Why some patients will also receive a new kidney

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. . People with type 1 diabetes may benefit from a pancreas transplant. Here to explain is Dr. Matthew Garner. He's an assistant professor of surgery specializing in transplant surgery at Upstate. Welcome to "The Informed Patient," Dr. Garner.

[00:00:28] Matthew Garner, MD: Thank you. It's a pleasure to be here.

[00:00:30] Host Amber Smith: Now to begin with, do I understand correctly that there are two parts to the pancreas, the exocrine part, which handles digestion of nutrients, and the endocrine part that regulates the glucose?

[00:00:42] Matthew Garner, MD: Essentially, yes. The pancreas is a fairly complex organ. And in general we sort of break it down into the function that it provides either in the endocrine function, which is sort of directly into your bloodstream to modulate things like your glucose level and to help control and prevent diabetes, and the exocrine function, which is sort of the digestive enzymes that it secretes in order to help you digest your proteins and other foods and fats.

[00:01:09] Host Amber Smith: So in type 1 diabetes, is the entire pancreas malfunctioning?

[00:01:15] Matthew Garner, MD: In rare cases it can be, but in general, type 1 diabetes is solely a disease of the endocrine function. Your insulin is produced with what we call beta cells, and in type 1 diabetes, those have been injured or destroyed, usually by the body's own immune system attacking them.

As a result, the pancreas usually functions normally for the rest of its functions. So your digestion works out reasonably well, however it loses its ability to allow the body to control glucose levels, and so you get type 1 diabetes.

[00:01:46] Host Amber Smith: How big is the pancreas in an adult?

[00:01:50] Matthew Garner, MD: I'm gonna cheat a little bit because the real answer is, it depends on how big you are. But on average about six inches, and then about maybe two inches wide. It is nestled sort of right underneath your stomach. The first part of the small intestine attaches to the stomach and performs a little loop that we actually just call the C loop, because it looks like the letter C. And nestled in the little C is the head of the pancreas. And then the tail goes off to the left. And that's how it gets its digestive juices for the exocrine function, right into the small bowel after the stomach. And it's also very close to the liver, which enables it to send its insulin and the endocrine functions sort of directly to the liver and sort of the first pass metabolism that allows the body to then use it and distribute that enzyme to the rest of the body.

[00:02:36] Host Amber Smith: So how is it that a transplant can cure type 1 diabetes?

[00:02:41] Matthew Garner, MD: In general, someone has developed type 1 diabetes due to the loss of their endocrine function from their pancreas. What we do by putting a new pancreas into someone is to replace that lost function.

So you have to attach the pancreas to the body in such a way that the arterial - you know, the blood supply coming into the pancreas - and the venous - the blood supply leaving the pancreas - is now hooked up to the recipient. Now, when that new pancreas develops and produces insulin, it is as it normally should, it now goes into the recipient's host body and is used and metabolized in the same way that insulin was used by the body prior to them developing their type 1 diabetes and sort of reverses the effects of it.

[00:03:25] Host Amber Smith: Do you leave the native pancreas in place, or does that come out when you transplant the new one?

[00:03:31] Matthew Garner, MD: So sometimes it has already been removed if the patient had some problem that necessitated the pancreas being removed. But if it is still in place, it's not hurting anyone, so we leave it alone. We put in the new one, essentially, because the old one, as I mentioned how it's located next to the small intestine, that's actually a bit of a tricky place to get to. So if you don't have to take it out, there's good reason not to, because it would increase the difficulty of the operation and the likelihood that there would be some sort of issue afterwards. If someone did need their pancreas removed, we would almost certainly do that before doing the transplant, in an effort to minimize how challenging this operation would be. Basically make it as simple as you possibly can so that the outcomes for the patients are better.

[00:04:15] Host Amber Smith: Now, can a transplant help someone who has type 2 diabetes? Because that's different than type 1.

[00:04:21] Matthew Garner, MD: That's a very good question. So that gets into some of the nomenclature. 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 as I mentioned, 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.

[00:07:50] Host Amber Smith: Interesting.

This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Matthew Garner, a transplant surgeon at Upstate, about pancreas transplants.

So who are pancreas transplants meant for, in terms of age, gender, disease, state? What, are the patients that you can help?

