Diabetes and Transplantations
Diabetes and Transplantations
Kidney Transplantation
A new kidney does not cure diabetes, and the disease may damage the new kidney just as it did the original ones. But it took many years for the person's own kidneys to fail. If the new kidney does develop diabetic nephropathy, it too will take many years to fail.
Kidney transplants are safest in people who do not have heart or blood vessel disease. Before you get a transplant, your doctor will check your circulatory system to see if it is healthy enough to risk the operation.
As with any operation, the healthier you are, the better you can withstand the physical stress of surgery. Possible side effects of surgery include bleeding and infection.
Immunosuppressive drugs are hard on the body, but people who get transplants must take these drugs the rest of their lives. Azathioprine and cyclosporine, two commonly used drugs, make it easier for you to get infections and have other side effects. You will need to avoid people who have infections, such as a cold or the flu. Also, you should not be immunized without first checking with your doctor. These drugs can also damage the kidneys. For example, using either of these medicines for many years could increase your risk for some cancers.
Because of these risks, kidney transplants are done only in people whose kidneys are failing.
Pancreas Transplantation
In people with type 1 diabetes, the islet cells in the pancreas no longer produce insulin. So it seems logical that giving a new pancreas to a person with type 1 diabetes would cure their disease. Usually it does. But the cure can be worse than the disease.
When the transplant takes, the patient no longer has diabetes and is unlikely to get it again. Insulin shots and frequent blood glucose testing are no longer necessary. Restoring normal blood glucose levels may stop complications from worsening, although many more studies are needed.
Pancreas transplants can be rejected, and roughly half of them are. Pancreases attached so that they drain into the bladder are rejected less often than pancreases attached in other body sites. When a transplant fails, the person gets diabetes again.
Pancreas transplants work only for people with type 1 diabetes. The major problem in people with type 2 diabetes isn't a failing pancreas, but the body's inability to respond to insulin in the right way.
Partial pancreas transplantation
When a whole cadaver pancreas is not available, a person can receive a portion of a pancreas from a living relative. Transplanting a partial pancreas from the same donor will help control blood glucose levels and protect the new kidney from further damage. Transplant success seems higher when patients and donors are matched for HLA types, and a pancreas transplanted along with a kidney is less likely to fail than a pancreas transplanted alone
Pancreas transplants are safest in people who do not have heart or blood vessel disease. Before you get a transplant, your doctor will check your circulatory system to see if it is healthy enough to risk the operation.
Islet Transplantation
In pancreatic islet transplantation, cells are taken from a donor pancreas and transferred into another person. Once implanted, the new islets begin to make and release insulin. Researchers hope that islet transplantation will help people with type 1 diabetes live without daily injections of insulin.
Immunosuppressive or anti-rejection drugs are needed to keep the transplanted islets functioning. Researchers do not fully know what long-term effects these drugs may have. Also, although the early results of the Edmonton Protocol are very encouraging, more research is needed to answer questions about how long the islets will survive and how often the transplantation procedure will be successful.
However, transplanting islet cells has several advantages over transplanting a pancreas. First, unlike the pancreas transplant, an islet transplant is a minor surgical procedure, is less expensive, and is probably safer. Second, scientists may learn how to protect these cells from attack by the immune system. Several methods are already under study. If successful, the person with an islet transplant would not need to take immunosuppressants. Surgery would then be safer and more effective for many people with type 1 diabetes.
Evaluating patients
Patients evaluated for transplantation undergo a series of tests as following
blood work
Blood tests helps to evaluate compatibility between a donor and recipient, Where in health of your kidneys and liver as well as your blood type, tissue type, and past exposure to viruses or diseases (such as hepatitis, chickenpox, or HIV)
urine studies
Some patients make urine even though they need a new kidney. If you can give us a urine sample, we will check how well your kidneys filter waste. We will also check for infections.
chest x-ray and EKG
These tests are done routinely on all patients to look for heart or lung problems.
abdominal ultrasound
This test uses sound waves to check the size and shape of your kidneys. Ultrasound also shows whether your gallbladder has gallstones that could cause problems after your transplant.
echocardiogram
This is like the abdominal ultrasound. Sound waves are bounced off your heart to look at the size of your heart and how well it works.
