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Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And we have a panel for you today in a thought leader conversation highlighting pancreas transplant. Joining me is Dr. Ashraf El-Hinnawi. He's an Associate Director of the UF Health Adult and Pediatric Kidney and Pancreas Transplant Program, and the Director of the Living Donor Kidney Transplant Program and a Clinical Associate Professor in the Division of Transplantation and Hepatobiliary Surgery at the University of Florida College of Medicine; and Dr. Georgios Vrakas, he's the Director of the Adult and Pediatric Kidney and Pancreas Program and a Clinical Associate Professor in the Division of Transplantation and Hepatobiliary Surgery at the University of Florida College of Medicine.

Doctors, thank you so much for joining us today. And Dr. Vrakas, I'd like to start with you. How common is pancreas transplant? How many are performed on a yearly basis? And give us a little information about your hospital's history with pancreas transplants.

Dr. Georgios Vrakas: Well, hello. Good morning. And thank you very much for hosting us. To start with, I'd just like to mention that myself and Dr. El-Hinnawi have arrived at the Shands about three years ago, so we tried, let's say, to revamp the pancreas program. We both have extensive experience from previous hospitals when it comes to pancreas transplantation, and we got here together in order to make sure that we have, let's say, the perfect result program, the perfect outcomes, and that's what we're aiming for. We don't want to do an operation just to do it. We want to make sure that our patients make the most out of it.

Pancreas transplantation started here at the Shands in 1995, so it's one of the all kinds of programs that started with pancreas. And we aim to do about 15 to 20 a year at the moment. That's the number we're aiming at. I mean, 20 pancreas a year is supposed to be a large program. And, of course, we are very selective in our recipients and, of course, with our donors. And we still are obviously trying to make sure that our list expands and we have the right recipients for the right donors.

Melanie Cole, MS: Thank you so much for that. And Dr. El-Hinnawi, can you give us some indications for referral to a transplant center? Who qualifies for pancreas transplant? As Dr. Vrakas said, you're very specific and there's very specific diagnostic criteria. So, speak about that for us.

Dr. Ashraf El-Hinnawi: Well, again, Melanie, thank you very much for having us. So, the indications over the year have expanded a little bit for pancreas transplantation. But in general, the main indications are type 1 diabetes, which is insulin-dependent diabetes mellitus associated with an end-organ damage or end-stage organ disease. Most commonly is kidney failure, and when they need a kidney transplant in addition. So, type 1 diabetes with end-stage renal disease is the main common indication. We expanded a little bit to type 2 diabetes, where they don't require a lot of insulin, also in association with end-stage renal disease.

And another indication for isolated pancreas only if they have what we call hypoglycemic unawareness, which means that sometimes they can have severe hypoglycemia and they can get into a hypoglycemic coma without having the signs to alarm them that this is going to happen. Like me, you, or, Georgios, if we become hypoglycemic, we'll feel it before we get into the severe part of it. So, we'll feel hungry, we'll be sweating. Those patients, sometimes they lack that, and this could be a life-threatening situation. So, the pancreas alone is indicated in those cases.

Melanie Cole, MS: Dr. Vrakas, what does the process look like when a patient gets to your transplant center? For referring physicians, they like to know about communication. Tell us a little bit about the process, the waitlist, experience, how wait time is calculated, all of those kinds of details.

Dr. Georgios Vrakas: As Dr. El-Hinnawi mentioned, yes, we offer pancreas transplantation for type 1 and type 2 diabetes based on some certain criteria that we're using. And, as Dr. El-Hinnawi mentioned, for example, for type 2 diabetes, we rely on the amount of insulin these patients are using. It's also how high the C-peptide will be. So, it's kind of focused. We don't want to put a pancreas in someone who's very resistant to insulin, because it's not going to benefit them.

And when it comes to the process, we have a specialized pancreas coordinator. So when the referral comes to us, we try and triage the referrals based, for example, on the presence of diabetes or not, and some other criteria, let's say the age. So normally, we consider someone for a pancreas when they are less than 60 years old. And, for example, the presence of nephropathy, of course, makes things a lot more straightforward because we go for the kidney and pancreas. And if they have the hypoglycemia unawareness, we can go just for the pancreas.

Now, when we get them triaged, then we have to look a bit further into this. We have to see how fit they are. So, the kidney and pancreas operation, I usually tell to my patients, it's kind of three times the magnitude of just the kidney. So, we have to make sure that someone is fit enough for the kidney and pancreas operation. It's a large operation. Of course, the benefits are significant. But on the other hand, we have to make sure that someone has a strong heart, so the cardiac workup has to be very good. And make sure that we have the adequate kind of vasculature, so not too calcified vessels, so that we connect both organs. So, we're looking not only doing the operation, but of course making sure that the patient is strong enough to overcome any potential complications that can follow a pancreas transplant.

