Indication, selection of patients and timing for pancreatic transplantation

For more than 20 years pancreas transplantation has been advocated as a therapeutic modality in patients with insulin-dependent diabetes mellitus. When successful, this procedure is the only method for attaining long-term normoglycaemia in diabetic recipients. However, because of the potential morbidity and mortality, pancreas transplantation should be restricted to diabetic patients in whom the complications of the diabetic state are more serious than those of surgery and chronic immunosuppression. Currently three recipient categories have been identified in which pancreas transplantation would seem justifiable. The first includes diabetic patients with end-stage nephropathy who are already obligated to life-long immunosuppressive therapy because of the kidney replacement. In this recipient category the main benefit of receiving a pancreas transplant in addition to a kidney is that the quality of life is markedly improved. In addition, it seems that a functioning pancreas transplant prevents the recurrence of diabetic nephropathy in the simultaneously transplanted kidney. Since the success rate with combined pancreas-kidney transplantations is approaching that of renal transplantation alone, there is little controversy about performing the combined procedure in diabetic uraemic patients. However, if the main objective of pancreas transplantation, namely to prevent the late diabetic microvascular complications, were to be fulfilled this intervention would have to be performed earlier in the course of the disease. Therefore, single pancreatic transplantations have recently been conducted in diabetic patients with early signs of clinical nephropathy which, currently, is the most powerful predictor of susceptibility to detrimental diabetic complications. Preliminary findings indicate that, in this second recipient category, single pancreatic transplantation and subsequent euglycaemia may prevent the progression of diabetic neuropathy and nephropathy; with regard to diabetic retinopathy the results remain obscure.(ABSTRACT TRUNCATED AT 250 WORDS)