• Credits

  • Section Writer: Dr. Om J Lakhani
  • Section Editor: Dr. Om J Lakhani

• Q. What are the indication for pancreatic and islet transplantation?

  • Pancreatic transplantation
    • Pancreas  + kidney transplant in those undergoing kidney transplant
      • Type 1 diabetes with severe recurrent ketoacidosis
      • Type 1 diabetes with recurrent severe hypoglycemia
  • Islet transplant
    • It is experimental and done under a research setting
    • Autografting of islet for patients undergoing pancreatic surgery is recommended

• Q. What are the advantages and disadvantages of pancreatic transplant over islet transplant?

  • Pancreatic transplant leads to better insulin independence compared to islet transplantation
  • However, morbidity is more with pancreatic transplant

• Q. Describe the technique of pancreatic transplant?

  • Whole pancreas with part of the duodenum containing ampulla of Vater is taken
  • It is placed laterally in the pelvis
  • Anastomosis is made with the iliac artery
  • Drainage of the exocrine secretion is done in the intestine (previously done in the bladder)

• Q. What is the immunosuppressive regimen used after pancreatic transplant?

  • Immediate post-op  - Anti T cell antibody
  • Chronic – Azathioprine / Mycophenolate   + Cyclosporine / Tacrolimus

• Q. How common is acute rejection after pancreatic graft?

  • Very common – 60-80%

• Q. How is rejection detected?

  • In Pancreas + Kidney transplant- the kidney is rejected first before pancreas so we see rise in creatinine
  • In pancreas transplant alone– increasing amylase and blood glucose are markers of rejection

Benefits and complications associated with kidney-pancreas transplantation in diabetes mellitus

• Q. What are the terms SPK, PAK, and PTA?

  • SPK- simultaneous kidney + pancreas transplant- both from a single cadaveric do not
  • PKA- Pancreas transplant after kidney transplant – pancreas from cadaveric donor, a kidney from liver or cadaver
  • PTA- pancreatic transplant alone
  • KTA- Kidney transplant alone

• Q. What are the benefits of a combined SPK transplant?

  • Improved survival – mainly due to the renal transplant
  • Better allograft survival
  • Reduced diabetic microvascular complication
  • Reduced macrovascular complication
  • reduced recurrence of diabetic nephropathy
  • Improved glycemic control
  • Improve counter-regulation to hypoglycemia
  • Improved quality of life

• Q. Is patient survival better with SPK over KTA?

  • Yes
  • However, there are no randomized control trials and the data is mainly from uncontrolled studies

• Q. Does SPK improve kidney allograft survival?

  • Yes
  • Allograft survival from cadaveric SPK is equal to liver donor KTA and better than cadaveric KTA

• Q. Are insulin levels in blood higher after pancreatic transplant vis a vis normal person?

  • Yes
  • This is because insulin is released into systemic circulation instead of portal circulation which increases the insulin level

• Q. Does pancreatic transplant worsen hypoglycemia or improve hypoglycemia?

  • It may cause mild hypoglycemia due to a higher insulin level
  • But the counterregulatory response to hypoglycemia improve
  • This is because of glucagon
  • This is one of the major advantages of the transplant

• Q. Are complications more with SPK or KTA?

  • More with SPK

• Q. What are the major causes of pancreatic graft failure?

  • Thrombosis and pancreatitis

• Q. Where the pancreatic exocrine secretions drained?

  • Earlier it was drained in the bladder- but had more complications – it used to cause normal anion gap metabolic acidosis because of loss of bicarbonate in the urine
  • So now it is drained in the intestine

Islet cell transplantation

• Q. Describe the steps in Islet cell transplantation? (Edmonton protocol)

  • 

• Q. Which are the immunosuppressants used in the Edmonton protocol?

  • Sirolimus
  • Tacrolimus
  • Daclizumab

• Q. What was the result of the trial published with the use of the Edmonton protocol in NEJM?

  • Improves glycemic stability and reduces hypoglycemia
  • But does not lead to insulin independence ^[1]

• Q. How are islet grafts monitored?

  • PET Scan
  • MRI with Magnetoencapsulation of the graft

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