Pap smear and mammogram
All women entering transplant protocols at NIH must have these tests. They should be done by a private doctor before visiting NIH as a transplant candidate. These tests should also be done yearly after transplantation.
PSA (Prostate-Specific Antigen)
This blood test should be done on all men over age 45 before transplantation and yearly after transplantation. The test measures a substance that may be a marker for prostate cancer.
PPD skin test
This test checks whether you have been exposed to tuberculosis. It must be done on each patient before transplantation. If you have a reaction to this test, you may need medication to prevent a more serious infection after transplantation.
And also the patient need to go for some Special Consultanst as following
kidney diseases
Even though you may have a doctor who sees you regularly for kidney disease, you will meet with our program’s doctor who will help us manage your care after transplantation.
transplant surgeon
One of our transplant surgeons will examine you to see which research studies you would fit in to. This doctor will also discuss your surgery with you.
anesthesiologist
One of our transplant anesthesiologists may also see you. This doctor will ask whether you have allergies or smoke.
This information helps the anesthesiologist use the safest way to put you to sleep during your transplant.
dentist
To prevent dental infections after transplantation, your teeth and gums must be examined. A full series of dental x-rays may be taken to look for potential trouble spots.
You may need to undergo more tests to give these specialists the information they need to ensure the best possible outcome for your surgery. The transplant study you take part in may require more tests, too. Your transplant coordinator will help you schedule your pretransplant tests and consults.
Waiting for your transplant
Staying healthy
If you smoke––quit! If you are overweight, exercise with your doctor’s guidance and start a diet recommended by your dietitian. Studies have shown that patients who exercise before transplantation recover quicker after this surgery. Ask your transplant doctors or coordinators what exercises are best for you. The better your condition at the time of transplant, the stronger you will be to handle the stress of surgery and hospitalization.
Staying in touch
It is important for all patients to keep in contact with their transplant coordinators, whether
they live far or near.
Preparing for surgery
Patients who have been on dialysis may be dialyzed before surgery. Several doctors will visit you to ask questions and do a physical examination. The anesthesiologist will also meet with you to discuss how you will be put to sleep for surgery.
Your nurses will teach you the following:
- coughing and deep breathing methods needed after surgery
- how to use a pillow to support your wound after surgery
- how to use the special breathing device(spirometer). You must use this often after
surgery
- how to control your pain after surgery
- how to let your nurses know if pain is going away (on a scale from 1 to 10).
Your nurses will also talk to you about the procedure and the equipment that will be used in your room when you return from surgery: heart monitors, intravenous (I.V.) lines, blood pressure monitors, and special devices on your legs to prevent blood clots.
Your surgery
You will be taken to the operating room on a stretcher. There, an operating room nurse and an anesthesiologist will meet you. You will be given some medication through your I.V. to help you relax. Antibiotics may also be given to you this way while you are prepared for surgery.
When you are in the operating room, one of the first things you will notice is that the temperature is cold. We will drape you with blankets to keep you warm. Also, the operating room is very bright. If the lights bother you, just keep your eyes closed. The nurses will explain everything to you.
When the surgeons are ready to begin your operation, you will get medicine through your I.V. lines. This medicine will make you sleep during the whole operation. You will be monitored very closely during the procedure. The doctors and nurses will constantly check your blood pressure, breathing, and heart rate. At times during surgery, a machine may help your breathing. This is routine during surgeries like yours requiring general anesthesia. When surgery is over, you will breathe on your own.
Your new kidney will be placed in your abdomen on the lower right or left side, or possibly in the center. Your own kidneys will usually not be removed during this surgery. Most new kidneys begin working in the operating room. But some (up to 30 percent) take longer to work.
