A pancreas after kidney (PAK) transplant is a treatment for patients who have a functioning kidney transplant and have insulin-dependent diabetes. The transplant is recommended for patients who would like to stop taking insulin. It is usually done at least 4 months after you have had a kidney transplant. The pancreas is removed from a person who has died (a deceased donor) and given to the person who needs it (the recipient).

The transplanted pancreas produces the insulin that the recipient needs, and responds to the recipient’s own blood sugar levels. The pancreas also produces enzymes, which are chemicals that break down tissues. Your body does not usually need the extra enzymes. The transplanted pancreas is joined to your blood vessels and intestines. These enzymes flow into your gut, and pass out of your body.

There are other treatments, but a PAK transplant might be the best treatment for some patients with insulin-dependent diabetes who are well enough for the operation. A pancreas transplant is major surgery and should be considered carefully. 

Benefits of having a PAK transplant

For most patients, a PAK transplant leads to a better quality of life. This is because they do not have to rely on injecting insulin, and because the risk of hypos is much lower. 

After the transplant, people can usually control their blood sugar well, and should not have dangerously low blood sugars. Conditions that are caused by diabetes, often become stable after having a PAK transplant, and sometimes even improve.

This includes heart and blood vessel conditions, and other conditions caused by diabetes, such as:

• diabetic retinopathy (damage to the eyes)
• diabetic gastroparesis (a gut condition)
• diabetic neuropathy (damage to the nerves)

Better blood sugar control is likely to prolong the life of the kidney transplant (make it last longer). Some patients will live longer after having a PAK transplant than if they did not have the transplant.

Risks of having a PAK transplant

As with any medical procedure, there are risks associated with having a PAK transplant, and it is important to understand them.

Some deceased donors will have had long-term health problems before they died. If these could affect you, we will discuss these with you before your transplant.

Some of this information may be worrying, but it is better for you to understand the potential risks, as well as the potential benefits, of having a PAK transplant. Everyone’s situation is different. We will talk to you about the risks and benefits before a decision is made about adding your name to the national transplant waiting pool (list).

Infection

After a PAK transplant you might get an infection in your chest, surgical wound, tummy (abdomen), or a urinary tract infection (UTI). This can usually be treated with antibiotics, but sometimes another operation is needed.

Bleeding

Bleeding that needs a blood transfusion happens to 40 to 50 out of 100 PAK transplant patients after surgery.

More surgery

Another operation may be needed due to bleeding, infection, or to rule out any problems with the first operation. Between 30 and 40 out of 100 PAK transplant patients need more surgery after the transplant.

Up to 15 out of 100 patients develop a hernia or weakness in the transplant scar and may need an operation to repair this. Sometimes, more surgery is needed months or years later if there are any complications.

Rejection

Sometimes your body may start to attack the pancreas, because it recognises it has come from another person. This process is called rejection. Between 10 and 20 out of 100 patients who have had a PAK transplant will have an episode of rejection during the first year.

Rejection is diagnosed by taking a tissue biopsy (sample of tissue to look at under the microscope) of the pancreas. Pancreas rejection can be difficult to diagnose and treat, but sometimes it can be treated by increased doses (amounts) of immunosuppressant medicine.

Risks of immunosuppressant medicines

You will need to take medicine to suppress your immune system during the whole time that the pancreas transplant lasts. You will already be taking immunosuppression medicines because of your kidney transplant, and the long-term risks are similar. For about 6 months after the PAK transplant, you will be given more immunosuppressants. There will be increased risks of side effects during this time.

While you are in hospital, the transplant pharmacist will talk to you about these possible side effects and how to monitor and manage them.

Conditions passed on from the donor

In rare cases, the transplanted organs may carry conditions such as cancer or infection. All deceased donors are tested for infections and for signs of cancer. It is very rare that serious conditions are passed on (less than a 1 in 1,000 chance). Your doctor will discuss this with you before your transplant.  If you think that the risks are too high, you can decide not to have the transplant. This will not affect the rest of your treatment and you will not lose your place in the transplant pool.

