For both types of diabetics, juvenile onset and adult onset, the goal of treatment has always been to maintain normal blood sugar for the purpose of decreasing complications of diabetes. Insulin and oral medications to control blood sugar are used commonly. A newer form of treatment for selected juvenile onset diabetics is pancreas transplantation.
Pancreas transplants have been performed since 1966, although they were considered experimental in the early years. Now, however, transplantation of the whole pancreas is becoming an accepted medical treatment. The University of Texas Medical Branch has offered this form of treatment since 1988.
ELIGIBILITY
Patients eligible for pancreas transplantation at UTMB must have Type I or juvenile onset diabetes and usually be 45 years of age or younger. In addition, the transplant candidate must have evidence of kidney failure although he or she does not have to be on dialysis. Pancreas transplants at UTMB are done at the same time a kidney transplant is done so that both the kidney and the pancreas come from the same donor. The donor is someone who has recently died and whose organs have been donated for transplantation. Sometimes, however, there may be consideration given to doing a pancreas transplant after someone has already had a kidney transplant.
People with Type II or adult onset diabetes are not candidates for a pancreas transplant, but may be eligible for a kidney transplant. Type II diabetics do not benefit from a pancreas transplant because in Type II diabetics the problem is not that of the pancreas not making insulin, but that the body does not utilize insulin properly.
THE TRANSPLANT PROCESS
Once the transplant evaluation tests are complete, they are reviewed by the transplant physicians. If the tests are all acceptable, then the patient is eligible from a medical standpoint. Besides undergoing the tests, the transplant candidate will meet with a transplant coordinator in order to learn all about what to expect, what possible risks and benefits are involved, and what responsibilities the patient has after the transplant. If the patient is medically suitable, and understands and is willing to accept the possible risks and benefits as well as responsibilities after the transplant, then the patient's name is put on the waiting list. When a compatible donor is available, the patient is notified to come to the hospital immediately.
The pancreas/kidney transplant (PKT) operation takes about 5 - 6 hours. The patient's own pancreas is not removed when the transplant is performed. The new pancreas, along with a small piece of bowel, is transplanted into the pelvis near the bladder and blood vessels. The kidney is transplanted into the other side of the pelvis, also near the bladder and blood vessels (see illustration). One of the functions of the pancreas is called the "exocrine" function. The pancreas produces enzymes that allow us to digest our foods. These drain out a main pancreas duct. These enzymes need a way to be eliminated from the body and this is done by either drainage into the bowel or into the bladder. Generally, patients who receive a pancreas/kidney transplant are in the hospital several days longer than a kidney recipient. The medications used to help the PKT recipient accept the organs, immunosuppressants, are discussed in the UTMB kidney transplant booklet. The dosages used for the PKT patients tend to be greater during the first six months than the kidney only patients.
POSSIBLE RISKS AND BENEFITS
The benefits of a successful pancreas transplant include greatly lessened if not completely removed diet restrictions, no need for insulin shots, and the blood sugar stays normal. Patients usually find that over time, eye and nerve problems caused by the diabetes stay stable, but some patients will see the problems continue to get worse, and a few patients might find some improvement. The risk of complications in the first few months after transplant is increased as compared to patients who receive kidney transplants alone. This is primarily due to the exocrine portion of the pancreas. The average pancreas/kidney recipient is hospitalized for problems about three times during the first six months after transplant. The problems are usually related to rejection, infection, or fluid balance.
1. REJECTION: Almost all PKT recipients experience at least one rejection and this is usually within the first six weeks after transplant. 95% of these rejections are reversed with additional immunosuppression and normal function is regained.
2. INFECTION: All transplant patients are more susceptible to certain viral infections (especially CMV). These infections can cause the kidney and/or the pancreas to malfunction. There are medications to use for treatment. Only a very few organs are lost to these infections. All transplant patients may also experience bladder infections, which may cause infection in the kidney itself because it is attached to the bladder. Medications which help the body keep the kidney are given in larger doses than the kidney transplant patient receives. This may make the PKT recipient more susceptible to infections.
3. FLUID BALANCE: Almost all PKT recipients are admitted at least once for dehydration. It is very important after the transplant that fluid intake is adequate. This may require 2 - 3 liters of fluid per day or more.
Other problems include possible bleeding or leaking at the place where the pancreas and the bowel or bladder are joined, which may require surgery to correct.
There is always the possibility that either one or both of the transplanted organs, the kidney and the pancreas, may not work. This may be influenced by what happens to the donor, how long the organs have been out of the body, and what happens during surgery. This is always disappointing. Experience has also shown that not all transplants work indefinitely, and that some transplants will fail months or years after transplantation.
FINANCES Finances for pancreas transplantation must be considered. Some insurance companies will pay for the cost. Medicare does not pay for pancreas transplants. The social worker will discuss financial options with you.
GOING HOME The follow-up care is much like that of a kidney transplant recipient. There are frequent clinic visits or blood tests which gradually become less frequent. The usual schedule for the post-operative visits is as follows:
1) Three times a week for the first week or two (if you live a distance away that makes these visits difficult, housing arrangements on the island will be arranged with the social worker);
2) Twice a week for the next 2 - 3 weeks, with one of those visits at your local nephrologist's office;
3) Once a week for about a month, alternating between UTMB and your local nephrologist;
4) Once every other week for about a month;
5) Then, once a month for about a year.
Depending on your local nephrologist, 85% of your care may be assumed by them after the first two or three months.
In addition to blood work, there will be a timed urine collection done each month for one of the clinic visits. Pancreas recipients continue to check blood sugars at home to watch for any changes in pancreas function for about the first year. We recommend that you bring an Accucheck with you to the hospital when you come for the transplant so that you will be ready to resume this at home.
SUMMARY
A pancreas transplant can restore you to a life without insulin therapy and with more freedom in your diet. In return, you must be committed to taking the extra care of yourself that a pancreas transplant requires. As with a kidney transplant, you must be committed to taking all your medications, doing the necessary tests at home, getting blood tests done on time, and keeping your clinic appointments.
If you decide you would like to have a pancreas transplant, the transplant team will be there to guide you, help handle problems, and answer any questions you may have.
