Solid Organ Transplantation
IV. Pancreas and Pancreas-Kidney Transplantation
Absolute Contraindications to Transplant
Introduction
Most Pancreas transplant recipients are between the ages of 35 and 49 (67%), with 15% between the ages of 50 to 64 (Milliman 2005). The majority of pancreas transplants are performed on diabetics, who are generally under the age of 60, with imminent kidney failure or who no longer respond to insulin therapy. Generally, patients have to be on insulin for at least 10 years before being considered for a pancreas transplant. Pancreas-Kidney transplants are generally done on diabetics with ESRD.
Eileen M. Demayo, RN, lead inpatient transplant coordinator at Northwestern Memorial Hospital in Chicago, IL presented the following information at United Resource Network’s, A Course In Transplantation For Case Managers in Newport, RI October 2003.
Types of Transplants
- Simultaneous pancreas and kidney transplant, which is more common that pancreas alone (SPK).
- Pancreas after kidney transplant – has some increase rejection rate (PAK).
- Pancreas alone are done for labile diabetics whose disease in uncontrolled. It is more difficult to monitor for rejection, because there is no kidney to monitor for rejection. Biopsy of the pancreas is not recommended (Demayo, E., RN 2003).
Objective of transplantation is to restore normal glucose metabolism without the need for exogenous insulin, and stop the progression of secondary complications of diabetes. With perfect control of carbohydrate metabolism, the development or further progression of the secondary complications of diabetes will possibly be prevented. Pancreas transplant will help prevent kidneys from developing nephropathy (Demayo, E., RN 2003).
Absolute Contraindications to Transplant
- AIDS or HIV.
- Acute (not-treatable) or chronic infection.
- Severe coronary artery disease
- Severe carotid artery disease.
- Chronic active hepatitis.
- Morbid obesity.
- Active substance abuse.
- Significant history of noncompliance, which is the number one reason for graft failure (Demayo, E., RN 2003).
Relative Contraindications
- Patients age > 50 for SPK and PAK.
- Active peptic ulcer disease.
- Malignancy within the past 5 years.
- Psychological dysfunction.
- Lack of family or support system (Demayo, E., RN 2003).
Evaluation
- Diagnostic Studies – ABO, HLA typing, CBC, Chemistry, LFT’s, lipids, amylase, lipase, Serologies (CMV, HIV, Epstein bar); C-peptide, Glycosylates hemoglobin; Chest x-ray; Cardiac evaluation (EKG, Adenosine stress test, Angiogram (with angioplasty/CABG if indicated); Mammogram, ultrasound of Gallbladder.
- Psychosocial assessment.
- Financial assessment (Insurance coverage, pharmaceutical coverage, home health coverage.)
Many patients go home with home health needs such as wound care and IV infusion.
Medicare only covers immunosuppression medications for 3 years at 80%. (Demayo, E., RN 2003).
Waiting Time
(As noted in 2005 Milliman Report)
- Simultaneous Pancreas and Kidney cadaveric transplant – there was a 50% chance of obtaining a transplant in 512 days in 2001 and a 25% chance of transplantation in 209 days in 2002.)
- Pancreas alone, data indicated a 50% chance of transplant in 244 days and 25% chance of transplant in 59 days in 2002. (Milliman 2005).
Relative Contraindications
- Patients age > 65 for kidney.
- Active peptic ulcer disease.
- Malignancy within the past 5 years.
- Psychological dysfunction.
- Lack of family or support system (Demayo, E., RN 2003).
Evaluation
- Diagnostic Studies – ABO, HLA typing, CBC, Chemistry, LFT’s, lipids, amylase, lipase, Serologies (CMV, HIV, Epstein bar); C-peptide, Glycosylates hemoglobin; Chest x-ray; Cardiac evaluation (EKG, Adenosine stress test, Angiogram (with angioplasty/CABG if indicated); Mammogram, ultrasound of Gallbladder.
- Psychosocial assessment.
- Financial assessment (Insurance coverage, pharmaceutical coverage, home health coverage.)
Many patients go home with home health needs such as wound care and IV infusion.
Medicare only covers immunosuppression medications for 3 years at 80%. (Demayo, E., RN 2003).
Complications
- Infection which increase after requiring treatment of rejection episode.
- Cardiovascular – Increase risk for post operative MI.
- Vascular Thrombosis (#1 problem for kidney transplant.)
- Preventive measures – heparin, aspirin, bedrest, restrict hip flexion.
