About Kidney and Pancreas Transplantation

When the pancreas does not produce adequate insulin, diabetes can result. With diabetes, high levels of sugar build up in the blood, often leading to serious complications involving nearly all tissues of the body. Short-term complications can include hyperglycemia (high blood sugar) and ketoacidosis (build up of acids in the blood). Untreated, these complications can be fatal. Even with insulin treatment, long-term complications include heart and blood vessel disease, kidney disease, blindness, and nerve damage to the legs and feet. If left untreated, diabetes can lead to death.

Life-sustaining therapy for diabetes involves supplying the insulin the pancreas cannot produce. This treatment is given through multiple insulin shots. Even with these injections, blood sugar levels can remain high or become too low, and are not controlled as well as by a normal pancreas.

Diabetes can also be treated with pancreas transplantation. When successfully transplanted, the pancreas produces steady levels of insulin, prevents high levels of sugar in the blood, and halts the progression of the long-term problems associated with diabetes.

The first pancreas transplant was performed in 1966, yet pancreas transplantation has only become an accepted treatment for carefully selected Type I diabetes patients within the past ten years. As of December 1993, more than 5,000 pancreas transplants had been performed worldwide. Almost three-fourths of these transplants were performed in conjunction with kidney transplants (combined kidney-pancreas transplant) for patients with both diabetes and kidney failure. For these patients, the combined kidney/pancreas procedure is superior to such treatment options as continued insulin therapy, dialysis, or kidney transplantation alone.

Throughout the years, several types of pancreas transplants have been performed. The first pancreas transplant (1966) involved transplanting only a portion of the organ. The most successful technique today—the one used at University Hospital—involves transplanting the entire pancreas, and most are combined with kidney transplants.

In fall 1997, University Hospital's Transplant Team performed the first isolated pancreas transplant and New York State's first kidney transplant combined with the transplantation of islets, the insulin-producing cells of the pancreas. At University Hospital, research continues to develop other techniques for the treatment of diabetes.

Patients who have Type I diabetes with kidney failure should discuss this option with their nephrologist or endocrinologist to determine if they are medically suitable. The primary contraindications for transplantation are active infection or recent cancer.

In some cases, people who have Type I diabetes without kidney disease may also be eligible for pancreas transplantation. These candidates frequently experience life-threatening fluctuation of their blood sugars and have difficulty regulating their blood sugars over a long period of time. The transplant surgeons at University Hospital are available to discuss the option of pancreas transplantation with patients, their primary care physicians, nephrologists, or endocrinologists.

University Hospital's transplant team will begin by requesting records from the primary care physician. Before any plans for surgery are made, the transplant team will evaluate the patient's medical status and schedule a complete evaluation.

Candidates for pancreas transplantation must demonstrate that they are able and willing to be involved in their own care. A great deal of the transplant's success depends on the patient's ability to take medications as instructed and to follow the recommendations of the transplant surgeons and nurses.

Most pancreas transplant candidates are under the age of 50.

Before patients become transplant candidates they must:

1. Attend a teaching session presented by a transplant coordinator. This session will address the questions and concerns of the patient and family.
2. Attend a pre-transplant interview with the transplant team, who will review all issues and answer questions.
3. A cystogram may be needed, which is a study of bladder function. To conduct this test, a catheter is placed temporarily into the bladder. To be determined by the team.
4. Undergo laboratory testing, including tissue-typing and HIV testing.
5. Complete a simple heart test called a Dobutamine Stress echocardiogram, which takes a couple of hours, is performed on an outpatient basis, and helps the transplant team assess the potential risk-level of the proposed surgery.

Following the interview with the team, additional tests may be requested. Many of the tests listed above can be performed by your nephrologist.

The recipient's pancreas is not removed, nor—as a rule—are the kidneys. However, a transplant surgeon will evaluate the option of kidney removal. The most common reason for removal of the original kidneys is frequent urinary infections.

Donor organs are obtained from stable, heart-beating individuals who have been declared 'brain dead' due to traumatic events. Brain death, or the determination of death by neurological criteria, is the irreversible cessation of all functions of the brain. In all cases, consent for organ donation is obtained from the donor's family or next of kin. Artificial support is used to keep the donor's other organs functioning until donation occurs.

A person selecting this type of transplant must wait until a suitable donor becomes available. Then, this donor undergoes extensive testing to document that the removed organs are functioning normally and are free of disease. Donor organs are matched to recipients based on blood type, tissue type, medical need, and length of time on the waiting list. Once a pancreas is removed from a stable donor, the team has approximately 24 hours to safely perform the transplant. During this time, laboratory testing determines compatibility between the donor and potential recipient.

• Anatomical Gift Program

Once approved for transplant, the candidate is placed on University Hospital's waiting list. The average waiting time for a pancreas transplant in the United States is 6 to 12 months, but it is hard to estimate how long the candidate will wait for a suitable donor organ. People on the waiting list continue to perform normal, daily activities. Some may be asked to lose weight or quit smoking.

Combined pancreas/kidney transplants are usually completed within 8–10 hours.

During the transplant operation, an incision is made in the center of the lower abdomen. The pancreas is placed on the right side of the abdomen and attached to the bladder or the bowel. This placement allows for fluid and enzymes that the body does not need to exit through the urine or stool. If a kidney is transplanted also, it will be placed on the left side of the abdomen through the same incision. Your transplant team will discuss the technique at the time of your evaluation.

The average hospital stay for an uncomplicated transplant is about two weeks.

Besides freeing the recipient from insulin injections, a successful pancreas transplant can sometimes reverse the complications of diabetes. For example, there may be improvements in the areas of diabetic numbness in the feet, and slow the advancement of retinopathyif these conditions are not too advanced.

Other than the risks of the operation, the main risks of any transplant procedure are associated with the long-term use of medications. These medications must be taken daily for the rest of the transplant's life, because the body can reject a transplanted organ at any time. There may be undesirable side effects from these medications. There may also be special considerations or disadvantages unique to individual patients; these will be discussed with the transplant team.

For 24 to 48 hours after surgery, transplant recipients are kept under observation in the Intensive Care Unit (ICU). Once stabilized, they are moved to regular rooms on the Transplant Unit.

To a great degree, transplant recipients determine the success of their transplants. For the rest of the transplant's llife, they must take daily medications to help prevent organ rejection. Prior to discharge from the hospital, they must learn the names, dosages, and major side affects of their medications. They will also be given special guidelines and instructions to follow after discharge.

For the first three months after the transplant, blood must be drawn two times a week, more frequently if there are complications. The frequency of the blood work usually decreases after three months, six months, and one year. These laboratory results help the transplant team identify a rejection episode, so it is important to adhere to this testing schedule. It is very important for transplant patients to be knowledgeable and involved in their own care following surgery.

Currently, private medical insurance and Medicare's End-Stage Renal Disease Program share the cost of kidney transplantation. The Veteran's Administration or Medicaid may provide financial aid for some patients, although aid must be applied for—and eligibility must be determined—on an individual basis.

Coverage for the pancreas portion of the must be determined prior to the surgery. Private insurance companies vary in this coverage. All candidates for the combined procedure will be interviewed by the University Hospital Transplant Financial Coordinator, where financial arrangements will be discussed in greater detail.