YourPancreasTransplant

Informationforpatients

Version1.1October2018

AndrewSutherlandJamesGilbert

MelaniePhillipsAnandMuthusamy

Whatispancreastransplantation?

Apancreastransplantisamajorsurgicalproceduretoplaceahealthypancreasfromadeceaseddonorintoapersonwhosepancreasnolongerfunctionsproperly.

Yourpancreasisanorganthatliesbehindthelowerpartofyourstomach(fig1).Oneofitsmainfunctionsistomakeinsulin,ahormonethatregulatestheabsorptionofsugar(glucose)intoyourcells.

Ifyourpancreasdoesn'tmakeenoughinsulinoryourbodyisunabletomakeuseoftheappropriateamountofinsulinmadebyyourpancreas,bloodsugarlevelscanrisetounhealthylevels,resultingindiabetes.

Whatdoesapancreastransplantdo?

Afunctioningpancreastransplantrespondstoyourbloodglucoselevelsbyproducinganappropriatelevelofinsulintomaintainbloodglucoselevelswithinnormalrange.Thismeansyounolongerneedtoinjectyourselfwithinsulinonaday-to-daybasis.However,themainadvantagetoyouisanincreasedlifeexpectancyandlongerkidneytransplantfunction.

Figure1:Anatomicalpositionofthepancreas.

Whocanhaveapancreastransplant?

Diabetescanbebroadlydividedintwotypes:

Type1diabetes:Yourownpancreasdoesnotmakeenoughinsulin,leadingtohighbloodsugars.Thisconditionislesscommonandtypicallyseeninchildrenandyoungadults.

Type2diabetes:Yourbodyisunabletomakeuseoftheappropriateamountofinsulinmadebyyourpancreas.Thisconditionisincreasingrapidlyacrossworld,itisassociatedwithobesityandistypicallyseeninadults.

Pancreastransplantationisusuallyreservedfortreatmentoftype1diabetes,asthetransplantedpancreasresolvestheissueofinsulindeficit.Inselectedcases,pancreastransplantsmayalsobeofferedtotreattype2diabetes.Themajorityofpancreastransplantsaredonecombinedwithakidneytransplantforpeoplewhosekidneyshavebeendamagedbydiabetes(simultaneouspancreaskidneytransplant,SPK).Pancreastransplantalone(PTA)isusuallyreservedfortype1diabeticsthatsufferfromfrequentlifethreateninghypoglycaemiceventsduetoapatient’sinabilitytorespondtolowbloodsugars.

Apancreastransplantcanrestorenormalinsulinproductionandimprovebloodsugarcontrolinpeoplewithdiabetes,butitisnotthestandardtreatmentforallpatientswithdiabetes.Thisprocedureisforselectedpeoplewithdiabeteswhoareconsideredtohavedevelopedorbeatriskofdevelopingcomplicationsduetothediabetes.

Thedecisiontohaveapancreastransplantistakenafterathoroughdiscussionofthepotentialrisksandbenefitsoftheprocedure,andwillbediscussedindetailbythemembersofthetransplantteamduringyourassessment.

Forpeoplewithanyofthefollowing,apancreastransplantmaybeworthconsidering:

Type1Diabetes Type2Diabetes

Kidneydamageduetodiabetes

Consistentlypoorbloodsugarcontroldespiteoptimisedinsulintreatment

ImpairedAwarenessofhypoglycaemia

BodyMassIndex(BMI)oflessthan30andconsistentlypoorbloodsugarcontroldespiteoptimisedinsulintreatment

Whatarethebenefitsofhavingapancreastransplant?

Diabetesaffectsthebloodvesselsofyourbodyandcausesprogressivedamagetovitalorganssuchaskidneys,heart,brain,eyesandnerves.Thisresultsinvariousdamageswhichyoumayalreadyhavebeenadvisedabout,orhavetreatmentfor(kidneydisease,heartattack,retinopathyneedinglaserorsurgerytotheeyes,poorsensationinyourfeet).Sometimeshavinglowbloodsugars(hypoglycemia)withoutanywarningmayputyouatriskofhavingmajorlifethreateningeventifyouareunabletoobtainimmediatemedicalassistance.

