Article from MD News Magazine, December 1997 Issue
A success rate significantly higher than national figures has made the pancreas transplant program of Willis-Knighton/Louisiana State University Medical Center an important medical option for many patients in this region who suffer from chronic renal failure as a result of Type 1 diabetes mellitus.
This December marks the two-year anniversary of the addition of the Pancreas Program to the services available through the Regional Transplant Center of Willis-Knighton/LSUMC.
The pancreas transplants provide the only cure for Type 1 diabetes mellitus (juvenile onset diabetes), and, according to Gazi Zibari, M.D., director of the Pancreas Program, and Donnie Aultman, M.D., director of the Renal Program, addition of the pancreas transplants was a natural extension of the success the center had already achieved with its kidney transplant program.
"The first kidney/pancreas transplant was performed at Willis-Knighton on December 30, 1995, through the combined support of LSUMC and Willis-Knighton," says Zibari.
The Regional Transplant Center is a result of an institutional partnership forged by LSUMC's John C. McDonald, M.D., director of the the Regional Transplant Center, a pioneer in the field of organ transplantation in the United States, and James Elrod, president of Willis-Knighton Health System.
In addition to kidney/pancreas transplants, the center provides liver transplantation. The Regional Transplant Center has been designated a "Center of Excellence" by the U.S. Department of Health and Human Services for its liver transplantation program, and is Medicare/Medicaid certified.
The availability of transplants for residents of the region was a driving force behind the establishment of the center, McDonald says. "The geographic location of our center is important since to the north it is 350 miles to Memphis, to the east it is approximately 400 miles to Birmingham, to the south 250 miles to Houston, and to the west 200 miles to Dallas before other Centers of Excellence exist," he says.
The regional access to transplants has several major benefits, including less inconvenience to patients and their families by not having to travel outside the area, the associated lower cost of care, and, in many cases, reduced waiting times for transplants due to shorter waiting lists, again a benefit in both convenience and reduced cost of overall care.
Kidney transplants have been available regionally since 1977 when Dr. McDonald established the kidney transplant program at LSUMC-Shreveport. In 1989 the program moved to Willis-Knighton through the joint venture, and since that time approximately 600 organs have been transplanted at Willis-Knighton, Aultman says.
The feasibility of adding a successful pancreas transplant program, though, has only become a reality during recent years.
"The first pancreas transplant in the world was done at the University of Minnesota in 1966," Aultman says. "For the first 15 years or so, through the early eighties, results with pancreatic transplantation were grim, primarily due to two factors: the technical aspects of the operation were difficult, and the anti-rejection drugs were poor, so there was a lot of rejection early on."
Success rates have improved dramatically, though, for several reasons Zibari says. "Good anesthesia and ICU care, good tissue typing, better organ preservation, the advances that have been made in new drugs for immunosuppression, and better techniques have resulted in making pancreatic transplantation far more successful than it was even just a few years ago," he says.
It was during a fellowship at Johns Hopkins Medical Center in Baltimore that Zibari first observed directly the benefits of pancreatic transplantation.
"I was very fascinated with the pancreas, to see patients who had been diabetic for some 25 to 35 years, who had been on dialysis for four or five years, and when the kidney and pancreas were put in, suddenly they were free of dialysis and free of insulin injection," Zibari says.
The enhanced patient benefits of a kidney/pancreas transplant are quite important, Aultman says. "Primarily it does two things for the patient," he says. "It allows them to be euglycemic, meaning they don't have to take insulin, and, most importantly in my mind, it keeps them from developing recurrent diabetic disease in the transplant kidney."
"Diabetic patients have multi-system problems. They have eye problems, many have cardiac problems, many with digestive tract problems, vascular problems, all related to the diabetes. The pancreas transplant, if successful, can halt progression of those complications," Aultman says, and in some instances even reverse or lessen damage.
With four to five million people with Type 1 diabetes in the U.S., and, according to the Louisiana Kidney Foundation, some 2,000 Louisiana residents on dialysis, the need for pancreatic transplantation for the region was significant. In Louisiana alone, the Louisiana Organ Procurement Agency reports some 35 individuals are already waiting for pancreas or kidney/pancreas transplantation.
Once the decision was made to provide pancreatic transplantation at the Regional Transplant Center, the service expansion went smoothly. "From doing kidney transplants, it was just a natural progression to do kidney and pancreas combinations in those patients with Type 1 diabetes," says Aultman.
