Successful Pancreas Transplantation Research Articles

Evolution of Pancreas Transplantation At A Single Institution-50+ Years and 2500 Transplants.

To describe the evolution of pancreas transplantation, including improved outcomes and factors associated with improved outcomes over the past 5 decades. The world's first successful pancreas transplant was performed in December 1966 at the University of Minnesota. As new modalities for diabetes treatment mature, we must carefully assess the current state of pancreas transplantation to determine its ongoing role in patient care. A single-center retrospective review of 2500 pancreas transplants was performed over >50 years in bivariate and multivariable models. Transplants were divided into 6 eras; outcomes are presented for the entire cohort and by era. All measures of patient and graft survival improved progressively through the 6 transplant eras. The overall death-censored pancreas graft half-lives were >35 years for simultaneous pancreas and kidney (SPK), 7.1 years for pancreas after kidney (PAK), and 3.3 years for pancreas transplants alone (PTA). The 10-year death-censored pancreas graft survival rate in the most recent era was 86.9% for SPK recipients, 58.2% for PAK recipients, and 47.6% for PTA. Overall, graft loss was most influenced by patient survival in SPK transplants, whereas graft loss in PAK and PTA recipients was more often due to graft failures. Predictors of improved pancreas graft survival were primary transplants, bladder drainage of exocrine secretions, younger donor age, and shorter preservation time. Pancreas outcomes have significantly improved over time through sequential, but overlapping, advances in surgical technique, immunosuppressive protocols, reduced preservation time, and the more recent reduction of immune-mediated graft loss.

Experience from 100 consecutive pancreas transplants amidst low national transplant activity: a retrospective study at a single center in Korea.

Since 1992, over 800 pancreas transplants have been performed in Korea. However, this number is significantly lower compared to the number of kidney or liver transplants. Between 2015 and July 2023, Pusan National University Yangsan Hospital conducted 100 pancreas transplants, accounting for about 20% of all transplants performed in Korea during this period. The study comprised 27 simultaneous pancreas and kidney (SPK) transplants, 23 pancreas after kidney (PAK) transplants, and 50 pancreas transplant alone (PTA) cases. Duodenoduodenostomy was the primary surgical technique employed for exocrine drainage, along with various modifications of the venous outflow anastomosis. The availability of brain-dead donors for kidney transplants was lower compared to isolated pancreas transplants. Patients undergoing SPK transplants faced significantly longer waiting times than those receiving PTA or PAK transplants. The rate of surgical complications was acceptable, with a notably low thrombotic graft failure rate of 1.0%. In the PTA group, acute rejection of the graft pancreas occurred frequently (18.0%), though this was not statistically significant (P=0.328). The pancreas transplantation survival rates were 91.0%, 78.5%, and 75.4% at 1, 5, and 9 years, respectively. The PTA group exhibited a lower graft survival rate than the SPK and PAK groups, with marginal statistical significance (P=0.059). Graft survival rates have improved over time due to advancements in surgical techniques and immunosuppressant strategies. By sharing our experiences, we aim to enhance the activity and success of pancreas transplantation in Korea.

Pancreas Transplantation for the Treatment of Pancreatic Exocrine Disorders

Pancreas transplantation is mostly performed to cure diabetes mellitus. However, patients with chronic pancreatitis, cystic fibrosis, benign pancreatic tumors or patients with other exocrine disorders of the pancreas can also be candidates for a pancreas transplant in combination with a kidney, liver or lung or for a pancreas transplant alone. With improvement in surgical techniques and immunosuppressive therapy, pancreas transplant outcomes have improved significantly over the past decade. Mounting evidence supports pancreas transplantation for the treatment of exocrine disorders as an important therapeutic option to restore both endocrine and exocrine function of the pancreas. Patient and graft survival rates are similar to those for pancreas transplants in diabetic patients. A successful pancreas transplant is also more cost efficient and puts less burden on health care spending. However, the risk of immunosuppression and surgery should be carefully evaluated and discussed with the patient. In this review article, we discuss pancreas transplantation for pancreatic exocrine disorders: indications, other treatment options, and outcomes.

Role of gastric peroral endoscopic myotomy (GPOEM) in chronic gastroparesis management after pancreas transplantation.

