I. The danger of diabetes
Diabetes is one of the major diseases that threaten human health. According to the latest data released by the International Diabetes Federation (IDF), the number of people with diabetes worldwide has reached a staggering number – 285 million. China has 43.2 million, the second highest number after India (50.8 million). However, the recently released data from the National Diabetes Epidemiological Survey (2007-2008) shows that the prevalence of diabetes among people over 20 years of age in China is 10.6% and 8.8% for men and women, respectively, and the overall prevalence of diabetes is 9.7%, thus, the total number of people with diabetes in the country is projected to be about The total number of diabetics in the country is estimated to be about 92 million. More seriously, the survey shows that the prevalence of pre-diabetes is as high as 15.5%, projecting that the number of pre-diabetes sufferers nationwide is about 148 million people.
Currently, diabetes causes about 3 million deaths per year worldwide, and diabetes is probably the fifth leading cause of death worldwide.” The main cause of death in diabetics is not diabetes itself, but the chronic complications caused by it, such as coronary heart disease, stroke, and diabetic nephropathy. Diabetic patients have systemic vasculopathy caused by elevated blood sugar, which can affect both large blood vessels and microvessels. Coronary artery disease in the heart (coronary heart disease) leads to heart failure, cerebrovascular disease can occur cerebrovascular accident (stroke), fundus vasculopathy can cause blindness, diabetic renal vasculopathy including large vessel lesions such as renal arteriosclerosis, small renal arteriosclerosis and glomerulosclerosis, which can develop into uremia.
Some statistics show that: among those who die of diabetes, cardiovascular disease accounts for 23%, cerebrovascular disease accounts for 23.6% uremic syndrome accounts for 9.8%.
Why should we perform combined pancreas or pancreas-kidney transplantation?
Although we have entered the 21st century, people are still plagued by advanced complications of diabetes. Diabetes remains the leading cause of blindness in adults, and diabetic nephropathy occurs in nearly half of patients and eventually leads to renal failure. In addition, diabetic neuropathy is the leading cause of nontraumatic limb amputation. In recent years, an increasing proportion of type 2 diabetes is complicated by coronary heart disease. Therefore, reducing the risk of developing diabetic complications is an important basic measure.
It has been the dream of mankind to cure diabetes by replacing the patient with a fully functional organ like a machine part. Insulin, invented in the 1920s, is an effective drug for the treatment of type 1 diabetes, and its application can keep the patient’s blood sugar at a relatively low level. However, it does not produce insulin according to the change of blood sugar like the pancreas in normal people, so that the body’s blood sugar is stabilized in a narrow physiological range for 24 hours. Nor can it delay the onset and development of the series of complications of diabetes (eye disease, kidney disease, etc.). Especially when the disease progresses to uremia, dialysis treatment has many complications, many patients go blind and have poor quality of life; diabetic patients with simple kidney transplantation often suffer from diabetic nephropathy again after a few years; scientists have found that combined pancreas and kidney transplantation can correct both diabetes and diabetes-induced uremia, and significantly improve the quality of life.
Combined pancreas-kidney transplantation is a surgical procedure in which a well-functioning pancreas and kidney are transplanted simultaneously in a patient with diabetes mellitus combined with kidney disease. In 1996, Kelly performed the world’s first combined pancreas and kidney transplant, and since then, the surgical techniques and procedures of pancreas transplantation and combined pancreas-kidney transplantation have been explored, innovated, improved and matured. After successful transplantation, the patient no longer needs long-term insulin injections and does not need to control diet like diabetic patients, but can maintain normal blood glucose levels and reverse or stop the development of cardiovascular, ocular and neurological complications of diabetes, and at the same time correct the uremia caused by diabetes and stop hemodialysis. In general, after transplantation, patients can return to normal life and work, except for taking anti-rejection drugs every day, which is no different from normal people, significantly improving the quality of life of patients. As of 2002, the cumulative total number of pancreatic transplantation and combined pancreatic and renal transplantation worldwide is nearly 20,000, and the longest postoperative survival time has been more than 20 years. In the past 10 years, the success rate of pancreas transplantation and long-term survival rate of patients have approached the level of kidney transplantation alone. Pancreatic transplantation and combined pancreatic and renal transplantation is a high technology in the field of surgery and has become the most effective method for the treatment of type 1 diabetes and some type 2 diabetes combined with uremia internationally.
What is the success rate of combined pancreas-kidney transplantation?
