pancreatic and islet cell transplantation. general principles pancreas graft survival rates have...

Pancreatic and Islet Cell Pancreatic and Islet Cell TransplantationTransplantation

GENERAL PRINCIPLESGENERAL PRINCIPLES

• Pancreas graft survival rates have significantly improved over the past decade,

• and now exceed 95% at 1 year

• and 70% at 5 years .

2Dr .yekehfallah-phd of nursing 201504/19/23

PRETRANSPLANT PRETRANSPLANT EVALUATIONEVALUATION

Absolute contraindications to transplantation

1/Active sepsis

2/Active viral infection

3/Acquired immunodeficiency syndrome (AIDS)

4/Malignancy (except if treated, nonmetastatic, without recurrence, and with sufficient post treatment follow-up)


Simultaneous transplantation of pancreas and kidney with bladder drainage


Types of Types of TransplantationTransplantation

WHOLE PANCREATIC

ISLET CELL

504/19/23 Dr .yekehfallah-phd of nursing 2015

Types of Whole Pancreatic Types of Whole Pancreatic TransplantTransplant

1 ) Simultaneous Kidney and Pancreas (SPK)

+

2) Pancreas after Kidney (PAK)

3) Pancreas alone (PTA)


Pancreatic: Transplant Pancreatic: Transplant

ProcedureProcedure

Arterial Anastomosis- Common iliac artery

Venous Anastomosis- Common iliac vein

Pancreatic duct + Loop of Duodenum

Cytostomy

Enterostomy704/19/23 Dr .yekehfallah-phd of nursing 2015

Islet TransplantationIslet Transplantation

Sites: Intrahepatic Subrenal Capsular Intrasplenic Intraperitoneal Subcutaneous


Islet TransplantationIslet Transplantation

Sites: Intrahepatic Subrenal Capsular Intrasplenic Intraperitoneal

Subcutaneous

Time: At laparotomy Renal Transplant Surgery Percutaneous Route

Advantages: Less invasive

Disadvantage: More Technical Expertise


INTRAOPERATIVE INTRAOPERATIVE CONSIDERATIONSCONSIDERATIONS

Metabolic careFrequent (at least hourly) intraoperative

monitoring of blood glucose levels is important, because the pancreas graft often begins to function immediately postreperfusion, resulting in decreasing blood glucose levels and no further need for exogenous insulin


POSTOPERATIVE CARE POSTOPERATIVE CARE

General:

Immediate postoperative: -chest radiography

-frequent electrolyte monitoring

-daily serum amylase

-lipase levels


POSTOPERATIVE CARE POSTOPERATIVE CARE Metabolic In the few grafts that have delayed function,

temporary administration of exogenous insulin may be necessary

- IV insulin infusion - hourly blood glucose monitoring

Bladder-drained monitoring : - dehydration and metabolic acidosis - fluid and electrolyte losses from the exocrine pancreas - Urine is collected over an 8-hour period on each postoperative day - hourly urinary amylase production (expressed as amylase U/hr) - urinary amylase excretion should increase daily



Kidney graft monitoring and management



Graft thrombosis prophylaxis• No prospective data are available to support

current empiric practices.• Some centers partially anticoagulate recipients

perioperatively for the first 3 to 7 days (e.g., heparin infusion at 300 to 700 U/h IV).

• Many transplant programs start recipients perioperatively on oral acetylsalicylic acid, which is continued indefinitely.


POSTOPERATIVE POSTOPERATIVE CONSIDERATIONS CONSIDERATIONS

Surgical complications

3/Surgical wound infection a/Superficial wound infection (1) Symptoms: - fever - wound drainage - cellulitis - leukocytosis. (2) Treatment: - IV antibiotics - local incision and drainage - open wound care with daily dressing changes



Medical complications1/Rejection a/Acute rejection(1) Symptoms : - hyperamylasemia - fever - graft tenderness - decreasing urinary amylase - serum creatinine elevation in recipients of a simultaneously transplanted kidney (SPK) - Hyperglycemia is a late symptom (2) Diagnosis confirmation: - percutaneous graft biopsy (gold standard).(3) Treatment:

(a) High-dose IV steroids(b) Anti-T-cell therapy



Medical complications1/Rejectionb/Chronic rejection(1) Associated with graft fibrosis and graft vasculopathy; irreversible.(2) Symptoms: - decreasing glucose tolerance - hyperglycemia - increasing HbA1c levels - decreasing or absent urinary amylase (bladder-drained grafts).(3) Treatment:

(a) Symptomatic: oral antidiabetic agents, return to exogenous insulin therapy(b) Pancreas retransplantation(c) Graft pancreatectomy usually not necessary

•


POSTOPERATIVE POSTOPERATIVE CONSIDERATIONSCONSIDERATIONS

Medical complications

3/Metabolic complications

a/Hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia:

all can occur as the consequence of large-volume diuresis of a simultaneous kidney graft (SPK). Monitor at least every 12 hours; substitute electrolytes as indicated.



Medical complications 3/Metabolic complications

b/Hyperkalemia (in SPK recipients) can be encountered with delayed

kidney graft function and may, depending on severity, require IV calcium chloride, insulin and dextrose, and bicarbonate. Potassium excretion can be augmented by IV loop diuretics; if diuresis cannot be induced, oral Kayexalate and dialysis may become necessary



Medical complications

3/Metabolic complications c/Hyperglycemia

may reflect transient delayed graft function (rare) and may require temporary exogenous insulin


How is Rejection detected?How is Rejection detected?

Enteric: Increased Blood Sugars

Urinary: Reduced urinary Amylase Increased Serum Amylase Increased Blood Sugars

Diagnosis of Rejection:

Cystoscopic Transduodenal biopsy

Transcutaneous Biopsy


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pancreatic and islet cell transplantation. general principles pancreas graft survival rates have...

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pancreatic transplant

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postoperative care general

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simultaneous kidney

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