Pancreas Transplant – The transplant process

The Transplant Process

The combined kidney and pancreas transplant surgery is indicated for patients who are on dialysis, but who are also diabetic and on insulin. The specifics of which dialysis dependent diabetics qualify for kidney and pancreas transplant are:

You must be insulin dependent
You should not be over weight (weight assessment on individual basis)
Your insulin requirements must be in excess (determined by your physicians)
Your doctors will have carefully assessed your condition and deemed your condition suitable for the pancreas surgery

In order to undergo pancreas transplantation, a number of steps and procedures must be followed to ensure a successful transplant process. These steps include:

1. Referral

Patients are usually referred to us by their nephrologist or endocrinologist. We do accept self-referrals! Patients are encouraged to seek transplant evaluation as soon as diagnosed with moderate hepatic insufficiency. This is to establish records, perform the appropriate workup, and proceed with transplant listing.

2. Workup

The Work up Process

After successfully completing your initial pre-transplant evaluation, your transplant coordinator will begin scheduling appointments for testing and procedures needed prior to transplant. Some of these tests or procedures will need to be updated annually. Your transplant coordinator will notify you when a test or procedure needs to be updated. It is important to keep up with your tests and procedures so that you can be transplanted when you get the call.

The combined kidney and pancreas transplant surgery is indicated for patients who are dialysis dependent but are also diabetic and on insulin. The specifics of which dialysis dependent diabetics qualify for and pancreas are:

You must be insulin dependent
You should not be over weight (weight assessment on individual basis)
Your insulin requirements must be in excess (determined by your physicians)
Your doctors will have carefully assessed your condition and deemed your condition suitable for the pancreas surgery

Required Testing

Simple blood tests including blood typing
EKG
Chest x-ray
Dental exam
Abdominal Ultrasound
Coronary Angiogram (for all patients over 45, diabetic, or risk factors/history of heart disease)
Cardiology consult (if you have risk factors, are diabetic or over age 45)
Colonoscopy (for all patients over the age of 50)
Mammogram and Pap smear for all women over the age of 40
Recent Prostate Specific Antigen (PSA) for all men over the age of 40

3. Patient Selection Committee

All patients will be presented at the Patient Selection Committee Meeting (PSC) after they have completed all their testing and have been seen by the multidisciplinary transplant team.

The purpose of the PSC is to review the results of testing, discuss visits with the multidisciplinary team, and to determine if they qualify for placement on the transplant wait list.

The results of the PSC discussion will be conveyed to the patient and referring physician within 10 days.

4. Listing

If you are approved and cleared by the multidisciplinary team in PSC, you will be added to the National Waiting List for pancreas transplant. You will be placed on the waiting list based on your blood type and antibody test.

The national organ waiting list is managed by an organization called the United Network for Organ Sharing (UNOS), a private, nonprofit agency that works with the federal government. UNOS keeps track of all the people in the United States who need pancreas transplants, and matches them with donors.

If you are not approved for listing at the time of PSC, your transplant coordinator will explain any additional testing or requirements to get you listed for transplant. On some occasions, you may not qualify for transplant. Your coordinator will explain in detail as well as send a letter to your primary doctor explaining the reasons you cannot be transplanted at this time.

5. Day of Transplant

When receiving a combined kidney and pancreas transplant, both the kidney and pancreas come from the same donor. Both the kidney and pancreas will have been prepared by your doctor before you enter the operating room. This preparation usually takes 2-3 hours.

If the organs are suitable, you will be escorted into the operating suite. The anesthesiologist will greet and evaluate you there. The process of anesthesia and IV line placement can be approximately 1-2 hours depending on your general health condition.

During surgery, a catheter will be placed into your bladder to drain urine. This catheter in generally removed 3 or 4 days after surgery. On rare occasions, depending on your condition, the catheter may be left in place. You will have a voiding trial (test to make sure you can pass urine) later at the clinic before the catheter is taken out.

The surgeon will make an 8-10 inch midline incision from below your chest to right above your pubic bone. In general, the pancreas is placed on the right side of your abdomen and the kidney is placed on the left side of your abdomen. Your own pancreas and kidneys are not removed during this surgery.

Your pancreas has complex connections to your blood vessels and intestines. The pancreas is connected to the blood vessels that lead to your right thigh. The pancreas also has a drainage tube, through which a fair amount of digestive juices are produced. This new pancreas, like your own pancreas, will continue to make digestive juices. The tube draining it will need to be connected to your intestines or less preferably to your urinary bladder for drainage.