[00:08:11] Matthew Garner, MD: The most common patient that we do transplants for pancreas for is for diabetes, replacement of the loss of endocrine function. Rarely, patients who have had pancreatectomies, they've had to have their pancreas removed for one reason or another, would get a pancreas transplant where you would also attempt to give them the exocrine function back. But that's fairly uncommon. Most commonly, we would do it for people that had diabetes.

Now, when we think about the pancreas transplant, one of the things we have to consider is that our endocrinology colleagues have done a terrific job in controlling diabetes. It is an easier disease to treat than it used to be. So our indications why we do pancreas transplants has changed. It used to be if you had type 1 diabetes, a pancreas transplant was frankly the best thing you could offer. And the limit was being able to get on the list and being healthy enough to get a transplant. Now, with continuous glucose monitors and glucose pumps, we do a better job of controlling diabetes.

The most common reason we now do a pancreas transplant is when we do it in conjunction with a kidney transplant. Diabetes, especially uncontrolled diabetes, is a one of the leading causes of kidney failure in this country. And, one of the consequences of a transplant is immunosuppression. So if I put a pancreas transplant into somebody, that pancreas didn't come from them. It came from somebody else. So their body is going to recognize it as foreign material, just like a virus or a bacteria, and it's going to try to attack it. We have to put a stop to that, otherwise it's not going to work.

So we have to give patients very powerful medicines called immunosuppressants, and those medicines reduce the immune system. They don't make it go away, but they slow it down. And what that means is that you're going to be at lifelong increased risk for things like infection and cancer, stuff that the immune system normally takes care of.

Now, for the patients that we do the transplant on, we've thought about this and we want to make sure that the benefit of the new organ exceeds the risk of the immunosuppression. And what's interesting about that is for dialysis patients, that's true for almost everyone. If you're healthy enough to survive a kidney transplant, you almost always benefit from getting one.

Pancreas is a little trickier. As I mentioned before, we have continuous glucose monitors and pumps, so we're able to do a better job at controlling it. There are still some patients that, despite their best efforts, their body is just not very forgiving. And they still benefit from a pancreas transplant by itself. But, the majority of patients who just have diabetes can be controlled by their endocrinologist. Where we step in is that patient who has already progressed to renal disease. So now you have a patient that clearly benefits from getting a kidney transplant, and you also have the opportunity to give them a pancreas transplant at the same time, almost always from the same donor.

And what that means is, there's no additional immunosuppressive risk? Well, there's a very small amount of additional risk because there's more tissue we're transplanting. But in general it comes from the same patient. You'll be taking the same medications. And when you give a patient with diabetes a kidney transplant - diabetes can and often does contribute to the eventual failure of that kidney transplant - so by also giving them a pancreas at the same time, not only do you improve their life in the sense that they come off of insulin, and their diabetes is better controlled, but you also help protect that kidney somewhat.

So that's where we're most able to help people, is in the folks that have already had kidney failure or kidney injury who also have diabetes. And that's where we look to intervene.

[00:12:06] Host Amber Smith: Are pancreas transplants ever used for pancreas cancer?

[00:12:10] Matthew Garner, MD: It is infrequent, but not impossible. You would not do the pancreas transplant at the time of treatment for pancreatic cancer because, as I mentioned, the immunosuppression increases the risk of cancer, and while it can be uncomfortable, unlike your liver, you can live without your pancreas. There are medications we can give you. You can take insulin. You can take the pancreatic digestive enzymes. It may not be a fantastic experience, but it is, you're still alive. And so we don't want to give you the additional risk of the cancer coming back.

However, it is not impossible for someone who had their pancreas removed for cancer, who has recovered from the cancer, to potentially be a candidate for a pancreas transplant. It would be fairly rare. But it would not be unreasonable if you were in that situation as a patient to talk to someone about it, to see what your options were.

[00:13:05] Host Amber Smith: Now, what is the process of matching a recipient with a donor for pancreas transplants?

