PANCREAS TRANSPLANTATION

There are approximately 118,075 patients who are on the organ transplant waiting list in the United States today. Approximately 934 individuals are waiting for a pancreas transplant and 1,710 are waiting for a combined kidney/pancreas transplant. It was in 1966 that two pioneering surgeons from the University of Minnesota, Dr. W.D. Kelly and Dr. Richard Lillehei performed the first successful pancreas transplant in a diabetic patient with renal failure.

The purpose of doing a pancreas transplant is to cure type 1 diabetes and achieve complete insulin independence. Approximately, 75 % of pancreas transplants today are performed on type 1 diabetics who also have renal failure and therefore receive a simultaneous kidney and pancreas transplant . This ensures that along with curing diabetes, renal failure is treated as well. Simultaneously transplanting both organs from the same deceased donor has been shown to work better with increased long term survival for both the kidney and the pancreas. Approximately 15 % of total pancreas transplants done today are on patients who have received a kidney transplant previously, technically known by the term pancreas after kidney transplant. The remaining 10 % of pancreas transplants are done in an isolated fashion known as pancreas transplant alone in patients with brittle type 1 diabetes who are otherwise without any kidney disease. A relatively newer option is islet transplantation, which has generally inferior long term results compared to whole organ pancreas transplantation.

There are an estimated 1,100,000 type 1 diabetics in the United States today, and 35,000 new cases are diagnosed every year. The total annual cost of diabetes exceeds $ 90 billion every year- this includes hospital and physician care, laboratory tests, pharmaceutical products, workdays lost and premature death. Presently, there is no practical insulin-delivery method coupled with an effective glucose sensory device that can replace the pancreas to achieve a constant euglycemic state. Most secondary problems of diabetes occur because of hyperglycemia such as nephropathy, sensory neuropathy, retinopathy and vascular complications and a successful pancreas transplant will work towards ameliorating these complications.

Approximately 1200 pancreas transplants are performed in the US every year. There are close to a 100 transplant centers that do this procedure but the number of transplants is limited due the donor organ shortage. The national 1 year patient, kidney and pancreas survival rates for recipients after a simultaneous pancreas and kidney transplant are 95 %, 91 % and 86 % respectively. Recipients of a pancreas after kidney transplant or pancreas transplant alone have a 1 year graft survival rate of 78-83 %.

RECOVERY FOLLOWING LIVING ORGAN DONATION SURGERY

The living kidney donor usually undergoes this procedure laparoscopically.  This usually involves one large and two to three smaller incisions. Most transplant centers will have the donor stay in the hospital for 3 to 5 days following surgery. The donor is allowed to drink liquids in a few hours following the operation and most donors can eat a regular meal the next day. The donor gets out of bed on post-operative day 1 and is usually walking in a day or so. Most patients will have some pain over their incisions for which they receive intravenous pain medications, which is then changed to oral pain medications before discharge.

Upon discharge, most patients will have some tenderness and itching over their incisions. The incisions should be carefully watched for redness, increasing tenderness, any discharge or unexplained fevers, in which case, the transplant center should be contacted right away to be evaluated for wound infections. Donors are set up for post-operative follow up in two to three weeks after discharge.  They are generally restricted from lifting anything heavy or from strenuous activity till the first post-operative visit. There are no dietary restrictions and the donors are encouraged to going back to their healthy lifestyle habits. Most people can get back to doing light exercise in the first week which can be advanced once the pain improves and the donor starts to feel more energetic.

LONG TERM RISKS TO LIVING ORGAN DONATION

Most living organ donors are screened and worked up extensively prior to their surgery and are usually picked as donors because they are in good health. Most donors remain healthy and go on to live long and healthy lives.

The post-operative recovery is usually 4 to 6 weeks, depending on the type of operation that has been performed. For example, the laparoscopic procedure for kidney donation involves one larger incision and two to three smaller ones. These tend to heal faster with less pain compared to the larger flank incision for open nephrectomy.

Some donors have long term problems associated with surgery such as pain due to nerve damage, hernia or intestinal obstruction. These are serious issues which may require long term follow up with the physicians at the transplant center and may also need surgical intervention, if serious. Currently, no long term data is available regarding these complications for living donors in the United States.