The decision as to where your pancreas should drain will depend on your anatomy and the general condition of your intestines. Many times, there is no clear choice until surgery has begun.

The kidney and pancreas transplant surgery will take between 4-6 hours. At the end of surgery, your kidney will have started to function and your pancreas will have started to normalize your blood glucose levels. You will leave the operating room with a tube to drain your stomach inserted through the nose and a catheter in your bladder to drain urine.

Getting the Call

Once you have received a call from the coordinator and you have accepted the organ offer, you will then be instructed to arrive at St Vincent as soon as possible. Please drive to St Vincent with as many important members of your family as necessary.

Your coordinator will ask you the following questions:

What time did you last eat or drink anything?
When was your last dialysis session?
Have you had any recent admissions to the hospital or new health problems?
Have there been any changes to your life situation (ie, support, financial, or emotional states that may impact your post-transplant care

Once these questions have been answered, you coordinator will instruct you not to eat or drink anything and come to the hospital. If you are diabetic, please inform the coordinators so that instruction about medication dosing can be given. You should bring all current medications and a bag with a set of clothes and other essentials for hospital admission.

Arrival to the Hospital

We strive to proceed with transplant ASAP, however we realize there may be need for further evaluation and or need for . You will be directed to Admissions and then the floor for nursing assessment, have some additional testing done including blood work, EKG, and chest xray, and any other testing that needs to be updated since your last clinic visit. You may require dialysis prior to your transplant. The transplant surgeon will order dialysis if needed.

On arrival to the hospital, you will be greeted by your surgeon. He will prefer to speak to you and your family members about the details of the process, including risks and benefits.

The Transplant Operation

You will receive the kidney and pancreas from the same donor.

Both the kidney and pancreas will have been prepared by your doctor before you enter the operating room. This prep work usually takes 2-3 hours.

If the organ is suitable, you will be escorted into the operating suite. The anesthesiologist will greet and evaluate you. The process of anesthesia and IV line placement can be an interval of 1-2 hours depending on your general health condition. During surgery, a catheter will be placed into your bladder to drain urine. This catheter in generally removed on post-op day 3-4. On rare occasions, depending on your condition, the catheter may be left in place. You will have a voiding trial later at the clinic prior to removal.

An 8-10 inch midline incision from below your chest to right above your pubic bone is made. In general, the pancreas is placed on the right and the kidney is placed on the left side of your abdomen. Your own pancreas and kidneys are not removed.

Your pancreas has a complex blood vessel anatomy. The pancreas is connected to the blood vessels that lead to your right thigh. The pancreas also has a drainage tube, through which a fair amount of digestive juices are produced. This new pancreas, like your own pancreas, will continue to make digestive juices. The tube draining it will need to be connected to your intestines or less preferably to your urinary bladder for drainage. The decision as to where your pancreas should drain will depend on your anatomy and the general condition of your intestines. Many times, there is no clear choice until surgery has begun.

The surgery will take between 4-6 hours. At the end of surgery, your kidney will have started to function and your pancreas will have started to normalize your blood glucose levels.

You will leave the operating room with a tube to drain your stomach inserted through the nose and a catheter in your bladder to drain urine.

6. Post-Transplant

After successfully receiving a transplant, our job is not done. A transplanted organ requires periodic maintenance and follow-up care to make sure both the organ and the patient continue to thrive!

Hospital Recovery

Once surgery is complete, you are then awakened and transported to the recovery room or directly to the , which is located on the 4th floor.

Your surgeon will have spoken to your family and they should be able to visit you within 1-2 hours of arriving at the ICU, Once your doctors consider your condition stable they will then transfer you to the 5th or 7th floor.

In general by now you will be free from most IV lines and allowed to eat and ambulate. During surgery a catheter will be placed into your bladder to drain urine. This catheter is removed on post op day 3-4. On rare occasion depending on your condition- the catheter may stay longer or you may even be sent home with a catheter to have a voiding trial later at the clinic.

By post-op day 4-5 you are ready for discharge. Instructions include:

Avoiding excess water intake.
Avoiding any food products with high potassium.
Resuming diabetic diet and care if diabetic.
Appropriate precautions for infection control.

