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Pancreas transplant

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Pancreas transplant



Introduction 

A pancreas transplant allows patients with type 1 diabetes to get a new source of insulin from a donated pancreas.

Most pancreas transplants are performed on people with type 1 diabetes who also have kidney failure. This means a pancreas transplant is usually performed at the same time as akidney transplant.

Pancreas transplants are also given to diabetic patients who don’t need a kidney, but who have life-threatening hypoglycaemic attacks.

Hypoglycaemic attacks are a serious complication of diabetes caused by low levels of glucose in the blood. About one in 10 pancreas transplants are carried out for this reason.

Pancreas transplantation is less common than kidney or liver transplantation, and only 200 such transplants are performed in the UK each year with more than 300 people on the waiting list.

The waiting time for a pancreas transplant is between one and two years because there is a shortage of suitable donor organs.

The pancreas and type 1 diabetes

The pancreas is a tadpole-shaped organ, around 10–15cm long that is located in the top half of the abdomen.

The pancreas has two main functions:


it produces juices which the body uses to digest carbohydrates, fats and proteins

it produces the hormone insulin which the body needs to break down glucose into energy


In cases of type 1 diabetes the pancreas does not produce any insulin because the insulin-producing cells, the islets, have been destroyed by the patient's own immune system.

Most people with type 1 diabetes are able to control the condition with regular injections of insulin. However, a small number of people go on to develop serious complications despite being given the best available treatment, such as:


kidney failure – when the kidneys are no longer able to filter waste products from the blood

diabetic retinopathy – where high levels of glucose in the blood damages the eyes, which can lead to loss of vision 

diabetic neuropathy – where high sugar levels have damaged the nerves in the hands and feet, meaning that sensation is lost and ulcers can occur

arterial disease – which affects the arteries to the heart, legs and brain


A pancreas transplant is often combined with a kidney transplant to reduce progression of the complications of diabetes.

What happens during a pancreas transplant

A pancreas transplant can be carried out in three ways:


Simultaneous Kidney Pancreas Transplant (SPK) – both the pancreas and kidneys are transplanted together, from the same donor. This is the most common type, accounting for nine out of 10 transplants. It is used in people who have kidney disease as a result of type 1 diabetes.

Pancreas after Kidney Transplant (PAK) – a person first receives a kidney transplant from a living or deceased donor. This is then followed by a pancreas transplant from a deceased donor.

Pancreas Alone Transplant (PTA) – only the pancreas is transplanted. This is a treatment for patients with very poorly controlled type 1 diabetes who have hypoglycaemic attacks without warning, and which may threaten their life.


Complications

A pancreas transplant is a complicated operation and, like other types of major surgery, there is a risk of complications. 

About one person in five needs further surgery in the first few days after transplantation to deal with problems such as infection and bleeding.

There is also the risk of rejection. This is when the immune system (the body’s defence against infection) thinks the transplanted pancreas is a foreign body and attacks it.

To prevent rejection a type of medication is given to suppress the immune system (immunosuppressants). These need to be taken for the rest of the person's life.

Long-term use of immunosuppressants carries its own risk of complications, such as increased vulnerability to infection and cancer.

Recovery

Having a pancreas transplant places a huge strain on the body and patients are usually in hospital for two to three weeks.

Someone who has had a pancreas transplant can normally carry out their usual activities after a few months.

Outlook

The outlook for people with a pancreas transplant, especially an SPK type of transplant, is relatively good.


SPK – around 85-90% of pancreases will still be functioning a year after the transplant, and half still functioning over 10 years later

PAK or PTA – around 80% of pancreases will still be functioning a year after the transplant, and half still functioning five years later


There can be problems with the pancreas after a year, but generally the long-term success rate is good. On average a transplanted pancreas functions properly for 10 years.

Why a pancreas transplant is carried out 

A pancreas transplant is mainly used to help treat people with type 1 diabetes.

In type 1 diabetes the body’s own immune system attacks and destroys the cells in the pancreas that produce insulin (the islet cells). Insulin is the hormone used by the body to break down glucose to produce energy.

A lack of insulin causes symptoms of tiredness and frequent urinating, as well as long-term complications, such as kidney disease and eye disease.

If a healthy pancreas is transplanted into the body it should start producing insulin which can help relieve symptoms and prevent complications from occurring or getting worse.