Gastroparesis is a common complaint among patients with diabetes. Symptoms tend to improve following successful pancreas transplantation (PTx), but persist despite euglycemia in a subset of patients. We aimed to assess the benefit of gastric peroral endoscopic myotomy (G-POEM) in persistent gastroparesis following PTx. This was a single center retrospective review of all patients who underwent G-POEM for persistent gastroparesis following PTx. Patient demographics, pre and post procedure perception of symptom severity according to the patient assessment of upper gastrointestinal symptoms severity index (PAGI-SYM), gastroparesis cardinal symptom index (GCSI) score, and 36-item short form survey (SF36) score along with gastric emptying scintigraphy (GES) were analyzed. Seven PTx recipients underwent G-POEM for persistent gastroparesis symptoms. The majority were female. All reported nausea/vomiting, abdominal pain, bloating, and post prandial fullness prior to G-POEM. The post procedure survey scores improved in all patients although this was not significant. The improvement in gastric emptying on GES was statistically significant. G-POEM is a relatively new treatment option for gastroparesis. While it requires specialized proceduralist and training, we have documented improvement in the management of symptoms. With increasing experience, we anticipate more significant benefit in post PTx patients with persistent symptoms of gastroparesis undergoing G-POEM.

Pancreas Transplantation Today: Quo Vadis?

Successful pancreas or islet transplantation is currently the only cure for type-1 diabetes mellitus. Since the first pancreas transplant in 1966, there have been various refinements of surgical technique along with improved immunosuppressive regimens, resulting in significantly improved outcomes, with contemporary research into graft monitoring and newer biomarkers, potentially lengthening graft survival rates further. Patients with insulin-dependent diabetes mellitus who are eligible for pancreas or islet transplantation represent a select group, the tip of the iceberg for a significant global diabetes disease burden. In the last fifty years there have been quantum advances in alternative technologies in diabetes therapy, both experimental and translational. Further development and improved access are required to treat the larger proportion of people suffering from diabetes. Emerging stem cell therapy is still experimental whereas alternatives including automated insulin delivery systems, islet cell transplantation are already used in some countries. While automated insulin delivery systems have increased in efficacy, they still do not achieve the near physiological control of blood sugar, which can be achieved by successful pancreas or islet transplantation. This state-of-the-art review provides a summary of pancreas and islet transplantation to its current place in diabetes therapy, along with alternative and future therapies, including the obstacles associated with the dissemination of these new therapies. With the advent of these modern cellular and technological advances, this review addresses the question: are we entering an era where whole organ pancreas transplantation could be replaced entirely by modern technological advances in diabetes therapy?

Pregnancy After Simultaneous Pancreas-Kidney Transplantation in Treatment of End-Stage Diabetes Mellitus: a Review.

The majority of patients with simultaneous pancreas and kidney transplant (SPKT) required transplantation owing to a long-standing history of insulin-dependent diabetes mellitus (IDDM). The disease causes multiple organ damage, impairs fertility, and affects quality of life. A successful kidney and pancreas transplant can improve health, ameliorate the consequences of pre-existent diabetes, and restore fertility. Good graft function, without any sign of rejection, and stable doses of immunosuppressant drugs are of utmost importance prior to the planned pregnancy. SPKT recipients who become pregnant may be at an increased risk for an adverse outcome and require meticulous multidisciplinary surveillance. We present experiences with SPKT pregnancies, traditional approaches, and recent considerations. In light of complex interactions between new anatomic relations and the impact of developing pregnancy and immunosuppressive medications, special stress is put on the risk of graft rejection, development of pregnancy complications, and potential harmful effects on fetal development. Recent recommendations in management of SPKT recipients who wish to commence pregnancy are presented as well. Key words: transplantation, pregnancy, pancreas, kidney, simultaneous pancreas and kidney transplantation (SPKT).

Neurogenic Orthostatic Hypotension: a Common Complication of Successful Pancreas Transplantation.