[00:13:11] Matthew Garner, MD: It is a little bit more complex than a kidney transplant. The reason for that is twofold. One, because we have fewer patients now that need pancreas transplants than patients that need kidney transplants, we tend to be very choosy about which pancreas is we de to be of acceptable quality. And there's a couple of reasons for that, but the most important one is the pancreas is an organ that ages fairly quickly in the human body. Even by the time you get to 40, it's not as strong as it was when you were in your twenties. It gets hurt pretty quickly. And that has something to do with the American diet and how we all are a little bit more overweight than we should be, and all those sorts of insulin resistance that you see in most of our patients, most people in America. But also just, it gets tired quicker than some of the other organs do. The kidneys can be in great shape for a long time. Usually the pancreas runs into trouble within a couple of decades, so we have to be more selective.

Additionally, even with your age, how the pancreas appears can vary somewhat dramatically from individual to individual. So it's actually a bit of an involved process. You're there. You know about these cases before the donor goes to the OR (operating room) for the procurement. You talk to the people that are doing the recovery and explain to them what you're looking for, what size you need, what sort of patient you're looking to give this to. You consider what other organs are being procured, and if the removal of those organs is going to potentially damage the pancreas. You then take a look, usually by photograph, of the pancreas in the donor before it comes out to make sure that it looks healthy, that it looks normal.

And then, once everything has been selected, you get the pancreas sent to you. You bring your own patient in. But then you spend a many-hour process of what we call back benching the pancreas, which is where it's out of the donor. It hasn't gone into the recipient yet. But you're in the operating room looking at it, tying off the small vessels and inspecting it very carefully to make sure that it looks and feels as good as it needs to in order to be able to use it. And I say feel because actually you do feel it. The pancreas feels differently. It's less dense as it becomes older and a little bit less functional. So you can use that as a guideline to help you decide whether or not this will be a good choice.

And if it's not, you pause. You stop and you don't use it because as I mentioned, we do this procedure less commonly now because of how good we are at glycemic control. So that means there is no reason to rush into this. So if you have a pancreas that you even have the slightest concern over, you pause because another opportunity is going to come fairly soon for that patient, and you don't need to worry about trying to throw together something that probably will work, but you're taking a risk. You can afford a greater sense of certainty.

[00:16:11] Host Amber Smith: So how does the waiting list in Central New York compare for pancreas versus kidney?

[00:16:17] Matthew Garner, MD: As I mentioned, the pancreas list involves fewer people because there are many people that are on dialysis who require a kidney transplant. And there are fewer of them that are candidates for pancreas transplant. Usually it's because they either don't have diabetes or because the diabetes they have is the sort of type 2 diabetes where a pancreas transplant is not going to be particularly helpful. As a result, many patients can get transplanted within a few years of being on the pancreas list. Sometimes even within one year, depending on your blood type and other factors. Whereas kidney transplant patients can be waiting more years than that, sometimes four to seven.

Now, what's also special about a pancreas transplant, you remember how I said earlier that you often do the pancreas and kidney transplant together? Well, when we talk about organ donation, we also have to consider the priority of how those organs are allocated.

And the way that it works is if I am taking a pancreas for one of my patients, the kidney from that donor comes with it. Normally, when you're just allocating a kidney by itself, it's just in the normal kidney waiting list. Essentially what this means is, is that the pancreas patient gets a kidney that comes from a much younger donor. And the reason for this is because we have to be choosy about the pancreases. And because the pancreas is a multi-organ procedure - you're putting in a pancreas and a kidney - it gets some additional priority. And that means that someone who otherwise would perhaps have to wait those seven years for a kidney transplant, not only do they get transplanted earlier, but they get an organ that comes from a younger donor that tends to work longer and work better. So that also works to the advantages of patients that are pancreas candidates.

Even if the pancreas has trouble and has difficulty functioning or doesn't work quite the way we would hope, because I hope I explained sufficiently, is a little bit more challenging to get to work even if it doesn't work, the kidney that has come with that donor usually tolerates the procedure very well and is of higher quality than what you could expect to receive being on the wait list for a kidney alone.

[00:18:37] Host Amber Smith: If you're doing a kidney and pancreas transplant, does one surgeon do those sequentially, or do you have two surgeons working on the two different organs at the same time?

[00:18:49] Matthew Garner, MD: It actually depends on your institution. So I have worked at places where there was one surgeon that did everything, and I will tell you honestly, that is a very unpleasant experience. It is a very long time, and at the end of that day, as the surgeon, you are very tired.

