 sec countries ( 375 million inhabitants ) and usa ( 298 million inhabitants).results . 
 the number of pt performed in usa was 2-fold higher than in sec , with the annual rate > 2.4 times higher in usa [ 5.084.64 versus 1.611.91 per million population ( p.m.p . ) ] . 
 dd and other dsot activity rates were only slightly higher in usa . in sec , 
 important differences in pt activity rate were found between countries in the same year ( 06.21 p.m.p . ) and in the same country between different years ( 6.212.47 p.m.p . ) , unrelated to dd or other dsot activity rate . 
 pt activity rate increased in sec from 1.61 to 1.91 p.m.p . but decreased in six countries . 
 the waiting list for pt at the end of 2006 was almost 2-fold higher in usa than in sec.conclusions . 
 differences in pt activity rate between 13 sec countries and usa were not related to dd or other dsot activity . 
 different waiting list inclusion criteria or incidence of diabetes complications may be considered in more specific studies .