A. Currently, pancreas transplantation is the only diabetes treatment that consistently normalizes glycosylated hemoglobin (HbA1c) levels, positively influences the progression of secondary diabetic complications, significantly ameliorates quality of life, and may prolong life. Most pancreas transplants are performed for selected, medically suitable patients with type I diabetes. Type II diabetes remains a relatively infrequent indication (<10% of all pancreas transplants).

B. Depending on the recipient’s native kidneys’ functional status, pancreas transplants are performed in three recipient categories.

1. Simultaneous pancreas-kidney transplants (SPKs) in preuremic and uremic patients.

2. Pancreas after kidney transplants (PAKs) in posturemic recipients of a previous kidney transplant (from a deceased or a live donor).

3. Pancreas transplants alone (PTA) in nonuremic recipients with extremely labile diabetes but adequate native renal function.

C. Pancreas graft survival rates have significantly improved and now exceed 90% at 1 year and 80% at 5 years (SPK).

Patients admitted to the hospital for pancreas transplantation must be evaluated for the following risk factors for adverse perioperative outcomes.

A. Coronary artery disease. Diabetics (those with and without end-stage renal disease [ESRD]) have a high incidence of coronary artery disease. In the course of their transplant workup, prospective pancreas transplant recipients will have been screened for coronary artery disease by noninvasive tests or coronary angiography. Immediately preoperatively, particular attention must be paid to new symptoms of angina, congestive heart failure, recent changes in exercise tolerance, and new, possibly ischemic, changes on the ECG.

B. Peripheral vascular disease. Assess for decreased peripheral pulses or new bruits on peripheral vascular examination, when compared to baseline. Infected diabetic foot ulcers are generally a contraindication to transplantation. Check also for new signs and symptoms of stroke and ischemic cerebrovascular disease.

C. Infectious disease. Diabetes in combination with uremia is a significant risk factor for infection. Preoperative evaluation must include chest radiograph, urinalysis, and careful assessment of indwelling catheters and catheter exit sites (hemodialysis catheters, peritoneal dialysis catheters [including a peritoneal fluid cell count and culture]) and of vascular access grafts. Active infection is a contraindication to transplantation.

D. Metabolic and fluid status. Hyperkalemic uremic patients admitted for transplant may need therapy before the transplant operation (e.g., oral sodium polystyrene sulfonate, intravenous [IV] insulin and glucose, dialysis). Hypervolemic recipients may also need preoperative dialysis. Hyperglycemia with metabolic acidosis requires preoperative correction.

E. Absolute contraindications to transplantation.

1. Active sepsis.

2. Active viral infection.

3. Malignancy (except if treated, nonmetastatic, without recurrence, and with sufficient posttreatment follow-up).

A. Operative technique.

1. All pancreas transplants currently performed are from deceased donors and entail transplantation of the entire organ with an attached segment of duodenum that serves as the conduit for the exocrine secretions.

2. Management of pancreatic exocrine secretions. Usually, the exocrine secretions are drained enterically via an anastomosis of the graft’s duodenal segment to the recipient’s small intestine (duodenoenterostomy, performed in >90% of all pancreas transplants). For PAK and PTA recipients, bladder drainage (creation of a duodenocystostomy) can provide a useful additional means to monitor for rejection (by measuring urinary amylase).

3. Venous pancreas graft drainage. The venous effluent of the pancreas graft can be drained systemically, into an iliac vein or the inferior vena cava (performed in >80% of all pancreas transplants), or portally, into the superior mesenteric vein. Portal drainage has theoretical, but clinically to date unproved advantages (host tolerance facilitation by portally delivered graft antigen; avoidance of potential sequelae of systemic hyperinsulinemia).

B. Cardiovascular care and monitoring.

1. Recipients may benefit from perioperative cardioprotection with β-blockers.

2. Hemodynamic monitoring: central venous pressure (CVP) catheter; arterial line and pulmonary artery catheter only if indicated (e.g., presence of moderate left ventricular dysfunction).

3. Maintain adequate intravascular volume status, avoiding high CVPs that can predispose pancreas grafts with systemic venous drainage to edema while providing adequate preload for optimal perfusion of the kidney graft (SPK recipients). Judicious fluid management to avoid fluid overload and acute myocardial strain is paramount.

C. Foley catheter, nasogastric tube.

D. Metabolic care. Frequent (at least hourly) intraoperative monitoring of blood glucose levels is important, because the pancreas graft often begins to function immediately postreperfusion, resulting in decreasing blood glucose levels and no further need for exogenous insulin.

A. General: Immediate postoperative chest radiograph and frequent monitoring of blood glucose and electrolyte levels; daily serum amylase and lipase levels.

B. Metabolic.

1. In the few grafts that have delayed function, temporary administration of exogenous insulin may be necessary (initially, most easily by IV insulin infusion with hourly blood glucose monitoring; adjust infusion rate to maintain blood glucose levels 80 to 120 mg/dL).

2. Bladder-drained recipients must be monitored closely for fluid and electrolyte losses from the exocrine pancreas, which can result in dehydration and metabolic acidosis. Urine is collected over an 8-hour period on each postoperative day, and hourly urinary amylase production (expressed as amylase units/hour) is determined. With normal pancreas graft recovery from preservation and reperfusion injury, urinary amylase excretion should increase daily before reaching its baseline, usually after discharge of the recipient from the hospital.

C. Kidney graft monitoring and management (see Chapter 134).

D. Provision of adequate immunosuppression.

1. Immunosuppression may include a combination of any of the following: polyclonal or monoclonal anti-T-cell agents for induction therapy during the first week (e.g., antithymocyte globulin, alemtuzumab [T-cell-depleting induction] or basiliximab [nondepleting induction]), steroids, calcineurin inhibitors (tacrolimus, cyclosporine), mycophenolate mofetil, mTOR inhibitors (sirolimus, everolimus).

2.

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