90 KIDNEY AND PANCREAS TRANSPLANTATION
Thomas E. Bak M.D., Michael E. Wachs M.D., Igal Kam M.D.

1. What are the most common indications for kidney transplantation?

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End-stage renal disease (ESRD) caused by hypertension, diabetes, glomerulonephritis, and polycystic kidney disease.

2. Why should patients be taken off dialysis and have kidney transplants?

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Although not a life-saving transplant like liver or heart transplantation, kidney transplantation will improve patients’ quality of life. Patient 5-year survival is higher posttransplant when compared with continued dialysis. Finally, there is a cost savings with kidney transplantation compared with long-term dialysis.

3. How long is kidney graft survival?

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Cadaveric kidney transplant survival rates have steadily improved over the years. Currently, 1-year graft survival is 90%, with a 10-year graft survival of > 50%.

4. How long can kidneys be kept “on ice”?

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Kidneys can survive and function after longer cold ischemia time than other solid organs. Function can be maintained up to 72 hours, although optimal function is achieved if cold ischemia is kept under 24 hours. Patients on the waiting list frequently continue to work and travel and still have plenty of time to get to the hospital for tranplant. Also, United Network of Organ Sharing (UNOS) kidneys are frequently sent via commercial airlines all across the country.

5. Where is the transplanted kidney placed?

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Most commonly, the kidney is placed in the right iliac fossa. The peritoneal cavity is reflected superiorly, and the external iliac vessels are exposed. The renal artery and vein are then anastomosed end-to-side to the iliac vessels.

6. What are the indications for nephrectomy?

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Indications for nephrectomy include chronic infection, symptomatic polycystic kidney disease, intractable hypertension, and heavy proteinurea. The majority of transplant recipients do not need to undergo native nephrectomies.

7. Are living-donor kidney transplants recommended?

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There are definite advantages to receiving a living-donor kidney. The average survival times of these kidneys are significantly better. Also, the long cadaveric kidney waiting time (usually measured in years) can be avoided. Donors are carefully screened to ensure health and lack of any coercion.

8. Is donating a kidney a major operation for living donors?

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The standard of care for donor operations has become a laparoscopic donor nephrectomy. This technique has proven to be safe, with no negative effects on the kidney. The benefits of this modification over the open technique are much quicker recovery and shorter return-to-work time. This has generally increased the number of people interested in being living donors.

9. What are the indications for kidney-pancreas (K-P) transplantation?

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In general, all type 1 diabetics who have poorly controlled diabetes despite optimal medical management should be considered for K-P transplantation as long as they are acceptable surgical risks. Unfortunately, many older patients have significant, even prohibitive, comorbidities. A pancreas transplant adds significant morbidity and mortality risks over a kidney-only transplant.

10. Can a patient undergo pancreas transplantation before or after a kidney transplant?

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Yes. Patients can receive a simultaneous K-P transplant. This is the most common course, and the operation is done through a midline abdominal incision with the pancreas and kidney placed on opposite iliac vessels. Patients can also receive a pancreas-only transplant or pancreas-after-kidney transplant. The survival for these grafts is similar. Some centers are now shifting to portal drainage of the pancreas, with the venous outflow established to the superior mesenteric vein.
KEY POINTS: KIDNEY AND PANCREAS TRANSPLANTATION

1. The most common indication for kidney transplantation is end-stage renal disease caused by hypertension, diabetes, glomerulonephritis, and polycystic kidney disease.
2. Cadaveric kidney transplant survival rates have steadily improved over the years, with current 1-year graft survival rates of 90% and a 10-year graft survival rate of > 50%.
3. In general, all type 1 diabetics with poorly controlled diabetes despite optimal medical management should be considered for kidney-pancreas transplantation as long as they are acceptable surgical risks.

11. How are digestive enzymes drained in a pancreas transplant?

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The donor pancreas is procured with a duodenal cuff still attached, with enzymatic drainage from the graft into this cuff intact. The duodenal cuff is then drained into a piece of recipient’s small intestine with an enteric anastomosis. An alternative is to attach the duodenal cuff to the bladder. This allows amylase levels to be followed in the urine, but metabolic and infectious complications frequently require a conversion to enteric drainage.

12. What are some complications commonly seen with pancreas transplant?

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Leakage from the duodenal cuff, graft venous thrombosis, infection, rejection, and graft pancreatitis are all potential complications. The incidence of these is decreasing as more experience is gained, and pancreas graft survival now approaches kidney graft survival.