Pancreas and Kidney-Pancreas Transplantation



Pancreas and Kidney-Pancreas Transplantation


Michelle James, RN, MS, APRN-CNS, CCTN



I. INTRODUCTION

A. Overview



  • The World Health Organization estimates that approximately 347 million people have been diagnosed with diabetes, worldwide.1


  • In the United States, there are approximately 29 million people, or 9.3% of the population, who have diabetes.2


  • Diabetes is classified into two main types: type 1 and type 2.



    • Type 1 diabetes results from cellular-mediated autoimmune destruction of pancreatic islet beta cells causing the loss of insulin production.



      • Type 1 diabetes (insulin dependent) affects 5% of those with diabetes, and although disease onset can occur at any age, it peaks in mid teenage years.2


    • Type 2 diabetes (non-insulin dependent) is the more common type, affecting 95% of those with diabetes.2



      • Type 2 diabetes usually occurs in adulthood and is characterized by insulin resistance. As resistance rises, the beta cells are eventually unable to produce the necessary amount of insulin to lower and maintain normal blood glucose levels.


      • In recent years, there has been an increase in type 2 diabetes diagnosed in children and adolescents.


      • Diet and obesity, older age, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity are associated with development of type 2 diabetes.


  • Pancreas transplantation has been performed since 1966.3


  • Goals of pancreas transplantation are



    • To restore normoglycemia in patients with labile diabetes


    • To halt or prevent secondary complications of diabetes3


  • The International Pancreas Transplant Registry (IPTR) reports3:



    • Greater than 35,000 pancreas transplants were performed between 1966 and 2011.









      TABLE 15-1 Patient and Graft Survival by Type of Pancreas Transplant

























      Procedure


      1-Year Patient Survival*


      1-Year Graft Survival*


      5-Year Graft Survival*


      Pancreas transplant alone (PTA)


      >95%


      77.8%


      82%


      Simultaneous pancreas-kidney (SPK) transplant


      >95%


      Pancreas: 85.5%


      Kidney: 93.4%


      Pancreas: 72%


      Kidney: 80%


      Pancreas after kidney (PAK) transplant


      >95%


      79.9%


      78%


      * Per 2011 IPTR data. Data from Gruessner AC. 2011 Update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the course of twenty-four years at the International Pancreas Transplant Registry (IPTR). Rev Diabet Stud. 2011;8:6-16.




      • More than 24,000 transplants were performed in the United States during this period.


      • More than 12,000 pancreas transplants were performed outside the United States during this period.


    • Table 15-1 depicts patient and graft survival by type of pancreas transplant.


    • Distribution of pancreas transplant volume by type of transplant is displayed in Figure 15-1.


  • Patients with severe or “brittle” diabetes are very limited in their ability to pursue normal activities of daily living due to



    • Frequent problems with high and/or low blood glucose


    • Hyperglycemia, which causes microvascular, macrovascular, and autonomic complications:



      • Microvascular complications:



        • Diabetic nephropathy



          • Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD), accounting for more than 44% of all new cases annually in the United States.4


        • Diabetic retinopathy


      • Macrovascular complications:



        • Accelerated cardiovascular disease including myocardial infarction (MI), cerebrovascular accidents (CVA), and peripheral arterial disease (PAD).






        FIGURE 15-1 Distribution of transplant volume by type of transplant.



      • Autonomic complications:



        • Gastroparesis


        • Peripheral neuropathy


        • Neurogenic bladder


        • Sexual dysfunction


        • Orthostatic hypotension


    • Hypoglycemia, reoccurring over time, causes a shift in the threshold for symptoms and counterregulatory responses to occur, referred to as hypoglycemic unawareness.



      • If not corrected, hypoglycemia may progress to diabetic coma and cause brain cell death or injury as the brain is the only organ that requires glucose for function.5


  • Most patients tend to do very well with a pancreas transplant.6,7,8,9



    • Quality of life may be dramatically enhanced.


    • Progression of complications of diabetes (neuropathy, nephropathy, and retinopathy) may be arrested.