It should be stressed that a pancreas transplant is not a routine treatment for type 1 diabetes. It is a major operation with risks of serious complications. You will also need to take lifelong medication, known as immunosuppressants, which prevent your body's immune system attacking the new pancreas. Immunosuppressants can cause a wide range of side effects.

As most people with type 1 diabetes are able to control their symptoms with insulin injections, in most cases the risks associated with surgery outweigh the potential benefits.

Who should have a transplant

A pancreas transplant is usually only recommended for people with type 1 diabetes who fail to respond to insulin treatment. This usually means they have developed complications or have a high risk of developing them in future.

For example, a transplant may be recommended if:


you have kidney disease, which can lead to kidney failure – a pancreas transplant is sometimes performed alongside a kidney transplant

you have frequent and severe episodes of hypoglycaemia (where your blood glucose levels drop to dangerously low levels causing symptoms such as dizziness and mental confusion)


Why you might be unsuitable for a pancreas transplant

The supply of donor pancreases is limited so a transplant will not be considered if it's unlikely to be successful. 

You may be considered unsuitable if:


you have severe coronary heart disease

you have recently had a heart attack

you are very overweight (obese)

you have a recent history of cancer, because there is a greater chance that the cancer could spread once you are on immunosuppression for the transplant (exceptions can be made for some types of skin cancer as these are unlikely to spread)

you have a serious mental health or behavioural condition, such aspsychosis or bipolar disorder, which means you would be unlikely to be able to comply with the medical recommendations after a pancreas transplant

you are in a very poor state of health and are unlikely to withstand the effects of surgery or having to take immunosuppressants


Additionally, a pancreas transplant may not be offered if you are:


abusing alcohol – most transplant centres only consider a person for transplant if they have not drunk alcohol for at least three months

abusing drugs – most transplant centres would only consider a person for transplant if they attend a drug rehabilitation course and remain free from drugs for at least six months (some transplant centres will accept people who are currently taking the heroin substitute methadone)

smoking – most transplant centres won't offer a transplant if a person still smokes, as smoking shortens the life of the transplants and makes diabetic vascular disease much worse


Preparing for a pancreas transplant 

If a pancreas transplant is thought to be a suitable option, you will be referred for an assessment.

The aim of the assessment is to determine:


whether you are healthy enough to have surgery and to tolerate the lifelong post-transplant medication

whether you are able and willing to take certain medications as directed

whether you have other health conditions that could prevent the transplant from being successful


During the assessment you will have the opportunity to meet members of the transplant team and ask questions. A transplant co-ordinator will act as your main contact and give you and your family support and advice. They will also explain what happens during the procedure and the risks involved.

In some cases, more investigations may be required before a decision is reached. This may include tests to help rule out coronary heart disease, such as:


blood tests

a Doppler scan – a type of ultrasound scan used to test your arteries and veins

an echocardiogram – where ultrasound waves are used to examine your heart and check how well it is pumping and whether there are valve problems

coronary angiography – where a special type of dye is injected into a blood vessel so X-rays of the arteries can be taken


The outcome of the assessment may help to determine whether:


you should join the active waiting list, which means you could be called for a transplant at any time

you need further treatment before you are fit enough to join the transplant list

you are unsuitable for having a transplant – if this is the case, the assessment team will explain why and offer you other treatment options, such as medication or an alternative form of surgery

you need to have a second opinion from a different transplant centre


Waiting for a donor

Once on the active waiting list, staff at the transplant centre will take your details so they can contact you at short notice when a suitable donor organ becomes available.

Finding a suitable pancreas will depend on:


your blood group

the availability of a suitable donor organ

how long you have been waiting compared with others on the waiting list


While you wait for a suitable donor organ to become available, you will be under the care of the doctor who referred you to the transplant centre. They will keep the transplant team informed of any changes to your condition.

Once you are on a waiting list for a transplant it is important to stay healthy. You can do this by:


taking medication prescribed for you

keeping all your appointments with your healthcare team

following recommended exercise and diet advice

avoiding stress by resting and relaxing as much as possible 

if you are on dialysis, try to avoid gaining weight in between dialysis sessions – the best way to do this is to eat a healthy dietand take regular exercise


A suitable donor

Staff at the transplant centre will contact you when a suitable donor pancreas is found. If no new medical problems have occurred since your assessment, you will be asked to go to the centre.
  