Background.Orthostatic hypotension (OH) is a poorly understood complication of simultaneous pancreas–kidney (SPK) transplantation. We sought to determine the incidence, timing, and relationship of OH to rapid glycemic control in the early posttransplant period.Methods.This was a nonrandomized retrospective single-center review of 75 SPK and 19 kidney-alone (KA) recipients with type 1 diabetes (DM).Results.OH occurred in 57 (76%) SPK versus 2 (10%) KA recipients (odds ratio [OR] 61.72, 95% confidence interval [CI], 9.69-393.01; P < 0.001). The median onset of OH was 12 (interquartile range [IQR] 9–18) days posttransplant and resolved in 85% of SPK recipients after a median of 2.5 (IQR 1.2–6.3) months. Among SPK recipients, independent risk factors for OH were a shorter duration of DM (OR 0.85, 95% CI, 0.73-0.98; P = 0.03) and rapid glycemic control in the early posttransplant period (OR 1.13, 95% CI, 1.01-1.27; P = 0.04), as evidenced by a larger percent change in hemoglobin A1c (HbA1c) from transplant to month 3. OH patients had a higher median baseline HbA1c [8.3% (IQR 7.2–10.0) versus 7.1% (IQR 6.8–8.3); P = 0.07], lower median 3-month HbA1c [4.8% (IQR 4.6–5.2) versus 5.2% (IQR 5.0–5.4); P = 0.02], and a larger reduction in HbA1c over time as compared to recipients without OH (P < 0.01).Conclusions.Our results show that OH is more likely to occur following SPK versus KA transplantation and is strongly associated with rapid glucose normalization within the early posttransplant period.

Pancreas transplantation would be easy if the recipients were not diabetic: A practical guide to post-operative management of diabetic complications in pancreas transplant recipients.

Diabetes mellitus remains a major public health problem throughout the United States with over $300billion spent in total cost of care annually. In addition to being a leading cost of kidney failure, diabetes causes a host of secondary hyperglycemic-related complications including gastroparesis and orthostatic hypotension. While pancreas transplantation has been established as an effective treatment for diabetes, providing long-term normoglycemia in recipients, the secondary complications of diabetes mellitus persist complicating the post-operative course of an otherwise successful pancreas transplantation. This review describes the mechanismand impact of diabetic gastroparesis and orthostatic hypotension in the post-operative course of pancreas transplant patients and analyzes the various treatment modalities, based on current data and extensive experience at our institution, to treat these respective complications. While gastroparesis and orthostatic hypotension remain challenging post-operative conditions, the establishment of institutional protocols and step-up treatment algorithms can help define more effective therapies.

Incidence and Outcomes of Significant Weight Changes After Pancreas Transplant Alone.

Background.Weight change, primarily weight gain, is a common problem among solid organ transplant recipients. The incidence of weight gain or loss after successful pancreas transplant alone (PTA) and the effect on graft survival is unknown.Methods.This was a single-center observational study among PTA recipients, transplanted at our center between January 1, 2005, and July 31, 2017, who had a functional pancreas graft for at least 1 year and documented weight change at the 1-year clinic visit.Results.In this cohort study of 105 PTA recipients, 28 had significant weight gain, 27 had significant weight loss, and the remaining 50 did not have significant weight change at 1-year posttransplant. When comparing the weight gain and no weight change groups, the weight gain cohort started to gain weight at 3 months posttransplant to 5 years or last follow up. Similarly, the weight loss group lost weight at 3 months posttransplant up to last follow up. Clinically significant weight gain or weight loss were not associated with uncensored or death censored graft failure in univariate regression and Kaplan-Meier survival analysis. Also, there were no significant differences between the groups in the glycated hemoglobin at last follow up.Conclusions.Approximately 50% of PTA recipients had a significant weight change at 1-year posttransplant, of which 25% gained significant weight and 25% loss. There was no significant difference in graft survival due to the significant weight changes. Further research is needed in this field.

Weight Gain After Simultaneous Kidney and Pancreas Transplantation.

Excessive weight (EW) gain is common after solid organ transplantation, but there is little information concerning obesity after pancreas transplantation. The study goal was to characterize EW gain after kidney-pancreas (KP) transplantation. This was a retrospective single-center review of 100 KP recipients transplanted between September 2007 and June 2015. The median percent weight gain for all recipients at 1 year posttransplant was 10% (interquartile range, 2.7%-19.3%) of baseline weight. EW gain, defined as greater than or equal to a 19% 1-year increase in weight, included all recipients (n = 26) above the upper limit of interquartile range for weight gain at 1 year. In multivariate analysis, recipient age <40 years, the use of tacrolimus/mammalian target of rapamycin immunosuppression, and an acute rejection event were independent risk factors for EW gain. At a mean follow-up of 43±23 months, there was no difference in patient or graft survival between the EW and non-EW cohorts. Although mean hemoglobin A1c levels between groups were equivalent, the EW versus non-EW cohort displayed a significant increase in mean insulin levels and a trend towards higher C-peptide levels. Criteria for posttransplant metabolic syndrome was met in 34.6% of EW versus 17.6% of non-EW cohorts (P = 0.07). At intermediate-term follow-up, EW gain after KP transplantation was not associated with an increased risk of death or graft loss, although there was a trend toward a greater risk of posttransplant metabolic syndrome. There may be a metabolic consequence of successful pancreas transplantation that results in EW gain in a proportion of recipients, leading to an increased risk of long-term cardiovascular complications.

