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Featuring Niraj Desai, Assistant Professor of Surgery
I’m Niraj Desai. I’m a transplant surgeon here at Johns Hopkins in the department of surgery, and I’m the director of the kidney and pancreas transplant program.
The pancreas transplant operation is done through an abdominal, mid-line incision. And that is a up and down incision on the abdomen. We connect the artery and the vein that both supply the blood to the pancreas and return the blood back to the body, and then once we allow the blood flow into the pancreas, we have to connect a small piece of intestine that comes with the pancreas organ to the patient’s intestine to allow the drainage of the excrement materials into the patient’s body. Previously, people would connect to the bladder, but we really don’t do that procedure anymore because the patients tolerate being connected to the intestines much better. It’s not associated with long-term complications like connecting it to the bladder is.
The combined kidney and pancreas transplant operation is done through an abdominal, mid-line incision, and that is an incision that runs up and down on the abdomen. And we place the kidney and the pancreas in, almost like two different operations in the abdomen. Typically, we’ll put the kidney in first, allow the blood flow back into the kidney, and let it start working, and then, in a separate location, but through the same incision, put the pancreas in. So the patient wakes up having had two operations done on the inside, but through one incision. Both organs are hopefully functioning immediately, they’re making urine, the creatinine is coming down, reflecting kidney function, and the pancreas is making insulin, and the glucose has become normal.
Pancreas after kidney transplant operations would be two separate operations done through two different incisions, two different hospital stays and, of course, two independent recoveries as well.
With the pancreas transplant alone, the quality of life is primarily focused upon normalizing someone’s glucose control. Patients who are typically undergoing a pancreas alone transplant have a very difficult quality of life from extreme difficulties in controlling their blood sugars. So they’ll run from being very low and having hypoglycemia, which can lead to passing out, or seizures, having to call for emergency help – problems like that. And then, alternatively, swings towards the high end, where they end up with very high glucoses and have to end up being hospitalized for control of their diabetes.
When the pancreas is successful, all their glocoses should become normal, and they avoid the lows and the highs and have excellent glucose control.
Long term, the advantage of that is that complications from diabetes, what we refer to as secondary complications, are either reversed or minimized.
The quality of life after the combined procedure is fantastic. These individuals come in with two problems: kidney failure, most of the time on dialysis, and a very long period of time of having been diabetic: taking insulin, having difficulties with controlling their glucoses. And after this single operation, both of those problems are fixed; so they feel fantastic. They are no longer on dialysis, or impending, about to go on, and they no longer have to take insulin and having swings in their blood sugars and having normal control.
So we’ve fixed the kidney problem, we’ve fixed their diabetes, and when this works well, it is an outstanding result for the individual.
So individuals that receive a pancreas transplant can expect the organ to last for ten years or more, on average. It is a very durable therapy and is able to function for many, many years when a patient is compliant, and especially when early rejection episodes are avoided.
Even from a deceased donor, a combined operation, it is probably mostly a function of us being able to monitor the kidney to pick up on problems related to rejection. It’s hard to track rejection of the pancreas, whereas it’s easy to track rejection of the kidney. So if you have both organs in and you follow the kidney quite easily and know that there’s trouble, and increase the immunosuppression if there’s rejection and treat both – in both organs. It tends to correlate, so if you’re having rejection of the kidney, you’re typically having rejection of the pancreas, and that’s at least an 80% correlation for the most time.
Initially after the operation is done, patients spend at least a week in the hospital and often a couple of weeks in the hospital. Once someone goes home, they are getting labs drawn twice a week, usually close to home, and coming back for outpatient visits on a weekly basis and then every other week, and then once a month. For the first couple of months, they’re back here for outpatient visits fairly frequently. But once time goes on, they are able to just follow up every three months, but still getting labs twice a week, then once a week, then every other week, and then monthly.
Long term follow up, which I would say is after the first year, patients are seen once every three months, in a doctor’s office appointment, and get labs drawn once a month.
Patients come to Hopkins to look into a pancreas transplant for several reasons. One, there’s a big team of people here who are dedicated to taking care of transplant patients. The expertise that these individuals bring is fantastic for this patient population. This includes surgeons, medical physicians, nurse coordinators, nurse practitioners, everyone together has had a lot of experience taking care of pancreas transplant patients and as a result, that collective experience is great for helping someone through the operating procedure and then the post-operative recovery.
The second reason that patients come to Hopkins to look into a pancreas transplant is the experience that we have with taking care of sensitized patients. These are individuals that have antibody in their blood stream, are often difficult to transplant, and the experience that has been gained in the kidney and pancreas transplant populations that have antibody that makes transplantation difficult draws individuals here, looking for a chance at transplant, when they haven’t been able to get that opportunity elsewhere because of these sensitization events that they have had in the past.