III. CANDIDATE SELECTION CRITERIA

A. Eligibility criteria can vary widely at each transplant center.

B. Objective measures of end-organ failure include



  • C-peptide deficiency


  • Frequent or severe metabolic complications:



    • Hypo- or hyperglycemia


    • Ketoacidosis


    • Hypoglycemic unawareness despite optimized medical management


  • Evidence of secondary complications such as



    • Peripheral neuropathy


    • Retinopathy


    • Gastroparesis


    • Coronary artery disease


C. Subjective measures of end-organ failure:



  • Numbness, tingling, or loss of perception in extremities


  • Lethargy


  • Nausea


  • Dizziness


  • Blurred vision, low vision, or blindness


IV. PREOPERATIVE PHASE

A. Candidate evaluation testing:



  • Evaluation protocols vary by institution and are individualized according to patient’s medical history and physical examination.


B. Patient and caregiver education



  • Principles of patient education



    • Before providing education, assess the patient for



      • Readiness to learn








        TABLE 15-2 Typical Evaluation Tests




















        Laboratory


        Cardiovascular




        • Electrolyte panel



        • Phosphate and magnesium



        • Uric acid



        • Liver function tests



        • Hgb A-1C



        • C-peptide



        • Fasting lipid panel



        • Amylase and lipase



        • CBC with differential



        • Coagulation profile



        • Serologies (CMV; HIV; EBV; HBV surface antigen, antibody, and core antibody; HCV antibody; and HAV IgG)



        • Urinalysis



        • 24-hour protein/creatinine clearance



        • Glomerular filtration rate



        • Thyroid function studies (T3, T4, TSH)



        • FANA (flourescent) and/or ANA



        • Blood type (ABO)



        • Prostate-specific antigen



        • PAP smear




        • 12-lead EKG



        • Chest radiograph



        • Echocardiogram



        • Ultrasound of carotid arteries



        • Nuclear stress test/or cardiac catheterization



        • Doppler ultrasound of peripheral vessels to detect vascular disease



        • Letter of clearance from cardiologist


        Immunogenetics


        Radiology




        • PRA



        • HLA typing/tissue typing




        • Bone density scan



        • Mammogram



        • Sigmoidoscopy/barium enema or colonoscopy


        Dental exam


        Psychosocial and financial consultation


        CBC, complete blood count; Hgb A-1C, glycosylated hemoglobin; CMV, cytomegalovirus; EBV, Epstein-Barr virus; HCV, hepatitis C; HBV, hepatitis B; HLA, human leukocyte antigen; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone; FANA, fluorescent antinuclear antibody; ANA, antinuclear antibody; PRA, preformed reactive antibody; HLA, human lymphocyte antibody; EKG, electrocardiogram.




      • Level of health literacy


      • Potential barriers to learning, for example:



        • Physiological (e.g., visual impairment)


        • Psychological (e.g., anxiety)


      • Preferred learning style


  • Education begins with the initial referral and continues throughout the transplant continuum. Topics discussed at one point in the continuum will often need to be reemphasized at subsequent time points. For the purposes of this chapter, key transplant phase-specific educational topics will be highlighted in the discussion of each particular phase.


  • Preoperative phase: key education topics include, but are not limited to, the following:



    • Topics required by the Centers for Medicare and Medicaid:



      • Evaluation process:



        • Results of physical exam, labs, and diagnostic testing


        • Patient selection criteria and suitability for transplant


        • Relationship of psychosocial issues to transplant success


        • Financial responsibilities for transplant


        • Requirement to follow a strict medical regimen


        • Outcome of the evaluation


      • Surgical procedure:



        • Detailed discussion of surgical procedure


        • Anesthesia risk; other potential risks


        • Risk related to the use of blood or blood products


        • Expected postsurgical course


        • Benefits and risk of transplant surgery relative to other alternatives


      • Alternative treatment options


      • Potential medical risks of transplantation:



        • Wound infection


        • Pneumonia


        • Blood clot formation


        • Organ rejection, failure, or retransplant


        • Lifetime immunosuppression therapy


        • Arrhythmias


        • Cardiovascular collapse


        • Multiorgan failure


        • Death


      • Potential psychosocial risks:



        • Depression.


