Pancreas transplant

A pancreas transplant is a surgical procedure to provide a new source of insulin in the form of a new pancreas for a patient with type 1 diabetes.

Introduction

A pancreas transplant is a surgical procedure to provide a new source of insulin in the form of a new pancreas for a patient with type 1 diabetes.

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

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 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:

  • end stage kidney disease – when the kidneys are no longer able to filter waste products from the blood
  • diabetic retinopathy – where high levels of glucose in the blood causes damage to 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 and brain

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

Read more about why a pancreas transplant is needed.

What happens during a pancreas transplant

A pancreas transplant can be carried out in three ways:

  • Simultaneous pancreas–kidney transplant (SPK) – both the pancreas and kidneys are transplanted. 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 – a person first receives a kidney transplant from a living donor. This is then followed by a pancreas transplant from a recently deceased donor.
  • Pancreas-alone transplant – 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.

Read more about how a pancreas transplant is performed.

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 four 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.

Read more about the complications of a pancreas transplant.

Recovery

Having a pancreas transplant places a huge strain on the body and typically patients are 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.

Read more about recovering from a pancreas transplant.

Outlook

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

On average a transplanted pancreas functions properly for 10 years.

Complications

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 four needs further surgery to deal with problems such as infection and bleeding.

Other complications of a pancreas transplant include:

  • rejection of the transplanted pancreas – this occurs in about a third of all pancreas transplants
  • clotting of the blood supply – this occurs in around one in 20 patients

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 38ºC (100.4ºF) 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
  • diarrhoea

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:

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.

Recovery

When you wake up after having a pancreas transplant, 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.

You will also have a special drain, called a catheter, inserted into your bladder to allow your doctors to check your kidney function.

Levels of an enzyme in your urine (urinary amylase) will also be measured.

Measuring these levels will help to determine whether your body is rejecting the new pancreas.

You will also have a tube passed through your nose into your stomach. This is called a nasogastric tube. You will usually need to stay in hospital for two to three weeks. Your wound stitches will be taken out at around three weeks.

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
  • monthly thereafter for six months
  • thereafter 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 – read more about the complications of immunosuppressants.

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.

Ivy's story

Former diabetic Ivy Ashworth-Crees, 59, talks about how much better her life is since her double kidney and pancreas transplant.

About 32 years ago I started to have diabetes and had to go on insulin injections four times a day. I also had to work very hard on my diet to make sure I didn’t eat too much sweet food.

After about 25 years I got kidney failure and in 2003 I had to go on kidney dialysis, which was very uncomfortable. It was tiring having to do it four times a day, as well as having the diabetes injections four times a day. I felt like my life was on hold.

I was on kidney dialysis for two years when they put me on the list to have a kidney transplant. The surgeon suggested that I could probably benefit from a kidney and a pancreas transplant, which meant I wouldn’t be diabetic any more.

When I got the phone call to say that I was going to Manchester for the transplant, I was absolutely hysterical. I was very emotional – thrilled and terrified.

When I came round after the operation, I was in intensive care. I stayed there for about three or four days, then they took me to the main ward.

The most difficult part was getting out of bed onto my feet, and starting to walk. They walked me up and down the ward for weeks until my legs got strong enough. That was very, very difficult – the pain was very bad. But it’s been worth it.

The doctor asked me to try to reduce my weight, so I joined the gym. I enjoy swimming and I think it’s helping me to keep a bit more active. The only problem is that I can’t walk too far.

It’s very, very important that I take the immunosuppressant drugs. If I don’t take them, my body may reject the kidney and pancreas. I have to take them for the rest of my life.

My life’s changed such a lot. I now take it for granted that I can eat what I want, including chocolates! I’m back at work, I don’t have an injection after my meals, I don’t have to rush home for dialysis, and my kidneys and pancreas are working well.

I feel blessed that I’ve been through this operation and it’s worked very well.

Preparation

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.

Once the assessment is complete, it will be decided whether a pancreas transplant is the best option for you. In some cases, more investigations may be required before a decision is reached.

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 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 keep 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 spending time resting and relaxing
  • if you are on dialysis, try to avoid gaining weight inbetween dialysis sessions - the best way to do this is to eat a healthy diet and 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.

The transplant

Pancreas transplants are carried out under general anaesthetic. This means you will lose consciousness and won't feel anything during the procedure.

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 four to six hours to complete. However, if you also need a kidney transplant at the same time, the procedure will take a further two 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 harvested during surgery.

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 it is unclear how safe or effective it may be in the long-term.

Why it is used

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

In cases of type 1 diabetes the body’s own immune system attacks and destroys the insulin-producing islet cells, and the pancreas stops producing insulin (a hormone used by the body to break down glucose into 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's a major operation with risks of serious complications.

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
  • 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, which means there are more people who would benefit from a transplant than there are donor pancreases.

Therefore, 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 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 complex psychological and social problems which means you are unlikely to stick to post-transplant treatments, for example if you are addicted to drugs or have a serious mental health condition
  • you are in a very poor state of health and are unlikely to withstand the effects of surgery or having to take immunosuppressants
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