pancreatic and islet cell transplantation. general principles pancreas graft survival rates have...
TRANSCRIPT
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)
3Dr .yekehfallah-phd of nursing 201504/19/23
Simultaneous transplantation of pancreas and kidney with bladder drainage
4Dr .yekehfallah-phd of nursing 201504/19/23
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)
6Dr .yekehfallah-phd of nursing 201504/19/23
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
8Dr .yekehfallah-phd of nursing 201504/19/23
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
9Dr .yekehfallah-phd of nursing 201504/19/23
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
10Dr .yekehfallah-phd of nursing 201504/19/23
1104/19/23 Dr .yekehfallah-phd of nursing 2015
1204/19/23 Dr .yekehfallah-phd of nursing 2015
13Dr .yekehfallah-phd of nursing 201504/19/23
14Dr .yekehfallah-phd of nursing 201504/19/23
POSTOPERATIVE CARE POSTOPERATIVE CARE
General:
Immediate postoperative: -chest radiography
-frequent electrolyte monitoring
-daily serum amylase
-lipase levels
15Dr .yekehfallah-phd of nursing 201504/19/23
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
16Dr .yekehfallah-phd of nursing 201504/19/23
POSTOPERATIVE CARE POSTOPERATIVE CARE
Kidney graft monitoring and management
17Dr .yekehfallah-phd of nursing 201504/19/23
POSTOPERATIVE CARE POSTOPERATIVE CARE
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.
18Dr .yekehfallah-phd of nursing 201504/19/23
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
19Dr .yekehfallah-phd of nursing 201504/19/23
POSTOPERATIVE POSTOPERATIVE CONSIDERATIONS CONSIDERATIONS
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
20Dr .yekehfallah-phd of nursing 201504/19/23
POSTOPERATIVE POSTOPERATIVE CONSIDERATIONS CONSIDERATIONS
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
•
21Dr .yekehfallah-phd of nursing 201504/19/23
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.
22Dr .yekehfallah-phd of nursing 201504/19/23
POSTOPERATIVE POSTOPERATIVE CONSIDERATIONSCONSIDERATIONS
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
23Dr .yekehfallah-phd of nursing 201504/19/23
POSTOPERATIVE POSTOPERATIVE CONSIDERATIONSCONSIDERATIONS
Medical complications
3/Metabolic complications c/Hyperglycemia
may reflect transient delayed graft function (rare) and may require temporary exogenous insulin
24Dr .yekehfallah-phd of nursing 201504/19/23
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
2504/19/23 Dr .yekehfallah-phd of nursing 2015
??
26Dr .yekehfallah-phd of nursing 201504/19/23