        • Posttraumatic stress disorder.


        • Generalized anxiety.


        • Feelings of guilt.


        • Future health problems may not be covered by insurer.


        • Alternative financial resources.


        • Future attempt to obtain medical, life, or disability may be affected.


      • National and transplant program outcomes from most recent Scientific Registry of Transplant Recipients center report:



        • 1-year patient survival.


        • 1-year graft survival.


        • Transplant program does or does not meet outcomes.



        • If center does not meet outcomes, Medicare B will not pay for immunosuppression medications.


        • Web sites for additional information www.ustransplant.org and www.optn.org.


      • Organ donor risk factors:



        • Health risk of donor could affect organ related to donor.


        • Medical and social history and age of donor.


        • Condition of the organ.


        • Risk of disease transmission including



          • Human immunodeficiency virus, hepatitis B, and hepatitis C


          • Cancer


          • Malaria


          • Disease not detectable at time of donor recovery


      • Right to refuse transplantation; right to withdraw consent for transplantation


      • Medicare B coverage for immunosuppressive medications:



        • Transplant must be performed at a Medicare-approved facility for Medicare to pay for immunosuppressive medications


    • United Network for Organ Sharing required topics:



      • Right to be listed at more than one transplant center and the ability to transfer accumulated wait time between transplant centers


      • Coverage plan for transplant program medical and surgical provider


      • Increased donor risk: advise patient at time of organ offer


    • Other potential topics:



      • Patient’s expectations regarding transplantation


      • Role of interdisciplinary team members


      • Waitlist and organ allocation


      • Preoperative or intraoperative immunosuppression


      • Posttransplant immunosuppression



        • The standard immunosuppression for pancreas transplant recipients typically includes



          • Tacrolimus (Prograf; FK506)


          • Mycophenolate mofetil (CellCept)


          • Prednisone (steroid)


  • See chapter on Patient Education for additional information.


V. SURGICAL APPROACH7,11

A. Native kidneys or pancreas are not removed during the transplant operative procedure.



  • Allows the exocrine function of the native pancreas to be preserved.


  • There are two surgical approaches to handle exocrine secretions produced by the transplanted pancreas.



    • Exocrine secretions are generally drained into



      • Enteric drainage (ED): bowel drainage:



        • When the pancreas is drained enterically, much of the approximate 2 L of exocrine enzymatic fluid and bicarbonate produced by the pancreas is reabsorbed in the bowel.


        • The donor portal vein is anastomosed to the side of the recipient’s superior mesenteric vein.







          FIGURE 15-2 Enteric drainage technique.


        • The transplanted donor duodenal segment is attached to the recipient’s jejunum to establish exocrine drainage.


        • The enteric drainage technique is shown in Figure 15-2.


        • The benefit of ED is that no fluid and electrolyte changes occur posttransplant due to its similarity to natural anatomy.


      • Bladder drainage (BD)12:



        • The systemic-bladder drainage technique directs venous outflow and insulin drainage into the iliac vein.


        • Exocrine drainage is via anastomosis of a donor duodenal segment to the recipient’s urinary bladder.


        • The bladder drainage technique is shown in Figure 15-3.






          FIGURE 15-3 Technique of a combined pancreas-kidney transplantation through a lower midline approach.



        • The benefit of bladder drainage is that rejection episodes in the pancreas can be detected more readily by measuring the exocrine enzyme (amylase) in the urine.


        • Bladder drainage may predispose the patient to



          • Dehydration


          • Recurrent urinary tract infections (UTIs), especially if patient has a history of neurogenic bladder with poor bladder emptying.


          • Cystitis


          • Metabolic acidosis (large amounts of sodium bicarbonate are emptied into the bladder)


          • Reflux pancreatitis


          • Hematuria


    • IPTR data indicate that there is no significant difference in the success rates between ED and BD techniques in SPK recipients.3



      • Most centers use the ED technique.