Melanie Cole, MS: Dr. El-Hinnawi, can you speak a little bit about any technical considerations you'd like to share? Any exciting technology, equipment in the procedure room, the surgical aspects of pancreas transplant? What would you like other providers to know that's really exciting at UF Health Shands Hospital?

Dr. Ashraf El-Hinnawi: Kidney-pancreas transplant is one of really the most complicated operations, not just in the field of transplantation, but in general, in all surgical aspects. We were raised during our residency that you don't mess with the pancreas. But here we are, we take it out from one person and put it another person. So, it's a very delicate, complicated operation. If it doesn't go perfect, there are potential complications associated with it.

First of all, it involves most of the time two organs. There is very delicate reconstruction of the organs before we do the transplant. At the transplant, it has, over the years, progressed from multiple different approaches, but the current approach is pancreas connected to the intestine and to the major blood vessels of the body, and the kidney is done the usual way on the other side of the abdomen.

Recently, there are some new approaches. We're not there yet, but there are many reported cases of doing robotic operations and stuff. But the experience is not great there yet and the outcomes are not probably very favorable until this point. But this is how we do it. We do a open technique. I think it's safer. It's a little faster. And this is how you achieve better outcomes from our standpoint. Most of these patients will stay in the hospital for five to seven days afterwards. When they go home, they are off insulin, they are off dialysis. That's a big life change for them. And the benefits of it, like Dr. Vrakas mentioned, are other than the big improvement in quality of life, I think they get years in the end of their life. So, they have more years to live because the progress of their disease stops after the transplant.

Dr. Georgios Vrakas: I'll also add here, I mean, Dr. El-Hinnawi is very humble to mention that our technique probably is what we take pride in as well, because we do it in a unique way that doesn't cause problems, let's say, and it has a very, very minimal risk of the portal vein thrombosis, which is a problem with different techniques that people would use over the years. So, the way we position the pancreas, we do it retroperitoneally. So, we have, let's say, to mobilize the colon and put it behind the colon on big vessels. So, we put it heads up straight on the IVC of the patient. So, we position the panasas in the retroperitoneum. At the same time, we make a window and push the duodenum of the pancreas straight into peritoneal cavity. So, it's kind of a transperitoneal approach, that has benefits when it comes to not causing problems with bowel obstruction that different techniques we have and not causing problems also with the positioning of the pancreas. The pancreas stays in the position where we put it. It doesn't move, and that helps us a lot when it comes to the recovery and avoiding any potential complications.

Melanie Cole, MS: Absolutely fascinating what you both do. And Dr. Vrakas, one of the things that I understand about transplantation in general is the need for organs. What do you see as the single greatest challenge facing patients on the pancreas transplantation waitlist today? Speak about managing the comorbid conditions when we're talking about type 1 diabetes and especially in children, as you said, the pediatric population. Tell us a little bit about some of the challenges including looking for organs.

Dr. Georgios Vrakas: When it comes to the pancreas, we normally don't do this in kids. We do it in adults, so more than 18, for the pancreas operations in general. We do the kidneys, of course, for the kids when they're more than 10 kilograms. But for pancreas, we're looking for adults. And, yes, the workup for the pancreas patient is a bit more extensive and we have to be a lot more cautious with diabetics, because as we all know, diabetes is a silent disease. It causes problems even to young people without them realizing this.

So, our testing, I think, it's pretty robust and the cardiac workup is pretty extensive as well. We do a lot more catheterizations when it comes to the work of diabetics. And when we place them on the list, obviously, we have to keep an eye on them. So, that's why we have the specialized coordinator that makes sure that we have this annual followup on our patients. We see them in person, making sure that they are doing well without any problems. And also, we repeat the vital parts of their investigations to make sure that we keep ourselves up-to-date with their health.

Average waiting time for a KP would be, let's say, about one to one and a half year in most cases, but it also depends on the organs that are available to us. And, as I said, we are very selective and we always send the team out when we think someone is promising. And then, we make the final judgment and that's what we tell our patients, be ready to come here when we think there's something available for you and don't get frustrated if you go home empty-handed. It could happen because we only know once our team reaches the donor, and they see with their own eyes whether this pancreas is transplantable or not. But this is for the best. I mean, we're looking for perfect organs that can last them for a lifetime. So, we're not going to risk it with something suboptimal.