Now where I've worked since then, it has always been a multis surgeon experience. And I think that is the optimal way to do it. And the reason for that is, is I mentioned that you're taking a look at the pancreas on the back bench and you're getting it organized. Well, that takes a long time. Actually determining whether or not the pancreas is usable doesn't take that whole experience. You can normally figure that out in about an hour or so. But the actual reconstruction can take many hours. If you have a second surgeon, they can actually start the case. The patient can come in. They can put the patient to sleep. They can open up, and they can get everything ready so that when the first surgeon is finished setting the table, completing the back bench of the pancreas, you're ready to sew it in. And that minimizes the amount of time the patient has to spend under anesthesia and also minimizes what we call the cold ischemia time.

Cold ischemia time is when the organ comes out of the donor, it gets put on ice and has to come to our recipient. That's called cold ischemia. The longer that is, the more difficulty any organ will have working. For pancreases you really want to get it in at about 12 to 15 hours. And having an additional surgeon there helps you speed that time up. And so it means that you can take more offers because you know that you can do it faster. So if they call you a little later or the pancreas is coming from farther away, it still becomes workable for you. On the other hand, if you're doing it all yourself, you have to be more choosy because you know it's going to take you longer to get everything done.

[00:20:30] Host Amber Smith: So what is recovery like for a pancreas transplant compared with a kidney - pancreas transplant?

[00:20:37] Matthew Garner, MD: Well, I'm actually going to change your question a little bit. I'm also going to talk about how the recovery is compared to a kidney transplant alone. So I think you really can compare all three of those things, because they sort of go hand in hand in a lot of ways.

Most of the time we do pancreas transplants, I said it's a kidney-pancreas. So the recovery period for a kidney-pancreas transplant is significantly longer than for a kidney alone. There's a couple of reasons for this. One, the more common one is, it's a bigger operation. You're putting in two organs. It seems like it's twice as much work, and it's close to that. The other thing is that the approach is different. So when you do a kidney transplant, you normally make your incision off to the side. If you're putting the kidney on the right side, the incision is on the right side. If you're putting the kidney on the left side, the incision's on the left side. For the kidney-pancreas transplant, most commonly, you actually make an incision in the middle. And that's because you kind of have to go on both sides. So it enables you to get access to both of them from the same location, and that can be very helpful.

Additionally, as I mentioned, you're putting in two organs. And the other thing is, kidney-pancreas patients, patients that need both a kidney transplant and a pancreas transplant, can be a little sicker than patients that just require a kidney transplant because they have two organ systems that are not working. And that can make it a little bit more difficult for them to recover from the operation.

You usually spend about a week in a hospital after a kidney-pancreas transplant, as opposed to three to four days if you're just having a kidney transplant. But obviously, if there's issues or complications, that stay can be extended longer. Also, postoperatively, you're more likely to be readmitted to the hospital if you have a kidney-pancreas transplant in the immediate postoperative period because there's more things that could potentially go wrong. And by that, what I mean is when you put a kidney transplant in somebody, you have to sew the kidney artery in, you have to sew the kidney vein in, and you have to sew the ureter in. When you do a kidney-pancreas transplant, you have to do that, but then you also have to sew the pancreas bowel to the recipient bowel, the pancreas artery and the pancreas vein. Those are additional steps, So you can think of it, instead of three things you have to worry about, there's six things you have to worry about. And so that means that It's about the same chance that any one of those will have a problem, but if you've got more of them, well, it's more likely. So our patients get readmitted more frequently. As a result, that initial postoperative period is a little bit rockier.

What I tell my patients is that there are some people who receive a kidney pancreas transplant that for the first three months will actually be pretty unhappy. I've even had some that have come up to me and said, "Dr. Garner, is there any way you can take this pancreas out of me? I'm tired of dealing with it. It's causing me nothing but trouble. I've got pain. I'm coming back to the hospital all the time. I just wish I was done with it." And I say, obviously, I'm sorry we can't do that. But also, I need you to bear with me because while it is true that most patients have difficulty in that first three months, it changes dramatically once you get past those first three months, and the pancreas is healed, and it's fit itself into the body, and it started to get used to its new environment. And essentially almost everybody at that point changes their tune. The experience is different now.

