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122 What are the risks & benefits of kidney-pancreas transplants?




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This article is from the Organ Transplant FAQ, by mike_holloway@hotmail.com (Michael Holloway) with numerous contributions by others.

122 What are the risks & benefits of kidney-pancreas transplants?

Question:
My wife's kidneys are failing and she will have to have a kidney
transplant soon. She is also a diabetic. The subject of a kidney-pancreas
transplant has come up. We are wondering if this is a wise option? What
are the risks? Her diabetes has been under very good control and she is
presently not suffering from any other side effects of diabetes, so this
option seems very attractive.

Answer:
The issue of whether to have a kidney transplant alone, or a combined
kidney pancreas transplant is extremely complex. The decision truly has
to be individualized. Unfortunately I cannot give the kind of individual
counseling your family needs in this forum. However, I would be happy to
mention several issues that should be addressed so that when you talk to
your nephrologists and surgeons you will have some background.

First of all, it is very clear that both kidney transplants and
kidney/pancreas combined (KP) result in longer life expectancy than
dialysis for diabetics. The best results in terms of graft survival
percentage is with a highly matched living donor kidney (usually from a
sibling). The next best results are from a less highly matched living
donor. Another advantage of a living donor kidney transplant is that it
can generally occur sooner, often before dialysis has even begun. The
wait for a KP is generally longer.

Most KP patients will not require insulin as long as the graft is
working. This is a particular advantage for a diabetic that has great
difficulty achieving control of their blood sugar and finds themselves in
the life threatening ranges of too high or too low very often. Another
advantage of a functioning pancreas is the progression of the retinal
disease, the neuropathy, and vascular disease may be slowed (but not
reversed) by a functioning pancreas. These advantages need to be weighed
against the higher rate of complications. These complications include
rejection, infections, the need for reoperation because of failure for
something to heal, dehydration due to the pancreas secretions, and
others.

Use the URL below for Graft and Patient Survival Rates for U.S.
Transplants (from the United Network for Organ Sharing
WWW site). http://www.unos.org/Data/main_default.htm
Jeff Punch, MD (transplant surgeon), University of Michigan
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This question is too complex for a brief answer. Pancreas transplantation
is life enhancing; but, unlike other transplants, not necessarily
life-saving or life-prolonging. Therefore, advice varies between
physicians as to the best choice for individual patients (i.e. to receive
a kidney transplant alone vs a combined kidney and pancreas transplant
from the same cadaveric donor vs a kidney transplant first, to be
followed by a pancreas transplant at a later date), and patients with
very similar medical histories may come to different conclusions
concerning the appropriateness of becoming pancreas transplant
recipients. In general, pancreas transplants will protect diabetic
patients who have difficulty detecting hypoglycemia (low blood sugars)
from suffering hypoglycemic seizures and comas. Working pancreas
transplants will also free the diabetic from the necessity of taking
insulin injections and of following a diabetic diet; and may over time
help to stabilize the progression of diabetic retinopathy and neuropathy,
and reduce the risk of the recurrence of diabetic changes in the
transplanted kidney (although these latter benefits are less definitely
proven). On the other hand, pancreas transplantation involves a more
extensive surgery and carries a higher risk of complication. My best
advice is for you and your wife to discuss the appropriateness of her
receiving a pancreas transplant with the physicians and staff of a
transplant program which offers pancreas transplantation as an option.

Alan Leichtman, MD (transplant nephrologist), University of Michigan

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