Diabetes Forecast

Pancreas and Kidney Transplants Show Better Results

By Erika Gebel, PhD , ,

The Procedure
1. The surgeon makes an incision down the center of the abdomen.
2. The donor pancreas, plus a section of donor intestine, is nestled into the lower abdomen, well below the old pancreas. The old pancreas is not removed—it continues to aid digestion.
3. The intestinal tissue adjoining the donor pancreas is connected to either the recipient's small intestine or, less often, the bladder. This allows any digestive juices the donor pancreas produces to be excreted.
4. Blood vessels in the donor pancreas are attached to an artery that supplies the organ with blood and also to a vein, through which the pancreas delivers insulin into the circulatory system.
If a kidney is also transplanted, the surgery continues:
5. The donor kidney is placed in the other side of the lower abdomen, across from the donor pancreas. Both old kidneys remain in place, unless they are causing complications such as high blood pressure.
6. Blood vessels from the body are attached to the new kidney to provide it with blood, which it filters.
7. The donor kidney's ureter (a tube that connects the kidney to the bladder for the excretion of urine) is attached to the recipient's bladder.
The final step (for either procedure):
8. The abdomen is stitched up. Transplant recipients can expect to spend about a week in the hospital.

Transplant Numbers

2,500: Americans waiting for simultaneous pancreas and kidney transplants

1,500: Americans waiting for just a pancreas transplant

1,200: Pancreas transplants per year in the United States

Julie Johnson Olson still gets choked up when she talks about the morning she got the call that they'd found her a donor. Olson, 54, of Iowa City, Iowa, will always be grateful for the simultaneous kidney and pancreas transplants she had 20 years ago. The story is the same for many transplant recipients: They've experienced the tension of waiting with a critical illness and then the wonder of new properly functioning organs. Pancreas transplants have been around for almost half a century, but the past decade has seen dramatic improvements, allowing more people to become diabetes-free and healthy longer.

In With the New
Many people with diabetes can control their condition through a mix of healthful eating, exercise, and medication. But some can't. "Only those with exceptional difficulty controlling diabetes" are good candidates for a pancreas transplant, says Dixon Kaufman, MD, PhD, FACS, professor of surgery at the University of Wisconsin–Madison. Donor pancreases are in short supply, and pancreas transplants require that recipients take anti-rejection medications for the rest of their lives. For people who can control their blood glucose with insulin, it doesn't make sense to trade one medication regime for another more expensive form of therapy, especially because the immunosuppressant drugs make people more susceptible to infections and certain types of cancer.

Yet some candidates, especially people who also require a kidney transplant, may be willing to accept the burden and side effects of anti-rejection medications in exchange for blood glucose control. "It wasn't worth going on the way I was with diabetes," says Olson, who had type 1. "The burden of having it was so great, I was willing to risk my life for the pancreas." The transplant puts diabetes into remission, at least as long as the pancreas survives, because the new pancreas produces enough insulin to normalize blood glucose levels. That's something that the pancreases of all people with type 1 and some with type 2 diabetes can't do. The surgery is done mostly in people with type 1 diabetes, but 8 percent of pancreas recipients have insulin-dependent type 2 diabetes.

After the recipient typically spends nine months on a waiting list for a pancreas, the transplant surgery takes about three hours (six if a kidney is transplanted during the same procedure). The donor pancreas is added to the recipient's body, leaving him or her with two pancreases. The original one continues to deliver digestive juices to the stomach and intestines. Surgeons hook the insulin-making part of the new pancreas up to the circulatory system, while its digestive secretions are shunted off to the intestines or bladder for excretion.

The transplanted pancreas begins to normalize the recipient's blood glucose levels while the person is still on the operating table. Olson has a printout of her vital signs taken during surgery. "You can see, my blood sugar dropped to 75 [mg/dl] and it just stays there," she says.

Who Is Eligible?
The most common trigger for a pancreas transplant is kidney failure. Two-thirds of pancreas recipients get a kidney at the same time. Diabetes, particularly uncontrolled diabetes, can take a toll on the kidneys—a condition called nephropathy. Over time, the kidneys may fail, requiring either dialysis or a new kidney.

Simultaneous pancreas and kidney transplants may be an option for a person with uncontrolled diabetes (sometimes called "brittle diabetes") who is younger than 55 and in relatively good health, but shows signs of declining kidney health. People with type 2 who aren't obese could be considered for the transplants, Kaufman says, but those who are very heavy should attempt to lose weight to get their diabetes under control before being considered. The new pancreas keeps blood glucose in the normal range, which protects the new kidney from suffering the same fate as the original organ.

People with erratic blood glucose levels—especially those who have hypoglycemia unawareness and can't sense when their blood glucose is low—but with no signs of kidney damage may be candidates for a pancreas-only transplant. This type of transplant doesn't have as good an outcome as pancreas/kidney transplants. The overall five-year survival rate for the transplanted organs is about 75 percent in pancreas/kidney transplants; it's about 55 percent for a pancreas-only transplant.

The reason for the difference, according to Kaufman, is that the "kidney acts as a beacon" for organ rejection. The kidney starts to spill protein into the urine very early in the rejection process. When that happens, doctors can take measures to halt rejection, prolonging the life of the transplanted kidney and pancreas.

Getting Better
All types of pancreas transplants, with or without a kidney, have improved in recent years. About 4 out of 5 pancreas transplants used to fail within five years; now most keep working that long. Pancreas recipients have the highest survival rate of any transplant, except for kidney transplants between related people. This is because even if the pancreas transplant fails, a recipient typically can resume taking insulin by injection or pump to control blood glucose levels.

Get More Info
For information on islet transplants in your area, visit the website of the Collaborative Islet Transplant Registry.

The improved pancreas outcomes are mostly due to advances in immunosuppressant drug therapy, says Kaufman. "The newer agents are more potent and more specific," he says, and have fewer side effects. Two drugs dominate the field: tacrolimus and mycophenolate mofetil. Steroid immunosuppressants used to be popular, but Kaufman says that 30 to 40 percent of doctors now avoid using them because of their often severe side effects.

Surgical techniques also have improved. There are fewer transplant failures from complications other than rejections and fewer complications in general. For example, doctors used to primarily hook the part of the pancreas that releases digestive fluid to the bladder. "For the first 15 years I had a real problem with dehydration," says Olson, whose surgery was done that way. She also had frequent urinary tract infections (UTIs). Now, surgeons usually connect the pancreas to the small intestine, which results in fewer complications. Olson had her pancreas drainage switched from bladder to intestine about five years ago, and her problems with UTIs and dehydration are no more.



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