Donors are highly encouraged to have regular follow up visits with their family physicians after organ donation. Kidney donors should be regularly monitored for high blood pressure, proteinuria and reduced kidney function in their remaining kidney. There have been some instances of the donors themselves requiring a kidney transplant later because of kidney failure. This should be discussed with the transplant team prior to the surgery so that risk factors could be identified which will predispose to kidney failure later in life.

The majority of donors can live a healthy life after kidney donation. Most transplant centers will caution the donors to restrict contact sports like football, wrestling, boxing, soccer, hockey and martial arts or wear padded vests under clothing for protection.

Pregnancy is usually not recommended for at least six months following donation. Female donors are encouraged to talk to their transplant teams and their og-gyn physicians to ensure good pre-natal care once they do get pregnant. Please be advised that some additional problems can occur after kidney donation as a result of the pregnancy such as pregnancy-induced hypertension, proteinuria  and pre-eclampsia.

LIVING KIDNEY DONATION – THE FACTS

There are more than 120,000 patients who are on the transplant waiting list today, of which almost 100,000 are waiting for a kidney donation to keep them alive and live a productive life. Many of these patients have to wait for years prior to getting that call for the transplant and many die waiting for one.

In order to ease this shortage, a viable option is living donor transplantation. This involves removing a kidney from a healthy donor that can then be transplanted into a recipient.

Here are some facts regarding living kidney donation.

1. 5,627 living donor kidney transplants were performed in 2016, of which 1,385 were from non-biological unrelated donors (24.6 %)
2. Living donors are required to be in good overall health and be older than 18 years.
3. There are three types of living donor transplants- directed donation, non-directed donation and paired donation.
4. In directed donation, which is the mot common, the donor names a specific person that will receive his kidney. The donor could be a biological relative such as a parent , sibling or child, biologically unrelated such as a spouse, a friend or co-worker or even someone who has heard about the recipient’s need for a transplant.
5. In non-directed donation, no specific recipient is named and the match is arranged based on medical compatibility.
6. Paired donation, which involves two pairs of living kidney donors and transplant candidates who do not have matching blood types.
7. Blood type incompatible donation is carried out between a donor and a recipient whose blood types do not match with each other. In normal circumstances, this would lead to rejection of the organ, but to decrease that risk, specialized treatment is given to the recipient before and after the transplant procedure.
8. Positive cross match donation is carried out between a donor and a recipient who do not match because of certain proteins known as antibodies in the recipient that would hasten the rejection of the donated organ. Specialized medical treatment is given before and after the transplant procedure to prevent this from happening.
9. Most donor surgeries are now performed laparoscopically, with smaller incisions that cause less pain and discomfort and results in faster recovery for the donor.
10. The recipient’s insurance will cover expenses for the donor such as the evaluation, surgery and limited follow up tests and medical appointments. However, the recipient’s or the donor’s insurance may not cover expenses from follow-up services if the donor has medical problems that occur from the donation. The recipient’s insurance usually will not cover transportation, lodging, long distance phone calls, child care or lost wages. Recipient’s with Medicare may provide coverage for donors with donation-related complications.

HEART TRANSPLANTATION

What is a heart transplant?

A heart transplant, also known as a cardiac transplant, is a procedure where a heart that is irreversibly damaged and failing that is replaced by another heart procured from a suitable deceased donor.

A record 3,191 heart transplants were performed in 2016 in the US.

Who is an appropriate candidate for a heart transplant?

Any patient who has end stage congestive heart failure who has less than a year to live without a transplant is usually considered an optimal candidate for this procedure. In addition, these patients have not had any success with other medical or surgical treatment options for their heart failure.

What are some specific indications for heart transplantation?

These include:

Dilated cardiomyopathy

Ischemic cardiomyopathy

Conventionally untreatable congenital heart disease

Ejection fraction less than 20 %

Untreatable angina or cardiac arrhythmias

What workup is required for someone to get a heart transplant?

Routine tests like blood work and urine are performed in every patient.  Additional testing to look for specific viruses, fungal and TB infections, Pap smears in women and a PSA test for men are also performed. These tests are standard for almost every transplant candidate.

Specific testing on the heart such coronary arteriogram, echocardiogram, chest x-rays, maximal venous oxygen consumption, right and left heart catheterization and a measurement of the pulmonary vascular resistance are some tests that would determine if a patient would benefit from getting a heart transplant.

What is considered as a “bridge to transplantation”?

