1. Pancreatic and Islet Cell Transplantation

2. GENERAL 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 20159/8/2015

3. PRETRANSPLANT EVALUATION 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 20159/8/2015

4. Simultaneous transplantation of pancreas and kidney with bladder drainage 4Dr.yekehfallah-phd of nursing 20159/8/2015

5. Types of Transplantation Types of Transplantation WHOLE PANCREATIC ISLET CELL 59/8/2015Dr.yekehfallah-phd of nursing 2015

6. Types of Whole Pancreatic Transplant 1 ) Simultaneous Kidney and Pancreas (SPK) + 2) Pancreas after Kidney (PAK) 3) Pancreas alone (PTA) 6Dr.yekehfallah-phd of nursing 20159/8/2015

7. Pancreatic: Transplant Procedure Pancreatic: Transplant Procedure Arterial Anastomosis- Common iliac artery Venous Anastomosis- Common iliac vein Pancreatic duct + Loop of Duodenum Cytostomy Enterostomy 79/8/2015Dr.yekehfallah-phd of nursing 2015

8. Islet Transplantation Islet Transplantation Sites: Intrahepatic Subrenal Capsular Intrasplenic Intraperitoneal Subcutaneous 8Dr.yekehfallah-phd of nursing 20159/8/2015

9. Islet Transplantation Islet 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 20159/8/2015

10. INTRAOPERATIVE CONSIDERATIONS Metabolic care Frequent (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 20159/8/2015

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15. POSTOPERATIVE CARE General: Immediate postoperative: -chest radiography -frequent electrolyte monitoring -daily serum amylase -lipase levels 15Dr.yekehfallah-phd of nursing 20159/8/2015

16. 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 20159/8/2015

17. POSTOPERATIVE CARE Kidney graft monitoring and management 17Dr.yekehfallah-phd of nursing 20159/8/2015

18. 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 20159/8/2015

19. POSTOPERATIVE 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 20159/8/2015

20. POSTOPERATIVE CONSIDERATIONS Medical complications 1/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 20159/8/2015

21. POSTOPERATIVE CONSIDERATIONS Medical complications 1/Rejection b/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 20159/8/2015

22. POSTOPERATIVE CONSIDERATIONS 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 20159/8/2015

23. POSTOPERATIVE CONSIDERATIONS 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 20159/8/2015

24. POSTOPERATIVE CONSIDERATIONS 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 20159/8/2015

25. 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 259/8/2015Dr.yekehfallah-phd of nursing 2015

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