Islets transplant

When the islets in your pancreas do not function, the production of insulin is either reduced/ ceases or the body is unable to use the insulin effectively or both. This results in a condition called diabetes. There are 2 types of diabetes:

Type 1 Diabetes: occurs when the body’s immune system attacks and destroys the islets and insulin can no longer be produced. Although Type 1 diabetes can occur at any age, it is usually diagnosed in childhood, teen, and young adult years.

Type 2 Diabetes is a chronic condition that affects the way your body metabolizes sugar. Your body does not respond to the effects of insulin. This is called insulin resistance and even with increasing insulin levels, this is not sufficient to control your blood sugar level.  This condition is caused by both lifestyle factors as well as your genetic makeup. You are at risk of developing diabetes if you are not physically active, overweight, or obese.  In Australia, Islet transplantation is carried out primarily in patients with Type 1 diabetes.

The sudden onset of these symptoms along with unexplained weight loss can occur in those with a Type 1 Diabetes.

Those with Type 2 Diabetes develop the above listed symptoms gradually over time. This is also accompanied by gradual weight gain.

Over time if diabetes is not managed well, it can lead to serious health complications. Possible complications include damage to large and small blood vessels, which can lead to heart attack, stroke, and problems with the kidneys, eyes, gums, feet and nerves.

When the Islet cells in your body are destroyed and resulting in Type 1 diabetes, your treatment will involve insulin injections several times a day or treatment with an insulin pump, following a healthy lifestyle and engaging in regular physical activity.

Type 2 Diabetes on the other hand can be managed through healthy diet and exercise if detected early and then with medicines and insulin if the condition worsens.

In many cases where the islets are damaged causing Type 1, Pancreatic Islet allo – transplantation can assist in the treatment of the condition.

Pancreatic allo Transplant is a procedure where the islets from the pancreas of a deceased organ donor are purified, processed, and transferred into your body. Once the islet cells are transferred, the beta cells in the islets start functions to make and release insulin.

The transplant is a treatment option if your body’s islet cells have been destroyed leading to Type 1 Diabetes, you are insulin dependent and your blood glucose is difficult to control.  The aim of the transplant is to help your body achieve normal blood sugar levels with or without daily injections of insulin. This also helps in reducing or eliminating hypoglycaemia unawareness. This is a dangerous condition where a you are unable to feel the symptoms of low blood glucose (hypoglycaemia). With the transplant, you will be able to feel the warning signs of hypoglycaemia. This can help you take measures to stabilise your blood glucose levels.

Most people require two transplants (involving two hospital admissions) to get maximum benefits from the procedure.

Some of the criteria to be considered for pancreatic islet transplantation (Inclusion criteria) are³:

• Type 1 diabetes for five years or more
• Severe hypoglycaemic unawareness (a condition where you will be unaware of a deep drop in blood sugar).  In fact, this is the number one indication for Islet transplantation
• Age >18
• Weight ideally <80 kg
• You have read and signed the islet-specific informed consent form
• Willing to use effective contraception measures
• Ability to understand the protocol and provide informed consent
• Your kidney function tests are conducive for transplantation

To see more of the inclusion criteria, visit the “Guidelines for Organ Transplantation from deceased Donors”.

There are several conditions that could exclude you from getting a transplant. Some of the exclusion criteria are outlined below

• Weight >80 kg
• Corticosteroid usage. You are likely to benefit the most if you have working kidneys (normal renal function). Obesity and steroid usage are likely to adversely impact your transplant.
• A positive pregnancy test or desire to fall pregnant following islet cell transplantation
• Malignant disease other than localised and excised skin squamous cell or basal cell carcinoma
• Liver disease, including any form of active viral hepatitis, portal venous abnormality, or cirrhosis
• Chronic pancreatitis
• Significant heart disease
• Respiratory disease like asthma
• Any form of chronic infection that could, viewed by the transplant team, pose a mortality risk after transplantation
• Any form of chronic or current acute mental or psychiatric illness that could impact your safety and the capability to adhere to medication in the peri- and post-transplantation period.
• Allergy to intravenous contrast agents and certain anti-rejection medication
• Any other disease that in the opinion of the investigator may pose a significant risk to survival or adherence post transplantation.

To find out more about the exclusion criteria, visit the “Guidelines for Organ Transplantation from deceased Donors”.

Donation Criteria

Only donors that are brain dead (DBD) can be considered for Islet transplantation. The suitability of a donor is based on the donor’s

• blood group
• body weight (over 20kg and ideally under 150 kg)
• age (between 3 years and 65 years)
• medication use (current and history of medication use)
• laboratory tests for diseases like hepatitis and other indicators.

To find out more about the Donor suitability criteria, visit the “Guidelines for Organ Transplantation from deceased Donors”.  Regardless of age, if a donor is accepted for heart, lung, liver and/or kidney donation, then the donor may be accepted for pancreatic islets³.

There is no accurate waiting time that can be predicated and the waiting period to a certain extent is dependent on the state where you live. While you are on the waiting list, you will be required to provide a monthly blood sample so that you can be matched with an islet donor. It is advisable to be in touch with your transplant team if:

• there is any change in your general health
• you are hospitalised for any reason
• there is a change in your contact details (address & telephone number or you decide to travel overseas)

The Call

When a donor who is a match is available, the transplant team will call you. If you are willing to go ahead with the procedure, you will be admitted to the hospital provided there has been no change to your general health while you were waiting e.g. you don’t have any infections.

Once you are in the hospital, your medical team will examine you and carry out several tests. A few hours before the transplant, an intravenous drip will be inserted into a vein in your arm and you will receive carefully adjusted doses of insulin and fluids containing glucose. You will be asked to stop all short acting insulin injections and to stop eating and drinking and monitored for glucose levels in your blood.

