SOLID ORGAN TRANSPLANTATION

IV.  Pancreas and Pancreas-Kidney Transplantation

Introduction
Types of Transplants
Absolute Contraindications to Transplant
Relative Contraindications to Transplant
Evaluation
Waiting Time
Complications

Introduction

Most Pancreas transplant recipients are between the ages of 35 and 49 (67%), with 15% between the ages of 50 to 64 (Milliman 2005).  The majority of pancreas transplants are performed on diabetics, who are generally under the age of 60, with imminent kidney failure or who no longer respond to insulin therapy.  Generally, patients have to be on insulin for at least 10 years before being considered for a pancreas transplant.  Pancreas-Kidney transplants are generally done on diabetics with ESRD.

Eileen M. Demayo, RN, lead inpatient transplant coordinator at Northwestern Memorial Hospital in Chicago, IL presented the following information at United Resource Network’s, A Course In Transplantation For Case Managers in Newport, RI October 2003.

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Types of transplants:

  • Simultaneous pancreas and kidney transplant, which is more common that pancreas alone (SPK).

  • Pancreas after kidney transplant – has some increase rejection rate (PAK).

  • Pancreas alone are done for labile diabetics whose disease in uncontrolled.  It is more difficult to monitor for rejection, because there is no kidney to monitor for rejection.  Biopsy of the pancreas is not recommended (Demayo, E., RN 2003).

Objective of transplantation is to restore normal glucose metabolism without the need for exogenous insulin, and stop the progression of secondary complications of diabetes.  With perfect control of carbohydrate metabolism, the development or further progression of the secondary complications of diabetes will possibly be prevented.  Pancreas transplant will help prevent kidneys from developing nephropathy (Demayo, E., RN 2003).

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Absolute Contraindications to transplant

  • AIDS or HIV.

  • Acute (not-treatable) or chronic infection.

  • Severe coronary artery disease

  • Severe carotid artery disease.

  • Chronic active hepatitis.

  • Morbid obesity.

  • Active substance abuse.

  • Significant history of noncompliance, which is the number one reason for graft failure (Demayo, E., RN 2003).

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Relative Contraindications

  • Patients age > 50 for SPK and PAK.

  • Active peptic ulcer disease.

  • Malignancy within the past 5 years.

  • Psychological dysfunction.

  • Lack of family or support system (Demayo, E., RN 2003).

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Evaluation:

  • Diagnostic Studies – ABO, HLA typing, CBC, Chemistry, LFT’s, lipids, amylase, lipase, Serologies (CMV, HIV, Epstein bar); C-peptide, Glycosylates hemoglobin; Chest x-ray; Cardiac evaluation (EKG, Adenosine stress test, Angiogram (with angioplasty/CABG if indicated); Mammogram, ultrasound of Gallbladder.

  • Psychosocial assessment.

  • Financial assessment (Insurance coverage, pharmaceutical coverage, home health coverage.)

Many patients go home with home health needs such as wound care and IV infusion.
Medicare only covers immunosuppression medications for 3 years at 80%. (Demayo, E., RN 2003).

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Waiting Time (As noted in 2005 Milliman Report)

  • Simultaneous Pancreas and Kidney cadaveric transplant - there was a 50% chance of obtaining a transplant in 512 days in 2001 and a 25% chance of transplantation in 209 days in 2002.)

  • Pancreas alone, data indicated a 50% chance of transplant in 244 days and 25% chance of transplant in 59 days in 2002. (Milliman 2005).

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Complications:

  • Infection which increase after requiring treatment of rejection episode.

  • Cardiovascular – Increase risk for post operative MI.

  • Vascular Thrombosis (#1 problem for kidney transplant.)

Preventive measures – heparin, aspirin, bedrest, restrict hip flexion.
            Diagnosis – HMPAO scan, renal scan.
            Treatment – Surgical removal of organ.

  • Bladder Anastomotic Leak

            Pancreas: Duodenal-bladder anastomosis.
Diagnosis – Ultrasound and analysis of fluids.
Treatment – Percutaneous nephrostogram with stent placement and surgical repair.

  • Dehydration/Electrolyte Imbalance (This is a big problem for patients who have been on dialysis, because they are use to being restricted on fluid intake and it is hard to change habits.)

Treatment – IV hydration, bicarbonate replacement, diuretics, hemodialysis.

  • Delayed Graft Function – Early use of nephrotoxic immunosuppressants such as Cyclosporin and Prograf.

  • Hematuria – from erosion of bladder mucosa and ulceration of the duodenal segment. 