From this point you should:


not eat or drink anything unless your blood sugars are very low

take your medication with you

pack a bag of clothes and essential items for your hospital stay


You will have a quick reassessment at the transplant centre. As you are being assessed, a second medical team will examine the donor pancreas. The transplant must be carried out as quickly as possible to ensure the greatest chance of it being successful.

As soon as the donor pancreas is confirmed as being in good condition and suitable for use, the transplant procedure can begin.

How a pancreas transplant is carried out 

At the start of the transplant a cut will be made in your abdomen (tummy). Your current pancreas will not be removed because it will continue to produce digestive juices while the donor pancreas produces insulin.

The donor pancreas will be connected to the blood vessels that carry blood to and from your leg (the right leg is usually used). A small portion of the donor’s small intestine will be attached either to your small intestine or, occasionally, your bladder.

If you are having a combined pancreas and kidney transplant, the kidney will be placed on the left-hand side of the lower abdomen. The pancreas will be positioned on the right-hand side.

A pancreas transplant operation can take three to four hours to complete. However, if you also need a kidney transplant at the same time, the procedure can take around six to eight hours.

Your new pancreas should start to produce insulin straight away, while your old pancreas continues performing other functions.

Islet transplantation

An experimental technique, known as islet transplantation, is now being used to treat type 1 diabetes.

Rather than transplanting an entire pancreas, the specialist cells contained in the pancreas that produce insulin (the islet cells) are isolated in a laboratory after the pancreas has been removed from the donor.

These cells are then transplanted into the liver by direct injection through the skin. This procedure is usually reserved for patients with life threatening hypoglycaemic attacks. Researchers are hoping that one day it will be possible to grow islet cells in a laboratory, reducing the need for human donors.

Access to this type of treatment is still very limited. Your diabetic specialist will be able to refer you if he thinks it is appropriate. 

As islet transplantation is still an experimental technique and it is unclear how safe or effective it may be in the long-term. 

Recovery 

When you wake up after having a pancreas transplant, you will first be cared for in an intensive care unit (ICU) or high dependency unit (HDU). After 12-24 hours you will be moved to a general transplant ward.

You will usually need to stay in hospital for two to three weeks. Your wound stitches will be taken out at around three weeks.

 What to expect after surgery 

 Painkillers 

After the operation you will be given painkillers as you are likely to feel some pain and discomfort.

You may be given a handheld device which allows you to access painkillers when you are in pain, known as patient controlled analgesia (PCA). This device operates a pump, containing painkillers, which is either:


attached directly to your vein

attached to a tube in your lower spine (an epidural cathether)


 Oxygen 

You will usually be wearing an oxygen mask after surgery and may be given physiotherapy to help clear your chest after surgey.

 Drains 

You will have a drain from the pancreas operation site. Drains are tubes that remove blood and other fluid from the operation site. 

You will also have a drain from:


the kidney operation site – if you have had a kidney transplant at the same time

your bladder (known as a catheter) – to allow your doctors to check your kidney function

your abdomen – to help prevent fluid building up

your stomach, passed up through your nose (known as a nasogastric tube) – this is to help keep your stomach empty


If the pancreas was joined to your bladder, levels of an enzyme in your urine (urinary amylase) will also be measured to determine whether your body is rejecting the new pancreas. Otherwise, the enzyme levels in the blood will be monitored.

 Dialysis 

If you have also had a kidney transplant, you may need temporarydialysis (a form of treatment that replicates the kidney's functions).

 Follow-up 

After a pancreas transplant the transplant team will need to review your progress regularly.

A typical follow-up schedule after discharge from hospital is outlined below:


two or three visits in the first three weeks

one visit a week for the next six weeks

every two weeks (fortnightly) thereafter for one month

thereafter reducing from monthly to every three months


Initially you will be seen at the pancreas transplant centre, but later you may be followed up at your local hospital.

 Immunosuppressants 

You will be given your first dose of immunosuppression during the transplant surgery. 

Over the first few months after the operation you will be given high doses of immunosuppressants to prevent the transplanted pancreas being rejected.

You will need to take immunosuppressants for the rest of your life, but the initial high dosage will gradually be reduced over the first six months. 

Unfortunately, the long-term use of immunosuppressants can cause side effects and complications.

Despite this you will still need to take them. If you stop taking immunosuppressants, your transplant will fail.

 Getting back to normal 

Most people will take at least three months off work following a pancreas transplant. Although light lifting is possible after six weeks, you should not lift anything heavy, such as a shopping bag, until three months have passed.

