Pancreas Transplantation Clinical Presentation

Evaluation of candidates for pancreas transplantation involves the following:

Renal disease

Preexisting advanced renal disease is observed in significant numbers of pancreas transplantation candidates. Therefore, coincident extrarenal disease should be assumed present.

Diabetic retinopathy

Diabetic retinopathy is a ubiquitous finding in patients with diabetes and end-stage renal disease (ESRD). Significant vision loss may be observed. Also, patients may be overtly blind. Blindness is not an absolute contraindication to transplantation because many blind patients lead very independent lives. Although rarely a problem, confirm that a patient with significant vision loss has an adequate support system to ensure help with travel and immunosuppressive medications.

Gastroparesis

Impaired gastric emptying (gastroparesis) is an important consideration because of its significant implications in the posttransplantation course. Patients with severe gastroparesis may have difficulty tolerating oral immunosuppressive medications that are essential to prevent rejection of the transplants. Episodes of volume depletion with associated azotemia frequently occur in patients with SPK transplants. Patients typically require careful treatment, including motility agents such as metoclopramide, cisapride, or erythromycin.

Coronary artery disease

The most important comorbidity to consider in patients with type I diabetes with diabetic nephropathy is coronary artery disease (CAD). Patients with diabetes and ESRD are estimated to carry a nearly 50-fold greater risk of cardiovascular events than the general population. This type of patient may have several risk factors in addition to diabetes for development of CAD, including hypertension, hyperlipidemia, and smoking. Because of neuropathy associated with diabetes, patients may have asymptomatic myocardial ischemia-induced angina. The prevalence of significant (>50% stenosis) CAD in patients with diabetes who are starting treatment for ESRD is estimated to be 45-55%.

Stroke

Patients with ESRD and diabetes also experience an increased rate of strokes and transient ischemic attacks. Deaths related to cerebral vascular disease are approximately twice as common in patients with diabetes compared to patients without diabetes once ESRD has occurred. Patients with diabetes experience strokes more frequently and at a younger age than do age- and gender-matched nondiabetic patients with stroke.

Peripheral vascular disease

Lower extremity peripheral vascular disease is significant in patients with diabetes. Patients with ESRD are at risk for amputation of a lower extremity. These problems typically begin with a foot ulcer associated with advanced somatosensory neuropathy.

Autonomic neuropathy

Autonomic neuropathy is prevalent and may manifest as gastropathy, cystopathy, and orthostatic hypotension. The extent of diabetic autonomic neuropathy commonly is underestimated.

Neurogenic bladder dysfunction is an important consideration in patients undergoing bladder-drained pancreas-alone transplantation or SPK transplantation. Inability to sense bladder fullness and empty the bladder predisposes to high postvoid residuals and the possibility of vesicoureteral reflux. This may affect renal allograft function adversely, increase the incidence of bladder infections and pyelonephritis, and predispose to graft pancreatitis.

The combination of orthostatic hypotension and recumbent hypertension results from dysregulation of vascular tone. This has implications for blood pressure control following transplantation, especially in patients with bladder-drained pancreas transplants who are predisposed to volume depletion. Therefore, careful reassessment of the posttransplantation antihypertensive medication requirement is important.

Sensory and motor neuropathies

These conditions are common in patients with longstanding diabetes. This may have implications for rehabilitation after transplantation. It also is an indicator for potential risk of injury to the feet and subsequent diabetic foot ulcers.

Mental or emotional illnesses

Mental illnesses, including neuroses and depression, are common. Diagnosis and appropriate treatment of these illnesses is an important pretransplantation consideration, with important implications for ensuring a high degree of medical compliance.

Type I diabetes is an autoimmune disease that results in selective loss of the insulin-producing beta cells of the islets of Langerhans. No reliable way to predict who will develop diabetes is available, nor does a cure exist. Transplantation of the pancreas is a treatment option designed to replace the islets. Immunosuppression to prevent organ rejection is sufficient also to prevent recurrent autoimmune diabetes.