After surgery, you may notice that one of your legs is swollen. This is because it is retaining fluid. If your new kidney is put on the right side of your abdomen, your right leg may retain fluid. The same will be true for your left leg if your new kidney is implanted on your left side. Once your new kidney is working well, this extra fluid will go away.
After surgery
Immediately after surgery, you will be taken to the postanesthesia care unit (PACU). There, you will gradually wake up.
PACU nurses will constantly check your blood pressure, pulse, and urine output while you recover. You will have a catheter (draining tube) in your bladder when you wake up, and you may feel pressure in that area. You will spend 1 to 2 hours in the PACU before you are taken back to your room.
The surgeon will talk with you and your family when you are in the PACU. You will be given medication to help lessen any pain.
you will be closely monitored for the first 24 hours. The following will be attached to you: I.V. lines, heart monitor wires, a blood pressure line, and a catheter from your bladder. You will be able to control your pain with a pump our nurses will show you how to use.
When you come back to the unit, a nurse will work closely with you to assure good urine output by measuring your urine often. It is normal to feel pressure in your bladder from the catheter placed there. This tube will stay in your bladder for 3 to 4 days after surgery. When it is taken out, we will ask you to urinate every 2 hours. This prevents a pressure build-up on the connection between your bladder and your new kidney. Be sure to collect your urine so that the nurses can measure it.
The first day after your transplant, your nurses will help you sit up and take short walks. Do not try to walk the first time without your nurse.
As with any major surgery, there are possible complications after kidney transplantation.
Delayed graft function
Delayed graft function is not graft rejection. It is not uncommon for a new kidney to delay working for several days, or even several weeks. Causes for delayed graft function include mild trauma to the kidney during removal, or receiving a kidney from an older donor. Usually, the kidney recovers slowly on its own.
Renal artery thrombosis
Blood clots may form in the renal artery of your new kidney within the first 2 or 3 days after transplantation. The most common symptom is a sudden decrease or stoppage of your urine output soon after your surgery. If your doctors suspect a blood clot, they will probably order a painless procedure called a renal ultrasound. This test looks at blood flow in the renal artery where the blood clot is suspected. Surgery may be needed to remove the clot so that your new kidney is not damaged.
Urine leak
Urine leaks are uncommon, but they may occur within the first few days after transplantation. They are caused by poor tissue healing of the connection between the newly transplanted kidney and your bladder. Symptoms include
- abdominal pain
- decreased urine output
- increased creatinine.
This problem is usually diagnosed with an intravenous pyelogram. Urine leaks are usually repaired with surgery.
Rejection
There are many forms of rejection. When rejection is detected early, we can alter your medications to control it. You may not realize your kidney is being rejected. You may feel fine, but if your lab tests show high creatinine or Beta 2 levels, rejection is occurring.
Hyperacute rejection rarely happens because we check your blood often before the transplant. If this type of rejection occurs, it happens in the operating room or within a few hours after surgery. In most cases of hyperacute rejection, the transplanted organ fails.
Acute rejection may occur 4 days after the transplant; the greatest risk is during the first 6 months.
Chronic rejection develops slowly. Its cause is unknown, but many cases have been related to not taking medications properly. This type of rejection is difficult to treat.
Diagnosing rejection
Checking for rejection is done regularly at visits to your doctors and with lab tests. Because rejection often has no symptoms, it is important to keep your appointments. Early detection of rejection allows for better
results.
Tests to detect rejection include
- blood tests to check for antirejection drug levels
- tests of your kidney function (creatinine and Beta 2)
- urinalysis
- renal biopsy.
Signs and symptoms of rejection
- decreased urine output
- swelling in ankles, feet, hands
- sudden weight gain
- weakness, fatigue
- flu-like symptoms
- fever
- racing pulse
- high blood pressure
- increase in creatinine and Beta 2 levels
- tenderness, warmth, swelling around or over the transplanted kidney
(Remember, there may be no symptoms of rejection.)