Now they're recovering, they're not being in the hospital anymore. They're not on dialysis. They're not taking insulin anymore. And they say, "wow, this is actually pretty good. I'm glad I went through that, but man, that was a rough time." So I try not to undersell how difficult it will be in those first couple of months. That's why you spend so much time with us. You're seeing us in clinic twice a week. We're talking to you all the time. We're asking you to call us if you sneeze too hard, practically, so that we can stay on top of these things. And we have to do a lot for our patients, and it often involves additional hospitalizations. But that goal of getting to the point where the pancreas is now stable and working, is worth it - both worth it for our patients and for us as a program, in terms of being able to do good work. If we didn't have good outcomes, we would stop doing this.

[00:24:38] Host Amber Smith: The transplanted kidney, that starts working right away though, right?

[00:24:42] Matthew Garner, MD: Usually it does. Again, not always, because sometimes kidneys have what we call delayed graft function where they don't work right away, and you have to do dialysis for a short time. But as I said before, the kidney for these patients comes from a very young donor, so it almost always works sort of as soon as you put it in. Rarely, because of a problem or some other issue, it may be a little delayed, and obviously nothing is perfect, so there are cases where they don't work at all, but it's actually a lot less common than for a kidney transplant alone, because the quality of the graft is higher.

[00:25:15] Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast with your host, Amber Smith. My guest is Dr. Matthew Garner. He's a transplant surgeon at Upstate, and we're talking about pancreas transplants.

So you can tell the kidney's working if it's making urine. How do you tell if the pancreas is working, and if that's going to be two or three months, what are you looking to measure, or looking for?

[00:25:40] Matthew Garner, MD: It's not that when I'm saying it's two to three months of recovery, it's not that the pancreas isn't working. In fact, if the pancreas isn't working after the surgery, it's actually one of the reasons to take it out. Because if a pancreas doesn't work sort of right away, it usually means it's not going to work at all.

So we tend to be pretty aggressive in a non-functional pancreas of removing it, because we would really like to spare our patients that story I told you about of the three months of it being difficult. But, when the pancreas does work, we normally determine it by looking at the patient's glucose levels because they should normalize fairly quickly. In fact, sometimes the pancreas can overwork, and they can actually get low, and you have to replace their sugar because they're actually making a little too much insulin. It's one of the reasons why these patients go to the ICU afterwards for close monitoring, to make sure they don't get into trouble because anything like that.

For the three months, it more has to do with sort of pain and complications with the healing of the pancreas, but it should work. Blood sugar is sort of one of the signs that we use to see whether or not it's working. We also check a couple of enzymes, which are amylase and lipase. In layman's terms, these enzymes are a normal part of the production cycle of the pancreas. They're used as digestive enzymes, but they get released into the bloodstream if the pancreas is hurt. So we can follow these sequentially in our patients to see if there's a problem. They may tell us if there's a leak from the pancreas and that bowel anastomosis didn't heal right. And it can also tell us that the pancreas is suffering injury, either because it's not getting enough blood or because it's having a rejection episode.

[00:27:13] Host Amber Smith: Does the other damage that they may have, eye problems and that sort of thing, does that get better, or does that continue after the transplant?

[00:27:21] Matthew Garner, MD: It doesn't really get better, but the important thing is it stops.

The ophthalmologist will do eye injections to treat retinopathy, but those come back if you have diabetes. But if you treat the diabetes, now they have a transplant, they may stop coming back. And so you've improved it, and maybe you don't have to follow up with your ophthalmologist as much as you used to, and you have to do less things to take care of yourself in that regard. So it can simplify some of their medical care in that way.

Actually what got me interested in pancreas transplant was that when I was a resident doing general surgery, we had a very busy vascular surgery program. And vascular surgery deals with a lot of the end stage complications of diabetes. And I did a lot of amputations and debridement for end stage diabetes. And it is, I just hated it. It was miserable. They were miserable. I was. Everyone was miserable. And the opportunity to do something to try to stop that was very exciting. And that's really the only surgical treatment we have for diabetes is the pancreas transplant. The medical doctors have a lot of things they can do, but it's the only thing that can be done surgically.

So it was the only way I could really get involved. But what it does is you have a patient who has gastroparesis, retinopathy and neuropathy. But what they haven't developed yet is they haven't developed the end stage vascular complications where they're losing their fingers, and they're losing their toes, and they're losing their legs, and then eventually dying of a massive heart attack, because that's ultimately how the diabetic disease progresses.

