Transplantation Of Kidney And Pancreas Case Study

A 28 year old woman with Type 1 DM since the age of nine visits the outpatient Diabetes Clinic for follow-up. Her weight is 62 kg (136.7 lb) and height 1.55 m (5 ft 1 in). On physical examination she looks pale and oedematous. The thyroid gland is palpable. The heart sounds are normal, and an apical holosystolic murmur is heard (II/VI). The subcostal organs are not palpable. The Achilles and patellar reflexes were not produced and there was ankle oedema. There is no superficial or deep sensory neurologic disturbances. Fundoscopy reveals background diabetic retinopathy. The patient receives six units of intermediate-acting insulin every morning and 2-8 units of very-rapid-acting insulin analogue before meals, depending on the measurements of the blood glucose. She has nephrotic syndrome, diagnosed eight years ago, and receives treatment with felodipine, furosemide, perindopril, aluminum hydroxide (AluCap), calcium carbonate-glycine (Titralac) and erythropoietin 2,000 IU, three times per week.

Despite the not particularly high level of glycosylated haemoglobin (HbAlc 7.7 percent), the daily blood glucose levels range between severe hypoglycaemia and heavy hyperglycaemia, often expressed with ketoacidosis. Laboratory results are as follows: Hct 29.2 percent, Hb 9.5 g/dl, WBC 5,900/mm3, PLT 373,000/mm3, glucose 108mg/dl (6.0mmol/L), urea 210mg/dl (34.9 mmol/L), creatinine 4.5 mg/dl (397.8 mmol/L), total cholesterol 253 mg/dl (6.08 mmol/L), LDL-cholesterol 141 mg/dl (3.65 mmol/L), HDL-cholesterol 69 mg/dl (1.78 mmol/L), triglycerides 124 mg/ dl (1.4 mmol/L), uric acid 5.3 mg/dl (0.32 mmol/L), SGOT 16U/L, SGPT 13 U/L: Urinalysis, protein 675 mg/dl, glucose > 1 g/dl.

From the recordings of her daily measurements, it is deduced that her DM is very unstable. All measurements range between 30mg/dl (1.67mmol/L) and 450mg/dl (25.0mmol/L) and no relation can be found between the units of consumed carbohydrates and the units of the insulin analogue injected before each meal. The patient reports that she was never able to control her blood sugar. Furthermore, she complains of severe gastroparesis symptoms and intense flatulence, which impede every effort to control her blood sugar, despite the use of prokinetic gastrointestinal medicines. A recent gastroscopy reveals bile-stained fluids in the stomach and food residuals, atrophy of the gastric and the duodenal mucosa and first degree oesophagitis in the distal part of the oesophagus. In the past she tried to manage the post-prandial hyperglycaemia by transferring the insulin injection after the meals, without success. A severe hypoglycaemic episode is manifested nearly once every two months.

At the first visit a statin was added and much time was spent trying to find some particular pattern in her blood glucose levels so useful advice could be offered. The effort was not successful, as seen during all the following visits.

Discussing the future, it was explained to the patient that the solution of choice, according to the international data, is a kidney and pancreas transplantation.

The patient did not wish to start renal replacement therapy straight away, despite the recommendations. Two years later, with levels of her serum creatinine ranging between 6.0-8.2 mg/dl (530.4-724.9 mmol/L), a simultaneous kidney and pancreas transplantation was performed.

After the successful transplantation of a cadaveric kidney and pancreas (drainage in the urinary bladder) the patient had normal pre-prandial and post-prandial blood sugar levels without the use of insulin, although a glucose tolerance test was abnormal. After another six months, the appearance of frequent complications (pancreatitis, urinary tract infections and acidosis) led to a new operation, during which the cadaveric pancreas was drained to an intestinal loop. After this operation, disturbances were cured. Four years after the transplantation, the patient has a normal glycosylated haemoglobin level, and there was no deterioration of her retinopathy or nephropathy.

Why is kidney and pancreas transplantation today considered to be the treatment of choice for patients with Type 1 DM with end stage renal disease? What are its advantages compared to the transplantation of the kidney alone?

The advantages of transplantation of the pancreas in combination with the kidney are better quality of life, stabilization of diabetic neuropathy and protection of the transplanted kidney from the consequences of hyperglycaemia. The allotransplantation of the kidney necessitates the administration of immunosuppressive therapy for life, which is accompanied by various undesirable effects. The transplantation of a pancreas together or after the transplantation of a kidney does not add any risks concerning the undesirable effects of the immunosuppressive medicines, which are taken anyway. According to one study, the survival of patients transplanted with a kidney and pancreas appears to be better than the survival of those transplanted with a kidney alone, although probably not statistically significant.

More analytically, the transplantation of the pancreas results in the secretion of insulin in a physiologic way after a glucose tolerance test. However, the insulin levels in the blood of transplanted individuals is double or triple that of normal persons, due to the bypass of the liver by the produced insulin (where its molecule is normally degraded to a great extent), and the intake of corticosteroids.

Generally, the recipients of a pancreas and kidney transplant have lower levels of triglycerides and LDL-cholesterol and higher levels of HDL-cholesterol than the recipients of a kidney transplant alone.

The secretion of counter-regulatory hormones, which is abnormal in patients with long-lasting DM, is improved or even restored after the transplantation of the pancreas. The ability to recognize hypoglycaemias is also corrected.

Moreover, the diabetic neuropathy of both the peripheral as well as the autonomous nervous system are stabilized or even improved. As regards diabetic retinopathy, the available data do not show any improvement.

The diabetic nephropathy of the transplanted kidney is prevented or minimized despite the nephrotoxic effects of cyclosporine. Even in pancreas transplantation alone, the damage of cyclosporine on the kidneys is less significant than the damage of the diabetic nephropathy in non-transplanted individuals.

There is also evidence that the microcirculation, but not the macro-angiopathy, is improved (less foot ulcers).

Finally, fertility of women with transplantation of kidney and pancreas is likely to be restored.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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