Endothelial function after pancreas transplantation—A single‐center observational study

Patients with diabetes mellitus treated with successful pancreas transplantation (PTX) normalize hyperglycemia, but are exposed to immunosuppressive drugs that may impair endothelial function. This study aimed to evaluate endothelial function in single PTX recipients. Flow-mediated dilatation (FMD) in the brachial artery was measured by ultrasound 8weeks after transplantation in single PTX (n=27) and compared with healthy controls (n=58), simultaneous pancreas and kidney recipients (n=9), and kidney transplant recipients with (n=41) and without (n=95) diabetes mellitus. Adjustments for age, gender, blood pressure, and body mass index were included in a linear regression model. Changes in FMD from before to 1year after transplantation were assessed in a subgroup of PTX recipients (n=9). Flow-mediated dilatation% in PTX recipients was not inferior to healthy controls (8.7±3.6 vs 7.7±3.3, P=.06) and simultaneous pancreas and kidney recipients (6.7±4.5, P=.24) in an adjusted model, and superior to kidney recipients with and without diabetes (3.0±3.0 and 4.8±3.3, respectively, both P<.005). FMD% improved significantly from eight weeks to one year after PTX, mean 7.9±4.2% vs 11.8±4.8% (N=9; P=.03). Flow-mediated dilatation is well preserved in patients undergoing pancreas transplantation and is not impaired when immunosuppressive drugs are introduced.

Reconstruction of a Pancreatic Allograft With Variant Arterial Anatomy for Transplantation.

Donor pancreas utilization rates remain low and aberrant donor anatomy can lead to organ discard by transplant centers. We report on a case of successful pancreas transplantation using a graft with variant arterial anatomy demonstrating that arterial reconstruction is a viable option if aberrant anatomy is encountered at the donor operation. Efforts must be made to use all pancreas grafts that are felt to be of appropriate quality.

The Current State of Pancreas Transplantation in the USA—A Registry Report

A successful pancreas transplantation is still the only method to provide long-term insulin independence and provide good metabolic control for patients with type I diabetes. Since the first pancreas transplant in 1966, the patient and graft survival after pancreas transplantation improved significantly. The aim of this report was to study the most recent outcome of pancreas transplants. Between 2011 and 2016, 5159 primary deceased donor pancreas transplants in diabetic patients were performed—4342 (84%) SPK, 399 PAK (8%), and 418 (8%) PTA. One-year (3-year) SPK patient survival reached 98% (95%), PAK 97% (93%), and PTA 98% (96%). The most influential risk factor for patient survival in all three categories was a failed graft. In SPK, older recipients and being on dialysis at the time of transplant also carried an increased risk to die. SPK pancreas graft function improved to 90% at 1-year and 83% at 3-year post-transplant; 87% and 74% for PAK; and 84% and 71% for PTA. One-year (3-year) kidney graft function for the simultaneous SPK kidney was 96% (90%). The difference in outcome between SPK and solitary transplants is still significant but the gap is narrowing. A risk factor for pancreas graft failure was especially young recipient age, but a careful donor selection can improve outcome. The majority of recipients received depleting antibodies for induction followed by a maintenance protocol of Tacrolimus in combination with MMF. Steroids were used more often in SPK (70%) compared to solitary pancreas transplants. In summary, outcome after pancreas transplantation has significantly improved due to refinement in immunosuppressive protocols and better donor and recipient selection. It can be successfully performed in patients with labile diabetes and will not only improve the quality of life of the patient but also can be life extending.

Defining kidney allograft benefit from successful pancreas transplant: separating fact from fiction.