Havingasuccessfulpancreastransplantwillreducetheon-goingdamagecausedbythehighlevelsofbloodsugarandoveraperiodofyearswillhelpimprovesomeofthereversibleeffectsofdiabetes.

Asaresult,ifyouhaveasuccessfulpancreastransplantyouarelikelytolivelongerandhavelesschancesoffurtherheartrelatedproblemsorstrokesthatmayaffectyourlifespan.Also,performedasacombinationwithakidneytransplant,youarelikelytohavethekidneytransplantworkmuchlongerifperformedwithapancreasinpeoplewithdiabetes.

Onadaytodaybasis,asuccessfulpancreastransplantwillofferyoutheopportunitytobecompletelyfreeofinsulintreatmentandhavenormalglucosecontrolwithahealthymixeddiet.

Whattypesofpancreastransplantsdoweperform?

Weperformthreedifferenttypesofpancreastransplant:

Simultaneouspancreaskidneytransplant(SPK):Ifyourkidneyshavebeendamagedbydiabetesandyouareondialysisorclosetoneedingdialysis,youwillreceiveapancreasandakidneyduringthesameoperation.Morethantwo-thirdsofpancreastransplantsworldwidearedonesimultaneouslywithakidneytransplant(SPK).

Pancreas-afterkidneytransplant(PAK):Ifyoualreadyhaveafunctioningkidneytransplant,andconsideredtobenefitfromapancreastransplant,youwillreceivethepancreastransplantasaseparateoperation(PAK).

Pancreastransplantalone(PTA):Ifyousufferfromfrequenthypoglycaemicevents,life-threatingcomplicationduetoyourinabilitytorespondtolowbloodsugars(hypoglycaemia),youwillreceiveapancreastransplantalone(PTA)

WhattestswillIneedforassessmentfortransplantation?Aswithallsurgicalproceduresyouwillassessedtomakesurethatyouarefitenoughfortheoperation.Weusuallyaskforyoutohaveascanofyourheartcalledanecho-cardiogramandatraceofyourheartcalledanECG.Youwillalsohavebloodtestresultsandyouwillhaveadetailedhistorytakenofyourdiabetesandanycomplicationsthatyoumayhave.Asmajorityofthecomplicationsoccurringaroundthetimeoftransplantisrelationtotheheartandlungs,youwillhaverigoroustestsoftheseorganfunctions.Thismayinvolveexerciseteststolookatyourheartandlungfunction.Wemayalsoneedsomespecialistteststhatlookatthebloodsupplytoyourheartandthequalityofyourbloodvesselsthatgotoyourlegs.

Whatarethealternativestopancreastransplant?

Islettransplantation:Ifyousufferfromtype1diabeteswithoutkidneyfailureandyouhavefrequenthospitaladmissionsduetoimpairedawarenessofyourhypoglycemiathenyoucouldbeconsideredforisletcelltransplant.Isletcellsareinsulinproducingcellsthatcanberemovedfromadeceaseddonorpancreas.Thesearetheninjectedintoyourliverandcanimproveglucosecontrolandrestoreawarenessofhypoglycaemia.Mostpeoplerequiretwoislettransplantations.Somepeoplebecomeinsulinindependentforalimitedperiodbuttheprimaryaimofisletcelltransplantistorestoreawarenessandreducethenumberofhypoglycaemiaevents.

