Published on 17 July 2022

    Diabetic patients suffering from severe disease could now find new recourse with the launch of Singapore’s first national pancreas transplant service. 

    From kidney and renal failure, to disease of the eyes and nerves, end-stage diabetes is associated with a host of debilitating complications. For patients suffering from such disease, dialysis may be a respite, but it is a temporary one – data shows that the global mortality rate for these patients remains high at 50% at the three-year point. 

    A pancreas transplant, however, pushes survival rates up to 90% or higher. The only treatment to establish a normal sugar state in diabetic patients without the need for insulin injections, pancreas transplants are most commonly performed together with a kidney transplant, in a procedure called a simultaneous kidney-pancreas (SPK) transplant.

    “It’s a technically challenging, multifaceted operation,” said A/Prof Glenn Bonney, Consultant at the Adult Kidney & Pancreas Transplantation Programme at National University Centre for Organ Transplantation (NUCOT), National University Hospital (NUH). He added that the procedure requires a multidisciplinary team of experts, including nurses, dietitians, nutritionists, physiotherapists, and pharmacists. 

    In an SPK transplant, the donor’s pancreas and kidney are removed in a graft, which includes part of the bowel and the major connected blood vessels. 

    But instead of removing the patient’s diseased pancreas and replacing it with the new, donated graft, the surgeon simply adds it on along the side of the tummy.

    “The pancreas is actually right at the back of the tummy,” explained A/Prof Bonney. “It is relatively hard to get to and operate on, and has high risks of surgery associated with it.”

    In the past, doctors believed that the new pancreas had to be in its original position, necessitating the removal of the diseased pancreas. But research has shown that this involves more risks than benefits, and as such, the new method no longer involves the removal of the old pancreas.

    “So the old pancreas is left in, and a new pancreas is transplanted in, often alongside a kidney...in a way that doesn’t [involve] the recipient in high-risk surgery,” said A/Prof Bonney. “And you can do a much safer operation.”

    Such advancements in surgical technique and medical care have, fortunately, helped SPK transplants see tremendous improvement over the past years. Today, outcomes have significantly improved  – from a 40% success rate in the 1980s, to over 90% today.

    And to date, over 50,000 such procedures have been performed worldwide.

    The launch of a national programme

    The pancreas transplant service was first proposed in Singapore in 2010. It was launched as a pilot programme two years later, and in April 2021, with five successful surgeries under its belt, the pancreas transplantation service received Ministry of Health approval to launch as a full-fledged national programme, catering to both type 1 and type 2 patients.

    This is novel, as SPK transplants were conventionally only performed in type 1 diabetic patients, explained Dr Hersharan Kaur Sran, a Senior Consultant at NUH’s Adult Kidney & Pancreas Transplantation Programme.

    “However, over 95% [of diabetics with kidney failure] are actually type 2 diabetics,” she said. “And there's been evidence, there are programmes overseas that have been extended to type 2 diabetics…and we now know that the outcomes are just as good.”

    As such, the programme – originally launched to cater to type 1 patients – was extended to type 2 patients in 2017. This, the team said, is a key move in helping Singapore in its war against diabetes. 

    For now, SPK transplants come with a strict patient selection criteria, including a maximum age cut-off of 55 years old. This is because of a combination of factors – for one, older patients don’t do as well with major surgeries.

    For another, there is the matter of the service being a limited resource, which has to be allocated to those who will benefit the most, added Dr Hersharan. 

    “Diabetes is a disease of getting older, really. So the majority are elderly,” she said. “But there are diabetics, especially type 1 diabetics, who get it when they’re young…so even in childhood, and even in their youth. 

    “These patients are the ones who end up with kidney failure in their middle age, so these are the ones we want to help the most, because they’ll get the most out of the organ transplant.”

    Mr Halim Bin Anuwar is one such patient. At the age of 18, he was diagnosed with type 1 diabetes. 

    Over the next 20 years, insulin injections became a daily occurrence. As his condition worsened, this number gradually increased to four times a day – and last year, he developed end-stage kidney disease, and began to undergo dialysis.

    “There [was] a strict regimen for me doing dialysis at home. I [couldn’t] afford to miss any sessions. So every night, at a certain time, I had to be at home for the dialysis session,” said Mr Halim, who is now 39.

    Fortunately, in February 2020, his medical team at Singapore General Hospital (SGH) referred him to be waitlisted for a transplant. He underwent the surgery just a few months later, in July, and was discharged nine days after the eight-hour surgery.

    Today, his kidney function is normal and he no longer needs either dialysis or insulin injections. He has also resumed work.

    “I have more time, I can [do] other activities in a stretch, maybe until close to midnight...before my meals, I can enjoy my food straight away, without taking any insulin jabs,” he said.

    Making a difference in patients’ lives

    With the establishment of the pancreas programme as a mainstream national service, the team hopes that more patients like Mr Halim can receive much-needed help. 

    “SKP transplants can make a big difference in patient survival,” said A/Prof Tiong Ho Yee, who is Director of the National Pancreas Transplant Programme as well as Senior Consultant at NUH’s Adult Kidney & Pancreas Transplantation Programme.

    He added, “The approval of pancreas transplantation as a national programme marks the culmination of several years of clinical efforts and research to bring this life-changing surgery to suitable patients suffering from type 1 diabetes mellitus with complications including renal failure.”

    The team also expressed their gratitude to the five patients for stepping up to participate in the pilot programme, as well as to the organ donors and their families. 

    “We and our patients owe a great debt of gratitude to the donors and their families, without which this programme would not have been possible,” said A/Prof Bonney.

    In consultation with A/Prof Tiong Ho Yee,  Director, National Pancreas Transplant Programme and Senior Consultant, Adult Kidney & Pancreas Transplantation Programme, NUCOT, NUH; Dr Hersharan Kaur Sran, Senior Consultant, Adult Kidney & Pancreas Transplantation Programme, NUCOT, NUH and A/Prof Glenn Bonney, Consultant, Adult Kidney & Pancreas Transplantation Programme, NUCOT, NUH.

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