To define the natural history of kidney allograft loss related to recurrent diabetes following transplant, and to understand the potential benefit of pancreas transplantation upon kidney allograft survival. A postulated benefit of simultaneous pancreas kidney transplant is that, unlike kidney transplant alone, euglycemia from the added pancreas allograft may confer a nephroprotective benefit and prevent recurrent diabetic nephropathy in the renal allograft. Recent large database analyses and long-term histological assessments have been published that assist in quantifying the problem of recurrent diabetic nephropathy and answering the question of the potential benefits of euglycemia. Further data may be extrapolated from larger single-center series that follow the prognosis of early posttransplant diabetes mellitus as another barometer of risk from diabetic nephropathy and graft loss. Recurrent diabetic nephropathy following kidney transplant is a relatively rare, late occurrence and its clinical significance is significantly diminished by the competing risks of death and chronic alloimmune injury. Although there are hints of a protective effect upon kidney graft survival with pancreas transplant, these improvements are small and may take decades to appreciate. Clinical decision-making regarding pancreas transplant solely based upon nephroprotective effects of the kidney allograft should be avoided.

Preserved Insulin Sensitivity and Kidney Function One Year After Successful Pancreas Transplantation

Introduction Pancreas transplantation (PTX) has become an established treatment for a selected group of patients with unstable type 1 diabetes mellitus. It may be performed as simultaneous pancreas and kidney transplantation (SPK) or as pancreas transplantation alone (PTA). Endured immunosuppressive therapy is prone to reduce insulin release, insulin sensitivity and kidney function over time. In this study, we aimed to investigate changes in these functions over the first year post-transplant in patients with surviving pancreas grafts. Methods We studied 67 patients that had undergone PTA (n=37) or SPK (n=30) with functioning grafts at one year after transplantation, and had repeated oral glucose tolerance testing (OGTT) and measured glomerular filtration rate (mGFR; iohexol clearance) at week 8 and 52 after transplantation. Glucose, insulin and c- peptide were sampled fasting and 120 minutes after glucose load. All patients were transplanted between September 2011 and November 2016 at our national transplant center. SPK and PTA patients received similar quadruple immunosuppressive therapy including ATG induction, tacrolimus (through levels of 10-12 tapered to 6-10 μg/L by 8 weeks) mycophenolate mofentil (2 g/day) and steroids (tapered to 10 mg/day by week 4 and 5 mg/day by week 26. Results From week 8 to 52 after transplantation the mean fasting blood glucose levels decreased significantly in both patient groups (SPK 5.4 to 5.1 mmol/L, PTA: 5.4 to 5.2 mmol/L; p<0.005). Mean 120-minute glucose levels were significantly higher in week 8 than in week 52 (SPK 6.5 vs 5.7 mmol/L, PTA: 5.4 vs 5.2mmol/L; p<0.005). Mean fasting insulin and 120-minute insulin levels were stable while fasting C- peptide levels were significantly reduced by week 52 (SPK: 1500 vs 1087 pmol/L, PTA: 1210 vs 1021pmol/L, p<0.005). mGFR did not change from week 8 to week 52 (SPK: 55 vs 59 ml/min/1.73m2, PTA: 71 vs 72 ml/min/1.73m2, p=0.24). Conclusion Glycaemia improved and fasting C-peptide concentrations were reduced one year after successful pancreas transplantation, indicating an improved insulin sensitivity. Kidney function was not negatively affected by the tacrolimus based immunosuppressive therapy over the first year.

Preneoplastic Lesion in a Pancreas Allograft: Dilemma for the Pancreas Transplant Surgeon

Although the relationship between immunosuppression and cancer risk is well-documented, the association between immunosuppression and the development of preneoplastic lesions (PNL) is less clear. PNLs pose a unique clinical conundrum in the transplanted pancreas because their prevalence in the general population is not infrequent. We present the case of a 58-year-old man with a history of diabetes mellitus type 1 who underwent successful pancreas transplantation with bladder drainage. His kidney function failed 13 years after his transplant and he developed recurrent painful hematuria with symptomatic anemia 2 years after initiating hemodialysis. Upon work-up, he was found to have a 4 cm intraductal papillary mucinous neoplasm in his pancreas allograft. At his enteric conversion, the intraductal papillary mucinous neoplasm was removed through a distal pancreatectomy due to concern for its malignant potential. He recovered well from surgery and continues to be insulin-free. With the rising incidence of PNLs from improved detection and the improved survival of pancreas allografts, the implications of PNLs may be more pronounced in the future. This case raises several important considerations for the pancreas transplant surgeon regarding adequate allograft surveillance protocols, treatment, and follow-up.