      • Approximately 10% to 25% of BD recipients undergo a surgical procedure called “enteric conversion” in the first 5 years following transplant due to recurrent UTIs, large duodenal leaks, severe or recurrent hematuria, or significant cystitis.7,11



        • Enteric conversion moves the duodenal segment (and as such, exocrine drainage) from the bladder to the bowel


    • When the pancreas is transplanted simultaneously with a kidney from the same donor, the kidney can serve as the early rejection detection mechanism.

B. Average length of surgical procedure:



  • 4 to 8 hours for combined kidney-pancreas transplant


  • 3 to 4 hours for isolated pancreas transplant


VI. POSTTRANSPLANT PHASE

A. Posttransplant course (Table 15-3)



  • Average length of stay: 7 to 14 days


  • May require 24- to 48-hour stay in intensive care unit for cardiac monitoring, depending on individual transplant center policy

B. Postoperative tubes, drains, and devices may include



  • Nasogastric (NG) tube in place for approximately 1 to 2 days, or until bowel function returns.


  • Foley catheter in place for generally 2 to 3 days.


  • Compression stockings or device to prevent deep vein thrombosis.


  • Incentive spirometer; coughing/deep breathing 10 times an hour while awake.


  • Central venous catheter for parenteral medications and fluid management until diet is advanced.


  • Surgical drain, if indicated.


  • Insulin infusion may be utilized to address hyperglycemia for the first 24 to 48 hours posttransplantation to “rest” the insulin-producing islet cells.7

C. Pain management:



  • It is important to continually assess the patient’s level of pain and response to analgesia throughout hospitalization.


  • Strategies to manage pain are guided by institutional protocols.









TABLE 15-3 Potential Complications and Appropriate Interventions






























































Potential Complication


Report Signs and Symptoms


Intervene as Ordered by Provider and Evaluate Patient’s Response


Collaborate with Interdisciplinary Team


Impaired wound healing


Wound leakage


Purulent drainage


Edge separation


Redness


Necrosis


Dehiscence


Wound care


Enzymatic debridement


Antibiotics


Hyperbaric oxygen treatments


Clinical provider


Wound care nurse


Nutritionist


Fluid and electrolyte imbalance


Poor skin turgor


Changes in daily weight


EKG rhythm disturbance


Dry mucous membranes


Decreased urine output


Mental status changes


Dyspnea


Rales


Edema


Distended neck veins


Daily weights


Replace urine output and nasogastric drainage with IV fluids.


Replace electrolytes.


Nutritionist


Clinical provider


Hypoglycemia


Cool and clammy skin


Diaphoresis


Mental status changes


Palpitations


Perform capillary blood glucose measurements.


Administer glucose.


Offer carbohydrates.


Diabetes educator


Nutritionist


Hyperglycemia


Polyuria, polydipsia


Fatigue, blurred vision


Perform capillary blood glucose measurements.


Administer insulin as prescribed.


Clinical provider


Pharmacist


Diabetes educator


Nutritionist


Hypotension


Vital sign changes


Orthostatic hypotension


Dizziness


Fluid boluses


Monitor I&O.


Limit activities.



Hypertension


Headaches


Administer vasoactive drugs as prescribed.


Monitor I&O.


Physician


Pharmacist


Altered bowel function


Abdominal pain


Constipation


Abdominal distention


GI stimulants


Stool softeners, laxatives


Suppositories


Enemas


Increase activity.


Encourage adequate fluid and fiber intake.


Ensure patient has a bowel movement at least every other day.


Clinical provider


Diarrhea


Diarrhea


Amount and consistency of stools


Stoma condition if applicable


Evaluate response to prescribed medications.


Reinforce patient’s knowledge regarding decreased GI motility and adverse effect of constipation on pancreas graft


Clinical provider


Altered nutrition


Low serum albumin


Changes in appetite


Weight changes


Calorie counts


Enteral and parenteral nutritional supplements


Nutritionist


Ancillary nursing staff


Altered mobility/self-care deficit


Level of independence with activities of daily living and ambulation


Incentive spirometer volumes


Encourage/assist with mobility


Involve family or other caregiver


Physical therapist


Respiratory therapist


EKG, electrocardiogram; GI, gastrointestinal; IV, intravenous; I&O, intake and output.


