Selected Podcast
Simultaneous Pancreas-Kidney (SPK) Transplant
Ty Dunn MD, MS discusses simultaneous pancreas-kidney (SPK) transplant. She emphasizes the relationship between type 1 diabetes and the destruction of these organs as well as the indications for both pancreas transplantation alone and SPK transplant. She shares the differences in the outcomes for SPK transplant versus pancreas-alone, or pancreas after kidney transplant and she tells us about the new allocation policies for kidney and pancreas transplantation. Lastly, she offers the recommendations for timing of referral for SPK transplant evaluation, and the advantages for individuals considering Penn Medicine’s Kidney and Pancreas Transplant program.
Featuring:
Learn more about Dr. Ty Dunn
Ty Dunn, MD, MS
Dr. Ty Dunn is a transplant surgeon who specializes in kidney and pancreas transplantation, pancreatectomy with islet auto-transplant and living kidney donation. Dr. Dunn has interests in the care of the diabetic patient, re-operative surgery, immunosuppression, humoral rejection, and infectious disease.Learn more about Dr. Ty Dunn
Transcription:
Melanie Cole (Host): Welcome to the podcast series from the specialists at Penn Medicine. I'm Melanie Cole, and joining me today is Dr. Ty Dunn. She's the Surgical Director of Kidney and Pancreas Transplantation and a Professor of Surgery at the Hospital of the University of Pennsylvania. And she's here today to discuss simultaneous pancreas and kidney transplant.
Dr. Dunn, it's a pleasure to have you with us today. We're talking about simultaneous pancreas kidney transplantation or SPK, but there's really another story and it's the relationship between type 1 diabetes and the destruction of these organs. Can you speak briefly to this and discuss some indications for both pancreas transplantation alone and SPK?
Dr Ty Dunn: Great. Thanks for having me. I'd be happy to do that. Type 1 diabetes is a disorder that classically affects younger people, often in childhood where the body's autoimmune response attacks the islet cells in the pancreas, and causes them to no longer make insulin. So, type 1 diabetics are completely reliant on external or exogenous insulin in order to stabilize their blood sugar and prevent the damage that's done from constantly having high blood sugar. And that damage is on the microvasculature of many different the organs, the brain, the eyes, the heart, the kidney, and the nerves. And so, patients with long-standing diabetes often will develop these microvascular complications over decades, and many will ultimately develop kidney failure as a result of the damage on the kidney from the longstanding diabetes.
Melanie Cole (Host): Well, thank you for that. So, type 1 obviously, as you just said, but we're seeing this epidemic in the country today, tell us about type 2 diabetes. Are they being considered for SPK at Penn Medicine?
Dr Ty Dunn: Great question. So yes, we do consider type 2 diabetics for a pancreas transplant, certainly selected type 2 diabetics. Many patients that develop type 2 diabetes will develop it in adulthood and it is associated with obesity, but not all type 2 diabetics are obese. So, it's important for patients that have modifiable risk factors like obesity to manage their obesity in the hopes that perhaps they can be free of their diabetes or have a less severe form of it.
So, type 2 diabetics have the metabolic disorder of insulin resistance and a secretory defect in insulin. And that is in many ways a very different disease, but in the end, when there's an imbalance in the ability of the amount of insulin that's produced and the amount of insulin that can be utilized, then you have uncontrolled blood sugars and you have the same end points of microvascular damage over time. And for that reason, we don't really differentiate a whole lot between type 1 and type 2 when it comes for candidacy for pancreas transplant, as long as the patient is lean and otherwise medically suitable.
Melanie Cole (Host): That's interesting. So tell us, are there differences, Dr. Dunn, in outcomes for SPK transplant versus pancreas alone or pancreas after kidney transplant?
Dr Ty Dunn: There are important differences between the different types of pancreas transplants. Pancreas transplant about 80% of the time is done in conjunction with a kidney transplant for patients with chronic kidney disease. When a pancreas is transplanted as its own organ and not at the same time as a kidney, it can be done in two ways. It can be done for patients that have already had a kidney transplant who are continuing to have to manage their diabetes and worry about end-organ complications. And that's called a pancreas after kidney transplant.
The other form of pancreas-alone transplant is for patients that are not uremic, that do not have significant kidney disease, who are simply really struggling with a lability of their glucose control and oftentimes severe autonomic dysfunction and hypoglycemic unawareness. And that's really where pancreas transplant can almost be lifesaving for those patients, because they often will go low sometimes in their sleep. And it is a cause of death in about 6% of patients on the waitlist each year.
Melanie Cole (Host): Dr. Dunn, tell us a little bit about the major changes in the new allocation system. It was back in 2014, but why was the newly revised kidney allocation system necessary? Tell us a little bit about that.
