Patient Follow-Up Management, Enteric Drained Simultaneous Pancreas-Kidney Transplant

Patients will be discharged from the hospital following induction therapy and stabilization of immunosuppression levels and absence of complications from the procedure. During the final days of the hospitalization they will be instructed regarding the identification of complications such as graft pancreatitis, anastomotic leaks, etc. In addition to the instruction of their medications they will be instructed in the maintenance of their personal outpatient flow sheet. This includes the recording of temperature, pulse, blood pressure, accu checks and documentation of medication intake.

Patients will be seen in follow-up in the clinic on Mondays and Thursdays. Laboratory examination collected during prior to the clinic visit will include electrolytes, calcium, phosphorous, uric acid, BUN, creatinine, glucose, serum amylase, CBC and FK506/Cyclosporine trough via TDX mono method. Physical examination, documentation of temperature, pulse, blood pressure and weight shall be recorded. Investigation for the predictable complication will be sought. The include the following:

1. Graft pancreatitis [week 1-2]
Patients with graft pancreatitis will complain of discomfort over their pancreas allograft. Serum amylase will also be elevated. Treatment consists of admission to the hospital, withholding of PO intake, and allograft rest. This may or may not include gut rest.

2. Hematuria [week 1-4]
Mild hematuria occurs in virtually all renal transplants during the first week. However, hematuria after discharge or after the first four weeks is consistent with cytomegalovirus infection. Investigation includes the collection of blood CMV antigen. Other causes of hematuria are a result of urinary tract infections. This is differentiated from a CMV etiology of hematuria by cytoscopy.

3. Anastomotic leak and fistula [week 1-6]
Extravasation of the pancreas exocrine enzymes through the duodenal-bladder or bowel anastomosis into the peritoneal cavity elicits moderate to severe peritoneal inflammation and pain in the lower abdomen. Initial management may include admission to the hospital and placement of a Foley catheter, gut rest and antibiotics. Anastomotic leaks usually require operative management. Early intervention avoids abscess formation and graft loss.

4. Intra-pancreatic graft abscess [week 6-10]
The formation of a abscess in the pancreas graft is a result of ischemic or inflammatory necrosis. Symptomology is that of intra-abdominal sepsis including fevers, toxicity and leukocytosis. Additionally, there will be the presence of graft tenderness. Diagnosis is confirmed by obtaining a "dynamic" abdominal CT scan of the abdomen. Treatment consists of pancreatic graft removal or debridement.

5. Rejection [week 1-12]
Simultaneous kidney/pancreas transplants are monitored for rejection by monitoring the renal allograft for rejection in a routine fashion. Almost all acute rejections occur within the first 90 days of transplantation. Frequent monitoring of serum creatinine are utilized to initially indicate rejection. Confirmation prior to treatment is achieved via ultrasonic evaluation of both grafts, obtaining a serum amylase as well as needle core biopsy of the renal allograft and pancreas allograft. Occasionally only the pancreas will undergo rejection prior to or without kidney transplant rejection. Serum amylase may or may not be elevated. All patients feel a fullness or enlargement of their pancreas graft. Many times the pancreas graft is tender. These findings indicate evaluation of the pancreas graft by ultrasound imaging and core biopsy. Patients require admission to the hospital for diagnosis, management and treatment.

6. Urinary Tract Infection [week 1-12]
Recurrent urinary tract infections have been problematic in the past. However, with the use of enteric drainage of the pancreas this problem has been greatly reduced. Symptoms are the same as other UTI's such as frequency, pain with urination and sometimes renal dysfunction with elevation of creatinine. Diagnosis consists of Urinalysis and culture to identify the causative bacteria and the use of appropriate antibiotics.

All patients have the complications of prolonged diabetes prior to transplantation. Therefore, we will help guide them to the appropriate physician for the management of those complications. All patients are instructed to arrange visits with their family or primary care physicians. Frequent visits to the transplant clinic do not replace ongoing management of the primary care physician. Dr. David Baldwin, Jr., the transplant endocrinologist and Dr. Janis Orlowski, the transplant nephrologist, associated with the Pancreas Transplant Program will be readily available to assist in the management of these complications. Therefore, pancreas transplant patients will undergo annual physical examinations by their family/primary care physician including electrocardiograms and myocardial stress tests as indicated. Included in the evaluation will be the evaluation of carotid and peripheral vascular disease.

Routine examination and health care maintenance will be encouraged by our program, but will not be arranged or completed by our program. These include mammography for female patients of 50 y/o or more, annual gynecological examination and PAP smears, the obtaining and following of prostate specific antigens, cholesterol1s and cancer surveillance.