SOLITARY PANCREAS TRANSPLANTATION FOR NONUREMIC PATIENTS WITH LABILE INSULIN-DEPENDENT DIABETES-MELLITUS

Background. Simultaneous pancreas-kidney transplantation has become a widely accepted treatment option for selected uremic patients with ins ulin-dependent diabetes mellitus (IDDM), Patient survival rates at 1 y ear exceed 90%, and rates of pancreas graft survival, 70%. However, so litary pancreas transplantation for nonuremic patients with IDDM has b een controversial because of the less favorable outcome and the need f or long-term immunosuppression with its associated morbidity and morta lity, Methods. We studied the outcome of 225 solitary pancreas transpl ants during three immunosuppressive eras: the precyclosporine (CsA) er a (n=83), the CsA era (n=118), and the tacrolimus era (n=24), Only pat ients with labile IDDM (e.g., hypoglycemic unawareness, insulin reacti ons, greater than or equal to 2 failed attempts at intensified insulin therapy for metabolic control) underwent solitary pancreas transplant ation. Using univariate and multivariate analyses, we looked at patien t and graft survival, the risk of surgical complications, and native k idney function during these three eras. Results. Pancreas graft surviv al improved significantly over time: 34% at 1 year after transplantati on in the pre-CsA era, 52% in the CsA era, and 80% in the tacrolimus e ra (P=0.002). Pancreas graft loss due to rejection decreased from 50% at 1 year in the pre-CsA era, to 34% in the CsA era, to 9% in the tacr olimus era (P=0.008), The rate of technical failures (i.e., the risk o f surgical complications) decreased from 30% in the pre-CsA era, to 14 % in the CsA era, to 0% in the tacrolimus era (P=0.001), Patient survi val rates at 1 year have ranged between 88% and 95% in the three eras (P=NS), Matching for at least one antigen on each HLA locus and avoidi ng HLA-B mismatches significantly decreased the incidence of rejection , The incidence of native kidney failure due to drug-induced toxicity decreased significantly over time, in part be cause only recipients wi th pretransplant creatinine clearance greater than or equal to 80 ml/m in received transplants, Conclusions. Solitary pancreas transplantatio n has become a viable alternative for nonuremic patients with labile I DDM, The risks of surgical complications and drug-induced nephrotoxici ty have significantly decreased over time. Using tacrolimus as the mai nstay immunosuppressant, patient and graft survival rates now no longe r trail those of simultaneous pancreas kidney transplantation.