Renal transplantation in diabetic patients is confirmed therapy while pancreas transplantation should be performed only in an investigational setting

Abstract

Kidney transplantation is now firmly established as the standard treatment for all diabetic patients with end-stage renal fallure. In an analysis of all renal transplants at the University of Minnesota between June 1, 1980 and May 31, 1987, there were no differences in renal allograft functional survival rates for diabetic and nondiabetic recipients. At one year the survival rates were 84% (n=151) and 86% (n=260) for those treated with azathioprine, prednisone and ALG; 86% (n=101) and 87% (n=104) for those treated with cyclosporine-prednisone, and 92% (n=165) and 89% (n=191) for those treated with triple therapy (cyclosporine, azathioprine, and prednisone). Pancreas transplantation remains an investigational procedure for nonuremic diabetic patients but may be considered therapeutic in diabetic renal allograft recipients because such patients are obligated to immunosuppression and only the surgical risks of pancreas transplantation need to be considered, which are now aceptably low. Recipients of pancreas transplants performed simultaneous with the kidney have patient and pancreas graft survival rates of >90% and ±60% at several institutions, including our own. The potential for benefit of pancreas transplantation, however, is greater in the nonuremic nonkidney transplant patient, and pancreas transplantations are being performed in such patients at a few institutions. An early beneficial effect of pancreas transplantation preexisting proliferative retinopathy has not been discerned, although long-term retinopathy has been stable in patients with functioning grafts. Preliminary studies have shown a beneficial effect on neuropathy and on microscopic lesions of diabetic nephropathy, but at the expense of cyclosporine toxicity. Pancreas transplantation as a solitary procedure will not realize its full potential until nontoxic, immunosuppressive regimens are available. At this time, pancreas transplatation is appropriate in selected patients with complications of diabetes that would otherwise progress to a stage more serious than the potential side effects of chronic immunosuppression, but it should be performed only in an investigational setting at institutions committed to long-term, formal protocol follow-up studies.