Evaluation Of Candidates For Pancreas Transplantation

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There are significant pre-existing morbidities of pancreas transplant candidates with advanced renal disease. It should be assumed that coincident extrarenal disease is present. Diabetic retinopathy is a nearly ubiquitous finding in patients with diabetes and end-stage renal disease. Significant vision loss may have occurred. Also patients may be overtly blind. Blindness is not an absolute contraindication to transplantation since many blind patients lead very independent life styles. Although rarely a problem, it should be confirmed that a patient with significant vision loss has an adequate support system to ensure help with travel and the immunosuppressive medications.

Autonomic neuropathy is prevalent and may manifest as gastropathy, cystopathy, and orthostatic hypotension. The extent of diabetic autonomic neuropathy is commonly underestimated. Neurogenic bladder dysfunction is an important consideration in patients receiving a bladder-drained pancreas-alone transplant or an SPK transplant. Inability to sense bladder fullness and empty the bladder predisposes to urine reflux and high post void residuals. This may adversely affect renal allograft function, increase the incidence of bladder infections and pyelonephritis, and predispose to graft pancreatitis. The combination of orthostatic hypotension and recumbent hypertension results from dysregulation of vascular tone. This has implications for blood pressure control posttransplant, especially in patients with bladder drained pancreas transplants that are predisposed to volume depletion. Therefore, careful re-assessment of posttransplant antihypertensive medication requirement is important. Sensory and motor neuropathies are common in patients with longstanding diabetes. This may have implications for the rehabilitation posttransplant. It also is an indicator for potential risk for injury to the feet and subsequent diabetic foot ulcers.

Impaired gastric emptying (gastroparesis) is an important consideration because of its significant implications in the posttransplant course. Patients with severe gastroparesis may have difficulty tolerating the oral immunosuppressive medications that are essential to prevent rejection of the transplants. Episodes of volume depletion with associated hypercreatinemia in patients with SPK transplants frequently occur. Patients typically require careful treatment modalities that include motility agents such as metoclopramide or erythromycin.

Advanced coronary artery disease is the most important comorbidity to consider in patients with type 1 diabetes with diabetic nephropathy. It has been estimated that uremic, diabetic patients carry a near 50 fold greater risk of cardiovascular events then the general population. The diabetic, uremic patient has several risk factors in addition to diabetes for development of coronary artery disease including, hypertension, hyperlipidemia and smoking. Because of the neuropathy associated with diabetes, patients are often asymptomatic because ischemia-induced angina is not perceived. The prevalence of significant (>50%) coronary artery stenosis in patients with diabetes starting treatment for end-stage renal disease is estimated to be 45-55%.

Uremic, diabetic patients also experience an increased rate of cerebral vascular accidents (strokes) and transient ischemic attacks. Deaths related to cerebral

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