Simultaneousisletkidneytransplant(SIK):Ifyouhavebeenconsiseredfromsimultaneouspancreaskidneytransplantbuteitheryouorweconsidertherisksofsurgerytobetoogreat,simultaneousisletkidneytransplantmaybeapossibilityforyou.Youwillreceiveisletscellsremovedfromthepancreasofthesamedeceaseddonorthatyoureceivethekidneyfrom.Itislikelyyouwillneedasecondisletcelltransplantafteryourinitialprocedureandalthoughsomepeoplebecomeinsulinindependentforalimitedperiod,theprimaryaimoftheisletcelltransplantistoimprovebloodglucosecontrol,restoreawarenessandreducethenumberofhypoglycaemiaevents.

Kidneytransplantationfromlivingdonor:Ifyouhavediabetesandrenalfailureyoucanalsoconsiderkidneytransplantalonefromalivingdonor.Livingdonorkidneytransplantcanoftenbeagoodoptionespeciallyifyouarenotconsideredfitenoughforasimultaneouspancreasandkidneytransplant.

Kidneytransplantationfromdeceaseddonor:Youcouldopttohaveakidneytransplantationfromadeceaseddonor,eitherduetoyourpersonalpreference,oruponadvicefromthetransplantteamiftherisksrelatingtotheoperationappeartobehigh(afterthoroughassessment).Afurtheroptionifyouarenotconsideredsurgicallyfitforapancreastransplantisasimultaneousisletandkidneytransplant.

Whenyoumeetthetransplantteamyouwillhavetheopportunitytodiscussalternativestopancreastransplant.

Wheredoesadonorpancreascomefrom?

Althoughitispossibleforalivingdonortodonatepartofapancreas,allpancreastransplantsintheUKareobtainedfromdeceaseddonors.Eitherpeoplewhohavesufferedbraindeath,usuallyasaresultofanbraininjury,knownasDonationafterBrainDeath(DBD)orDonationafterCirculatoryDeath(DCD)frompatientswhoaredeclareddeadfollowingabsenceofbreathingorheartbeat.

HowlongwillIwaitfor?

Onceyouareassessedasbeingsuitableforapancreastransplantyouwilljointhenationalwaitinglist.

Unfortunately,itisnotpossibletopredicthowlongyoumayhavetowaitforatransplantandthismostlydependsonthetypeoftransplantyouareexpecting.Itmaybeseveralmonthsorpossiblyyearsbeforeasuitabledonorpancreasbecomesavailable.IntheUK,halfofthepeoplewaitingforapancreastransplantwillhavereceivedoneafterawaitofatleast13months.Thewaitingtimealsodependsonyourbloodgroupandhowlongittakesforasuitabledonorwhosebloodandtissuetypesmatchyourstobecomeavailable.

WhatshouldIdotohelpmyselfwhileIamonthewaitinglist?

Itisimportanttostayashealthyaspossibletoincreaseyourchancesofasuccessfultransplant:

• takeyourmedicationsasprescribed• followyourdietandexerciseguidelines• keepallappointmentswithyourhealthcareteam• stayinvolvedinhealthyactivities,includingthosethatbenefityouremotionalhealth,

suchasrelaxingandspendingtimewithfamilyandfriends.

MakesurethetransplantteamknowshowtoreachyouatalltimesOnceadonorpancreasbecomesavailable,itmustbetransplantedassoonaspossibleandideallywithin12hours.Youshouldkeepapackedhospitalbaghandyandmakearrangementsfortransportationtothetransplantcentreinadvance.Youwillusuallybeabletostayathomeuntilthetransplantteamnotifiesyouthatasuitablepancreasisavailable.Livingwithseverediabetescanbestressfulenoughwithouttheaddedanxietyofwaitingforapancreastobecomeavailable.PleasecontactyourGPorthetransplantcentreforadviceifyouarestrugglingtocopeemotionallywiththedemandsofwaitingforatransplant.Youmayalsofinditusefultocontactasupportgroup,suchasDiabetesUKorDiabetes.co.ukoralocalkidneypatientsassociationifyouarealsowaitingforakidneytransplant.

WhathappenswhenIamcalledin?