Controlling Rejection
You can do a few things to protect yourself from rejection.
- Follow your schedule for lab work and doctor/transplant clinic visits.
- Take all your antirejection medications exactly as prescribed.
- Report any changes in your blood pressure, pulse, and temperature.
- Notify your nurse or doctor at NIH whenever you get sick.
Treating rejection
If you think you are having a rejection, and your local doctor confirms this, we will begin treatment depending on the severity of rejection:
- We may simply increase your current antirejection treatment.
- You may need to receive high doses of steroids intravenously at home.
- You may need to go the hospital for a course of intravenous treatment with thymoglobulin, OKT3, and Atgam.
Once treatment has started, you will have tests to find out whether these medications are working. Rejection usually resolves with treatment, but several medications needs if for a stubborn rejection.
Medications commonly used to prevent/treat rejection
- prednisone
- tacrolimus (Prograf, FK506)
- CellCept (mycophenolate mofetil)
- sirolimus (Rapamune, rapamycin)
- cylcosporine (Neoral, SangCya, Sandimmune)
- Thymoglobulin
- Atgam
- OKT3
- azathioprine (Imuran)
- cyclophosphomide (Cytoxan)
- methylprednisolone (Solu-Medrol)
- daclizumab (Zenapax)
- Medications used after transplantation
- acyclovir
- ganciclovir
- Septra, Bactrim
- Mycelex Troche
- CytoGam
- pentamadine
Infections after transplantation
Leaving the hospital after a transplant can be exciting. You may be overwhelmed by all the instructions you will receive about how to take care of yourself at home. But by following them, you can help prevent complications and make your recovery more enjoyable for you and for your family.
The drugs you take to prevent rejection can also increase your risk for infection. The following information will help you recognize infections and take precautions to stay healthy and infection-free.
Good handwashing is the first step to preventing germs from entering the body. This is important for your family members, too. Germs lie on surfaces of countertops, doorknobs, handrails, and even on money–– things we touch every day. Washing your hands for about 15 seconds with an antibacterial soap and water will greatly reduce the chances of infection.
Watching for infections: wound care
For the first few weeks after your transplant it will be very important to care for your surgical wound. A wound infection can be serious. Keep your incision site clean and dry. Wash the area with soap and water, avoiding deodorant soaps or other products that may irritate sensitive skin.
Symptoms of surgical wound infection
- site becomes red or hot to the touch
- drainage
- swelling
- tenderness
- fever
Be certain to notify your transplant coordinator or doctor if any of these symptoms develop.
Urinary tract infections
A common complication after transplantation is urinary tract infection.
Symptoms
- burning or painful urination
- cloudy, concentrated, or foul-smelling urine
- frequent urination with persistent abdominal or pelvic pain
- blood-tinged urine
- fever
Cytomegalovirus (CMV))
One of the most common viral infections after transplantation is a disease called CMV. Many people in the United States have been exposed to CMV. During your transplant evaluation, you will have a blood test to determine previous exposure to this virus.
After transplantation, the risk for this disease becoming reactivated is high because the immune system is suppressed. CMV can also be transmitted through the donor organ you receive if the donor was exposed to the disease. If you have never had a CMV exposure but your donor did, you may develop the disease. If you were exposed in the past, the disease may reactivate.
Throughout your posttransplant care, CMV blood tests will be done regularly to be sure that this disease is not active. If you have any flu-like symptoms, please report them to your transplant center. We will do blood tests to determine if you need antiviral medications such as ganciclovir or acyclovir.
Immediately after your surgery, you may receive anti-CMV drugs if you or your donor have been exposed to the disease. This treatment may be restarted if you have a rejection episode requiring high doses of immunosuppressive medications. Your transplant center should follow you closely for infections such as CMV. By keeping in close touch with us, you can alert us to potential problems.
High blood pressure
High blood pressure (hypertension) is one of the most common posttransplant complications.
