SKP and All That Jazz

OK, I've been told that it's been more than a month since my last post.....but I haven't really got any news. I've had some bad dealings with the hypoglycemia lately, but no news from the tx center.  And so I'm just going to post the following Public Service Announcement in an effort to answer more of the questions that I am asked all the time.

Thanks for checking in here!

What is a simultaneous kidney-pancreas transplant (SKP)?

A kidney-pancreas transplant is an operation to place both a kidney and a pancreas – at the same time – into someone who has kidney failure related to type 1 diabetes.
In many cases, both transplanted organs may come from the one deceased donor. However, it is also possible for the kidney to come from a living donor (a family member or friend) and the pancreas from a deceased donor.
This type of transplant treats both kidney failure and diabetes because the new organs replace the function of the failed kidney and the pancreas. The first successful kidney-pancreas transplant in the U.S.A. took place in 1966.
Since then, more of these operations are occurring each year. In 2008, more than 800 were done at transplant centers in the United States

Who is a candidate for SKP?

Adults whose kidneys have failed because of type 1 diabetes are possible candidates for a kidney-pancreas transplant. In type 1 diabetes, the pancreas does not make enough insulin, a hormone that regulates the blood sugar level in your body. The transplanted pancreas can produce insulin and correct this type of diabetes. People with type 2 diabetes are not candidates for a combined kidney-pancreas transplant. In type 2 diabetes, the pancreas makes insulin, but the patient’s body tissues are not able to use this insulin properly. For this reason, a pancreas transplant would not help to correct type 2 diabetes. However, people with this type of diabetes can still have a kidney transplant if they develop kidney failure because of their diabetes.

Medical Criteria for SKP

Usually, a patient with insulin dependent diabetes (Type 1, juvenile diabetes) whose kidneys have failed (“end stage renal disease” (ESRD)) and who requires dialysis, or a patient whose e-GFR is near 20/mL/min or less. The transplant center where you have your evaluation will provide more information about candidate requirements.

Which patients may not be considered for SKP transplantation?

A kidney-pancreas transplant is usually NOT an option in a person with:

• HIV infection
• Active Cancer
• Poor adherence to treatment
• Substance abuse problems
• Severe mental retardation
• Severe coronary artery disease and/or congestive heart failure.

Is it possible to have kidney and pancreas transplants at different times?

Yes. Sometimes, a patient who has kidney failure because of type 1 diabetes may have a kidney transplant first, followed by a pancreas transplant at a later date.

How long is the wait?

The waiting time for a kidney-pancreas transplant varies, depending on your blood group and how long it takes for a suitable deceased donor to become available. According to the United Network for Organ Sharing (UNOS), the average wait for a pancreas is 300 to 400 days, while the wait for a combined kidney and pancreas is about 300 days. As of July 2009, there are more than 2,200 candidates listed on the national waiting list awaiting a kidney-pancreas transplant.

How successful are kidney-pancreas transplants?

Patient survival after SKP transplantation is more than 90 percent at two years. The national average for survival rates of kidney pancreas transplants is 94.1 percent still functioning well one year after the operation, and 87.1 percent at three years.
The best results are usually achieved with a closely matched kidney from a living donor (usually from a sibling). Statistics show that the next best results are achieved with a kidney from a less closely matched living donor (such as a spouse or friend). The success rates are also good for combined kidney-pancreas transplants from deceased donors. The best results are usually achieved when both the pancreas and a kidney come from the same donor: a deceased donor. This is because the risk of rejection is significantly reduced. However, there have been several transplants performed using a living donor, with one kidney and a pancreas segment being donated.

How are folks evaluated for a kidney-pancreas transplant?

In general, patients with type 1 diabetes and kidney failure are considered for kidney-pancreas transplants only if they do not have other serious problems related to diabetes, such as heart disease or severe blood vessel disease.
You will meet with many transplant team members including a transplant surgeon, a kidney specialist, a transplant coordinator and a social worker at the transplant center. In addition to a medical history review and physical examination, you may receive:

• Blood tests, including blood and tissue typing
• Tests to evaluate your diabetes. This will confirm that you have Type 1 diabetes
• Evaluation of your kidneys, including a 24-hour urine test if you are not on dialysis
• Tests of your heart and lung function
• Social and psychological evaluation
• Neurological tests to evaluate loss of sensation in hands and feet
• Eye and dental exam. Being legally blind was in the past an exclusion criteria. The transplant center will provide more information about this condition affecting your candidacy.

If all the tests go well, you will be accepted for a kidney-pancreas transplant and placed on the transplant center’s waiting list. You will also be registered on the national computerized registry, which is maintained by UNOS.