Possible complications following kidney/pancreas transplant include:

Clot in the pancreas or kidney: Usually noted within the first 24-48 hours post-op, and can present with sudden abdominal pain and an acute rise in your blood sugars. The treatment for this condition is unfortunately removal of the pancreas or kidney, and we are not able to salvage an organ under these circumstances. You may in the future qualify for a second transplant.
A break in the suture line of the bowel or bladder: This suture line break down leads to leakage of stool in the case of bowel drainage or urine and pancreatic juice. Both complications require urgent repair, which may or may not be successful, and may lead to multiple surgeries and/or eventual pancreas removal.
Delayed Graft function: Sometimes the transplanted kidney may not function immediately, and occurs in approximately 30-50 percent of deceased donor kidneys and less than 10% of live related or non-related kidneys. During this delay, the kidney is either making little urine or no urine at all, and you may need dialysis. Sometimes you may be discharged home on dialysis as we monitor improvement in your kidney function over time.
Post-op pain
Post-op bleeding requiring blood transfusion
Infections that may include large abscesses which require wash out procedures and placement of drains.
Urine leakage from the bladder suture line, for which you will be taken back to surgery for an attempt at correction.
Hernia formation requiring surgical intervention.

We advise all patients interested in pancreas transplant there may be up to 30% chance of a second surgical procedure to repair or possibly remove the kidney and/or pancreas. The rate of pancreas clot nationally is 1-5% and we are proud to have better than expected pancreas results at St. Vincent.

Discharge from Hospital

Going Home from Transplant

During your admission to the hospital for pancreas transplant, the transplant coordinator will meet with you and your designated caregivers to discuss and educate you about how to take care of your new organ. A log book and manual will be given during your first teaching session.

You will be taught to monitor for:

Signs and symptoms of rejection or infection
How to record your weight, urine output, blood pressure, heart rate, and temperature
The education sessions take place immediately after transplant, throughout your hospital stay, and upon discharge.

Medications

A transplant Pharmacist will review all of your new life-long medications to prevent rejection. All other medications you are taking will also be reviewed with you before discharge.

24-Hour Nursing Care

A nurse is available 24 hours a day, 7 days per week including weekends and holidays. They can be reached at (213) 484-5551. The nurse can answer any questions you have related to transplant and call your doctors with any urgent needs.

The first 90 days

After leaving the hospital, you will follow up in the transplant clinic closely, as frequently as daily until you are stabilized. Labs are done every clinic visit in the morning before you take your medications. The transplant team will monitor your lab results, urinary output, vital signs, and incision closely to assure no complications arise.

What to bring to your clinic visit

Your log book (tracks urine output, vital signs, and blood sugar if necessary)
Medication list
All your medication bottles
Snacks, comfort items (pillow, blanket, books, etc) while you are waiting

At the end of your clinic visit, your transplant coordinator will review any medication changes and provide a new medication list, prescriptions and lab orders for the next visit. It may be necessary to call you at home with lab results. Keep your medication list with you and be prepared to write down any changes to your medications.

The First 5 years

Once you are more stable, you will be seen less frequently in the transplant clinic. You will need to follow up with your primary doctor 90 days after transplant and regularly after that. Your primary doctor will manage any related health issues such as high blood pressure and diabetes, and your regular annual health exam and cancer screenings. You will also need to follow up with any specialist physicians regularly such as Endocrinology and Cardiology.

What to bring to clinic

Medication list
Any new medications or changes prescribed by another doctor
Any requests or orders from your primary or other doctor(s)

Five years and beyond

Your transplant doctors will continue to watch for any signs of problems with your pancreas. These can include:

Chronic Rejection: this occurs when your transplanted pancreas slowly stops working. Usually, this type of damage may be caused by your immune system attacking the organ. Sometimes, other issues such as high blood pressure, diabetes, high cholesterol, or high levels of immunosuppressants, or the original cause of your pancreas disease, may also slowly damage your new organ.
Some of the most common symptoms of rejection include:
- Fever
- Tenderness over the pancreas
- Elevated pancreas function tests and blood sugars
- High blood pressure
Coronary heart disease
Cancers, including skin, breast, vulvar, cervical and colon cancer

A needle biopsy may be needed to find the reasons for ongoing problems with the pancreas transplant. Possible treatments for chronic rejection include different types of immunosuppression, steroids, or other medications.