Dr Ty Dunn: This change in the kidney allocation system was really an important change in how we deliver organs to patients in the United States. Prior to that time, patients didn't get on a transplant list until they came to the transplant center and got listed either with a qualifying GFR of 20 or below or because they were on dialysis. They didn't get any waiting time credit if they had been on dialysis for a long time. And recognizing that there are health disparities in patients' access to transplant and referral for transplant, it was important to not penalize patients that couldn't get themselves early referred and so that they could gain all the credit from when they actually started dialysis. So, that really leveled the playing field from the kidney perspective. And a lot of patients that had been on dialysis for a long time were able to go rightly to the front of the list because they had banked all of that waiting time and accrued the complications of dialysis and needed to get off dialysis ASAP.
The other important thing that happened in the kidney allocation change was that the pancreas allocation was completely disconnected from the kidney allocation. And that's important because prior to this, there were many different local variances and irregular practices all across the country about when a pancreas should be allocated with a kidney, or you might think of it as when the kidney would go with the pancreas. The deceased donor that can donate a pancreas is typically a fairly young and lean and pretty healthy person. So, it's not common for a deceased donor to be able to donate a pancreas. And when they can, we want to make sure that pancreas and the kidney can go as a unit for the most commonly practiced type of pancreas transplant, the simultaneous kidney pancreas. And so in doing so, you no longer had to be like in the top 15% of the kidney list or whatever your local variance was. It was much clearer and much more transparent in how these kidneys were shared over distances and also how they were prioritized for different populations.
Melanie Cole (Host): Well then, Dr. Dunn, what does the process look like when a patient gets to your transplant center? What's involved in management of patients on the waitlist?
Dr Ty Dunn: So when patients come to the transplant center for a kidney and pancreas or a pancreas-alone transplant, it's important to understand that we work first and foremost on education about the transplant process to make sure that the decision for transplant is in concordance with that patient's wishes. Transplant isn't for all people, but the first step is to become educated about what the risks are and what the potential benefits are and how that weighs in the balance for that particular individual. After that, we make sure that they are medically and surgically suitable and appropriate and give them an individualized risk assessment, so that they can take that personalized recommendation and apply it to their own context and make sure that they feel ready and appropriate to go forward or perhaps not.
From there, it's important to recognize that the patient's kidney disease continues to be managed by their referring nephrologist and their referring dialysis center. The transplant center does not manage that disease. This is different than other organs such as heart failure, lung failure and liver failure where those end-organ failures are very much managed within the transplant center. Likewise, for patients that need a pancreas transplant, their endocrinologist manages their diabetes.
And, once they are transplanted, I have a transplant endocrinology team that follows the patients with the transplant nephrologists and the transplant surgeons in order to kind of pick up all of the different things we need to do in their aftercare. And we do collaborate with their referring physicians and often start alternating appointments.
Melanie Cole (Host): Well, that leads me very well into the question about multidisciplinary management and how important it is for these patients and certainly after the procedure itself, but speak about your team at Penn Medicine for us.
Dr Ty Dunn: Yes, this is a really important part of choosing a transplant center. One thing I think that we really are lucky to have here at Penn Medicine, we have specialists in many different disciplines that are very hard to come by. For example, we have extensive experience in a team that only does transplant infectious disease. This is in addition to the routine infectious disease care that they would provide in the community. They specialize in the care of transplant patients and the unusual sometimes rare infections that they may have. And also advising our patients on travel history and things like that, vaccinations, is really, really a big part of our team.
We also have transplant psychiatry. Patients with long standing diabetes and chronic diseases such as kidney disease often live with a lot of anxiety and sometimes depression and gearing up for their transplant is like gearing up for their next marathon. We want to be there to support them and provide them with the tools to help manage their anxiety and depression as they go through this major change and recovering from surgery.
Melanie Cole (Host): Such an important point, Dr. Dunn. As we get ready to wrap up here, what are the recommendations for timing of referral for SPK transplant evaluation and the advantages for individuals considering Penn Medicine's kidney and pancreas transplant program?
Dr Ty Dunn: Timely referral is one of the most important things I think that a treating physician can consider in patients that look like they're progressing towards the end-stage kidney disease.
We really like to have our diabetics referred earlier. Although they can't get listing credit for UNOS wait time until they achieve a GFR of 20, it takes a while to come into the transplant center to complete their full evaluation and perhaps undergo their diagnostic testing and determine whether they're appropriate for transplant. And diabetics sometimes have a more precipitous decrease in their GFR. And for that reason, we really want to get them oriented early and get them educated about living donation and allow them to have time to find a living donor so that we hopefully can do what's called a preemptive transplant. And that is a transplant that's done just when they're about to need to start dialysis, so they can skip over that whole chapter in their end-stage renal disease.
