1. Kidney, Pancreas & Intestinal Transplantation Mr James Gilbert Consultant Transplant & Vascular Access Surgeon

3. A Lot to squeeze in!

5. Kidney Transplantation

7. 54,824 adults on dialysis in UK Represents 108 per million population (pmp) 6891 new starters in 2012 Continues to rise year on year Figure 2.2. Growth in prevalent patients by treatment modality at the end of each year 1997–2012

8. But dialysis is not great long term: 1 Yr Survival5 Yr Survival10 Yr Survival Polycystic Kidney Disease94%70%42% Glomerulonephritis88%58%37% Hypertension77%33%14% Diabetes71%29%11%

9. Transplant is a ‘treatment option’ Ultimate form of RRT Improves quality and quantity of life Allows normal diet and fluid intake Progressive reversal of anaemia & bone disease All patients with ESRF should be considered Not necessarily for everyone There is an alternative (HD, PD, Conservative) Transplants don’t last forever

10. Kidney Transplant Rates

11. Living Transplant Rates

12. Life enhancing or life saving? Doubles life expectancy (20 years vs. 10 years overall) Cost of transplant = 1 year dialysis costs!

21. Pancreas Transplantation

22. The insulin-dependent diabetic is: 25 times more prone to blindness 17 times more prone to kidney disease 5 times more often afflicted with gangrene Twice as often afflicted with heart disease Has a life expectancy 1/3 less than that of the general population

23. Pancreas Transplantation: Only treatment that reliably offers type 1 diabetics: – Insulin independence – Normal glucose metabolism – Normal Diet – Ameliorate secondary complications DM – Improved quality and quantity of life Now associated with improved outcomes Viewed more enthusiastically rather than sceptically

24. UK pancreas and islet activity

25. Pancreas Donors by type

26. 2013 Pancreas & islet Tx by donor type & centre

27. Any pancreas program should: Have overall low morbidity & mortality Eliminate need for insulin and BM monitoring Eliminate hypoglycaemic events Create a euglycaemic state with pre and postprandial sugars comparable to non diabetics Achieve HbA1c levels comparable to those in non diabetics

28. Best results achieved when: Have a ‘perfect’ donor – Young, slim DBD Donor Have a ‘perfect’ recipient – Pre-dialysis and slim ‘Perfect’ retrieval and short cold ischaemic time No complications Ideals rarely possible but must strive for ‘perfection’ due to sensitive nature of the pancreas Hence fussy pancreas transplant surgeons

29. Donor considerations Age: <55 (DBD) <50 (DCD) Girth < 90cm / BMI < 27 ‘Good health’ history Minimal ‘down time’ Minimal fatty infiltration or fibrosis of parenchyma Short cold ischaemic time

30. Pancreas donor age

31. Pancreas donor BMI

32. Surgical options Simultaneous Pancreas & Kidney (SPK) Pancreas after Kidney (PAK) Pancreas Alone (PAT) (Islets) – Radiological guided infusion into portal system

33. Indications SPKPAKPTA IDDM Hyperlabile IDDM Diabetic Nephropathy: Cr Clearence <20 ml/min Stable Kidney allograft function >2 diabetic complications Significantly impaired QOLProgressive diabetic complications Hypoglycaemic Unawareness (3 rd Part assistance needed) Hyperlabile IDDM after kidney transplant Acceptable kidney function Significantly impaired QOL

34. Portal vein onto IVC Exocrine drainage to proximal SB Y-Graft onto distal aorta / RCIA Kidney onto left iliac vessels SPK Transplant

35. PAK / PA Transplant Recent move to bladder drainage (2011) Consequence of inferior outcomes c/w SPK – 70% 1 yr survival 2010/11 Use urinary amylase as a measure of function Higher morbidity for the patient but ? Better graft survival (time will tell)

36. Common peri-operative problems Bleeding Thrombosis Graft Pancreatitis Delayed Graft Function Prolonged ileus / exacerbation gastroparesis – Need for TPN Sepsis – Peri-pancreatic collections – Pancreatic leaks

37. Graft Pancreatitis Appears during the first few days and common Usually self limiting Pain and tenderness at the graft site Associated peri-pancreatic oedema / collection High drain amylase Usually result of: – Ischaemic reperfusion injury – More common in marginal organ, DCD & larger recipient – Handling – Infection

38. Oxford Pancreas Programme Activity & Outcome Data April 2011 – Mar 2013

39. Transplant type and Donor type DBDDCDTotal SPK11514129 PAK314 PTA191130 Total13726163

40. Transplant Outcomes (1 Year) Transplant Type Insulin Independence Dialysis Independence Deaths SPK115/129122/1297/129 PAK3/4-0/4 PTA26/30-1/30 Total 144/163 (88%) 122/129 (95%) 8/163 (4.9%) 3 deaths in first 30 days: 1 with ARDS, 2 Cardiac Arrest.

41. Mortality Comparison 2 times more likely to die each year on waiting list than in first year after transplant

42. SPK outcomes 2007 – 2012 (DBD)

43. Isolated Pancreas outcomes 2007 – 2012 (DBD)

44. Pancreas Outcomes 2007 – 2012 (DCD)

45. Cause of graft loss 2007 - 2012

46. Intestinal Transplantation

47. Intestinal Transplantation - Types Isolated Small Bowel Multivisceral Whole Liver & Small Bowel Modified Multivisceral

48. Indications Presence of irreversible intestinal failure with – Impaired venous access for TPN (reduced to the last two suitable veins for placement of the feeding catheter) – Progressive fibrotic liver disease (usually from TPN) – Life threatening episodes of catheter related sepsis Broadly two situations that lead to intestinal failure: 1.Short gut syndrome (less than 40 cm in length) 2.Non functioning bowel

49. Isolated Small Bowel Multivisceral

50. Liver & Small Bowel

53. The Problem: Difficult Abdominal Wall Closure A Solution: Abdominal Wall Transplant

54. The sentinel skin graft Novel concept for graft surveillance Skin more allo-sensitive and rejects before organs Early cases suggest a lead time of 2 weeks Provides option for PAT / intestinal transplant where organ monitoring very difficult Based on vascularised skin island from forearm 2 cases to date Number of re-do PAT patients being listed for SSG