Pancreas transplantation

pancreas transplant is an organ transplant that involves implanting a healthy pancreas (one that can produce insulin) into a person who usually has diabetes. Because the pancreas is a vital organ, performing functions necessary in the digestion process, the recipient’s native pancreas is left in place, and the donated pancreas is attached in a different location. In the event of rejection of the new pancreas, which would quickly cause life-threatening diabetes, there would be a significant chance the recipient would not survive very well for long without the native pancreas, however dysfunctional, still in place. The healthy pancreas comes from a donor who has just died or it may be a partial pancreas from a living donor. At present, pancreas transplants are usually performed in persons with insulin-dependent diabetes, who can develop severe complications. Patients with the most common, and deadliest, form of pancreatic cancer(pancreatic adenomas, which are usually malignant, with a poor prognosis and high risk for metastasis, as opposed to more treatable pancreatic neuroendocrine tumors or pancreatic insulinomas) are usually not eligible for valuable pancreatic transplantations, since the condition usually has a very high mortality rate and the disease, which is usually highly malignant and detected too late to treat, could and probably would soon return. Better surgical method can be chosen to minimize the surgical complications with enteric or bladder drainage. Advancement in immunosuppression has improved quality of life after transplantation.

Pankreastransplantat ex-situ Präparation mit Rekonstruktion der Arterien und Verlängerung der Pfortader.tif

Medical uses

In most cases, pancreas transplantation is performed on individuals with type 1 diabetes with end-stage renal disease, brittle diabetes and hypoglycaemic unawareness. However, selected type 2 diabetics can also benefit from a pancreas transplant. The indications for a type 2 diabetic are a BMI<30 kg/m2 and low overall insulin requirement (< 1 U/kg/day). The majority of pancreas transplantation (>90%) are simultaneous pancreas-kidney transplantation.

As of currently, pancreas transplantation remains as the most effective treatments for diabetes. As such, it has improved the quality of life in uremic diabetic patients.

Complications

Complications immediately after surgery include thrombosis, pancreatitis, infection, bleeding and rejection. Rejection may occur immediately or at any time during the patient’s life. This is because the transplanted pancreas comes from another organism, thus the recipient’s immune system will consider it as an aggression and try to combat it. Organ rejection is a serious condition and ought to be treated immediately. In order to prevent it, patients must take a regimen of immunosuppressive drugs. Drugs are taken in combination consisting normally of ciclosporin, azathioprine and corticosteroids. But as episodes of rejection may reoccur throughout a patient’s life, the exact choices and dosages of immunosuppressants may have to be modified over time. Sometimes tacrolimus is given instead of ciclosporin and mycophenolate mofetil instead of azathioprine.

Technical failure is a primary complication for a graft failure within the first three months after transplantation. Vascular thrombosis accounts for 50% of these graft failures. Pancreatitis accounts for 20%, infection for 18%, fistulas for approximately 6.5%, and bleeding accounts for about 2.4% of all pancreatic graft failure.

Types

There are four main types of pancreas transplantation:

  • Pancreas transplant alone, for the patient with type 1 diabetes who usually has severe, frequent hypoglycemia, but adequate kidney function.This pancreas transplant known as PTA has as of recently been showing up with good results. This is the least performed method of pancreas transplantation and requires that only the pancreas of a donor is given to the recipient.
  • Simultaneous pancreas-kidney transplant (SPK), when the pancreas and kidney are transplanted simultaneously from the same deceased donor. This is the most commonly performed pancreas transplant operation. Indications for an SPK are End Stage Renal Disease with type 1 diabetes (with other diabetic complications like neuropathy, gastroparesis etc.) This is the most common type of pancreas transplantation. The basic reason for this is that patients are mostly already on immunosuppressive drugs and the addition of the kidneys simultaneously reduces the risk in surgical procedure.
  • Pancreas-after-kidney transplant (PAK), when a cadaveric, or deceased, donor pancreas transplant is performed after a previous, and different, living or deceased donor kidney transplant. This method is usually recommended for diabetic patients after having a successful kidney transplant. The downside of this procedure is that patients are required to go through surgical risk twice.
  • Simultaneous deceased donor pancreas and live donor kidney (SPLK) has the benefit of lower rate of delayed graft function than SPK and significantly reduced waiting times, resulting in improved outcomes.

Preservation until implantation

Standard practice is to replace the donor’s blood in the pancreatic tissue with an ice-cold organ storage in the solution, such as UW (Viaspan) or HTK until the allograft pancreatic tissue is implanted.

Prognosis

The prognosis after pancreas transplantation is very good. Over the recent years, long-term success has improved and risks have decreased. One year after transplantation more than 95% of all patients are still alive and 80–85% of all pancreases are still functional. After transplantation patients need lifelong immunosuppression. Immunosuppression increases the risk for a number of different kinds of infectionand cancer.

It is unclear if steroids, which are often used as immunosuppressant, can be replaced with something else.

 

Reference:

https://en.wikipedia.org/wiki/Pancreas_transplantation


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