Pancreas and Kidney Transplants: New Lease on Life
The word is used with equal parts hope and disbelief in the diabetes online community. It’s alluded to in scientific meetings. And if you ask whether anyone has ever been, you may be told “not exactly.” But Travis Blackwelder says it out loud, with a sense of wonder: “Cured.”
Blackwelder, 41, of Provo, Utah, was diagnosed with type 1 diabetes when he was 15 years old. He doesn’t have it anymore.
What he does have is a new pancreas and kidney—pumping out insulin and other hormones and filtering toxins from the blood, respectively. He received the two-organ transplant in September 2013. Since then, he’s been a new man: no more dialysis for renal failure, no more testing blood glucose, no more insulin shots. “I can’t imagine going back,” he says, “and I hope I never have to. My life is totally different.”
Blackwelder is one of a growing number of people who have had a simultaneous pancreas-kidney transplant, a surgery that, while not an option for most people with diabetes, is life changing and sometimes lifesaving.
The most frequent candidates for a simultaneous pancreas-kidney transplant (SPK) are people with diabetes whose kidneys are failing due to nephropathy (kidney disease). Often, they are on dialysis—hooked up several times each week to a machine that takes hours to completely filter their blood—and on a strict renal diet. Transplant candidates may also have hypoglycemia unawareness or be unable to control their blood glucose, even with careful monitoring. Some people with diabetes and renal failure have a kidney transplant without a pancreas transplant, but most go in for both, says endocrinologist Sue Kirkman, MD, professor of medicine at the University of North Carolina–Chapel Hill. Much less common are pancreas-after-kidney (PAK) transplants and pancreas transplant alone (PTA). PTAs are more controversial because people are, essentially, exchanging type 1 diabetes for lifelong immunosuppression.
“If a patient needs a kidney transplant, they already need to take on the slight risks of the immune-suppressing medicines for the kidney. Getting a pancreas as well can have enormous benefits,” Kirkman says. “If the pancreas transplant works, it frees the person from the highs and lows of insulin therapy.”
But transplants are not for everyone. People who have cancer, HIV, or severe heart disease, or who might not be able to adhere to the strict regimen of after-surgery care are not eligible for the surgery. Those who are eligible, though, are willing to wait for the privilege. (About 2,000 people are on the U.S. waitlist for the surgery.) If they’re able to receive the SPK transplant, they have great odds: The national average kidney-pancreas transplant success rate in adults is 95 percent at one year after the operation, and 92.5 percent at three years.
The patients who visit Jeffrey Campsen, MD, surgical director of pancreas transplants at the University of Utah, usually already know they want SPK transplant surgery when they see him. He says most patients don’t have to be convinced of a transplant’s benefits. “People are losing their sight; they’re losing their limbs,” he says. “They come to us and say, ‘I can’t live with diabetes anymore.’ ” Patients meet with a medical transplant doctor, a transplant surgeon, social worker, pharmacist, diabetes educator, and financial advisor to determine if they qualify for the transplant medically, emotionally, and mentally. If they do, they’re put on the transplant list, and the waiting game begins. The average wait for a combined kidney and pancreas transplant is about three years, according to the United Network for Organ Sharing.
It’s often hard to find a donor pancreas—only 7 percent of all people who donate any organs can become pancreas donors, says David Axelrod, MD, chief of the solid organ transplant division of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. The transplant team wants to make sure patients are 100 percent ready to take care of two new organs that are precious commodities. “We have to pick and choose who’s going to do well with the surgery, but also who’s going to do well being a steward of this organ that’s going to be in their body for decades,” Campsen adds. “The responsibility of our patients accepting these organs is huge. You want to be cured of diabetes, but you also have to be responsible for protecting this gift that someone gave you.”
That’s not lost on Blackwelder. He was on the transplant list—and dealing with kidney failure—for more than a year before he found out he would receive a new pancreas and kidney. The joy of health is tempered a bit by knowing someone else died to make it possible. “I’m very sensitive to that donor and that donor’s family,” he says. “It’s the worst-case scenario for them, but it’s certainly blessed my life.”