Data from Robertson PR. Benefits and Complications Associated with Kidney-Pancreas Transplantation in Diabetes Mellitus. Uptodate Online Version. Available at www.uptodate.com/application/topic.asp?file=renltran/14457&type=A&selectedTitle=2˜6. Accessed January 2, 2015; Esterl RM, Abrahamian GA, Sutherland DE, et al. Care of the pancreas transplant recipient. In: Irwin RS, Rippe JM, eds. Irwin and Rippe’s Intensive Care Medicine. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:1857-1865; Gremizzi C, Vergani A, Paloschi V, et al. Impact of pancreas transplant on type 1 diabetes-related complications. Curr Opin Organ Transplant. 2010;15:119-123; James MM. Nursing care of the pancreas transplant recipient. Crit Care Nurse Clin N Am. 2011;23:425-441; Kaufman D, Koffron A. Pancreas Transplantation. eMed J. 2001. Available at www.emedicine.com/med/topic2605.htm. Accessed January 2, 2015; Troppmann C. Complications after pancreas transplantation. Curr Opin Organ Transplant. 2010;15(1):112-118; Humar A, Ramcharan T, Kandaswamy R, et al. Technical failures after pancreas transplants: why grafts fail and the risk factors—a multivariate analysis. Transplantation. 2004;78:1188-1192; Goodman J, Becker YT. Pancreas surgical complications. Curr Opin Organ Transplant. 2009;14(1):85-89.



D. Anti-rejection medications7,13:



  • Most patients receiving pancreas transplants will receive triple therapy immunosuppression although regimens vary at individual transplant centers, including steroid-sparing protocols.



    • Triple therapy includes



      • A calcineurin inhibitor: tacrolimus (Prograf) or cyclosporine (Neoral or Gengraf)


      • An antiproliferative agent: mycophenolate mofetil (CellCept) or mycophenolic acid (Myfortic)


      • A corticosteroid: methylprednisolone (Solu-Medrol) IV or oral prednisone


    • Sirolimus (Rapamycin/Rapamune) is being used for some patients in lieu of a calcineurin inhibitor to minimize the nephrotoxic effects associated with calcineurin inhibitors.


    • Most patients will remain on tacrolimus and mycophenolate long term but may taper off prednisone within the months following transplant (if they initially received prednisone).


  • Induction therapy is utilized by some pancreas transplant centers to minimize or avoid steroids due to the impact steroids have on blood glucose levels. These agents include



    • Basiliximab (Simulect), monocolonal antibody


    • Alemtuzumab (Campath), monoclonal antibody


    • Antilymphocyte globulin (Thymoglobulin), polyclonal antibody


  • See the Chapter on Transplant Pharmacology for additional information regarding immunosuppression medications and their side effects.

E. Other medications: See Table 15-4:



  • See Chapter on Noninfectious Diseases for additional information about posttransplant medications.









TABLE 15-4 Commonly Prescribed Nonimmunosuppressive Drugs
































Antimicrobials



Antibiotics


Trimethoprim-sulfamethoxazole against Pneumocystis carinii pneumonia and UTI; penicillins with beta lactamase inhibitor, quinolones, cephalosporins, aminoglycosides, linezolid



Antifungals


Anti Candida albicans: nystatin, clotrimazole; Broad spectrum: fluconazole, ketoconazole; Anti Streptomyces: amphotericin B



Antivirals


Anti herpes: acyclovir, valacyclovir, famciclovir Anti cytomegalovirus: ganciclovir, valgancyclovir, immunoglobulin, cytogam, foscarnet


Supplements


Sodium bicarbonate, magnesium oxide, potassium phosphate


Analgesics


Narcotics, non-narcotics, muscle relaxants


Cardiovascular


Beta blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers cholesterol-lowering agents, diuretics


Acid reducers


Hydrogen ion (H2) blockers, proton pump inhibitors, antacids


Insulin and anti-hyperglycemic medications


Long-acting, regular insulin sliding scale, oral hypoglycemic agents

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Oct 27, 2018 | Posted by in NURSING | Comments Off on Pancreas and Kidney-Pancreas Transplantation
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