Before, During, and After a Pancreas Transplant: What You Need to Know

Understanding the Process of Pancreas Transplantation

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An organ transplant is a very complicated process leading to a surgery that is the treatment of last resort for organ failure. In this case, the transplant would be a treatment or a cure for pancreatic failure or pancreatic disease.

For most people, a transplant never becomes a necessity, and they are able to manage their disease with medication, surgery or other therapies.

For rare individuals, a transplant becomes necessary because their disease is so severe that without a new organ they will not survive long term.

Simply stated, a transplant is done when the organ the patient was born with is so sick or diseased that they need a replacement organ from a donor.

Functions of the Pancreas

The pancreas plays a significant role in the human body’s ability to digest food effectively and maintain a stable blood glucose level in the blood. The pancreas performs this function with two main roles in the body: making hormones and making enzymes used in the digestion of food. 

Ninety-five percent of the pancreas works to produce digestive enzymes that are used in the breakdown of food in the gut. The pancreas produces three enzymes: amylase, lipase, and protease. Amylase breaks down carbohydrates, lipase breaks down fats, and protease breaks down proteins found in the diet.

If this portion of the pancreas is working poorly, a condition called exocrine pancreatic insufficiency, these enzymes can be replaced by a prescription medication that is taken by mouth. This type of pancreas issue does not lead to a pancreas transplant, as the condition can be treated with medication.

 

The best-known function of the pancreas is hormone production. The first hormone produced by the pancreas is glucagon, a hormone that increases blood glucose (sugar) levels in the blood. It is released when blood glucose levels are too low and need to be increased. The second hormone that is produced by the pancreas is insulin. Insulin is released when glucose levels in the blood are too high and need to be decreased. The third hormone is somatostatin, which works to keep the activity of insulin and glucagon at appropriate levels. 

The pancreas works hard to avoid having overly high or overly low glucose levels and the symptoms and health conditions that can result. Low glucose levels are not typically a problem for most people, but a lack of insulin is a very common issue faced by millions of Americans but known by a different name: diabetes

When the body becomes resistant to insulin and/or fails to make enough insulin, the condition is called type II diabetes. When the pancreas makes no insulin, we refer to this as type I diabetes. Typically, it is type I diabetics who require a pancreas transplant, as other types of diabetics are able to be treated with medication in most cases.

It is also possible for type II diabetics to stop making any insulin over time, which can also lead to transplantation.

A pancreas transplant is performed when the pancreas is no longer able to work well enough to control the glucose levels in the blood, quality of life is unacceptably poor, complications of diabetes are severe or worsening, and the benefits of surgery outweigh the risks of the transplant.

When It's Needed

Being a type I diabetic alone doesn’t make a pancreas transplant necessary, as many individuals are able to live full and rich lives with well-controlled glucose levels. It is difficult-to-control diabetes, often referred to as “brittle” with little control over glucose levels and symptoms, that leads to a transplant.

 This means that when the severity of diabetes has reached the point where the patient is very ill and medication cannot provide better disease control, a transplant may be the last resort of treatment.

According to the American Diabetes Association (ADA), the qualifications for a pancreas transplant in individuals without significant kidney disease are as follows:

  1. Frequent, acute and severe metabolic complications such as very high glucose, very low glucose or ketoacidosis. 
  2. Incapacitating clinical/emotional problems with insulin therapy
  3. Failure of insulin to prevent acute complications

Risks

The risks associated with pancreas transplant are more significant than many standard surgeries, as the patient is often sicker prior to surgery and the procedure is complex. These risks are in addition to the standard risks that patients face when having any surgery, and the risks associated with general anesthesia.

Common Risks of Pancreas Transplant Surgery

  • Infection
  • Poor glucose control
  • Bleeding
  • Blood Clots
  • Rejection of new organ
  • Organ failure
  • Nausea
  • Vomiting
  • Diarrhea
  • Reaction to anesthesia
  • Difficulty weaning from the ventilator

Finding a Surgeon

Seeing a transplant surgeon typically involves getting a referral from your own physician to the transplant center that performs pancreas transplant near your home. In many cases, there may only be one nearby, but in large cities, you may have multiple options. The referral is typically made by your endocrinologist, a physician specializing in the treatment of hormone issues, or a gastroenterologist who treats issues with digestion. A referral can also be made by primary care and other specialties involved in your treatment.