In recent years, the success rate of combined pancreas-kidney transplantation is similar to that of other substantive organs, with a 1-year survival rate of more than 84% for transplanted pancreas. In experienced transplant centers, the 1-year survival rate of the recipient can reach 95%-100%, and the 1-year survival rate of the transplanted pancreas reaches 90-95%. China’s combined pancreatic and renal transplantation started late, and the first combined pancreatic and renal transplantation was performed in Wuhan Tongji Hospital in 1989. In the initial stage, the success rate of combined pancreas-kidney transplantation was not high, and the bladder drainage method used was easy to cause urinary tract infection and many complications, and there were few long-term survival cases. In recent years, through in-depth research, Tongji Hospital has made a new breakthrough in combined pancreatic and renal transplantation technology and was the first in China to apply a modified jejunal drainage surgical method. This method simplifies the surgery and reduces post-transplant surgical and metabolic complications. Moreover, we have developed a unique treatment plan for postoperative prevention of transplant pancreatic pancreatitis, thrombosis, rejection and pancreatic leakage. Since January 2000, 55 cases of combined pancreatic and renal transplantation have been performed, with a success rate of over 95%, which is the unit with the highest number of combined pancreatic and renal transplantation cases and the highest success rate in China, forming a unique advantage. Its research project has passed the appraisal of Hubei Provincial Science and Technology Department and reached the international advanced level.
Which patients can do combined pancreatic and renal transplantation?
Type 1 diabetes mellitus with end-stage renal failure: when diabetes mellitus is complicated by uremia, it is mostly accompanied by other complications of diabetes mellitus, such as diabetic retinopathy and diabetic neuropathy. At this time, pancreas transplantation is not only for the prevention of advanced diabetic syndrome, but also more mainly for the treatment of diabetic end-stage renal disease. However, the long-term results of kidney transplantation alone are not good, so patients with type I diabetes who need kidney transplantation should preferably undergo combined pancreas-kidney transplantation. Uremic diabetic patients who are already on dialysis are usually selected. Pre-dialysis patients with serum creatinine of 300-500 μmol/L are generally in better condition and more likely to recover after transplantation.
Type 2 diabetic patients who have already had a kidney transplant, if the transplanted kidney is functioning well and there are no postoperative complications, a pancreas transplant is needed to prevent the occurrence of diabetic complications and interrupt the course of diabetes. Pancreas transplantation should generally be performed before the transplanted kidney shows clinical signs of secondary diabetic nephropathy.
Type 3 diabetes mellitus with end-stage renal failure: Since type 2 diabetes mellitus has both insulin resistance and relative insulin deficiency, transplantation of a fully functional pancreas can overcome the insulin resistance of type 2 diabetes mellitus.
V. Can the pancreas be transplanted alone?
Before the mid-1980s, due to the ineffectiveness of pancreas transplantation and the progress of medical treatment, the purpose of pancreas transplantation in diabetes was to improve the patient’s quality of life, not to save the patient’s life as early as possible like liver transplantation or heart transplantation, and the application of lifelong immunosuppressive drugs after the operation would lead to the corresponding side effects, so it was not advocated to perform pancreas transplantation alone. Therefore, the indications for simple pancreas transplantation are strictly controlled, and most patients are considered for combined pancreas and kidney transplantation or pancreas transplantation after kidney transplantation only in the advanced stage of diabetes, especially when it is complicated by uremia. In fact, the earlier a pancreas transplant is performed, the lower the incidence of diabetic complications and the better the quality of life of the patient. With the improvement of transplantation techniques, the number of patients receiving a simple pancreas transplant is gradually increasing. The reason for this is that the most fundamental measure for diabetic nephropathy is to perform pancreas transplantation before the onset of nephropathy to normalize blood sugar and prevent the onset and development of diabetic nephropathy.
In recent years, due to the improvement of surgical techniques, the introduction of highly selective and potent anti-rejection drugs such as primaquine and FK506, the application of the U.S. Wisconsin (UW) organ preservation fluid, the damage to the organ is reduced to a minimum, as well as the increase in the early diagnosis of pancreatic rejection, greatly improving the survival rate of the transplanted pancreas, the survival rate of the transplanted pancreas 1 year after simple pancreas transplantation reached more than 80%, achieving a combined pancreatic and renal The survival rate of the transplanted pancreas after simple pancreas transplantation is more than 80%, achieving similar results as combined pancreas-kidney transplantation.
Sixth, the main targets of simple pancreas transplantation are.
1, patients with type 1 or type 2 diabetes requiring insulin therapy.
2. Type 1 diabetic patients with the following conditions should be operated as soon as possible
① Pre-proliferative retinopathy, or laser treatment is ineffective.
② Blood sugar fluctuates greatly and is difficult to control with insulin therapy.
③ Need super conventional dose of insulin to control blood sugar.
④ Severe neuropathic pain.
⑤ Pre-uremic nephropathy with persistent proteinuria greater than 0.5g/24h.