The Role of Pancreas The Role of Pancreas Transplantation in the Transplantation in the Long Term Management of Long Term Management of Diabetes Diabetes Christopher Johnson MD Christopher Johnson MD Professor of Surgery Professor of Surgery Division of Transplant Division of Transplant Surgery Surgery Medical College of Wisconsin Medical College of Wisconsin Brought to you by
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
The Role of Pancreas The Role of Pancreas Transplantation in the Long Transplantation in the Long
Term Management of Term Management of DiabetesDiabetes
Christopher Johnson MDChristopher Johnson MDProfessor of SurgeryProfessor of Surgery
Division of Transplant SurgeryDivision of Transplant SurgeryMedical College of WisconsinMedical College of Wisconsin
Brought to you by
Learning objectives:Learning objectives:
1. 1. This talk will increase your understanding about This talk will increase your understanding about the rationale (including risk/benefit assessment) the rationale (including risk/benefit assessment) for pancreas transplantation in the for pancreas transplantation in the management of diabetes.management of diabetes.
2. This talk will allow you to better appreciate 2. This talk will allow you to better appreciate some of technical and immunological some of technical and immunological challenges associated with pancreas challenges associated with pancreas transplantation transplantation
3. This talk will help you to better anticipate 3. This talk will help you to better anticipate therapy options for diabetic patients who have therapy options for diabetic patients who have chronic kidney disease.chronic kidney disease.Brought to you by
no disclosuresno disclosures
Brought to you by
Tight control reduces end organ damage but Tight control reduces end organ damage but increases the risk (2-3 fold) of severe increases the risk (2-3 fold) of severe hypoglycemic episodes (hypoglycemic episodes (1).).
1 DCCT. The Diabetes Control and Complications DCCT. The Diabetes Control and Complications Trial Research Group The Effect of Intensive Trial Research Group The Effect of Intensive Treatment of Diabetes on the Development Treatment of Diabetes on the Development and Progression of Long-Term Complications in and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus. Insulin-Dependent Diabetes Mellitus. N Engl J N Engl J MedMed 1993; 1993; 329329: 977–986. : 977–986.
DCCT trial (1441 patients randomized to DCCT trial (1441 patients randomized to intensive insulin vs. conventional insulin) intensive insulin vs. conventional insulin) designed to examine the effect of tight designed to examine the effect of tight
control on 2control on 2°° complications (followed > 6yrs) complications (followed > 6yrs)
Pancreas after kidney (already on IS) Pancreas transplant alone (severe life-
threatening complications of DM) Islet after kidney (no surgical
procedure) Islet transplant (no surgical procedure
but requires IS) Brought to you by
Combined kidney/pancreas Combined kidney/pancreas transplant is the most common transplant is the most common
scenario for pancreas scenario for pancreas transplantation:transplantation:
Brought to you by
Indications for Simultaneous Indications for Simultaneous Kidney and Pancreas Kidney and Pancreas
Transplant:Transplant: Presence of ESRD (or eGFR < 20 Presence of ESRD (or eGFR < 20
ml/min)ml/min) Presence of diabetes: type 1 or 2 Presence of diabetes: type 1 or 2
(meeting age (< 55) and BMI criteria (meeting age (< 55) and BMI criteria (<30)(<30)
Lack of major complications and/or Lack of major complications and/or severe cardiovascular disease which severe cardiovascular disease which limits life expectancylimits life expectancy
Brought to you by
Figure 13: Unadjusted 1-year, 3-year, 5-year and 10-year pancreas graft survival by transplant type
Brought to you by
Reversal of Lesions of Diabetic Nephropathy after Pancreas Transplantation
Fioretto, Paola; Steffes, Michael W.; Sutherland, David E.R.; Goetz, Frederick C.; Mauer, Michael.
Survival estimates for patients with kidney graft function at 1 year. Abbreviations: LD, living donor; CAD, cadaveric.
Long-term survival following simultaneous kidney-pancreas transplantation versus kidney transplantation alone in patients with type 1 diabetes mellitus and renal failure
Am J Kid Disease 41:464-470. 2003
Brought to you by
Figure 2: Waiting list death rates by diagnosis, 1999–2008.