Causes
- changes in kidney function
- side effects from your medication
- too much sodium (salt) in your diet
Symptoms
- dizziness
- headache
- swelling of your hands, legs, and feet
Treatment
Your doctors will prescribe medications to lower high blood pressure.
Continue on a low-sodium diet.
Heart disease
There have been reports of kidney recipients developing heart diseases such as congestive heart failure, strokes, and heart attacks. Age, gender and hypertension all contribute to the development of heart disease. But you can control some of the risk factors by
- not smoking
- keeping your weight within a range recommended by a dietitian
- exercising regularly
- staying on your recommended diet.
Cancer
The risk for developing cancers may be increased by long-term use of standard antirejection medications. These medications suppress the immune system so that it cannot easily recognize malignant cells. The most common cancers reported in transplant recipients include skin cancers, cervical cancers in women, solid organ tumors, and lymphomas.
To decrease the risk of serious complications from cancers, you can do the following:
- have annual Pap smears and mammograms (women)
- have annual prostate exams (men)
- report any unusual lumps or pains
- have annual colorectal exams (recipients over age 50)
- carefully examine your skin regularly for new moles or changes in the shape, color, or patterns of any mole.
Osteoporosis
Osteoporosis is a disease that causes bones to become thin and brittle. This is especially a problem for women after menopause. It can also be a problem for anyone who takes steroids. When bones become thin and brittle, they break more easily. This is why it may be important for some patients to take calcium supplements or other medications to help decrease bone wasting.
Steroid-induced diabetes
For patients with a family history of diabetes, or for those who have been on a diet to control diabetes, insulin may be needed shortly after transplantation if you are taking high doses of steroids.
Exercise
After transplantation, the quality of life improves for patients who exercise regularly. Studies at the University of California at San Francisco show that exercise helps decrease stress and increase a feeling of well-being. It also helps with weight loss and weight maintenance. Your transplant doctors will recommend an exercise plan to fit your new lifestyle. To keep your new “lease on life,” exercise at least three times a week. Long walks are a wonderful way to exercise. Walking with a friend or family member is also a good time to share thoughts and feelings. It is a great way to build or rebuild relationships.
Diet
For the first month after surgery, your goal is to eat enough of the right foods so that you can heal, maintain your strength, and increase your energy level. As your new transplant begins to work, food will taste better and your appetite will improve. For kidney transplant recipients, having a diet that is low in fat and high in magnesium and phosphorous is important. Below are examples of foods that are high in magnesium and phosphorus.
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Foods high in magnesium and phosphorus
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Magnesium
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Phosphorus
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tofu
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milk and milk products
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all-bran cereal
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potatoes
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nuts
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yogurt
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wheat germ
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wheat germ
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spinach
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macaroni and cheese
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peanut butter
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sunflower seeds
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Temperature
- If your temperature is more than 100°F, lie down and rest. Take your temperature again in 30 minutes.
- Your temperature will be highest between 4 p.m. and 9 p.m. and lowest in the morning when you wake up.
- Notify NIH if you have shaking chills, even if your temperature is normal.
- Do not take your temperature after exercising, eating or drinking, or chewing gum. These activities raise your temperature.
Blood pressure
Your blood pressure may be highest in the morning. Record your blood pressure:
- when you wake up
- 2 hours after taking your blood pressure medication
- in the evening.
Call your doctoe if the lower number of your blood pressure is greater than 100.
Weight
- Weigh yourself at the same time each day.
- Call the transplant center at NIH if you
- gain more than 2 to 3 pounds in 24 hours.
- Exercise is important for weight control and weight loss.
Outdoor activities
- Wear sunscreen when working outside or playing games or sports.
- In hot weather, drink lots of fluids to prevent dehydration and to keep your new kidney happy.
- Wear gloves when gardening. Dirt can carry harmful bacteria and fungus.
- Treat your pets to prevent them from picking up ticks. Ticks can carry serious diseases.