Whenanorganbecomesavailableforamemberoftheteamwillphoneyou.Youwillbeaskedaboutyourgeneralhealthandifyouareondialysis,whatmodeofdialysisyouareonandwhenyoulasthaddialysis.Youwillbeaskedtoattendthetransplantunitandyouwillbeadvisedabouteatinganddrinkinginpreparationfortheoperation.Timeisextremelyimportantintransplantationtomaintainthevitalityoftheorgans.Itisveryimportantthatwecancontactyouatalltimes.Thisismostofteninthenight.Whenyoureceivethecallyoumustarriveatthehospitalassoonaspossible-andbyyourownmeansoftransport,ifpossible.Ifyoucannotbecontactedinalimitedtime,theorgansmaybeofferedtoanotherpatient.Unfortunately,itisalsopossiblethatevenonceyouhavebeencalledinthetransplantoperationmaynotgoaheadforavarietyofreasons,usuallyforissuesrelatedtothedonororthepancreasitself.Asthesituationisconstantlyevolvingwithvariouscrucialpiecesofinformationbeingputtogethertoproceedwiththetransplant,thetransplantteamwillkeepyouconstantlyinformed.

Whatisthesurgerylike?

Thisoperationisperformedundergeneralanaesthesia,soyouareunconsciousduringtheprocedure.Theanaesthetistgivesyouananaestheticmedicationasagastobreathethroughamaskandinjectsaliquidmedicationintoyourvein.

Afteryouareunconsciousyouwillhaveoneverticalincisionortwoincisions(cuts)madeinthelowerpartofyourabdomen(stomach)dependingontheconsultantsurgeonandyourtransplantcentre.Thesurgeonplacesthenewpancreasalongwithasmallportionofthedonor’sintestine,usuallyontherightsideofyourlowerabdomen.Thebloodvesselsofthepancreasareconnectedtothebloodvesselsthatsupplybloodtoyourlegsandthedonorintestineisattachedtoyoursmallintestine.Yourownpancreasisleftinplacetosupportdigestion.

Ifyouarealsoreceivingakidneytransplant,thebloodvesselsofthenewkidneywillbeattachedtobloodvesselsinthelowerpartofyourabdomen(stomach),ontheoppositesite,usuallytheleft.

Theureterofthekidneywhichisthetubethatlinksthekidneytothebladder—willbeconnectedtoyourbladder.Unlessyourownkidneysarecausingproblems,suchashighbloodpressureorinfection,theyareleftinplace(fig2).

Pancreastransplantsurgeryusuallylastsaboutthreetofourhours.Simultaneous(doneatthesametime)kidneyandpancreastransplantsurgerytakesafewmorehoursforexamplesixtoeighthours.

Figure2:Thisdrawingshowsthepositionofthenewpancreasandkidneyinthelowerpartofyourabdomen(viewinsidetheabdomenfromthefront).

Whatwillhappenaftertheoperation?

AfterthesurgeryyouwillbemovedintherecoveryareawhereyouwillbemonitoredpriortobeingtransferredtoeithertheHighDependencyUnitorIntensivecare.Whileyouareintherecoveryareayoumayhaveanultrasoundscan.Thisisascanjustlikeapregnantmotherhasusinganultrasoundscanmachine.Thescanisneededtocheckthatthebloodisflowinginandoutoftheneworgan(s).

Onceyouarefullyconsciousfromthegeneralanaesthesia,youwillbeawarethatyouareattachedtoseveraltubes,monitorsandmachines.Thisequipmentwasputintopositionwhileyouwereasleep.

Theymayinclude:

• thePCA:whichisamachinethatdeliverspainkillersthroughatubeintoyourbody,andiscontrolledusingahandhelddevicethatyoucancontrol.It’sfullnameis:patientcontrolledanalgesia(PCA)

• Epidural:Insomecasesyourpainwillbecontrolledbyacatheterwhichisplacedaroundthespinalcordduringyouranaesthetic.