Getting on the Transplant List

After meeting with the staff at a transplant center, you will be evaluated for a potential transplant. This will mean a review of your medical records, blood tests, possible imaging studies, and other tests designed to determine if you are well enough to tolerate a transplant surgery but sick enough to need a new organ.

If the testing indicates a need for a transplant, as well as the ability to survive the surgery, and recovery with a good outcome, and if additional qualifications are met such as the ability to afford the surgery and the ability to manage the medications needed after surgery, the patient can be placed on the transplant list to wait for an organ to become available.

The number of pancreata (plural of pancreas) available for transplant is, unfortunately, small. There is only one pancreas available per donor. Diabetics cannot be a pancreas donor. Additionally, the pancreas is fragile and frequently responds poorly to critical illness in the donor, so many individuals without diabetes still cannot donate their pancreas. This leads to a shortage of transplantable organs for those who are waiting.

Types of Transplants

There are two types of pancreas transplants being performed currently. The most common type is when the entire pancreas is removed from a donor and placed in a recipient. When individuals say “pancreas transplant” this is the procedure to which they are typically referring. The other type of transplant is the pancreatic islet transplant, where some of the cells that make up a pancreas are transplanted into the recipient.

Pancreatic Islet Transplant

During a pancreatic islet cell transplant, the pancreas is removed from a donor and islet cells are transplanted into the recipient. After the organ is recovered, the pancreas is taken to a research lab where the islet cells, which produce insulin and other hormones, are separated from the other cells of the pancreas. These islet cells only make up 5 percent of the total mass of the pancreas, so the amount of cell tissue removed is considerably smaller than a whole pancreas. It is these islet cells that are transplanted into the recipient. Interestingly, these cells are transplanted into the liver by being infused through a blood vessel. The cells remain in the liver and begin producing insulin in that location.

In the United States, this procedure is performed at major university hospitals that perform research into pancreatic islet cell transplantation. This type of procedure is still considered experimental and is only performed as part of multiple research studies at different facilities at this time.

The qualifications for islet transplant are sometimes different from whole organ transplants, as there is research being done on the role of islet transplantation as a treatment for chronic pancreatitis. The typical patient will have at least two and more often three islet transplant procedure to experience the full benefit of the transplant.

Multi-Organ Transplant

For some individuals, pancreas issues can lead to significant issues with other organs, particularly the kidneys. For some diabetics with difficult-to-control glucose levels, the kidneys become badly damaged, often leading to kidney failure and the need for dialysis.

For these individuals, a pancreas transplant alone may not be enough to restore them to good health, they are also in need of a kidney transplant so they can be free of dialysis. Ideally, these individuals will receive a kidney and a pancreas transplant from the same donor at the same time, but some patients do receive the organs from different donors at different times.

How Its Transplanted

Pancreas transplant begins with an entirely different procedure—the surgery to remove the pancreas from a donor. A whole organ transplant is more common than the donation of a pancreas segment. Whole organs come from deceased, brain-dead donors. Segments of the pancreas typically come from a donor who is a friend or relative who wants to help the recipient.

Once the donated organ or segment is removed, there is a short window to transplant the organ into the recipient, typically eight hours or less. The pancreas is very delicate, responding poorly to being touched and moved, so surgeons work to only touch the adjacent tissues during surgery. Once the pancreas is confirmed viable for a recipient, or possibly before, the potential recipients are notified that an organ has become available for transplant. They are then asked to report to their transplant center.

Once recovered (the term “harvest” is no longer used) the pancreas is transported from the hospital where it is recovered to the transplant center where the pancreas will be placed in the recipient.

The surgery to place the organ into the recipient begins with the patient being intubated and placed on a ventilator along with the administration of general anesthesia. Once the patient is asleep, the procedure can begin. 

The skin is prepared to decrease the risk of infection, and an incision is made in the abdomen. The pancreas is attached to the duodenum, the first segment of the small intestine so that digestive enzymes can be released onto food as it exits the stomach. Using blood vessels obtained from the donor, the pancreas is connected to a blood supply for its own needs and to release hormones into the bloodstream.