Melanie Cole (Host): Thank you so much, Dr. Dunn. What an informative podcast this was. Thank you for joining us. And to refer your patient to Dr. Dunn at Penn Medicine, please call our 24/7 provider-only line at 877-937-7366. Or you can always submit your referral via our secure online referral form by visiting our website at pennmedicine.org/referyourpatient.
That concludes this episode from the specialists at Penn Medicine. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.
Melanie Cole (Host): Welcome to the podcast series from the specialists at Penn Medicine. I'm Melanie Cole, and joining me today is Dr. Ty Dunn. She's the Surgical Director of Kidney and Pancreas Transplantation and a Professor of Surgery at the Hospital of the University of Pennsylvania. And she's here today to discuss simultaneous pancreas and kidney transplant.
Dr. Dunn, it's a pleasure to have you with us today. We're talking about simultaneous pancreas kidney transplantation or SPK, but there's really another story and it's the relationship between type 1 diabetes and the destruction of these organs. Can you speak briefly to this and discuss some indications for both pancreas transplantation alone and SPK?
Dr Ty Dunn: Great. Thanks for having me. I'd be happy to do that. Type 1 diabetes is a disorder that classically affects younger people, often in childhood where the body's autoimmune response attacks the islet cells in the pancreas, and causes them to no longer make insulin. So, type 1 diabetics are completely reliant on external or exogenous insulin in order to stabilize their blood sugar and prevent the damage that's done from constantly having high blood sugar. And that damage is on the microvasculature of many different the organs, the brain, the eyes, the heart, the kidney, and the nerves. And so, patients with long-standing diabetes often will develop these microvascular complications over decades, and many will ultimately develop kidney failure as a result of the damage on the kidney from the longstanding diabetes.
Melanie Cole (Host): Well, thank you for that. So, type 1 obviously, as you just said, but we're seeing this epidemic in the country today, tell us about type 2 diabetes. Are they being considered for SPK at Penn Medicine?
Dr Ty Dunn: Great question. So yes, we do consider type 2 diabetics for a pancreas transplant, certainly selected type 2 diabetics. Many patients that develop type 2 diabetes will develop it in adulthood and it is associated with obesity, but not all type 2 diabetics are obese. So, it's important for patients that have modifiable risk factors like obesity to manage their obesity in the hopes that perhaps they can be free of their diabetes or have a less severe form of it.
So, type 2 diabetics have the metabolic disorder of insulin resistance and a secretory defect in insulin. And that is in many ways a very different disease, but in the end, when there's an imbalance in the ability of the amount of insulin that's produced and the amount of insulin that can be utilized, then you have uncontrolled blood sugars and you have the same end points of microvascular damage over time. And for that reason, we don't really differentiate a whole lot between type 1 and type 2 when it comes for candidacy for pancreas transplant, as long as the patient is lean and otherwise medically suitable.
Melanie Cole (Host): That's interesting. So tell us, are there differences, Dr. Dunn, in outcomes for SPK transplant versus pancreas alone or pancreas after kidney transplant?
Dr Ty Dunn: There are important differences between the different types of pancreas transplants. Pancreas transplant about 80% of the time is done in conjunction with a kidney transplant for patients with chronic kidney disease. When a pancreas is transplanted as its own organ and not at the same time as a kidney, it can be done in two ways. It can be done for patients that have already had a kidney transplant who are continuing to have to manage their diabetes and worry about end-organ complications. And that's called a pancreas after kidney transplant.
The other form of pancreas-alone transplant is for patients that are not uremic, that do not have significant kidney disease, who are simply really struggling with a lability of their glucose control and oftentimes severe autonomic dysfunction and hypoglycemic unawareness. And that's really where pancreas transplant can almost be lifesaving for those patients, because they often will go low sometimes in their sleep. And it is a cause of death in about 6% of patients on the waitlist each year.
Melanie Cole (Host): Dr. Dunn, tell us a little bit about the major changes in the new allocation system. It was back in 2014, but why was the newly revised kidney allocation system necessary? Tell us a little bit about that.
Dr Ty Dunn: This change in the kidney allocation system was really an important change in how we deliver organs to patients in the United States. Prior to that time, patients didn't get on a transplant list until they came to the transplant center and got listed either with a qualifying GFR of 20 or below or because they were on dialysis. They didn't get any waiting time credit if they had been on dialysis for a long time. And recognizing that there are health disparities in patients' access to transplant and referral for transplant, it was important to not penalize patients that couldn't get themselves early referred and so that they could gain all the credit from when they actually started dialysis. So, that really leveled the playing field from the kidney perspective. And a lot of patients that had been on dialysis for a long time were able to go rightly to the front of the list because they had banked all of that waiting time and accrued the complications of dialysis and needed to get off dialysis ASAP.