• anoxygenmask• cannulas:tubesthatprovidenutrients(thegoodnessoffood)andfluidintoyourveins• NG(nasalgastric)tube:aplastictubethatgoesthroughyournoseintoyourstomachtokeepyour

stomachempty.Insomecaseyoumayalsohaveafeedingtubeinsertedtohelpwithyournutritionfollowingyourtransplant

• drains:plastictubesthatareplacedtoremovebloodandotherfluidfromtheoperationsite• catheter:atubeinyourbladderthatallowsyoutourinatewithoutgoingtothetoilet(urinary

catheter).• stent:aninternaltubebetweenthebladderandyourtransplantkidney(insimultaneouspancreas

kidneytransplantation)calleda‘stent’toprotectthejoiningwithyoururinarybladder–thiswillneedtoberemovedbyashortprocedureafewweeksafterthetransplant.

ThePCA,whichisforpaincontrolwillberemovedgraduallyduringthefirst48hoursandyouwillhaveotherintravenous(inthevein)ororal(bymouth)painkillerstohelpyouwithanypainyoumayhave.

Youroxygenmaskisrequiredtohelpyourbreathingfor24to48hoursafteryoursurgery.

Theurinarycatheterstaysinplaceforaboutfivedays.Thisissowecanmonitoryoururineoutputandincaseofasimultaneous(doneatthesametime)kidneytransplant,thecatheterhelpstokeepyourbladderemptyandtoprotectthejoiningbetweentheureterandthebladder(ifyouhaveanewtransplantedkidney).Ifyouhaveonlyhadapancreastransplanteitherapancreas-afterkidneytransplant(PAK)orasimultaneouspancreaskidneytransplant(PTA),thecathetermayberemovedonceyouarewellenoughtogotothetoilet;inspecialcircumstanceswherethepancreasglandisdrainingitssecretionstothebladder,youmayneedtohavetheurinecatheteruntiladvisedbythetransplantteam.

Thenasogastrictubehelpstokeepyourstomachemptyor‘decompressed’,untilnormalbowelfunctionreturns.Thishelpstoprotecttheareawhereyournewpancreasisattachedtoyoursmallintestine.Theabdominaldrainsplacedtoremoveanyexcessfluidfromyourabdomen,areusuallyremovedafterfewdaysasyourrecoveryprogresses.Afterfewdays,asyourconditionimprovesandtheplastictubesstarttoberemoved,youwillbemovedtooneoftherenalwards.Duringyourentirehospitalstay,nurses,doctorsandsurgeonswillcloselymonitor(check)yourrecovery.

Everydayyouwillbereviewedonconsultant-ledwardrounds.Nursingstaffwillregularlymeasureyourbloodpressure,pulseandtemperature,bloodsugarlevels(tomonitorifyournewpancreasisworking)andurineoutputseveraltimesaday.Youwillhavedailybloodsamplestakenforanalysisinthelaboratorytoaccuratelycheckonthefunctionofyourneworgan(s),aswellasthedruglevelsofyouranti-rejectionmedication.Youmayreceivesomeinsulinintheearlydaysafteryouroperation.

Duringyourhospitalstayyouwillreceiveafurtherrepeatultrasoundscansand/orCTscansofyournewpancreas.Thesetestslookspecificallyatthebloodflowofyournewpancreas(andkidney,ifrequired)andwillshowupanynarrowingorblockagesofthebloodvessels.

Whattoexpectafteryourtransplant

Youmayexperiencesomepainanddiscomfort,butyouwillhaveaspecialinfusionpump(PCA)attacheddirectlytoaveininthebackofyourhandorarmtogiveyoupainrelievingdrugs.Youcanpressahand-heldbuttonwhenyoufeelpainordiscomfortandthepumpwilldeliverthecorrectpre-programmeddoseofpainkillingdrugsdirectlyintoyourvein..

