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Transplant Center

Kidney/Pancreas Transplant Program

Kidney/Pancreas Transplant Program | SPLK Procedure | Indications and Contraindictions - Kidney/Pancreas | Indications and Contraindictions - Pancreas | Kidney/Pancreas Transplant Team

Indications and Contraindictions - Kidney/Pancreas

 

Indications for Simultaneous Pancreas-Kidney (SPK) Transplantation

Patients with insulin dependent (Type 1, juvenile diabetes) diabetes who have end stage renal disease (ESRD) and require dialysis or expect to require dialysis in the next 12 months may be considered for SPK transplantation.

Patients may be evaluated for transplantation prior to the institution of dialysis. Patients are eligible for SPK transplantation if their creatinine clearance (Clcr) calculated by the Cockcroft-Gault formula is less than 30 ml/min. The Cockcroft-Gault formula for calculation of Clcr is now considered to be superior to actual measured creatinine clearance as determined by a 24-hour urine collection, due to inherent inaccuracies and collection difficulties.

The formula is as follows:

Clcr (ml/min) = (140-age)(wt. kg)
                          creatinine (mg/dl) x72

For women, the result is multiplied by 0.85

Patients referred for SPK transplantation, who are acceptable candidates by all criteria, are counseled about possible living donor kidney transplantation. Since there is an extreme shortage of cadaver kidneys in the United States and because living donor kidneys have a survival advantage over cadaver kidneys, diabetic patients with ESRD referred for SPK transplantation should consider living donor kidney transplant alone (LDKTA) followed by a pancreas after kidney (PAK) procedure.

The University of Maryland is the world leader in performing laparoscopic living donor nephrectomy, markedly reducing the cost and morbidity of living kidney donation. Furthermore, the University of Maryland has become the largest and most successful center in the United States in performing solitary pancreas transplants (PAK). Thus for patients referred for SPK transplantation, we offer the option of LDKTA plus a pancreas after kidney (PAK) procedure at a later date.

The LDKTA and PAK option carries equal pancreatic transplant success as SPK transplantation (see accompanying article; Bartlett ST, et al., Ann Surg,224:440-452,1996) combined with the added survival advantage of LDKTA. Patients presenting for SPK transplantation with no living donor options will wait for cadaveric SPK transplantation. Those with living donor options are offered the choice of cadaveric SPK or LDKTA plus PAK transplantation.

SPK Transplantation can be considered in Type 1 diabetic patients with ESRD when the patient has:

  1. Documented Type 1 diabetes. Special care is given to exclude recipients with Type 2 diabetes. Candidates with a strong family history, or late age or gestational onset, have a C-peptide level determined after glucose loading. Only those individuals with C-peptide levels of 0.2 ng/ml or less with a simultaneous glucose level of 300 mg/dl or greater are further considered for transplantation.

  2. Evidence of at least one type of progressive secondary diabetic complication including:
    1. diabetic retinopathy
    2. diabetic neuropathy
    3. diabetic gastroparesis
    4. accelerated atherosclerosis
  3. A rare indication for pancreas transplantation is extremely brittle diabetes. These patients may not have secondary complications. However, these individuals have frequent hypoglycemic episodes, with evidence of impairment of employability or the safety of the patient or children in their care. Usually there is evidence of frequent emergency room visits for hypoglycemia or diabetic ketoacidosis.

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Contraindications for Simultaneous Pancreas-Kidney (SPK) Transplantation

There are certain absolute contraindications to SPK transplantation:

  1. HIV infection
  2. Disseminated or untreated cancer
  3. Severe psychiatric disease
  4. Unresolvable psychosocial problems
  5. Persistent substance abuse
  6. Severe mental retardation
  7. Un-reconstructable coronary artery disease or refractory congestive heart failure

Relative Contraindications to SPK transplantation:

  1. Cardiovascular disease. All Type 1 diabetic patients require dobutamine stress echocardiography or exercise or pharmacologic stress scintigraphy prior to consideration. Candidates with positive stress testing or with a history of congestive heart failure will require consultation with a cardiologist prior to transplantation. Candidates with a positive stress test usually will require cardiac catheterization and possible angioplasty or bypass.

  2. Treated malignancy. The cancer-free interval required will vary from two to five years depending on the stage and type of cancer. Consultation with a board-certified oncologist is required in these cases.

  3. Substance abuse history. Patients must present evidence of involvement in 12 months of drug free rehabilitation. This includes written documentation of participation in rehabilitation including negative random toxicologic screens.

  4. Chronic liver disease. Candidates with chronic hepatitis B or C or persistently abnormal liver function testing must have hepatology consultation prior to consideration.

  5. Structural genitourinary abnormality or recurrent urinary tract infection. Urologic consultation is required prior to consideration.

  6. Past psychosocial abnormality. Master of Social Work (MSW) or psychiatry evaluation, as appropriate.

  7. Aortoiliac disease. Patients with abnormal femoral pulses or disabling claudication, rest pain or gangrene will require evaluation by a board-certified vascular surgeon prior to consideration. Patients with significant aortoiliac occlusive disease may require angioplasty or aortoiliac grafting prior to transplantation. In most cases, this consultation will be performed by Stephen Bartlett, M.D., the director of transplantation, who is board certified in vascular surgery (American Board of Surgery, certificate of added qualifications in vascular surgery #100002). Patients with significant aortoiliac occlusive disease may require angioplasty or aortoiliac grafting prior to transplantation.

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This page was last updated on: February 18, 2008.