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ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

performed; however, whole� organ cadaveric pancreas transplantation

is preferred. The donor pancreas is placed intra peritoneally through

an oblique lower abdominal incision."

Enteric Drainage versus Bladder Drainage

The pancreas can be transplanted with a segment of the duodenum to

facilitate drainage of pancreatic exocrine secretions.J2 Enteric draillage

involves anastOmosis of the donor duodenum to a loop of the recipient's small bowel.J4 Bladder drairrage is obtained by anastomosing the donor duodenum with the recipient's urinary bladder.32 This permits

exocrine secrerions to be expelled wirh the urine and allows monitoring

of urine amylase as a marker for rejection.n.34 The disadvantage of

bladder drainage is that urologic and metabolic complications are common. Large quantities of sodium bicarbonate that are produced by the pancreas and duodenum are lost, which can result in metabolic acidosis ]5 The pancreas also secretes 1 to 2 liters of fluid each day ; thus, if the patient is not adequately hydrated, the loss of this additional fluid

results in volume depletion or dehydration. Reflux of the urine into the

transplanted organ may cause pancreatitis, and irritation of the bladder

mucosa from the digestive enzymes of the pancreas often results in uri�

nary tract infections and urethral stricture formation.J5 Enteric conversion after transplantation may be required if there are persistent poor bladder function and recurrent urinary infections .J2,34 Despite its disadvantages, the bladder drainage technique is more common than the enteric drainage technique, because it allows monitoring of urine amylase for detection of rejection ]1 Enteric drainage is more difficult to monitor for acute rejection and has more episodes of infection post

procedure. Ultimately, bladder, rather than emeric, drainage is the

choice of the transplant surgeon.J2

Illdicatioll of Pallcreatic F'II/CtiOIl Post Trallsplallt

Within 24 hours, the transplanted pancreas should be producing

insulin. Analysis of blood glucose response and C-peptide levels is

used to determine a successful pancreatic transplant. I mmediately

after transplantation, blood sugar levels are monitored every hour,

because glucose levels typically drop 50 mgldl each hour, and dextrose infusion may be necessary." The blood glucose level should range berween 80 and 1 50 mgldl within a few hours after the transplantationY C-peptide levels are elevated, and blood sugar level

ORGAN TRANSIlLMITATION

719

re turn s to normal within 2 to 3 days postoperative ly.6 After a diet is

starre d, serum glucose is monitored four times a day. Recipients

should rerurn to normal or near-normal fasting plasma glucose levels, glycosylated he moglobin levels (which tepresent the avetage blood glucose level over the previous several weeks), and glucose

tOlerance tests.J1.J6 The recipient wean s ftom insulin and becomes

insulin indepen dent with n ormal carboh ydrate metabolism for an

indefin ite period.IJ.,. The need for strict adherence to a diet and

constant blood sugar monitoring should dimin ish.6 Long-term follow-up studies indicate the insulin indepen dence can be sustained for at least 5 years.36

l'ostoperative Care alld ComplicatiOl's

The recipient is often placed on strict bed rest for a few days postoperatively to prevent kinking of the vascular al lografts that may result from a position shift of the pancreas. 1J A Foley catheter is left in place

for at least the first week to prevent disten tion of the bladder and

leakage from the bladder anastomosis.13 During the first postOperative day, a baseline radion uclide blood flow study of the pancreas an d a Doppler ultrasonography of the allograft vasculature are pe rformed. Repetition of these studies and operative interven tion are performed urgently with any sign of pancreatic dysfunction.13

Acute rejection after pancreas transplan tation is difficult to diagnose. Nonspecific clinical criteria, such as fever, allograft tenderness, ileus, abdominal pain, hematuria, leukocytosis, and hyperglycemia,

can be used in combination to detect acute pancreas rejection,J2,J5

Hyperglycemia does not occur until 80-90% of the graft has been

destroyed. 17 A decrease in bicarbonate , urine pH, or urine amylase

levels of more than 25% from baseline, an elevation of serum amylase, or a combination of these factors also indicates acute pancreas rejection in a bladder-drained pancreas transplant recipicm.12,1J,15,J5

Percutaneous ultrasound-guided or cystoscopic biopsy of the transplanted pancreas is use d as a sensitive histOlogic method to confirm acute graft rejection. 15.12

Complication s related to the bladder drainage procedure in pancreas transplantation include urinary tract infections, dysuria, urethritis, dllodenocystosromy fistulas, duodenal-bladder anastomotic leak, duodenal stump leak, chronic hematuria, allograft pancreatitis, metabolic acidosis, dehydration, and h yperkalemia.",J I Severe dehydration and acidosis can occur secondary to large losses of bicarbonate in the urine. I) Other potential complications include graft thrombosis,

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ACUTE CARE HANDBOOK FOR PIIVSICAL THERAPISTS

decreased pancreatic function, peritonitis, pancreatic abscess, intraabdominal bleeding, and infections.··32

Clinical Tip

Remind pancreas transplant recipients to drink enough nuids to rehydrate themselves during and after exercise.

Hydration is critical in patients with a bladder-drained pancreas. Recipients must take in 3-4 liters of nuid per day."

Pancreas-Kidney Transplantation

Types of Pancreas-Kidney Transplaltts

1 .

Simultalteous Paltcreas-Kidltey (SPK) traltSplOlltS. Typically,

SPK transplants are offered to patients who have type I diabetes mellitus

with diabetic nephropathy and renal insufficiency. SPK transplants are

more common than a non-life saving pancreas transplantation alone, as

physicians are reluctant to use potent immunosuppressive drugs in

patients with diabetes before they need a concomitant renal transplant.3•

The benefits of a successful SPK transplant include normoglycemia, elimination of dialysis, and prevention of reoccurring diabetic nephropathy in the kidney graft.3I,3.

SPK transplants may be cadaveric or from living donors, in which

case a segmental pancreas transplant is performed. Using an abdominal midline incision, the pancreatic graft is implanted first on the right side, and then the kidney graft is implanted on the left side."

2.

Paltcreas after kidltey (PAK) traltsplaltts. A pancreas trans-

plant is performed on a patient who has already received a cadaveric

or a living donor kidney transplant.

Postoperative Care mId Complicatiolts

In SPK transplants, pancreas rejection episodes frequently occur concurrently with renal allograft rejection. Rejection of the donor pancreas is more difficult to diagnose; therefore, acute rejection of both allografts is recognized by a deterioration in kidney function (i.e., an

increase in serum creatinine).J4,J6 When rejection is clinically suspected, kidney biopsy specimens are obtained.

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The SPK transplant involves a more complex surgical procedure, with more complications and rehosp italiz ations and a higher incidence of rejection and immunosuppression required

than renal transplant alone." The ad vantage of near-perfect glu·