You can start gentle exercise when you feel fit enough (although not before six weeks).

More vigorous activities such as contact sports or horse riding may not be recommended – at least in the short-term – as they could damage your transplanted organs. You should discuss the issue with the doctor in charge of your care.

 Complications of a pancreas transplant  

A pancreas transplant is a complex operation and, as with other types of major surgery, there is a risk of complications.

Complications following pancreas transplants are common. About one person in five needs further surgery to deal with problems such as infection and bleeding.

Other potential complications are described below.

Rejection of the pancreas

Rejection is a normal reaction of the body. When a new organ is transplanted, your body’s immune system sees it as a threat, and attacks it in the way it would attack any foreign organism, such as bacteria or a virus.

To reduce the immune system's response, immunosuppressant medications are given and must be taken for life.

The rejection rate of pancreas transplants is lower in older people. The risk of developing complications after the procedure is higher in people who are over 50 years old.

Signs that could indicate a rejection include:


tenderness, pain and swelling of the new organ

decreased urine output if you have a kidney transplant at the same time

high temperature (fever) of 38C (100.4F) or above

abdominal pain

being sick (vomiting)

increase in blood glucose level

sudden increase in weight

flu-like symptoms

ankle swelling

shortness of breath

any areas that are red, warm to touch or have a discharge


If you have any of these symptoms, contact a member of your transplant team immediately.

Rejection is usually treated by increasing the dosage of your immunosuppressants.

Other complications

Some other possible complications of a pancreas transplant are outlined below.

Blood clots (thrombosis)

Thrombosis is a blood clot in one of the deep veins in the body. It is an early complication that often occurs within 24 hours of a pancreas transplant.

A thrombosis in one of your own veins can be treated with medication designed to thin the blood.

A thrombosis in the transplanted pancreas itself usually results in it failing and being removed.

Pancreatitis

Pancreatitis is inflammation (swelling) of the pancreas and is common in the first few days after surgery.

Symptoms of pancreatitis include:


a dull pain in your abdomen

nausea (feeling sick)

vomiting


Pancreatitis should pass within a few days.

Eye disease

Most patients notice their vision gets worse in the first three months after a pancreas transplant, and then it starts to improve after this time. If patients are on steroids as part of their immunosuppressant treatment any pre-existing cataracts may get worse following a pancreas transplant.

Fluid retention

Fluid retention (oedema) is more likely to occur for several days after a simultaneous kidney and pancreas transplant (SPK).

This can cause swelling of your feet and ankles.

Urine leakage

Sometimes urine can leak as a result of a breakdown in some of the transplanted tissue. It usually occurs during the first two or three months after the transplant. Surgery to repair the leak will usually be required.

Infections

Following a pancreas transplant, a number of different infections can occur, such as:


urinary tract infections

viral infections, such as cytomegalovirus

fungal infections, such as thrush


Antibiotic, antiviral or antifungal medications can be used to treat infections.

Abdominal abscess

An abdominal abscess is a serious complication that can occur one to six months after the surgery. Symptoms include abdominal pain and a high temperature (fever).

A computerised tomography (CT) scan will often be used to determine whether an abdominal abscess is present.

They can be treated using a combination of antibiotics and surgery to drain away the pus.

Death

As with all major surgery, there is a risk (between two and five in 100) of dying in the first year after a pancreas transplant, from a complication such as an infection, heart attack or stroke. However, your chances of being alive 10 years later are much higher following a successful pancreas transplant.

Immunosuppressants

Taking immunosuppressants following a transplant carries its own risks.

You will have to take a dose high enough to prevent your immune system rejecting the pancreas, but not so high your body is unable to fight off infection.

Finding the right dose can be difficult, and it may take months to find the most effective dose that causes the fewest side effects.

Two widely used immunosuppressants are:


tacrolimus

mycophenolate


Side effects that you may have while taking immunosuppressants include:


an increased risk of developing infection and cancer

shaking of the hands

weight gain

mood swings

diarrhoea or abdominal pains

hair thinning

thinning of the bones (osteoporosis)

muscle weakness

feeling sick

being sick

stomach ulcers

blurred vision

insomnia

acne


Most of these side effects start to improve once the right dose of immunosuppressants has been identified. However, even if your side effects become very troublesome, you should never suddenly stop taking your medication. If you do, your pancreas could be rejected.





Pancreas transplant