What we do is, we try to put a stop to that. And what's really interesting about diabetes is that if you stop it for, let's say, 15 or 20 years, which, if you have a good graft and you get lucky and you take care of it, it might last that long. That is enough of a break, that now you have an opportunity to die of natural causes. Because the diabetic disease often takes a while to develop. So many of our patients would get amputations at 55 or 60. Well now, that's turned into 75. So what you've done is you've delayed the progression of disease so the fact is that they have a chance to die of something that's, frankly, more humane.

And, that's very rewarding. But it's also nice because it means you don't often have to do, like, six pancreas transplants on somebody because that one that functions for a while is usually enough to get them over the so they don't have problems with these end stage diseases.

[00:29:35] Host Amber Smith: What about vascular injuries? People with diabetes are concerned about amputations. Can transplants help avoid that?

[00:29:43] Matthew Garner, MD: When you've progressed to the point of needing amputations, that means you're already in sort of the problematic category. The problem is also, I mentioned we have to sew in the pancreas. The blood vessels need to be good enough for us to be able to do that safely. So patients that often already are at the state of getting amputations usually have too advanced disease at this point to do a pancreas transplant safely. Unfortunately. It would be really great if you could, because obviously those are the folks that are in the most need of it. But what you're trying to do is to identify the patients that are on the pathway to getting there but are five to 10 years away from it, and getting involved before it gets to that point.

Which leads me to another question. As a patient, how do you know if you need a pancreas transplant? And the answer is, there's, 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, as I mentioned before, if you get a kidney and a pancreas and 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.

[00:32:19] Host Amber Smith: So what sorts of guidance do you give your transplant patients for how to live afterwards, after two or three months, when they've sort of recovered from the operation. How do they move forward?

Well, the most important thing is, it actually sounds silly to say it, but it's healthy living, which is to say you have a new organ that is taking care of your diabetes and your kidney failure, but the damage that your body sustained from being on dialysis or having kidney failure and kidney disease, and from the diabetes that was as uncontrolled as it was to lead to that kidney failure, that still existed, it still happened. What the pancreas transplant does is it stops that from progressing while your glucose is controlled. But it doesn't mean that that damage didn't exist before. Our patients often have gastroparesis, which is slow movement of digestive contents through their bowels and their stomach. They often have neuropathy, loss of sensation. They may have poorly healing wounds because their blood supply compromised. And they may have trouble seeing from disease in their eyes.

What's important, though, is you want to continue to do those things that keep you healthy: to eat a balanced diet, to exercise, to be active, to help yourself from developing those other issues, and of course seeing us in clinic, getting your organs checked and making sure you're not developing rejection, and taking your medicines every day. It's all hard to do.

One of the things that I tell people is that, you describe things are a marathon? A transplant, or a pancreas transplant, it's not a marathon. It's an ultra marathon. It's one of those 200 mile races, except it's over the course of your entire life. And it's actually not hard on any given day. What's hard is, there's a lot of things that you have to do every day for the rest of your life. And if you forget to do some of those things, they can cause problems down the road, even with very slight variations. And that's one of the things that's very challenging about it.

So what I tell people to do is to see their doctors, obviously. To watch their diet and exercise. Because the other thing that you want to do is, after your pancreas transplant, the most common reason that people get diabetes after it again is they get type 2 diabetes. They had type 1. We fixed that. But now they've gained weight, and they've developed type 2 diabetes. Now, I will say there's an important caveat to there. Some of the medicines that we have to use, I mentioned to suppress the immune system, that has a very wide ranging effect on the body. And one of those things some of those medicines do is they actually can increase your insulin resistance. So not everybody who gets a transplant will get type 2 diabetes, but the rate of it goes up rather significantly. So if you're not careful in watching your diet and exercising, it's pretty easy to gain a little weight and to get into trouble there, where if you had had normal kidney function and normal pancreas function, you wouldn't necessarily have gotten there on your own.

So it unfortunately just requires a lot of diligence on the part of our patients. And it's hard work.

Well, Dr. Garner, this has been very informative. I thank you so much for making time for this interview.

[00:35:23] Matthew Garner, MD: I appreciate you having me.

[00:35:25] Host Amber Smith: My guest has been Dr. Matthew Garner. He's a surgeon at Upstate who specializes in transplant surgery. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.