Other infections, such as cytomegalovirus (CMV), are very common. They can often be passed on from transplanted organs, but cause little, or no long-term harm. You might need to take medicine to reduce the risk of these milder infections. We speak to you about this at the time of your operation. 

If the transplant does not work

Sometimes, organs that have been transplanted never work. This happens in 3 to 5 out of 100 pancreas transplants. The failed transplant will then need to be removed by a surgeon. Your own pancreas is not removed and will stay in the same place. 

Sometimes the transplanted pancreas may work for a few days or weeks, but then stop working. This may be due to a blood clot within the pancreas, or for other reasons. Occasionally, the pancreas may be working but might have to be removed due to infection or leakage of enzymes.  

Overall, about 10 out of 100 transplanted pancreases need to be removed within the first year.

Other risks

Between 1 and 2 patients out of 100 develop a blood clot in the legs or lungs after having a pancreas transplant. Heart attacks or strokes happen in 3 to 5 out of every 100 patients after the transplant. However, in the long term, your risks of heart attacks or strokes are likely to be reduced by having the transplant.

Very rarely, the blood supply to the spinal cord or legs is damaged as a result of the transplant operation. If the blood supply to the legs is very poor, amputation (removal) of the leg might be needed. Amputation is more likely if you already have poor blood supply to your legs before the transplant. Up to 2 in 100 patients have this problem. Problems with the blood supply to the spinal cord are very rare (about 1 in 500 patients), but could lead to leg paralysis.

Rarely, the blood vessels supplying the pancreas become swollen, or may bleed into other organs. These problems cause tummy (abdomen) pain, back pain, or bleeding in the bowel. This happens in 1 or 2 in 100 patients, and will need major surgery to fix it. This can happen in a pancreas transplant that is working well, or even after the pancreas has stopped working or has been surgically removed. 

If the transplanted pancreas needs to be removed, your own intestines will need to be repaired at the site where the transplanted pancreas was attached.

If the surgeon feels that it is unsafe to try to repair your intestines, they will need to bring your intestine out to your tummy (abdomen) wall. This is called a stoma. This happens in 2 to 4 out of 100 patients after having a pancreas transplant. Fluid from your intestines will be emptied into a bag that is attached to your tummy wall. This is not permanent, and more surgery will be needed 4 to 6 months later to remove the stoma and repair your intestines.

Sometimes the anaesthetic, the surgery, or the immunosuppressant medicine can damage your kidneys. It is important that you have good function of your transplanted kidney before the PAK transplant operation. Blood tests will be done to check this.

Survival

Sadly, between 2 and 4 out of 100 patients will not survive the first year after pancreas transplant surgery. This may be because of complications from the surgery, the immunosuppressant medicines or other health issues. In the long term, some patients will live longer after having a PAK transplant than if they did not have the transplant.

Asking for your permission (consent)

We want to involve you in decisions about your care and treatment. If you decide to go ahead with the treatment, you will be asked to sign a consent form. This states that you understand what the treatment involves and agree to have it.

You can read more about our consent process. 

Other treatment options

If you have diabetes that is not controlled well, you must have specialist treatment to try to improve it. You should have seen a specialist diabetes doctor for advice. Other treatment options may include:

Insulin pump

An insulin pump releases regular insulin into your body. With careful dietary advice, an insulin pump can improve the diabetic control of many patients, and may avoid the risks of severely low blood sugars. You might need a referral to a specialist diabetes team to consider this treatment. 

Islet transplant

An islet transplant is a different type of pancreas transplant. The donated pancreas is broken down into the clumps (islets) of the cells that produce insulin. These clumps are then injected through your tummy (abdomen) skin, into the main vein leading into the liver. The clumps stay in the liver and produce insulin. This will have been discussed with you as part of your assessment if it is an option for you. 

Simultaneous pancreas-kidney (SPK) transplant

If your kidneys do not work well, you may be suitable for a simultaneous pancreas-kidney (SPK) transplant. This is when you receive a kidney and pancreas transplant at the same time. The pancreas surgeons will check your kidney function to see if this needed.