Treatment – Cystoscopy and cauterization of bleeding site.  Conversion to enteric drainage.

  • Graft Pancreatitis – Reflux of urine into pancreas.

            Treatment – Insertion of Foley catheter.  Anticoagulation.

  • Intra-Abdominal Abscess – Anastomotic leak of enteric drained pancreas.

Treatment – Broad spectrum antibiotics and surgical intervention.

  • Gastro-Intestinal Bleeding – Anticoagulation, bleeding from the anastomosis.

Treatment – blood transfusions, IV hydration, Surgical intervention (Demayo, E, RN 2003).

Although successful pancreas transplantation achieves euglycemia and complete insulin independence, this occurs at the expense of hyperinsulinemia and chronic immunosuppression (Stratta et al., 1995).

 

The OPTN/SRTR 2005 report indicates that immunosuppressive practices and trends after pancreas transplants, in contrast to other solid organ transplants, vary with the different recipient categories.  Research data has documented that pancreas allograft rejection rates are highest in non-uremic recipients of a pancreas transplant alone (PTA), next highest in post-uremic recipients of a pancreas after kidney transplant (PAK), and lowest in uremic recipients of a simultaneous pancreas and kidney (SPK) (1, 2).  Because of the variances in the patients’ conditions and the type of transplant they are receiving, induction and maintenance regimens differ between the three recipient categories: comparisons are usually made between solitary pancreas transplants (PTA and PAK categories) versus combined pancreas and kidney transplants (SPK category).  Immunosuppressive therapy after pancreas transplants continues to evolve; there appears to be a primary trend toward steroid avoidance, but avoidance of calcineurin inhibitors is also practiced.  (2005 OPTN/SRTR Annual Report).

According to the OPTN/SRTR report (2005) the use of antibody induction therapy remains higher for pancreas recipients than for recipients of any other solid organ.  In 2004, the rate of such use reached over 80% in all three recipient categories.  This rate is higher than it was five years ago, when 63% (PTA) to 67% (PAK) of pancreas recipients were given induction therapy.  (2005 OPTN/SRTR Annual Report).

As noted in the 2005 OPTN/SRTR Annual Report the trends of maintenance immunosuppressant therapy in the first year after transplant are as follows:  The most common combination therapy for the first year in all three recipient categories is now tacrolimus-mycophenolate mofetil.  Since 2000, it was given to 55%-60% of SPK and PAK recipients.  The second most common combination protocol was tacrolimus-rapamycin, given to 15%-20% of all recipients in 2002 and 2003.  Since 1999, cyclosporine-based immunosuppression has accounted for less than 10% of maintenance therapy (highest in the SPK category).  In 2003, tacrolimus monotherapy was used for 2%-3% of SPK and PAK recipients and up to 17% of PTA recipients.  The calcineurin inhibitor-free rapamycin-mycophenolate mofetil protocol saw a slight increase in 2003 (2% SPK, 1% PAK and PTA).  Over time, the use of tacrolimus-rapamycin (versus tacrolimus-mycophenolate mofetil) increased: In the second year following transplantation, about 17%-20% of recipients in all three categories received tacrolimus-rapamycin (versus 55% on tacrolimus-mycophenolate mofetil).  This change may reflect tacrolimus-mycophenolate mofetil-associated gastrointestinal problems.  In the second year following transplantation, < 2% of all protocols were rapamycin-mycophenolate mofetil (calcineurin inhibitor-free).  (2005 OPTN/SRTR Annual Report)

The OPTN/SRTR Annual Report 2005 noted that graft survival rate for Pancreas alone to be 76.9% at one year and 55.8% at 5 years.  For pancreas after kidney the one year survival rate was 77.6% at one year and 56.7% at 5 years.  Kidney-pancreas (kidney) graft survival rate at one year was 91.7% and 76.5% a 5 years.  Kidney-pancreas (pancreas) graft survival rate was 85.8% at one year and 71.0% at 5 years.  (2005 OPTN/SRTR Annual Report).

The Milliman Research Report 2005 listed the cost of pancreas transplant and the first year following as follows:  Evaluation - $12,400; Procurement - $67,200; Hospital - $98,800; Physician - $20,500; Follow-up - $40,800; Immunosuppressants $31,100.  The cost of Kidney Pancreas was noted as:  Evaluation - $12,400; Procurement - $118,000; Hospital - $70,400; Physician - $20,500; Follow-up - $40,800 and Immunosuppressants - $31,000.  (Milliman 2005).

 

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