- Wash all fruits and vegetables - even prepackaged ones.
- At picnics, be sure that meat is thoroughly cooked and that any mayonnaise-based products are cooled. This way, unwelcome bacteria will not make your food their home.
- Do not store your medication in the heat or direct sunlight. Heat and light can make medications less effective.
1. If you notice symptoms of infection:
- fever higher than 100°F (38°C)
- chills
- tenderness or drainage at access site or incision site
- cough with sputum
- diarrhea
- painful urination
- sore throat
- earaches
- changes in your ability to think clearly
- bloody urine
- skin rashes or lesions
- mouth sores
- exposure to someone with an infectious disease such as chickenpox or tuberculosis
- shortness of breath
- increased fatigue.
2. If you notice symptoms of rejection:
- weight gain of more than 2 to 3 pounds in 24 hours
- pain over the site of your new kidney
- decreased urination during the day
- swelling in your hands and feet
- swelling in your abdomen
- bloody urine.
3. If you have any of these symptoms:
- shortness of breath
- vomiting
- bloody or dark stools
- increased or decreased heart rate
- skin growths or changes in moles
- abdominal pain
- severe headaches or blurred vision.
4. If you have questions about medications:
- if you want to take herbal medications or health food supplements
- if the instructions for taking your medications are unclear
- if you are given a prescription by another
- doctor or if an over-the-counter medication is suggested
- if you are unable to take your medications
- if your medication supply is low.
How to control infections
- Wash your hands! This is important for both you and your family members.
- Avoid handling pet waste. This includes emptying kitty-litter boxes and bird cages. Wash your hands well after petting animals.
Tips for avoiding the flu or colds
- Get a flu shot every year.
- Avoid crowded areas such as malls and stadiums during cold and flu season.
- Avoid people who have sore throats or colds.
- Do not share utensils or drinking glasses.
- Do not allow anyone to use your thermometer.
- Ask family members to throw away their dirty tissues promptly.
Sexual adjustments after transplantation
Your renewed energy will probably allow you to have a greater interest in sexual activity. This activity will not hurt your new kidney nor will it increase the likelihood of rejection. If you have more than one sex partner, you must protect yourself from the risk of infections such as sexually transmitted diseases by using condoms. Diseases such as hepatitis, herpes, AIDS, and gonorrhea can all be transmitted sexually. Transplant recipients have an increased risk for infection and should protect themselves.
- You may resume sexual activities 4 to 6 weeks after receiving your transplant.
- Be certain to discuss birth control methods with your transplant doctor or coordinator.
- Women who would like to become pregnant after transplantation should discuss this with their transplant doctor or coordinator.
Studies have shown that women can have successful pregnancies after transplantation. But the best outcomes have been reported in recipients who wait at least 2 years after their surgery. There have been no reported problems for male transplant recipients who wish to father a child. Men can father children at any time once they resume sexual activity.
There have been no reports of increased birth defects among children of transplant recipients.
Returning home to family and friends is often the first traveling you will do after your transplant. However, you may begin traveling more––for work or pleasure. Traveling can not only take you to new places; it can also lead to potential problems for your immune system. Because you are immunocompromised, you need to be alert and sensible when traveling.
For example, when taking public transportation, realize that many people will be traveling with you, sometimes in close spaces such as buses, trains, and planes. Air is recirculated in these close spaces, which means you may be breathing air containing viruses and bacteria from other passengers. For the first year after transplantation when your immunosuppression is highest, we recommend that you avoid mass transportation whenever you can. If you decide to travel, it may be advisable to wear a mask to filter the air as much as possible.
Also, travel can take you across several time zones. This may affect when you take your medications. For the first day, keep your watch set on your own time zone and take your medication as usual. On the second day, reset your watch ahead an hour or two. Do this each day until you reach your new time zone. Medications should be taken within an hour of the prescribed time, so when you are changing time zones, keep this in mind.