The other important thing that happened in the kidney allocation change was that the pancreas allocation was completely disconnected from the kidney allocation. And that's important because prior to this, there were many different local variances and irregular practices all across the country about when a pancreas should be allocated with a kidney, or you might think of it as when the kidney would go with the pancreas. The deceased donor that can donate a pancreas is typically a fairly young and lean and pretty healthy person. So, it's not common for a deceased donor to be able to donate a pancreas. And when they can, we want to make sure that pancreas and the kidney can go as a unit for the most commonly practiced type of pancreas transplant, the simultaneous kidney pancreas. And so in doing so, you no longer had to be like in the top 15% of the kidney list or whatever your local variance was. It was much clearer and much more transparent in how these kidneys were shared over distances and also how they were prioritized for different populations.
Melanie Cole (Host): Well then, Dr. Dunn, what does the process look like when a patient gets to your transplant center? What's involved in management of patients on the waitlist?
Dr Ty Dunn: So when patients come to the transplant center for a kidney and pancreas or a pancreas-alone transplant, it's important to understand that we work first and foremost on education about the transplant process to make sure that the decision for transplant is in concordance with that patient's wishes. Transplant isn't for all people, but the first step is to become educated about what the risks are and what the potential benefits are and how that weighs in the balance for that particular individual. After that, we make sure that they are medically and surgically suitable and appropriate and give them an individualized risk assessment, so that they can take that personalized recommendation and apply it to their own context and make sure that they feel ready and appropriate to go forward or perhaps not.
From there, it's important to recognize that the patient's kidney disease continues to be managed by their referring nephrologist and their referring dialysis center. The transplant center does not manage that disease. This is different than other organs such as heart failure, lung failure and liver failure where those end-organ failures are very much managed within the transplant center. Likewise, for patients that need a pancreas transplant, their endocrinologist manages their diabetes.
And, once they are transplanted, I have a transplant endocrinology team that follows the patients with the transplant nephrologists and the transplant surgeons in order to kind of pick up all of the different things we need to do in their aftercare. And we do collaborate with their referring physicians and often start alternating appointments.
Melanie Cole (Host): Well, that leads me very well into the question about multidisciplinary management and how important it is for these patients and certainly after the procedure itself, but speak about your team at Penn Medicine for us.
Dr Ty Dunn: Yes, this is a really important part of choosing a transplant center. One thing I think that we really are lucky to have here at Penn Medicine, we have specialists in many different disciplines that are very hard to come by. For example, we have extensive experience in a team that only does transplant infectious disease. This is in addition to the routine infectious disease care that they would provide in the community. They specialize in the care of transplant patients and the unusual sometimes rare infections that they may have. And also advising our patients on travel history and things like that, vaccinations, is really, really a big part of our team.
We also have transplant psychiatry. Patients with long standing diabetes and chronic diseases such as kidney disease often live with a lot of anxiety and sometimes depression and gearing up for their transplant is like gearing up for their next marathon. We want to be there to support them and provide them with the tools to help manage their anxiety and depression as they go through this major change and recovering from surgery.
Melanie Cole (Host): Such an important point, Dr. Dunn. As we get ready to wrap up here, what are the recommendations for timing of referral for SPK transplant evaluation and the advantages for individuals considering Penn Medicine's kidney and pancreas transplant program?
Dr Ty Dunn: Timely referral is one of the most important things I think that a treating physician can consider in patients that look like they're progressing towards the end-stage kidney disease.
We really like to have our diabetics referred earlier. Although they can't get listing credit for UNOS wait time until they achieve a GFR of 20, it takes a while to come into the transplant center to complete their full evaluation and perhaps undergo their diagnostic testing and determine whether they're appropriate for transplant. And diabetics sometimes have a more precipitous decrease in their GFR. And for that reason, we really want to get them oriented early and get them educated about living donation and allow them to have time to find a living donor so that we hopefully can do what's called a preemptive transplant. And that is a transplant that's done just when they're about to need to start dialysis, so they can skip over that whole chapter in their end-stage renal disease.
Melanie Cole (Host): Thank you so much, Dr. Dunn. What an informative podcast this was. Thank you for joining us. And to refer your patient to Dr. Dunn at Penn Medicine, please call our 24/7 provider-only line at 877-937-7366. Or you can always submit your referral via our secure online referral form by visiting our website at pennmedicine.org/referyourpatient.
That concludes this episode from the specialists at Penn Medicine. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.