Once a pancreas and kidney become available, a surgical team “recovers” the organs from the donor, who had to have been young (between ages 4 and 55), healthy, without diabetes, and not obese, says Axelrod. “The quality of [the] organ is directly related to its success.” The organs’ arteries are repaired, and the organs are transported to the recipient, who has been prepped for surgery. It’s time for the transplant.
In the Operating Room
An incision is made in the recipient’s abdomen, and from there, it’s all about the kidney, says Charles Bratton, MD, surgical director of pancreas transplants at the Medical University of South Carolina in Charleston. The donor kidney is placed in the lower left abdomen near the left pelvis and attached to blood vessels that supply the leg in order to bring blood to and from the new organ. Then the team watches what happens next. The kidney should start to function immediately.
If the kidney transplant goes well, the surgical team moves forward with the pancreas transplant. The donor pancreas is placed in the lower right abdomen near the right pelvis and attached to the vein and artery that supply the right leg. It’s also attached to a small part of the small intestine, says Axelrod, because in addition to regulating insulin and glucagon (the hormone that signals the body to raise blood glucose levels), the pancreas excretes digestive enzymes; those need a place to exit the transplanted pancreas. And then the team watches again. “As soon as we hook the new pancreas up, they don’t need insulin anymore,” he says. “Diabetes is cured, in that they no longer need insulin, and blood glucose is controlled.” The procedure can take between four and six hours, with a hospital stay of several weeks.
There are, of course, risks in surgery. Bleeding, infection, and clotting are all possibilities in the operating room. But those risks are on par with other abdominal surgeries. Because the intestine and pancreas are sewn together, there is a slight possibility of an intestinal leak.
You may have noticed that there has been no mention of removing the patient’s faulty organs. There is usually greater risk of something going wrong in surgery if organs are removed, so unless they pose a serious threat, such as repeated infection, it’s safer to leave them in. The donor organs are placed in a different location than the originals because the recipient’s organs are still in place; they’re still secreting digestive fluids normally.
Most patients stay in the hospital for five to seven days after surgery, recovering. They start a series of immunosuppressant drugs, which they’ll have to take as long as they live in order to keep their bodies from rejecting the donor organs. They’ll also have to maintain an intense schedule of doctor visits. But they aren’t taking insulin or facing dialysis anymore.
They are paying for the privilege of their new lease on life: The National Kidney Foundation reports that anti-rejection medications can cost upwards of $2,500 per month, and estimates put the total cost of transplant and aftercare at nearly half a million dollars. However, Medicare can cover transplant costs, and insurance companies and hospitals have financial assistance officers or social workers to help patients navigate the costs of their care.
The University of California–San Diego Health System reports that kidneys from living donors last an average of 14 years, while kidneys from deceased donors last an average of 10 years. Pancreas transplants typically last between eight and 10 years. Patients can work with their long-term care team to maximize the longevity of their donated organs, and can resume taking insulin by injection or pump if their new pancreas fails. A lifetime on immunosuppressant drugs comes wit its own risks: Osteoporosis, muscle weakness, and type 2 diabetes are common. On top of that, you’ll have the same risk as the general population for developing type 2 diabetes.
Patients must learn how to eat and exercise all over again because they are no longer doing either to manage blood glucose but to focus on fighting organ rejection. For Blackwelder, who lived with diabetes for decades, eating in a healthful way was easier after surgery. He’s no longer drawn to high-sugar, high-carbohydrate foods, though it took him a few weeks to stop automatically counting his carbs. He takes nearly 25 pills a day to keep his new kidney and pancreas in tip-top shape. He’s lost 25 pounds, and says, “It feels like I have my own body back.” Exercising is easier, he says, because he has more energy. He walks every morning for 45 minutes and is getting back into his weight-lifting routine. Buoyed by his medical care team and wife, Collette, he’s committed to making his new organs work for him for years to come.
“This is a game-changer,” he says. “I have to go back years to when I had this much energy, this much vitality, and felt this good. Life is just different for me.”
Good to Know
To learn more about simultaneous pancreas-kidney transplants or to find support, you can visit:
The National Kidney Foundation, which provides information and resources: kidney.org/atoz/content/kidpantx
The National Foundation for Transplants, which helps with fund-raising and support for those awaiting transplants or those who have already received one: transplants.org
Transplant Buddies, an online support group for transplant recipients: transplantbuddies.org