Itisfairlycommontoexperience“bloating”(inyourtummy)orabdominaldistensioninthefirst48-72hoursaftertheoperation.Thisisduetohavingageneralanaestheticandsurgery.Whenyourbowelstartstorecoveritsfunction,wewilladviseyoutohavetabletpainkillerstohelptogetyoumobileandpainfreeagain.

Youmaygetacough.Havingphysiotherapywillhelptoclearyoursecretionseffectivelyandtopreventchestinfections.

Ifyouhavealsohadakidneytransplant,youmayneedtohavetemporarydialysisjustuntilyournewkidneystartstofunction.

HowlongIwillbeinhospital?

Theaveragepost-transplanthospitalstayisabouttwoweeks.Thisvariesdependingonhowyouarefeelingandifadditionaltestsorinterventionalproceduresarenecessary.Sometimesifspecialmedications,suchasantibioticsareneededtopreventinfectionsyoumayhavetostayinhospitaluntilthetreatmentcourserecommendedhasbeencompleted.

DoIneedfollowupappointments?

Closemonitoringwithfollowupappointmentsisveryimportant.Yourtransplantteamwilldevelopacheck-upschedulethatisrightforyou.However,pleasebepreparedforthefirstfewweekstocomebacktotheclinictwoorthreetimesperweek.Ifyouliveinanothertownyoumayneedtomakearrangementstostayclosetothetransplantcentre.

Ifyouhavehadacombinedkidneyandpancreastransplantyouhadastent(softplastictube)placedintheureter(betweenthekidneyandthebladder).Thiswillneedtoberemovedunderlocalanaestheticfourtoeightweeksafteryourtransplant.

HowlongmightIbeoffwork?

Thisdependsonyourrateofrecoveryfromtheeffectsoftransplant.Inthefirstfewweeksafteryouroperationyouwillneedtoattendclinicappointmentsforuptothreetimesaweekforfollowupappointments.

Also,itisverynormaltohavealittleornoappetite.Youmayalsofeelverytiredonadailybasis.Thiswillimproveasweeksfollowaftertransplantation.Mostpatientscanbeoffworkforaboutthreemonthsandsomeneedevenlonger.Pleasediscussyourprogresswiththetransplantteamwhowillbeveryhappytoadviseyou.

Whatarethecomplicationsoftheoperation?

Pancreastransplantsurgerycarriesariskofcomplicationswhichcanoccurduringand/oraftertheoperation.Theymayincludesomeofthefollowing:

Bleeding

Aswithalloperations,thereisariskofbleeding.Thisismorecommoninpancreastransplantationasanumberofmedicationsandinfusionsaregivenaftertheoperationtokeepthebloodthinandpreventthrombosis(clotting)ofthepancreasgraft.Approximately10percentofpatients(10in100)havesomebleedingaftertransplantationthatmayrequirebloodtransfusionsorareturntotheoperatingroom.

Thrombosis(bloodclot)

Thereisariskofabloodclotforminginthebloodvesselsofthetransplant.Thisiscalledthrombosisandcanoccurin10percentofpatients(10in100).Thisismostlikelyduringthefirstweekafterthetransplantandmayresultintheorganbeingremoved.Youwillbemonitoredverycloselyforsignsofthiswhileyouareinhospitalandwhenyoureturnhome.Youwillhaveregularbloodsamplestakensowecancarryoutspecialclottingteststomeasurehoweffectivelyyourbloodisclottingandtoavoidtheriskofbleeding.

Pancreatitis

Pancreatitisisaninflammationofthepancreas.Acertaindegreeofpancreatitisisinevitable(cannotbeavoided).Thisisduetodamagetothepancreasduringtheprocessofremovalfromthedonor,storageiniceduringtransportationandre-warmingwithyourblood-thisiscalledischemiareperfusioninjury.

Thesymptomsusuallysettlespontaneously(bythemselves)inthemajorityofthetransplantswithinafewdays.Ifthisgraftpancreatitisisnotgettingbetteronitsown,youmayneedtohavefurthersurgerytowashoutanyfluidcollections,oryoumayhavetubesplacedintoyourabdomentodrainthesefluidcollections.Thevastmajorityofpancreatitisgetsbetteronitsown,butapproximatelyfiveto10percentofpatients(fiveto10in100),mayneedthetransplantedpancreastoberemoved.