Melanie Cole, MS: Dr. El-Hinnawi, tell us about the experience of a multidisciplinary team, because that would be so important for these patients. Tell us about your team.

Dr. Ashraf El-Hinnawi: You mentioned a very, very good point. So, the field of transplantation only gets bigger and more complex with time. And the subspecialties in the field of transplantation are becoming more valuable and very important. So, we have a transplant clinical pharmacist, we have a transplant nephrologist, we have a transplant infectious. Disease, We have transplant surgeons and transplant social worker, transplant dietician. So, it is really very complex care for patients, and no one single-handedly can take care of everything. So, we all depend on each other as a big multidisciplinary team. All our meetings, like when we select patients for transplantation, when we consider any organ for transplant, when we take care of patients pre and post-transplant, we always have a team doing that. Each one will be more focused on their field of expertise, but we all share the information and we all communicate to come up with the best decision or best care for the patients.

Melanie Cole, MS: I'd love to give you each a chance for a final thought here. And Dr. El-Hinnawi, I'd like you to speak a little bit about the future of pancreas transplantation. And is it determined by several issues such as the ongoing shortage of donor organs that has fueled search for alternative therapies? Can you speak about any research you're involved in, anything you would like other providers to know and take away from this podcast today?

Dr. Ashraf El-Hinnawi: The field of pancreas transplant, I will be honest with you, has been bigger in the past. When I first started my practice, we used to hear more about pancreas transplant. We used to do more pancreas transplants. But nowadays, there is a lot of advances in the care and management of diabetes on the medical side. So, we are not seeing as many referrals for transplant as we used to, because the complications of diabetes are being better managed now and delayed. So, they don't show up as they used to do in the past. So, the referral part is becoming a little smaller because we're not getting as many patients with the indications for the transplant, but there's nothing better than kidney and pancreas transplant for type 1 diabetics on dialysis.

So, I would like to have everybody aware that this is still the best option. This is still as close to cure as possible for type 1 diabetes and end-stage renal disease. We appreciate how medical care is progressing, but that does not eliminate the need for the pancreas and kidney transplant. So, I would like everybody who hear us from the medical field, from patients, from nephrologists, that this is still the best option out there. So if you have any patients who has type 1 diabetes or even type 2 diabetes with end-stage renal disease, or anybody with a hypoglycemic awareness, the best approach is to do a kidney-pancreas transplant.

The organs in pancreas, they are not limiting as other organs like in kidney or liver transplantation, where the need is much more than the available organs. In pancreas, we still have the ability to be a little bit more selective when it comes to choosing organs, because the lists are not very big. So, I think it's an excellent option. The wait times are much better than kidney only transplant, and we need to keep the awareness there for all our providers, even general practitioners, anybody in the medical field. It's good to be aware that this is a really excellent option for the patients who are in need for it.

Melanie Cole, MS: Those were such interesting aspects that you brought up. As an exercise physiologist myself, I see that diabetes treatment has really improved. So, that would certainly indicate a fewer need. And I love that you pointed out that because fewer of these are done. There is not such a high demand for the organs as well. Those were excellent points. And Dr. Vrakas, last word to you. I'd like you to speak to other providers about the program at UF Health Shands Hospital, what you would like them to know about early referral.

Dr. Georgios Vrakas: First of all, let me say that, I agree with all the details mentioned by Dr. El-Hinnawi when it comes to the referrals that we get. And yes, type 1 diabetics would benefit from a KP, especially at the stage where it leads to nephropathy. And type 2, yes, as you mentioned, we see less now. I mean, there are new medications like the Januvia or the Ozempic out there that have made sure that people lose weight and they have better tolerance to the insulin.

When it comes to the referrals for us, we always try and fast track all the pancreas referrals. Because it's a unique list, it's kind of a shortcut almost to the kidney and pancreas because people would benefit from both organs and they get them faster compared to a kidney. That's why we prioritize all these diabetics that are referred to us to make sure that we list them as fast as we can so that we can start accumulating points and get a good organ selection from our point of view.

So, that's our promise to the other providers, that we'll do our best to list their patients as soon as we can, make sure that we do that safe workup and we're not going to risk their health trying to do a kidney-pancreas. The fittest of all are getting listed and they're fast-tracked on the waiting list.

Melanie Cole, MS: Thank you both so much for joining us and telling us about the program at UF Health Shands Hospital and for sharing your incredible expertise. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.