These are interim treatment options that support a candidate while he is waiting for a donor heart to become available. These include oral therapy and procedures done to artificially support the failing heart such as an intra-aortic balloon pump or implantable devices known as assist devices.

Who will not be a candidate for a heart transplant?

Usually patients who are older than 65 years old are evaluated on an individual basis to determine candidacy.  In patients with severe pulmonary hypertension, active severe infections or cancers, untreatable psychosocial issues such as substance abuse (tobacco, alcohol or drugs) or an inability to comply with medical follow-up are not considered candidates.

What are the outcomes of heart transplants?

Currently, 1 year survival rates are approximately 80 % or higher with almost 70 % patients alive after 5 years. It has been shown that in patients who have high blood pressure, diabetes or obesity (BMI > 35) have increased mortality.

FINANCIAL AND INSURANCE ISSUES FOR LIVE ORGAN DONORS

1. WHO PAYS FOR LIVING DONATION?

Most recipients have private insurance or Medicare. These entities will cover the cost of the:

1. evaluation and medical workup for the procedure
2. donation surgery
3. post-operative care

Expenses not covered by either the donor’s or the recipient’s insurance generally include:

1. lost wages during recovery. However, donors might be apply for sick leave, FMLA or state disability
2. travel expenses
3. treatment for unrelated conditions discovered during workup
4. some follow-up expenses, check with the transplant center

2. WILL HEALTH OR LIFE INSURANCE COVERAGE BE AFFECTED BY DONATION?

Under the ACA, it is illegal to charge donors more or refuse coverage for a pre-existing condition.

However, difficulty getting life insurance or facing higher premiums have been reported. This may be avoided by having the transplant center inform the insurance carrier that data does not show increased risk of death in donors.
Living Organ Donor Network offers life, disability and medical insurance for complications arising from donation.    

                      

3. IS ANY FINANCIAL ASSISTANCE AVAILABLE FOR LOST WAGES, TRAVEL AND LODGING?

Donors are responsible for time lost from work. Some employers may allow the donor to use short-term disability or provide paid leave.  

Some donors use a combination of vacation time, sick leave and/or short term disability during their recovery phase.

The National Living Donor Assistance Program provides financial assistance to those who would like to donate but are unable to afford the travel and living expenses associated with donation.

Grants from the American Transplant Foundation and other non-governmental organizations can help with expenses such as mortgage payments/rent, utilities, car payment or insurance.

4. ARE THERE ANY LAWS RELATED TO TAKING TIME OFF TO DONATE A KIDNEY?

Federal Government

30 days paid leave for organ donation and 7 days for bone marrow donation, which is over and above the sick and annual leave.

State Government

Most states have now started modeling the same rules as applied by the federal government.

Private sector employees

Eight states which include AR, CT, IL, LA, ME, MN, NE and OR allow a leave of absence for private sector employees, which may only apply to bone marrow, but not organ donation.

CORNEAL TRANSPLANTS

The cornea is the eye’s outermost layer. It is clear and dome shaped and covers the front of the eye. It helps with focusing of the vision, along with the lens, on the retina so that the things we look at are clearly visible.

A corneal transplant serves to replace diseased or scarred corneas with a new, healthy one from a tissue donor.

Approximately 40,000 corneal transplants are performed every year in the United States, according to the National Eye Institute (NEI). This procedure, also known as keratoplasty, is performed when a diseased cornea is removed and replaced with a healthy one.

There are essentially two types of keratoplasties –

1. Penetrating keratoplasty (PK) is the traditional procedure that replaces the entire thickness of the cornea during the transplant procedure.
2. Endothelial keratoplasty (EK), when the inner layer of the cornea is replaced with a healthy one in certain medical conditions when the inner layer is diseased and is not functioning well.

This procedure can usually be performed under either local or general anesthesia. After measuring the affected corneal area, a circular, button-shaped, full-thickness section of tissue is removed and replaced with a matching button from the donor tissue and sutured in place. Traditional PK surgeries could take upto two hours to perform and are usually done on an outpatient basis. A protective shield covers the eye during the healing process

Almost anyone can be a cornea donor today. Approximately 75 % of donated corneas come from persons between 34 and 70 years old, with one third coming from people aged 61 to 70. Success rates of 75 % after 10 years has been shown for these donor corneas after they are transplanted.