PANCREAS TRANSPLANTATION - INDICATIONS AND OUTCOMES

Nearly all uraemic diabetic candidates for kidney transplants are candidates for a pancreas transplant. The best treatment option is to receive a living related donor kidney transplant first, followed later by a pancreas transplant from either a living related (segmental graft) or cadaver (whole organ or segmental) donor [22, 28]. For those without a living related donor for a kidney, a pancreas transplant can be performed simultaneously with a renal transplant from a cadaver donor. This approach promotes the highest kidney transplant survival rates and, coupled with pancreas transplantation, ensures the best overall outcome for the patient. The incentive to perform a living related donor kidney transplant is now even more compelling since the insulin-independence rates with a PAK can be as good as with a SPK transplant. Currently, the major role of pancreas transplantation is as an adjunct to kidney transplantation in pre-uraemic, uraemic, or post-uraemic diabetic patients. Non-uraemic, patients with hyperlabile diabetes or emerging complications must be carefully selected for the procedure. Current immunosuppressive regimens have many side-effects, and HLA matching, although improving the probability of long-term success, cannot eliminate its need. At least some immunosuppression is required even for recipients of a segmental graft from a non-diabetic identical twin donor, since in its absence the original autoimmune process will recur in the graft [31]. Immunosuppression sufficient to prevent rejection is always able to prevent recurrence of disease, but again, the recipient must have problems with diabetes such that the potential side-effects are an acceptable trade-off. When anti-rejection strategies with fewer consequences than the present regimens are available, pancreas transplants will be an alternative to exogenous insulin as a treatment for diabetes before the predisposition to secondary complications is declared. © 1992 Springer-Verlag.