Pancreas and islet cell transplantation: now and then.

Pancreas transplantation currently can be offered with the same probability of success as other solid organ transplants. In diabetic uremic recipients of kidney transplants, the addition of a pancreas is routine in many centers. For selected patients with labile diabetes and hypoglycemia unawareness, a successful pancreas transplant can dramatically improve quality of life. Islet transplantation is an alternative to pancreas transplantation that can reduce surgical morbidity, but is much less successful at the moment. The theoretical, immunological advantages of islet transplantation have not yet been realized. Part of the problem lies in the reduced beta cell mass that occurs with organ dispersal and islet purification. Diabetogenic immunosuppressants need to be eliminated in order to allow optimal function of what is engrafted. The immunosuppressants (eg, mycophenolate mofetil, rapamycin) give this possibility. Whether islet transplantation will replace pancreas transplantation remains problematic. Ultimately, and neither should be needed for Type I diabetes, since autoimmune diseases should be preventable by appropriate manipulation of the immune system in those identified at risk. Our personal goals as transplanters should be obsolescence.