Pancreas organ transplantation

Diabetes mellitus is a very common and dreadful disease which cannot be cured by exogenous insulin substitution. Many of the patients suffer from recurrent, and sometimes rather dangerous, hypo- or hyperglycemias and, in the long term, from the well-known secondary diabetic complications. At the moment, pancreas transplantation is the only known therapy to reliably reestablish endogenous insulin secretion responsive to normal feed back controls. Within the last decade, pancreas transplantation has evolved as a clinically well-established procedure. Nevertheless, the perioperative risk after pancreas/kidney transplantation is still higher than after isolated kidney transplantation. However, the benefits of a functioning pancreas graft for the patients are enormous. Ten-year survival of type-I diabetic patients with combined pancreas/ kidney grafts is dramatically better than of those with an isolated kidney graft. Long-term function of the pancreas grafts is excellent, reaching more than 60% after 10 years. Contrary to kidney transplantation, chronic rejection does not seem to be a major problem. Blood glucose levels in the fasting state, after glucose challenge, and in the postprandial state are completely normalized. A significant peripheral hyperinsulinemia, however, is found when the pancreas graft is connected to the systemic venous circulation. Thus, portal venous drainage of the pancreas graft, which is already being performed by a few transplant centers routinely, might be the procedure of choice for the future. Beneficial effects on secondary diabetic lesions can only be expected after a rather long observation period. In addition, for all secondary diabetic complications, there is a point of no return. Nevertheless, significant improvement of diabetic polyneuropathy, diabetic nephropathy, and the disturbed microcirculation has been convincingly demonstrated. The effect on diabetic retinopathy, however, is still controversial. One of the most impressive effects for the pancreas graft recipients seems to be the enormous improvement in quality of life, which is reported unanimously by almost all patients. Thus, simultaneous pancreas/kidney transplantation can be regarded as the optimal and only causal therapy for type-I diabetic patients with end-stage renal disease.