Pancreas transplantation

Although intensified insulin therapy regimens enable normalization of blood glucose levels and related metabolic parameters, these regimens are associ ated with an increased incidence of hypoglycemic episodes. Pancreas transpl antation has achieved the goal of providing insulin independence with stabl e and continuous normoglycemia. But because of the associated morbidity and mortality and the need for lifelong immunosuppression after transplant, it is difficult to justify pancreas transplantation in diabetic patients at a pre-uremic stage. Pancreas transplantation is therefore performed in conju gation with renal transplantation. The majority of renal transplant centers , however, have been reluctant to perform simultaneous kidney-pancreas tran splantation in insulin-dependent uremic patients because of the additional risks associated with pancreas transplantation. More recently, refinements in surgical technique, introduction of new immunosuppressive agents, and be tter selection of transplant candidates have contributed to improved surviv al. Today, combined pancreas-kidney transplantation is an accepted treatmen t for carefully selected patients with insulin dependent diabetes and end-s tage renal disease and in a small group of patients with uncontrolled sever e metabolic problems. The effect of a euglycemic state after pancreas trans plantation on the progression of micro- and macroangiopathy remains to be p roved, although recently there is evidence to suggest that some end-organ l esions may be halted or even ameliorated. Further improvement in anti-rejec tion strategies may achieve better long-term graft survival and provide the incentive to perform pancreas transplantation at an earlier stage, before severe secondary complications of diabetes develop.