Doctors have used transplants of the pancreas to treat diabetes on a limited basis for decades, but advancements and a better understanding of the procedure have resulted in more people turning to them as an option to control their blood sugar — mostly in severe cases. (Ulysses Muñoz / Baltimore Sun video)
John Lewentowicz took insulin for 30 years to control his blood sugar and treat his type 1 diabetes.
But he still suffered from complications from the disease. He lost two toes because of nerve damage and poor circulation. He would shake and pass out when his blood sugar fell too low.
"It really takes a toll on your body," he said.
Relief finally came last year when Lewentowicz underwent a pancreas transplant at the University of Maryland Medical Center. The procedure cured Lewentowicz's diabetes and the 53-year-old no longer takes insulin.
"It made me feel 1,000 percent better," said the former casino dealer who lives in New Jersey. "It gets better every day."
Deep in the gut, the pancreas produces digestive enzymes and key hormones such as insulin. Type 1 diabetes occurs when the body's immune system attacks the cells that create insulin in the pancreas.
Joseph Scalea, University of Md. transplant surgeon, talks about the success of patient John Lewentowicz after a combined kidney and pancreas transplant. (Karl Merton Ferron, Baltimore Sun video)
Doctors have used transplants of the pancreas to treat diabetes on a limited basis for decades, but advancements and a better understanding of the procedure have resulted in more people turning to them as an option to control their blood sugar — mostly in severe cases.
Nearly four out of five pancreas transplants used to fail within five years, according to the American Diabetes Association. As surgery techniques have improved, there are now fewer complications, the association said. Pancreas transplants have one of the highest survival rate of any transplant procedure.
The improvements are mostly due to better drugs used to protect a patient's compromised immune system after a transplant. In most transplants, the body's immune system attacks the new organ as foreign, so patients must take immunosuppressants to increase the likelihood of success.
The drugs can lower a transplant recipient's resistance to other diseases. Newer immunosuppressants, however, have fewer side effects, doctors said.
"We are more comfortable and have gotten better with transplants in general," said Dr. Asha Thomas, director of endocrinology at Sinai Hospital of Baltimore. "We better understand what happens to people and our bodies when we take immunosuppressant drugs over a long period of time."
The University of Maryland Medical Center is performing many more pancreas transplants than it once did. Doctors performed 41 of the procedures last year and expect to do 50 this year. The medical center is expanding the programming and touting its expertise because it says few doctors specialize in it.
"It is an under-appreciated treatment option for diabetes," said Dr. Joseph Scalea, director of pancreas and islet cell transplantation at the University of Maryland Medical Center, who performed Lewentowicz's transplant.
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Pancreas transplants are usually saved for the more serious cases of diabetes, such as when a patient can't control their blood sugar levels despite taking insulin and eating a healthy, low-sugar diet. Their blood sugar levels may fluctuate so much that they could black out, making it so they can't drive or do other tasks.
Other good candidates include people who also need a kidney transplant, in many cases because the organ was damaged by complications from diabetes like Lewentowicz.
About 85 percent of pancreas transplants are performed on people who are already on immunosuppressants or would need them anyway after a kidney transplant, said Dr. Niraj Desai, director of the kidney and pancreas transplant program at the Johns Hopkins School of Medicine.
"The risk benefit ratio has to be optimized to make it worth the big surgery," Desai said. "Surgery comes with the potential for complications and other problems."
It took Lewentowicz years to convince doctors to give him a kidney transplant. His kidney had been destroyed by complications from diabetes, as well as the chemotherapy to treat a brain tumor, so he received regular kidney dialysis to clean wastes from his blood.
Five transplant centers, including the University of Maryland in 2013, turned him down out of concern that the immunotherapy might cause his cancer to return. He was approved for the procedure only after the advancement of immunotherapy protocols finally made it possible.
"We have to make sure they can tolerate the process," said Scalea, an assistant professor of surgery at the University of Maryland School of Medicine, who noted that transplants are complicated, serious procedures.
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Type 2 diabetes is caused when the body becomes resistant to insulin and can't use it properly. Eating a bad diet high in sugary foods can lead to it. About 10 percent of all pancreas transplants are performed in people with type 2 diabetes, according to the Mayo Clinic.
Another reason transplants aren't a common option for type 2 diabetics is that the drugs to treat the disease have gotten better over time, both Scalea and Thomas said.
"There has been a lot of evolution of the medications to treat diabetes," Thomas said. "There are so many drugs that are available now than there were five or 10 years ago."
Thomas said she would recommend a pancreas transplant only as a last resort.
New technology also has made it easier and more convenient for people to track their blood sugar levels. For instance, there are glucose sensors that can be placed on the belly or arm that automatically measure blood sugar levels every five minutes, Thomas said.
Still, pancreas transplants are becoming more common for those with type 2 diabetes who have low insulin resistance and low insulin production, according to the Mayo Clinic.
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Scalea said patients' sugar levels begin to stabilize quickly after a pancreas transplant.
"Within 20 to 30 minutes the new pancreas begins to work and the diabetes begins to go away," Scalea said. "In three to four hours the person's blood sugar is pretty normal. We have a lot of fun with that. We check the blood sugar every ten minutes and watch it change."
Lewentowicz has adapted well to the immunosuppressants. Six months after the transplant, he was cleared to participate in his favorite activities — bowling and golfing. His blood sugar remains stable and he doesn't miss the inconvenience of checking his glucose levels and giving himself insulin.
"I recommend anyone who has type 1 or type 2 diabetes consider this surgery," he said, "because it completely changes your life."