Consequences of pancreas transplantation.

PKT has become an important option in selected IDDM patients being considered for kidney transplantation because of its ability to offer superior glycemic control and improved quality of life. As both kidney graft survival and overall mortality are comparable following PKT and kidney transplantation alone at many centers, neither the survival of the patient nor the success of the kidney transplant need be jeopardized by the addition of a pancreas graft. The greater morbidity of PKT can be justified by the evidence that a pancreas graft will prevent recurrent diabetic nephropathy, result in greater improvements in sensory/motor neuropathy, and in some but not all studies, cause greater stabilization of eye disease. Improvements in lipid profiles observed after PKT but not after kidney transplant alone may predict better cardiovascular outcomes as well. Determination of who should receive an isolated pancreas transplant is more complex. Success rates are lower than after PKT. It remains important to ascertain that the candidate is susceptible to diabetic complications, or has repeated bouts of hypoglycemia or ketoacidosis unresponsive to other measures to justify the risks of long-term immuno-suppression. More difficult to determine is whether or when individuals who have advancing diabetic complications yet relatively preserved renal function (creatinine clearance > 70 mL/min) should become candidates. For now, each individual is considered on a case by case basis and the relative risks and benefits for each individual are carefully assessed. However, patient selection will be greatly aided by further research assessing the long-term risks and benefits of all types of pancreas transplantation. Pancreas transplantation will remain an important option in the treatment of IDDM until alternative strategies are developed that can provide equal glycemic control with less or no immunosuppression or less overall morbidity. Most of the research to date has concentrated on the consequences of pancreas transplantation on microvascular complications. However, cardiovascular disease events represent the greatest cause of mortality in pancreas transplant candidates. Thus, changes in cardiovascular risk after pancreas transplantation may be more important to long-term survival than any other factor and should receive greater attention in future studies.