The drip will keep running for the first 48 hrs after the transplant to help you stabilise while the islets settle in their new environment.

The transplant procedure takes place in the radiology department of the hospital. It is a relatively minor procedure that involves injecting the islets though a small catheter. You will be given a local anaesthetic to numb the right side of your chest. Your radiologist will insert the catheter (a small plastic tube) through your liver into the portal vein. The islets will then be injected over a period of 15 to 30 minutes.

You may be given a general anaesthetic instead of a local anaesthetic. This will either be at your request or at the recommendation of your doctor. Either way, this will be discussed before you have the procedure.

In rare cases, you might have to have a larger operation. This might occur if your radiologist finds it impossible to find your portal vein. Your surgeon will locate a vein on the surface of your bowel which is connected to the portal vein and inject the islets cells into this vein.

Immediate recovery after the procedure

After the procedure, you will be referred to the ward and monitored closely. Your medical team will look at several factors including hourly checks of your glucose levels and signs of bleeding. Your blood glucose levels will be monitored via the drip in your arm through which you will continue to receive insulin and glucose. The medical team will aim to keep the blood glucose levels as close to normal as possible.

You will be able to eat and drink after 4 hours. Short acting doses will now be administered to manage your glucose levels after your meals.

You will undergo an ultrasound of the liver the day after your transplant to check for any signs of bleeding or clots. You will also undergo tests to monitor your kidneys, liver, blood and the levels of anti-rejection drugs in your body.

Discharge from hospital

You will need to stay in the hospital for 3 days after the transplant. However, if there are complications e.g. infections you may have to stay back longer.

Discharge from hospital is often an exciting and significant step in your road to recovery.  A lot has gone on behind the scenes to ensure you have been able to receive this transplant, enabling you to regain your health or improve your quality of life.

Be sure to thank all the staff at the hospital, who were involved in your care, as they would surely appreciate it.

For at least a few weeks afterwards, do not over-do things.  But also do not lounge around all day.    Spend the time appreciating those around you and what this generous donation has done to improve your quality and quantity of life.

Tests and monitoring

After your transplant, it may take between 6 weeks to 12 weeks for the transplanted islets to start functioning and you might start to see a decrease in your insulin requirement 2-3 weeks after the procedure. You will be advised to monitor your blood glucose levels several times a day and to keep in touch with your medical team.

Your medical team will need to see you very often for the first few weeks after your transplant.

Your insulin requirements will probably drop by a quarter or half during the first 3 months after your first transplant.

After your second transplant, you may be able to stop taking insulin and stay off it for a few months. It has been seen that most islet transplant patients continue to take a small dose of insulin. Taking a small dose of insulin after an islet cell transplant may be beneficial to the transplant and extend the length of time that it continues to work.

 Stages of returning to activity, including work

Return to work or other activities only if you feel up to it.  It is recommended you start slowly in the first instance.  This also includes sexual activity. If in doubt, ask your doctor.  Don’t be shy – they have heard it all before.

Healthy lifestyle 

Let good nutrition and exercise be part of your healthy lifestyle. Everything and anything in moderation until you are completely stable.

• Avoid foods that may interact adversely with your medication.
• Maintain good food hygiene while preparing your meals.
• Maintain personal hygiene, including dental hygiene
• Clean open wounds and cuts with antiseptic. Consult your GP if your wound becomes red and painful.
• Always check with your transplant doctor if another doctor suggests you should receive any immunisations. The Mantoux test for tuberculosis and immunisations for yellow fever and polio for example are not recommended as are any other immunisations using live or weakened bacteria or viruses.  However, influenza vaccinations or immunoglobulins are okay.
• Reduce the risk of infection by maintaining your hygiene and reporting symptoms early. If possible, avoid coming into contact with people who have a cold or the flu.
• Avoid coming into close contact with children or people with chicken pox or measles and other viral and bacterial infections.

For more on caring for your new heart after discharge and the precautions to take, please refer to the section on “After your Transplant”.

Driving after Transplant Surgery

You may wish to resume driving as soon as possible after your surgery. You must check with your doctor to clarify when it is safe to drive. Before driving, ensure that you are alert and not fatigued, no longer experiencing significant pain or taking medications that can cause drowsiness.

For information on assessing fitness to drive, please visit the website www.austroads.com.au . The guidelines on this website outline the responsibility drivers, health professionals and the licensing authorities. The rules for driving are very clear and are set out to protect you, the transplant doctors and the general public.

It is highly recommended that you do not smoke after your transplant, and drink alcohol in moderation. Check with your doctor on the limits to your alcohol intake.

It is highly risky to smoke marijuana or use other illegal drugs. These drugs may interact with your anti-rejection medicines, lowering the levels in your blood and making them less effective at preventing rejection.

Respect your new Islets!

After your first transplant, you may need a second transplant. The timing of a second islet cell transplant will vary quite a bit between individuals. If your first transplant is very successful, you may be advised to delay having a second transplant until there are signs that this is required. These include whether you are able to control your blood glucose levels (and avoid hypos), your insulin requirement and the results of your blood and urine tests. A small number of transplant patients never need a second transplant.

If you have had a second transplant there is a small chance that you may still need Insulin, but will have a better control of your sugar with lesser hypos.

This information is intended for educational purposes only. Transplant Australia acknowledges that each patient experience is different and does not provide this information as a substitute for medical advice. Please contact your transplant unit or doctor if you need medical advice.

Transplant Australia gratefully acknowledges the contribution of Dr Henry Pleass (Professor of Surgery at Westmead Clinical School, University of Sydney) in developing and reviewing this material.