Successful pancreas transplantation alone is associated with excellent self‐identified health score and glucose control: A retrospective study from a high‐volume center in the United States

The benefits of pancreas transplantation are often difficult to measure. Here, we sought to determine the difference in quality of life for diabetic patients with and without a functional pancreas transplant alone (PTA). Pancreas transplant alone cases from 1993 to 2015 were considered. An IRB-approved survey inclusive of 15 questions spanning four domains was employed. Chi-square, Fisher's exact, and the T test were used where appropriate. A total of 137 PTAs were performed during the study period. Of those reached (n=32), 94% responded to the survey. Self-reported health scores were better (2.1 vs 3.0) for those with functioning pancreata (n=18) vs those with a non-functional pancreas (n=14), respectively (P=.036). Those with a functional pancreas had a HgbA1c of 5.3, vs 7.7 for a non-functional pancreas (P=.016). Significant hypoglycemia was reported in two of 18 with a functional transplant vs nine of 14 patients with a failed transplant (P=.003). Daily frustration with blood sugar affecting quality of life was significantly higher for patients with non-functional pancreas grafts (P<.001). Pancreas transplantation alone is associated with better glucose control than insulin. In addition, recipients of functional PTAs have improved quality of life and better overall health scores than those with failed grafts.

Long-term Effects of Pancreas Transplantation on Diabetic Retinopathy and Incidence and Predictive Risk Factors for Early Worsening

Limited data are available regarding the long-term effects of pancreas transplantation on the progression of diabetic retinopathy (DR) and the incidence and associated risk factors for early worsening of DR. Patients who underwent successful pancreas transplantation between January 2007 and October 2015 and were followed for 1 year or longer were consecutively enrolled. Variables regarding demographic, systemic, metabolic, and surgical factors were reviewed for each patient. DR progression was defined as (i) development or aggravation of macular edema requiring intravitreal anti-VEGF injections and/or (ii) progression of DR severity requiring panretinal photocoagulation (PRP) and/or pars planar vitrectomy (PPV). Early worsening was defined as progression within 1 year of posttransplant. Three hundred three eyes of 153 patients were included in the analysis. At the pretransplant ocular evaluation, 221 eyes (72.9%) showed advanced DR with history of PRP and/or PPV. During a mean follow-up period of 4.2 years, 62 eyes (20.5%) experienced DR progression, and early worsening was noted in 57 eyes (18.8%). DR with recent PRP within pretransplant 1 year and pancreas transplant alone were significant risk factors for early worsening. In 4 of 5 patients who received pancreas transplant, the degree of DR remained stable over time after transplantation. Meanwhile, early worsening of DR could occur in patients at risk, particularly within the first posttransplant year. We suggest that physicians should have a high index of suspicion and carefully monitor for early worsening of DR and timely manage possible ocular deterioration.

Pancreas Transplantation Is Feasible in Donors With Shprintzen-Goldberg Syndrome

Shprintzen-Goldberg syndrome (SGS) is an autosomal dominant connective tissue disorder. To date, this report is the first account of a successful pancreas transplantation from an SGS donor. The similarity of the outcomes from previous year-on-year pancreas transplantations at the same center demonstrates promising results. Increasing awareness of the utilization of donors with SGS may promote expansion of center-specific criteria for organ acceptance. Therefore, every consideration should be given for use of organs from donors with this genetic abnormality because there is no evidence to suggest poorer allograft viability.

Long-term diabetes complications after pancreas transplantation.

The intention of this study is to summarize present knowledge about adverse effects of hyperglycemia in diabetes, and in this context review more recent data concerning the effects of pancreas transplantation on a wide range of diabetic complications. Effective blood glucose control by insulin delays progression of microvascular complications and probably improves survival in type 1 diabetes. A successful pancreas transplantation combined with a kidney graft has recently been found to prevent diabetic kidney lesions, and registry data support improved long-term patient survival. Cardiovascular mortality was reduced in one study, even though coronary heart disease was not significantly altered. Advanced coronary lesions may be too advanced in these patients at baseline. However, with a successful single pancreas transplant, which is generally performed in patients with near-normal kidney function, pancreas transplantation may improve left ventricular function. Development of retinopathy and neuropathy is delayed with functioning pancreas grafts, and both quality of life and certain skin lesions may improve after pancreas transplantation. In patients with type 1 diabetes, pancreas transplantation may improve cardiac outcomes and ameliorate diabetic lesions in the kidney transplant. Also quality of life, neuropathy, retinopathy, and healing of certain skin lesions may be improved.