Typically, the transplanted pancreas rests closer to the belly button than the original pancreas, which is found deeper in the abdomen. This placement in the front of the abdomen allows a biopsy to be easily taken in the future, if necessary.

The patient’s own pancreas, referred to as the “native pancreas”, remains in place unless there is a specific reason to remove it. Once the pancreas is attached to the intestine and blood vessels, the incision can be closed and the patient is taken to the intensive care unit (ICU) to be closely monitored during their recovery.

Recovery

The typical patient will spend several days in ICU after a transplant procedure. Most will spend at least seven days in the hospital before going home to continue their recovery. Most patients return to their normal activities within 4-6 weeks of surgery.

Life After Transplant

One of the more challenging aspects of life and health after a transplant is the prevention of rejection of the organ. Frequent visits to the transplant center are typical after surgery and are less frequent as time passes unless there are issues with the new organ. For many, a return to normal life is possible after surgery, but others may find that they are improved, but still unwell.

For all transplant patients, a medication regimen to prevent rejection will be a fact of life. Even if the organ doesn't function well, anti-rejection medication will be needed, and that medication may lead to more frequent illnesses like common colds and the flu as it lowers the immune system.

Long-Term Risks

Potential issues in the months and years following a pancreas transplant appear to be few in number, but can be serious. Taking good care of overall health by eating well, following the surgeon's instruction, and routinely exercising are important. Taking care of your emotional health after transplant is also important, and often gets overlooked in the effort to be physically well. 

Also important is being vigilant watching for the following signs: 

  • Organ rejection
  • Reaction to rejection medications
  • Poor glucose control
  • Decreasing organ function over time
  • Known complications of rejection medications 

Anti-Rejection Medications

Medications—some of which are similar to commonly prescribed steroids—are used to make the body accept the new organ, but these medications come with potential complications along with their enormous benefits.

Common side effects of anti-rejection medications include:

  • Nausea
  • Diarrhea
  • Vomiting
  • Swollen face
  • Swollen gums
  • Acne
  • Hair loss
  • Intolerance of sun
  • Blood pressure elevation
  • Cholesterol levels elevated
  • Bone loss (osteoporosis or osteopenia)

Organ Rejection

Organ rejection is a significant issue after a transplant of any kind, and some patients will experience an episode of rejection in the initial months following the transplant. The key to surviving an episode of rejection with a healthy transplanted organ is to identify the problem early and get treatment immediately.

Common symptoms of pancreas rejection include:

  • Fever
  • Pain in or over the new organ
  • Unstable blood glucose
  • Nausea
  • Vomiting
  • Abdominal Pain
  • Dark urine
  • Decreased urine output

Long-Term Outcomes

Overall, the outcomes that patients experience after pancreas transplantation are quite good. Survival rates are about 95 to t98 percent at one year, 91 to 92 percent three years after transplant, and 78 to 88 percent at five years. The majority of deaths were due to cardiovascular disease, rather than complications from surgery, and occurred greater than three months after being discharged from the transplant facility.

Also of importance is how well the transplanted pancreata did after surgery. At one year after surgery, 78-88 percent of patients had a functioning pancreas and 27 percent had a functioning pancreas ten years after surgery. Functioning means no need for insulin, normal glucose levels when tested after fasting, and normal or slightly elevated hemoglobin a1c results. This means that patients with a “non-functioning” pancreas may still not need insulin but have an elevated hemoglobin a1c, or may be totally insulin dependent.

A Word From Verywell

A pancreas transplant, whether it is a whole organ or islet cells, is a very serious procedure with a life-long impact on health and wellbeing. For many, the transplant is a solution to a very serious problem and leads to a major improvement in quality of life. Less commonly, the procedure leads to complications, poor health, and for some, no improvement in glucose control. 

It is important to weigh the current impact of pancreatic disease against the potential rewards and complications that come with a transplant procedure, and proceed with caution after learning as much as possible about the procedure.

Source:

Pancreatic and islet transplantation in diabetes mellitus. Up to Date. https://www.uptodate.com/contents/pancreas-and-islet-transplantation-in-diabetes-mellitus