Fig. 7.3. Algorithm for screening transplant candidates with Type 1 diabetes for coronary artery disease.

creas (plus kidney with SPK transplant) prior to procurement of the organs. This sequence of events has several advantages: i) it will allow the transplant center performing the pancreas transplant the choice to also procure the pancreas; ii) it will allow patients to be admitted to the hospital and the re-evaluation process to begin simultaneously, rather than sequential, to the procurement of the organs; iii) it will minimize the cold ischemia time of the pancreas prior to implantation. Pancreas allografts do not tolerate cold ischemia as well as kidney allografts. It is ideal to revascularize the pancreas within 24 hours from the time of crossclamping at procurement. Finally, it will also allow identification of 0-antigen mismatched donor-recipient pairs to be identified prior to procurement that will minimize cold ischemia time if the organs need to be transported across country.

A. Preopterative Transplant Care

The pancreas transplant recipient is admitted to the hospital, re-evaluated and a final decision made whether or not to proceed with surgery. The re-evaluation process is similar to that for kidney-alone transplant recipients, emphasizing workup for infectious disease or other acute medical issues that would contraindicate surgery. There are several special considerations for the diabetic patient. Careful management of diabetes pretransplant is important for patients not allowed eat or drink prior to surgery. A bowel preparation is performed for patients that will undergo enteric drainage of the pancreas transplant

B. Cadaveric Pancreas Donor Selection

Identification of suitable cadaveric organ donors for pancreas transplantation is one of the most important determinants of outcome. The contraindications of cadaveric pancreas procurement for transplantation are outlined in Table 7.1.

Several anatomic and physiologic factors have been identified that affect the results of pancreas transplantation. In general, the criteria that determine an appropriate donor for pancreas transplantation are more stringent than for kidney or liver donors. Cadaveric pancreas organ donors are typically between the ages of 10 and 55 years. The lower age limits typically reflect the anticipated small size of the splenic artery that may preclude successful construction of the arterial Y-graft needed for pancreas allograft revascularization. The use of older donors has been associated with increased technical failure due to pancreas graft thrombosis, a higher incidence of posttransplant pancreatitis, and decreased pancreas graft survival rates. This may be consequent to reduced tolerability of cold ischemia time, but this has not been rigorously studied. The weight of the cadaveric organ donor is an important consideration. Obese donors over 100 kg are frequently not found to be suitable pancreas donors. Obese patients may have a history of type 2 diabetes, or the pancreas may be found to be unsuitable for transplantation because of a high degree of adipose infiltration of the pancreas. Obviously, weight alone does not exclude a donor, it is evaluated in conjunction with the height. There is also a lower weight limit that guides the decision for pancreas recovery. Recipients less than 30 kg must be carefully considered since this is also a reflection of potential small size of the splenic artery.

Importantly, pancreata from relatively older donors (age 55-65) and obese organ donors are associated with very successful islet isolation recovery required for an islet transplant. Therefore, application of beta cell replacement therapy, in general, and islet transplantation, in particular, should be considered for nearly all cadaveric organ donors.

Hyperglycemia and hyperamylasemia are very frequently observed in cadaveric organ donors. Hyperglycemia is not a contraindication to pancreas procurement for patients who are known not to have type 1 or type 2 diabetes. Hyperglycemia is generally benign and caused by a combination of factors including administra-

Supplements For Diabetics

Supplements For Diabetics

All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.

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