- Diagnosis – HMPAO scan, renal scan.
- Treatment – Surgical removal of organ.
- Bladder Anastomotic Leak
- Bladder anastomosis.
- Diagnosis – Ultrasound and analysis of fluids.
- Treatment – Percutaneous nephrostogram with stent placement and surgical repair.
- Dehydration/Electrolyte Imbalance (This is a big problem for patients who have been on dialysis, because they are use to being restricted on fluid intake and it is hard to change habits.)
- Treatment – IV hydration, bicarbonate replacement, diuretics, hemodialysis.
- Delayed Graft Function – Early use of nephrotoxic immunosuppressants such as Cyclosporin and Prograf.
- Hematuria – from erosion of bladder mucosa and ulceration of the duodenal segment.
- Treatment – Cystoscopy and cauterization of bleeding site. Conversion to enteric drainage.
- Graft Pancreatitis – Reflux of urine into pancreas.
- Treatment – Insertion of Foley catheter. Anticoagulation.
- Intra-Abdominal Abscess – Anastomotic leak of enteric drained pancreas.
- Treatment – Broad spectrum antibiotics and surgical intervention.
- Gastro-Intestinal Bleeding – Anticoagulation, bleeding from the anastomosis
- Treatment – Blood transfusions, IV hydration, Surgical intervention (Demayo, E., RN 2003).
The OPTN/SRTR Annual Report 2005 noted that the use of induction immunosuppression for kidney transplantation continued to increase steadily through the decade. In 2005, 72% of kidney transplant recipients were receiving induction immunosuppression, compared to 46% in 1995. The administration of antithymocyte globulin (rabbit), the most commonly used induction agent, has increased: it is currently used for 37% of patients. In 2003, the first year that usage for alemtuzumab was reported, it was used for 4% of patients; this practice nearly doubled in 2004 to 7%. (2005 OPTN/SRTR Annual Report).
In order to ensure the survival of the allograft, kidney transplant recipients must be maintained on immunosuppression therapy for life. According to data published in the 2005 OPTN/SRTR Annual Report, tacrolimus-mycophenolate mofetil is the most frequently used maintenance immunosuppression combination at one and two years following transplantation, and its prevalence for maintenance use has increased in recent year. At one year after transplantation in 2003, 51% of patients were receiving tacrolimus-mycophenolate mofetil, 17% were receiving cyclosporine-mycophenolate mofetil, 8% tacrolimus-sirolimus, and 1% sirolimus-mycophenolate mofetil. Both the tacrolimus-sirolimus and the sirolimus-mycophenolate mofetil regimens were more prevalent at one and two years after transplant than at discharge, indicating a significant switch toward these combinations after transplant. Surprisingly, at one year about 7% and at two years about 2% of patients were receiving tacrolimus alone, compared to about 4% at discharge. All of these percentages refer to medication regimens regardless of steroids, meaning that most of the patients were on steroids in addition to the indicated regimens. However, data from OPTN/SRTR outlines a trend toward steroid avoidance with 23% of all first transplants in 2004 discharged without steroids. The report notes the first significant numbers of steroid avoidance protocols were seen in 2000, when 5% of patients were discharged without steroids; there has since been a steady increase in the prevalence of steroid-free regimens. Steroid avoidance protocols are used more frequently for living donor transplant recipients (28% in 2004) than for recipients of deceased donor. (2005 OPTN/SRTR Annual Report).
The OPTN/SRTR Annual Report 2005 noted that graft survival rate for Living Donor kidney to be 95.1% at one year and 80.2% at 5 years. For cadaveric donor kidneys the one year survival rate was 89.0% at one year and 66.7% at 5 years. Graft survival rate does depend significantly upon the recipient’s compliance with treatment regimens. With each subsequent transplant the survival rate of the allograft reduces. Typically no more than three kidney transplants will occur over the course of a patients life. When estimating the cost of kidney transplantation one must consider the cost of a return to dialysis in the event of graft failure, along with the cost of re-transplantation. A return to dialysis must be factored into the plan for a period before each transplant procedure. This should likely be a period equal to the average time for donor procurement.
The Milliman Research Report 2005, outlines estimated average 2005 first-year charges associated with kidney transplant to be as follows: Evaluation – $12,300; Procurement – $50,800; Hospital $62,900; Physician – $17,700; Follow-up – $40,200; Immunosuppressants – $26,100. (Milliman 2005).