Pancreas Transplantation Clinical Presentation

Updated: Apr 13, 2022
  • Author: Joseph Sushil Rao, MD; Chief Editor: Ron Shapiro, MD  more...
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Presentation

History

Candidates for pancreas transplantation require evaluation for the following complications of diabetes:

  • Kidney disease
  • Retinopathy
  • Coronary artery, cerebral vascular, and peripheral vascular disease
  • Gastropathy
  • Neuropathy

Kidney disease

A significant number of pancreas transplantation candidates have preexisting advanced kidney disease. Therefore, coincident extrarenal disease should be assumed present. Candidates for PTA transplants must be evaluated for the likelihood of progression of kidney dysfunction once nephrotoxic immunosuppression is started, as these patients may eventually need a kidney transplant as well. Some of the relative benefits of SPK transplant (shorter waiting time for a kidney than for kidney alone candidates and improved pancreas graft function compared with PTA recipients) may warrant waiting for eventual SPK rather than proceeding with PTA.

Diabetic retinopathy

Diabetic retinopathy is a frequent 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. However, it is essential to confirm that a patient with significant vision loss has an adequate support system to ensure help with travel and immunosuppressive medications.

Coronary artery disease

A significant 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 the development of CAD, including hypertension, hyperlipidemia, and smoking. They may have asymptomatic myocardial ischemia because of neuropathy associated with diabetes. The prevalence of significant (> 50% stenosis) CAD in patients with diabetes who are starting treatment for ESRD is estimated to be 45-55%. [18]

Cerebral vascular disease

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.

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 essential to prevent rejection of the transplants. Episodes of volume depletion with associated azotemia frequently occur in patients with simultaneous pancreas-kidney (SPK) transplants. Patients typically require careful treatment, including motility agents such as metoclopramide, cisapride, or erythromycin.

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 and reflux into the donor duodenum. This may adversely affect renal allograft function, 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 predisposed to volume depletion. Therefore, careful reassessment of the posttransplantation antihypertensive medication requirement is required.

Sensory and motor neuropathies

These conditions are common in patients with longstanding diabetes. This may have implications for rehabilitation after transplantation. It also indicates the potential risk of a foot injury 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 essential pretransplantation consideration, with important implications for ensuring a high degree of medical compliance.