Brought to you by
Diabetics who receive k/p gain more Diabetics who receive k/p gain more life-years than k-alone or non-life-years than k-alone or non-
diabeticsdiabetics::
Brought to you by
k/p transplants are equally successful for type 1 and type 2 diabetes:
data from SRTR 2010
Brought to you by
What is the role of pancreas What is the role of pancreas transplant in type 2 transplant in type 2
diabetes?diabetes? Diabetes affects 10% of the Diabetes affects 10% of the
populationpopulation 90-95% is type 290-95% is type 2 Distinction between type 1 and 2 not Distinction between type 1 and 2 not
always clear cutalways clear cut
cC –peptide is not accurate in renal failure
Brought to you by
suggested criteria:suggested criteria:
Brought to you by
Brought to you by
Organ Procurement: Simultaneous Liver and Pancreas Removal
Brought to you by
Back table dissection:Back table dissection:
Brought to you by
More back table dissection…More back table dissection…
Brought to you by
Back table Reconstruction of Pancreatic Allograft
Brought to you by
Arterial “Y” Graft of Donor Iliac Artery
Portal Vein Mobilization
Brought to you by
Bladder Drainage with Systemic VenousAnastomosis
Enteric Drainage with Portal VenousAnastomosis
Brought to you by
Trends in maintenance immunosuppression therapy prior to discharge for simultaneous kidney-pancreas transplantation 1994-2003American Journal of Transplantation 2005;5(Part 2):874-886
Brought to you by
Incidence of rejection during first year among simultaneous kidney-pancreas recipients
American Journal of Transplantation 2005;5(Part 2):874-886
Brought to you by
ADVANCES IN PANCREAS TRANSPLANTATION.Transplantation. 77(9) Supplement:S62-S67, May 15, 2004.
Drachenberg CB, Papadimitriou JC, Klassen DK, et.al: Evaluation of pancreas transplant needle biopsy. Reproducibility and revision of histologic grading system. Transplantation 1997;63(11):1579-1586.
Drachenberg C, Klassen D, Bartlett S, Hoehn-Saric E, Schweitzer E, Johnson L, Weir J and Papadimitriou J:Histologic grading of pancreas acute allograft rejection in percutaneous needle biopsies.
Transplant Proc 1996;28(1):512-513
Diagnosis of Pancreatic Allograft Rejection (is difficult)
Brought to you by
Brought to you by
PAK and PTA have higher rate of PAK and PTA have higher rate of immunologic graft loss after 1 immunologic graft loss after 1
yearyear
Indications for isolated pancreas transplant (PAK or
PTA): Frequent and/or severe
hypoglycemic events consistent failure of insulin-based
management to prevent acute and chronic complications (poor control).
clinical and/or emotional problems associated with the use of exogenous insulin therapy that are so severe as to be incapacitating Brought to you by
IDDM, age > 18 years with an upper age limit of ?Ability to withstand surgery and immunosuppressionPsychosocial stability/ social support/ compliance/ commitment to long-term follow-upDiabetic secondary complicationsHyper-lability/ Hypoglycemic UnawarenessFinancial resources (USA)Absence of any exclusionary criteria: - renal function - coronary disease
Brought to you by
Mortality risk/benefit of PAK and PTA:
American Journal of Transplantation 2004; 4: 2018–2026
Mortality on waiting list: Mortality after transplant:
spkSPK
Brought to you by
Islet IsolationIslet Isolation1. Organ Procurement
Failed islet transplants are associated with sensitization to
HLA antigens:
Brought to you by
Whole Pancreas Transplantation
+ +
Pancreatic Islet Cell Transplantation
Brought to you by
Brought to you by
Successful islet transplants decrease Successful islet transplants decrease progression of nephropathy and progression of nephropathy and
retinopathyretinopathy
Preservation of renal function
Decreased progression of retinopathy
Brought to you by
Conclusions:
Pancreas transplants when successful, normalize glucose metabolism and increase quality (and quantity) of life.
“Good risk” diabetics (type 1 or 2) with renal failure should receive either a living donor kidney transplant or a combined kidney/pancreas transplant
Brought to you by
Conclusions:
“Good risk” diabetics with a functioning kidney transplant (and problematic BS control) should be considered for pancreas after kidney
“Better risk” diabetics without kidney disease, but with life threatening manifestations should be considered for pancreas transplant alone
“Good” = age < 55, BMI < 30, insulin use < 1U/kg/day, no or minimal CAD, PVD
Brought to you by
This platform has been started This platform has been started by Parveen Kumar Chadha with by Parveen Kumar Chadha with the vision that nobody should the vision that nobody should suffer the way he has suffered suffer the way he has suffered because of lack and improper because of lack and improper healthcare facilities in India. healthcare facilities in India. We need lots of funds We need lots of funds manpower etc. to make this manpower etc. to make this vision a reality please contact vision a reality please contact us. Join us as a member for a us. Join us as a member for a noble cause.noble cause.