Hi everyone.
We generally don't see many diabetic patients with gastroparesis make it to transplant.
We have one such patient transplanted five years ago who spent most of the two years after her transplant as an inpatient vomiting in hospital. Finally she had modest relief from a 24h subcutaneous metoclopramide infusion pump. She sadly died four years after her transplant with a functioning graft. Before her transplant, we had speculated that some of her vomiting was secondary to uraemia and would be improved by the renal transplant - we were wrong. Ultimately she reported being happy that she had the transplant for freedom for dialysis. It did feel like we probably did the right thing facilitating her transplant, though it was a little depressing seeing her in hospital for most of the two years after her transplant.
We currently have a similar young woman who received a simultaneous pancreas kidney transplant a month ago at another centre. She is continuously vomiting, with little response to IV anti-emetics. All investigations normal (CT abdo/pelvis, CMV PCR, WCC, CRP, amylase, ECG). She did have some history of gastroparesis pre-transplant, but relatively mild.
Should we be transplanting diabetic patients with gastroparesis (concern for inability to absorb immunosuppressive meds)? Any other investigations we should do for other causes (OGD etc.)? Any tips in managing immunosuppressive meds when vomiting (IV MMF, sub-lingual tacrolimus..)? Any tips on reducing vomiting?
We have had similar experience with SPK patients with a history of gastroparesis. In house we did all IV immunosuppression meds and transitioned to sublingual tacrolimus. We ended up placing a PICC line and initiating TPN with limited as tolerated PO liquid intake. The last two patients took ~2 months before they were back to their baseline. Another thing to consider is switching from cellcept to myfortic in these patients early. We had one patient with similar gastroparesis and intractable ascites, there are some case reports of cellcept being the culprit, we switched to azathioprine and it was amazing how quickly the patients condition resolved.
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