Pancreas transplantation for type I diabetes mellitus. Do the benefits offset the risks and cost?

Combined pancreas-kidney transplantation is becoming increasingly acceptable as the preferred procedure for selected patients with insulin-dependent (type I) diabetes who are being considered for kidney transplantation. This is because the combined procedure has the added benefit of superior glycemic control and improved quality of life with greater potential for rehabilitation. Neither patient mortality nor kidney-graft survival is significantly altered by adding a pancreas to a kidney transplantation. However, overall morbidity after the combined operation is greater than that after kidney transplantation alone. This increase in morbidity and the higher total cost must be balanced against the extra benefits to the patient. These benefits include (1) attainment of normal glucose concentrations without the use of exogenous insulin and despite the use of corticosteroids, (2) greater improvement in lipid profiles, and (3) heightened quality of life. It is hoped that continued advances in immunosuppressive strategies and diagnostic technology will enhance the already good results achieved with pancreas transplantation. Other strategies for treatment of type I diabetes are being actively investigated, including islet-cell and fetal pancreas transplants, gene therapy, implanted insulin pumps, and artificial pancreas units. Although any or all of these methods may have a role in the treatment of diabetes mellitus in the future, it will be difficult for any technique to improve on the quality of glucose metabolism already achieved by vascularized pancreas transplantation.