What does the operation involve?

In the kidney-pancreas transplant operation, the pancreas is placed on the right side of your lower abdomen, and the pancreatic vessels are attached to the right iliac artery and vein. The iliac vein and artery are major blood vessels in your lower abdomen. The pancreas is also attached to the intestines or bladder to drain its secretions. Then, the kidney is placed in the left side of the lower abdomen. The kidney blood vessels are attached to the left iliac vessels and the ureter is attached to the bladder. Usually, your own kidneys and pancreas are not removed.
The surgical procedure usually lasts four to six hours, and your hospital stay is typically two to four weeks. After the surgery, the pancreas begins to make insulin within hours, and the blood sugar is normalized. From this point on, insulin shots are usually not required unless the body rejects the new pancreas. Studies show that good function of the new pancreas may help slow the progression of other problems related to diabetes, such as nerve and eye damage, and decrease the chance that diabetic changes may occur in the transplanted kidney.

What can one expect after the operation?

The post-operative care of the kidney/pancreas recipient is very similar to the recipient of a kidney alone. While the recipient of a kidney transplant is not usually monitored in the intensive care unit, the recipient of a kidney/pancreas may spend a day or so there for careful monitoring of both kidney and pancreas functioning. If there are no complications such as rejection or infection, you should be able to go home in seven to ten days. Remember that you will need to take special medicines, called immunosuppressive or anti-rejection medications, following your transplant surgery to help prevent your body from rejecting your newly transplanted organs. It is necessary to take these medications exactly as the doctor prescribes for the rest of your life. In addition, you will have regularly scheduled tests as an outpatient to monitor the function of your transplanted organs and will be encouraged to maintain a healthy lifestyle through diet and exercise.

What complications may occur?

The main complications that may occur are infection and rejection. In order to prevent rejection, it is important to take your medications exactly as ordered by your doctor. The symptoms of rejection you need to watch for may include tenderness around the transplanted organs, decreased urine output, increase in blood glucose level, fever, abdominal pain and vomiting.
If you have any of these symptoms, speak to your transplant team right away. You will be evaluated regularly at the transplant center. Sometimes, early symptoms of rejection are hard to notice, but they can be detected in your blood work and treated. Most kidney-pancreas transplant patients will have a rejection episode during the first few months, and they will need to return to the hospital for treatment.
The medications you need to take to prevent rejection lower your body’s immune defenses, which increases your chance of getting an infection. This risk is higher right after your transplant because the doses of your medications are higher. During this time, it is important to avoid large crowds and people who are sick, especially with contagious illnesses such as colds or flu. You should wash your hands often. After a while, the doses of your medications will be reduced, and the chance of getting infections will be less.

Do the anti-rejection medications have side effects?

Yes. These medications have many potential side effects. All of them can increase your chances of getting infections (see previous question). Other side effects depend on the specific medications you are taking. It is important to learn the side effects that each of your medications may cause and understand what to do if you have any of them. Some side effects are more serious and require an immediate call to your transplant team and quick adjustments in your medications. Other side effects may be more of a bother, but not life-threatening, and they can be dealt with at your next clinic visit. Ask your transplant team what to do to help minimize side effects.

How can I cope with fears about rejection and other concerns?

Although transplantation gives most recipients a new lease on life, with added freedom and increased energy and productivity, it is normal to experience some stress. For example, it is not unusual to have fears about rejection, concerns about returning to work and other activities, and feelings of isolation. Here are some strategies that may help you to better cope with these and other challenges:

• Join a local support group for transplant recipients
• Learn as much as possible about and be involved in your medical care and progress
• Find personal quiet time to think about your feelings, identify concerns and plan for the adjustments you need to make
• Get to know the members of your transplant team, and discuss the issues that most concern you.

Can I return to work and other activities after the transplant?

It may be possible to return to your previous employment, start a new job or work part-time. However, if this is not possible, there are many other types of fulfilling and productive activities you can explore. These may include continuing your education, pursuing hobbies, volunteering, starting an exercise program, traveling or spending quality time with family and friends. If returning to work is an option for you, you may want to ask the transplant social worker at your center for information about the rehabilitation services provided through your state’s Department of Vocational Rehabilitation.

Other sources of help and information

You can also check the following resources for additional general information:
National Kidney Foundation1-800-622-9010
United Network for Organ Sharing 1-888-894-6361 http://www.unos.org/
National Transplant Assistance Fund1-800-642-8399 www.transplantfund.org/
State Kidney Programs1-800-733-7345
American Kidney Fund1-800-638-8299 www.kidneyfund.org