Furtheroperations

Approximatelyoneoutofeveryfivepeoplewhohaveapancreastransplantwillneedtogobacktooperatingtheatreforafurtherproceduretodealwithanyoftheabovecomplicationsshouldtheyoccur.

Othercomplications

Thegeneralrisksaresimilartothosefollowinganytypeofmajorabdominalsurgery,includingwoundinfection,infectioninsidetheabdomen,cardiac(heart)complications,deepveinthrombosis(bloodclotsinthelegs)andpulmonaryembolism(bloodclotswhichmovetothelungs).

DoIneedtotakemedications?

Yeswillneedtotakedrugscalledimmunosuppressives.Thesehelptokeepyourimmunesystemfromattackingyourneworgan(s).Stoppingorirregularintakeofthesemedicationswillinevitablyleadtotransplantlossandseriousproblemsforyourhealth.Moredrugsmaybegiventohelpreducetheriskofothercomplicationssuchasinfectionandhighbloodpressure,afteryourtransplant.Onceyouarecomfortableaftertheoperationyouwillbegintolearnaboutyournewmedications.Thedrugswillbelistedonamedicationrecordcardandthepharmacistwillseeyoutoexplainwhattheydoandhowtotakethem.Youwillthenstarttotakeyourmedicationsyourselfcloselysupervised(monitored)bythenursingstaff.Onceyouareconfidentwithtakingyournewmedicationsyouwillbeabletotakeyourmedicationsunsupervised,asyouwoulddoathome.Thistrainingaimstohelpyoubecomefamiliarandconfidentwithtakingallyournewmedicationsbeforeyougohome.

Complicationsofimmunosuppression

Intheearlydaysfollowingatransplant,thesurgeryandtheimmunosuppressiondrugsmakeyourbodymorevulnerabletochest,urinaryandothertypesofinfections.Youwillbegivenantibioticsandanti-viraldrugstohelppreventandtreatanyactiveinfection.

Rejection

Yourbody’snaturalimmuneresponseistotryandgetridoftheneworgan(s),byorganisingaplannedresponseagainstthedonor’scells.Immunosuppressionmedicationshelptocontrolthisresponse.However,despitetheimmunosuppressionmedications,rejectiondoesoccurinaboutoneinfourtransplants.Rejectioncanaffectthepancreasorthekidney,orbothorgansatthesametime.Itisimportanttoidentifysignsorsymptomsofrejectionearlysoeffectivetreatmentcanbegiven.Thisisusuallydonebygivingadditionalimmunosuppressionmedications.

Tofindoutwhetheryourbodyisrejectingtheorganyoumayneedabiopsyofthetransplantedorgan(s).Thismeansasampleoftheorganiscollectedusingalongneedle.Thisisdoneusinglocalanaesthetic(toreduceanydiscomfortforyou),whichnumbstheareawheretheneedleisinserted.

WhatdrugsdoIneedtotake?

Toprotectyourtransplantedpancreas(andkidney,ifthathasbeentransplantedtoo)fromrejectionbyyourimmunesystemyouwillneedtotakepowerfulmedicationscalledimmunosuppressiondrugs.Thedoseoftheimmunosuppressionmedicationswillbeprogressivelyreducedfollowingyourtransplant,butifyouweretostoptakingtheimmunosuppressivemedicationsyournewpancreas(andkidney,iftransplanted)wouldstopworkingandwouldberejectedbyyourbody.

