Patient selection

Patient selection

Once the indication for pancreas transplantation is satisfied the patient needs a comprehensive assessment of cardio - vascular and surgical fitness. An anaesthetic review , echo - cardiogram and assessment of inducible cardiac ischaemia using dynamic imaging such as a myocardial perfusion scan or stress echocardiogram should be perfor med. If cardiac assessment demonstrates occult ischaemic heart disease (IHD) then angiography and revascularisation via angioplasty or bypass surgery may be needed prior to wait-listing. Patients with diabetic nephropathy usually have other manifestations of secondary diabetic complications, including sensory neuropathy , retinopathy , gastropathy , peripheral vascular disease, foot ulcers and autonomic neuropathy leading to postural hypotension. These complications should be sought and discussed prior to listing as they can have an impact on whether a pancreas transplant is appropriate and - may alter the surgical strategy . For example, the significant anticoagulation required post transplant can lead to retinal haemorrhage; in a patient with severe retinopathy , this can lead to a deterioration in vision and even blindness. Patients with severe gastropathy may require a feeding jejunostomy at the time of transplant surgery , as gastropathy and bowel dysfunction are frequently exacerbated by surgery , which can - lead to vomiting, di ffi culties absorbing immunosuppressants and malnutrition. The overall risks of this major surgery - and immunosuppression in a patient with advanced diabetic complications have to be balanced with the likely benefits in severely overweight patients: most transplant centres have a 2 body mass index (BMI) cut-o ff (e.g. <32 /uni00A0 kg/m ). Types of transplant and patient selection /uni25CF /uni25CF /uni25CF /uni25CF

There are three main types of solid organ pancreas transplant: SPK; PTA; PAK The most common indication for pancreas transplant is type 1 diabetes with diabetic nephropathy Hypoglycaemic unawareness and life-limiting complications from insulin therapy are indications for pancreas transplant alone A comprehensive preoperative assessment of surgical /f_i tness and occult cardiac disease is essential prior to wait-listing