Indications for Pancreas Transplantation
(Solitary pancreas transplant, pancreas transplant alone, pancreas after kidney)
Patients with insulin dependent (type 1, juvenile diabetes) diabetes may be candidates for pancreas transplantation. Patients who are candidates for solitary pancreas transplantation are individuals with secondary diabetic complications that are progressive despite the best medical management.
These secondary complications include diabetic neuropathy, retinopathy, nephropathy, gastroparesis, and autonomic neuropathy or extremely brittle diabetes. In some cases these patients will have received a prior kidney transplant, usually from a living donor (living donor kidney transplant alone - LDKTA).
Documentation of progressive disease can come from a board-certified endocrinologist with whom the patient has a long-standing relationship. Objective testing from a retinal examination by an ophthalmologist (retinopathy), electromyogram and nerve conduction testing (neuropathy), gastric emptying studies (gastroparesis) and cardiorespiratory reflux testing (autonomic neuropathy) may be valuable in uncertain cases.
For patients for whom the indication is brittle diabetes, there should be evidence of frequent hypoglycemic events despite an attempt at optimal management by an endocrinologist. Patients with brittle diabetes as the primary indication should have evidence of impairment of employability, hypoglycemic-induced accidents involving themselves or small children in their care. Usually there is evidence of frequent emergency care for hypoglycemia or diabetic ketoacidosis.
Contraindications for Pancreas Transplantation
There are certain absolute contraindications to pancreas transplantation:
- HIV infection
- Disseminated or untreated cancer
- Severe psychiatric disease
- Unresolvable psychosocial problems
- Persistent substance abuse
- Un-reconstructable coronary artery disease or refractory congestive heart failure
Relative Contraindications to Pancreas Transplantation:
- Cardiovascular disease. All Type 1 diabetic patients require dobutamine stress echocardiography or exercise or pharmacologic stress scintigraphy prior to consideration. Candidates with positive stress testing or with a history of congestive heart failure will require consultation with a cardiologist prior to transplantation. Candidates with a positive stress test usually will require cardiac catheterization and possible angioplasty or bypass.
- Treated malignancy. The cancer-free interval required will vary from two to five years depending on the stage and type of cancer. Consultation with a board-certified oncologist is required in these cases.
- Substance abuse history. Patients must present evidence of involvement in 12 months of drug-free rehabilitation. This includes written documentation of participation in rehabilitation including negative random toxicologic screens.
- Chronic liver disease. Candidates with chronic hepatitis B or C or persistently abnormal liver function testing must have hepatology consultation prior to consideration.
- Structural genitourinary abnormality or recurrent urinary tract infection. Urologic consultation is required prior to consideration.
- Past psychosocial abnormality. Master of Social Work (MSW) or psychiatry evaluation, as appropriate.
- Aortoiliac disease. Patients with abnormal femoral pulses or disabling claudication, rest pain or gangrene will require evaluation by a board-certified vascular surgeon prior to consideration. Patients with significant aortoiliac occlusive disease may require angioplasty or aortoiliac grafting prior to transplantation. In most cases, this consultation will be performed by Stephen Bartlett, M.D., the director of transplantation, who is board certified in vascular surgery (American Board of Surgery, certificate of added qualifications in vascular surgery #100002). Patients with significant aortoiliac occlusive disease may require angioplasty or aortoiliac grafting prior to transplantation.