Disease's type and severity can vary widely, need professional assessment

[00:00:00] Host Amber Smith: Here's some expert advice from transplant surgeon Matthew Garner from Upstate Medical University. How can a person with diabetes know if they need a pancreas transplant?

[00:00:12] Matthew Garner, MD: You really can't. You have to come see us. Because it is so challenging to be able to determine whether or not you would benefit from one that I can't even expect most kidney doctors to have a good explanation of that.

What I can tell you is that if you have renal failure, if you're being referred for a kidney transplant, and you also have diabetes, you should be seen at a center that does both pancreas and kidney transplants. Because you want someone to look at you from the perspective of, could this person be a pancreas candidate? The answer to that may very well be no. And that's OK. Because ultimately what we want to do for you is to give you the best treatment we can. And for some patients, that is doing a pancreas transplant. For other patients, it's to say, "look, that's a too high risk surgery for you because it is a much bigger operation, so that what we're going to do instead is just work with your endocrinologist to get better glycemic control after the kidney transplant."

But if you go to a center that just does kidney transplants, there's not a good way to then get a pancreas transplant. And it is a little easier to get the kidney and the pancreas done at the same time than to do the kidney first and the pancreas later. We can do that. But it's a little bit more complicated because every time you do a surgery, it places that kidney transplant at a little bit of risk. And that risk is easier to tolerate when it's all at once. When you do it afterwards, and then the kidney doesn't work because of a problem, that's a tough pill to swallow. So we will do it if need be, because there are some patients that still benefit from that. But we preferentially try to do both at the same time to avoid that.

Additionally, you get a kidney and a pancreas from the same donor, the immunological burden on the patient is lessened, because they only have tissue from one donor as opposed to from two donors.

Now the way that we describe diabetes can be a little confusing. So in general, we refer to type 1 diabetes as someone who produces no insulin. They have had destruction, usually from an autoimmune process, which is the body attacking itself. They no longer produce insulin of any kind.

Type 2 diabetes is more characterized by insulin resistance. What insulin resistance is, when your body gets used to producing a lot of insulin. This is more common in people that are overweight, but it can happen to people that are of normal size as well. And what that resistance means is your pancreas needs to produce more and more insulin in order to achieve the same effect. And at a certain point, the engine is running as fast as it can. It's making as much insulin as it can. And yet it's not making enough in order to control the blood sugar, and you get diabetes. And then you have to take additional medicines or potentially even insulin to supplement that.

There is a term that some people use called diabetes 1.5, which is not an official term because it is kind of confusing. What that effectively refers to is a type 2 diabetic, someone who does make insulin and had insulin resistance, but doesn't really make much insulin anymore. So when your pancreas gets to the point where it has to work as hard as it can to make insulin because you have insulin resistance, what can happen to that over time is, in layman's terms, it sort of gets tired. It burns out. And so the amount that it can produce, just like an engine, you run too hard and too fast. It produces less and less insulin.

So sometimes we see patients who have type 2 diabetes, and their insulin production is so low they are basically functioning like a type 1 diabetic. And that's really important because when we put in a new pancreas it produces insulin normally, but it's just a normal pancreas. It's not a super pancreas. It's not going to produce any more insulin than your old pancreas could at its best. So if you are a type 2 diabetic, that still produces a lot of insulin, well, even if I put in another pancreas and it's working at full volume, that may still not be enough for you. Then I've done this surgery, and you're still on insulin, you still have diabetes. I haven't really helped you. So we try to avoid doing that.

On the other hand, if you're the sort of person who was a type 2 diabetic, saw that you were, lost weight, got some of your other diabetes under control, but still has it, and when we test you, we find that you don't make much insulin, now you're the sort of person that even though you're a type 2 diabetic, you're kind of behaving like a type 1. And that's a person because your problem, even though initially was insulin resistance, now it's more of a production problem. You're not making enough insulin. So what we do is we can put a pancreas into that person, and that extra insulin it produces is now enough to sort of make up for what was lost. And, you can take someone and correct their diabetes.

Now those patients will have a higher rate of recurrence, obviously, because they do have some of that insulin resistance that a type 1 diabetic doesn't usually have. But in careful patient selection, you can find people that can still benefit from that. But in general, the average type 2 diabetic will not benefit from a pancreas transplant.

[00:05:24] Host Amber Smith: You've been listening to transplant surgeon Matthew Garner from Upstate Medical University.