Atthetimeofyouroperation,youwillreceiveaninjectionofadrugthatreducestheabilityofyourimmunesystemtorejectyourtransplantedorgans.Thisisfollowedbylong-termdrugtherapymostcommonlywithacombinationoftwodifferenttypesoftabletmedications,Tacrolimus(Adoport)andMycophenolatemofetil(MMF).Youmaybegivenadditionalmedicationssuchastabletsteroidsifthereisconcernregardinggraftrejectionorintolerancetoanyoftheotherimmunosuppressionmedications.

Whatarethesideeffectsofthesemedications?

Aswithallmedications,theanti-rejectionmedicationscancauseavarietyofsideeffects.However,itisimportanttorememberthatyoumaynotexperiencealloranyofthese.Themostcommonarelistedbelow.

Tacrolimus(Adoport)–immunosuppressionmedication

·tremor(shakyhands)

·upsetstomach(usuallyinearlyperiodoftreatment,normallyresolves)

·sleepdisturbances

·increaseinbloodpressure

·increaseinbloodsugar(diabetes)usuallywithhighbloodconcentrationofthedrug

·hairloss

·moodchanges

·headaches

Mycophenolatemofetil(MMF)–immunosuppressionmedication

·reductioninyourwhitebloodcellcount(andtheconsequentriskofinfection)

·upsetstomachincludingdiarrhoea,nauseaandvomiting

·riskofbirthdefects(discussthisindetailwiththetransplantpharmacistifyouoryourpartnerareplanningongettingpregnant).

Whataretherisksofthelong-termimmunosuppressivemedications?

Astheanti-rejectionmedicationssuppressyourimmunesystemyouwillbeatgreaterriskofinfections.Theseinfectionscanpotentiallybecomelifethreateningasyourbodyisnotabletoprovideitsusualresponsetoinfectionwhileyourimmunesystemislowered.Youaremostvulnerableforthefirstthreetosixmonthsafteryourtransplant.Youwillbeonpreventativedosesofmedicationsagainstcommoninfectionsthatoccuraftertransplantation,thesemedicationswillbegraduallywithdrawnastheriskreduces.Long-termimmunosuppressionmedicationincreasestheriskofyoudevelopingsomeformsofcancer,relatingtoyourskinorlymphglands(lymphoma).Wewillmonitoryoucloselyforanysignsofthesecancersafteryourtransplant,astheycanusuallybeeffectivelytreatediffoundearly.Wewillalsogiveyouadviceaboutskincareprotection-includingsunprotection.

Whathappensifthepancreastransplantfails?

Ifyournewpancreasfails,youcanresumeinsulintreatmentsandconsiderasecondtransplant.Thisdecisionwilldependonyourcurrenthealth,yourabilitytowithstandsurgeryandyourexpectationsformaintainingacertainqualityoflife.

Howsuccessfulispancreastransplantation?

Successratesoftransplantsareusuallyreportedintwoways:

Patientsurvival:thepercentageofpatientswhoarealiveaftertransplant.Itisusuallymeasuredatoneandfiveyearsaftertransplant.

Graftsurvival:thepercentageofthetransplantedorgansstillfunctioning.Itisusuallymeasuredatoneandfiveyearsaftertransplant.

IntheUKthepatientsurvivalatoneyearandfiveyearsafterpancreastransplantis97percentand89percentrespectively.Inotherwords,afterapancreastransplant97outof100patientsarestillaliveatoneyearandmorethan89outof100patientsatfiveyears.

InSPK(simultaneouspancreaskidneytransplants)thepancreasgraftsurvivalatoneyearandfiveyearsis88percentand78percent,respectively.Inotherwords,afterSPK,88outof100pancreaseswillstillbefunctioningatoneyearand78outof100pancreasesafterfiveyears.

InPTA(pancreastransplantalone–wherethereisnokidneytransplanted),thepancreasgraftsurvivalatoneandfiveyearsis80percentand53percent,respectively.Inotherwords,afterPTA,80outof100pancreaseswillbestillfunctioningatoneyearand53outof100pancreasesafterfiveyears.

Version1.1October2018AndrewSutherland

JamesGilbertMelaniePhillips

AnandMuthusamy