"We already had a well-established program of transplantation at this institution. The surgical aspects, the medications, the critical care were very similar to what we had been used to," he says.
"It's nice when you have a well-established and well-organized program in existence," Zibari adds, noting that "Here, every system you can think of, from nurse coordinators, social workers, psychologists, endocrinologists, anesthesiologists, cardiologists, critical care, nephrologists, interventional radiologists - all those personnel were already in place."
With outstanding success rates and resulting growth in all areas of the WK/LSUMC Regional Transplant Center, the center's clinic has recently tripled its space with a move to a new 6,000 square foot office on the fourth floor of the Diagnostic and Surgical Building on the Willis-Knighton medical campus.
"The start of the program was small," says Nancy Noles, R.N., clinical director for the WK/LSUMC Regional Transplant Center, "but now we're experiencing rapid growth of the program due to the life-enhancing benefits it offers to patients in the region.
"We see about 450 patients per month and provide follow-up for an additional 300 in the region," she says.
Rhonda Webb, M.D., a nephrologist with Northwest Louisiana Nephrology, has observed the development of the kidney/pancreas program closely. With several of her patients having already benefitted from pancreas transplants at the center, she sees the pancreas transplantation program as a vital service to the region.
"Primarily what we see for long term diabetics that have a kidney transplant alone, is that they still have all the long term complications of diabetes," she says. "I feel very strongly that if you are a Type 1 diabetic and you want a chance for long term survival, you need a pancreas transplant.
"Having observed the success rates of the Willis-Knighton/LSUMC transplant program since its inception," Webb adds, "I have become a strong supporter of pancreas transplants for Type 1 diabetics," also noting the recent improvements in the technical aspects and advances in immunosuppressants in providing significantly better outcomes.
Patients such as Webb's who are referred to the clinic are initially evaluated by the center's multidisciplinary team.
On the day of the first visit, Aultman says, a new patient sees "the surgeon, the nephrologist, the endocrinologist if necessary, social worker, nurse coordinators, dietician and financial advisor. There are extensive workups which include history and physical exams, electrocardiogram, chest X-ray, and many of them require a cardiac workup of their heart to assure that they are appropriate medical candidates for the operation."
Generally, the indications are for a patient who has Type 1 diabetes with uremia or renal failure, Zibari says. "That is the classic patient who would benefit from a combined kidney/pancreas transplantation," he says, noting that about 80 percent of the cases being done nationally are the combined kidney/pancreas, with about 10 percent each of pancreas alone, and pancreas after kidney.
Additionally, Aultman says, there are a selective group of patients, even with Type 2 diabetes, who, when they have developed end stage renal disease, could be considered for combined kidney/pancreas transplantation.
Other transplantation options would be the pancreas alone before patients develop end stage renal disease, or for a patient who already has had a kidney transplantation from a family member.
From a related live donor, the center can remove the donor kidney through a laparoscopic procedure which greatly speeds recovery for the donor, with a pancreas then being transplanted when a donor organ is available.
Any appropriate candidate who is medically fit can qualify for the program.
Patient management during the pre-operative period is carried out primarily by the patient's nephrologist and/or endocrinologist.
In the months following surgery, patients visit the transplant clinic for close management of immunosuppressive therapy, as well as evaluation of renal and pancreatic function to monitor closely for any evidence of rejection. Transplant patients have access to the transplant staff 24 hours a day, seven days a week, should any problems arise.
After about six months of stable function, the patient's own physician resumes primary care, providing lab information to the transplant physicians for continued immunosuppression control.
As part of the multi-disciplinary approach of the transplant center, patients are actively involved in making their care successful.
"A long with the medical support team, the success of the program relies on the patients themselves and their compliance," Zibari says. "We can take care of the technical aspects of transplantation, but the patient has to do his or her part in taking care of themselves."
Zibari and Aultman both note the importance of organ donors in making the transplant programs successful, as well as the importance of notifying family members when an individual has made the decision to be a donor. "It's important to discuss that decision with the family," Zibari says, "so they will be aware and supportive of the individual's wishes. "An important point is the gratitude we feel to the family of the donor," Zibari says. "Without organ donation, none of this would be possible. We should always remember the donor and the donor families - it's truly the gift of life which they provide!"
For more information on becoming an organ donor, call the Louisiana Organ Procurement Agency (LOPA) at 800-833-3666.