Pancreas transplantation


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Pancreas transplantation

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Pancreas transplantation

  1. 1. The Role of Pancreas Transplantation in the Long Term Management of Diabetes Christopher Johnson MD Professor of Surgery Division of Transplant Surgery Medical College of Wisconsin Brought to you by
  2. 2. Learning objectives: 1. This talk will increase your understanding about the rationale (including risk/benefit assessment) for pancreas transplantation in the management of diabetes. 2. This talk will allow you to better appreciate some of technical and immunological challenges associated with pancreas transplantation 3. This talk will help you to better anticipate therapy options for diabetic patients who have chronic kidney disease. Brought to you by
  3. 3. no disclosures Brought to you by
  4. 4. Tight control reduces end organ damage but increases the risk (2-3 fold) of severe hypoglycemic episodes (1). 1 DCCT. The Diabetes Control and Complications Trial Research Group The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin- Dependent Diabetes Mellitus. N Engl J Med 1993; 329: 977–986. Brought to you by
  5. 5. DCCT trial (1441 patients randomized to intensive insulin vs. conventional insulin) designed to examine the effect of tight control on 2° complications (followed > 6yrs) Retinopathy Neuropathy Incidence progression Prevalence of neuropathy Brought to you by
  6. 6. A successful pancreas transplant completely normalizes blood sugar control However, it requires life long immunosuppression Brought to you by
  7. 7. Types of pancreas transplants:  Kidney/Pancreas (pts undergoing kidney transplantation)  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
  8. 8. Combined kidney/pancreas transplant is the most common scenario for pancreas transplantation: Brought to you by
  9. 9. Indications for Simultaneous Kidney and Pancreas Transplant:  Presence of ESRD (or eGFR < 20 ml/min)  Presence of diabetes: type 1 or 2 (meeting age (< 55) and BMI criteria (<30)  Lack of major complications and/or severe cardiovascular disease which limits life expectancy Brought to you by
  10. 10. Figure 13: Unadjusted 1-year, 3-year, 5-year and 10-year pancreas graft survival by transplant type Brought to you by
  11. 11. Reversal of Lesions of Diabetic Nephropathy after Pancreas Transplantation Fioretto, Paola; Steffes, Michael W.; Sutherland, David E.R.; Goetz, Frederick C.; Mauer, Michael. NEJM 339:69-75 July 9, 1998 Number 2 Brought to you by
  12. 12. 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
  13. 13. Figure 2: Waiting list death rates by diagnosis, 1999–2008. Brought to you by
  14. 14. Diabetics who receive k/p gain more life- years than k-alone or non-diabetics: Brought to you by
  15. 15. k/p transplants are equally successful for type 1 and type 2 diabetes: data from SRTR 2010 Brought to you by
  16. 16. What is the role of pancreas transplant in type 2 diabetes?  Diabetes affects 10% of the population  90-95% is type 2  Distinction between type 1 and 2 not always clear cut cC –peptide is not accurate in renal failure Brought to you by
  17. 17. suggested criteria: Brought to you by
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  19. 19. Organ Procurement: Simultaneous Liver and Pancreas Removal Brought to you by
  20. 20. Back table dissection: Brought to you by
  21. 21. More back table dissection… Brought to you by
  22. 22. Back table Reconstruction of Pancreatic Allograft Brought to you by
  23. 23. Arterial “Y” Graft of Donor Iliac Artery Portal Vein Mobilization Brought to you by
  24. 24. Bladder Drainage with Systemic Venous Anastomosis Enteric Drainage with Portal Venous Anastomosis Brought to you by
  25. 25. Trends in maintenance immunosuppression therapy prior to discharge for simultaneous kidney-pancreas transplantation 1994-2003 American Journal of Transplantation 2005;5(Part 2):874-886 Brought to you by
  26. 26. 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
  27. 27. ADVANCES IN PANCREAS TRANSPLANTATION. Transplantation. 77(9) Supplement:S62-S67, May 15, 2004. Burke G, Ciancio G, Sollinger H Brought to you by
  28. 28. Post-Transplant Complications •Early post-operative complications (Bleeding, infection) •Venous Thrombosis •Reperfusion pancreatitis •Pancreas is a relatively low-flow organ •Unrecognized inherited hypercoagulable state in the recipient •Transplant Pancreatitis •Mild - transient amylase elevation for 48-96h •Severe – fat necrosis, infected peripancreatic fluid •Kidney (urine leak, ureteral stricture) Surgical Aspects of Pancreas Transplantation: Brought to you by
  29. 29. Radiologic tools for transplant evaluation: Brought to you by
  30. 30. Splenic vein thrombosis: Brought to you by
  31. 31. Fluid collection on CT: Brought to you by
  32. 32. Drachenberg CB, Papadimitriou JC, Klassen DK, 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
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  34. 34. PAK and PTA have higher rate of immunologic graft loss after 1 year
  35. 35. 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
  36. 36. Isolated Pancreas Transplant: Recipient Selection Criteria IDDM, age > 18 years with an upper age limit of ? Ability to withstand surgery and immunosuppression Psychosocial stability/ social support/ compliance/  commitment to long-term follow-up Diabetic secondary complications Hyper-lability/ Hypoglycemic Unawareness Financial resources (USA) Absence of any exclusionary criteria: - renal function - coronary disease Brought to you by
  37. 37. 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
  38. 38. Islet Isolation 1. Organ Procurement 2. Distension with Collagenase 3. Digestion & Mechanical Separation 4. Purification of Islets 5. Quantification Brought to you by
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  44. 44. The “Edmonton Protocol”  Efficient Isolation Procedure  Reliable Collagenase  Steroid Free Immunosuppressive Protocol  IL-2R Blockade  Tacrolimus  Sirolimus Brought to you by
  45. 45. Only 31% remained insulin independent at 2 years N Engl J Med 2006;355:1318-30. Brought to you by
  46. 46. Failed islet transplants are associated with sensitization to HLA antigens: Brought to you by
  47. 47. Whole Pancreas Transplantation + + Pancreatic Islet Cell Transplantation Brought to you by
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  49. 49. Successful islet transplants decrease progression of nephropathy and retinopathy Preservation of renal function Decreased progression of retinopathy Brought to you by
  50. 50. 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
  51. 51. 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
  52. 52. This platform has been started by Parveen Kumar Chadha with the vision that nobody should suffer the way he has suffered because of lack and improper healthcare facilities in India. We need lots of funds manpower etc. to make this vision a reality please contact us. Join us as a member for a noble cause. Brought to you by
  53. 53. 011-25464531, 011-41425180, 011-66217387 +91-9818308353,+91-9818569476 A WORLDWIDE MISSITION Contact Us:- JOIN US