When is a pancreas transplant recommended for patients with diabetes?

Pancreas Transplant Indications for Diabetes

Pancreas transplantation is primarily recommended for type 1 diabetic patients with end-stage renal disease who are undergoing or have undergone kidney transplantation, as this improves both kidney survival and quality of life while restoring normal glycemia. 1

Primary Indication: Diabetic Patients with Renal Failure

The strongest indication for pancreas transplantation is in diabetic patients with imminent or established end-stage renal disease who have had or plan to have a kidney transplant. 1 According to the American Diabetes Association guidelines:

• The successful addition of a pancreas does not jeopardize patient survival 1
• May improve kidney graft survival 1
• Restores normal glycemia and eliminates the need for exogenous insulin 1
• Pancreas graft survival is better when performed simultaneous to kidney transplant (SPK) rather than after kidney transplant 1
• Patients must meet medical indications for kidney transplantation and not have excessive surgical risk for the dual procedure 1

Secondary Indication: Pancreas-Alone Transplant (Highly Selective)

In the absence of kidney disease, pancreas transplantation should only be considered when ALL three of the following criteria are met: 1

1. History of frequent, acute, and severe metabolic complications (hypoglycemia, hyperglycemia, ketoacidosis) requiring medical attention 1

2. Clinical and emotional problems with exogenous insulin therapy that are so severe as to be incapacitating 1

3. Consistent failure of insulin-based management to prevent acute complications 1

Critical Caveat for Pancreas-Alone Transplants

Pancreas-only transplants require lifelong immunosuppression to prevent graft rejection and potential recurrence of the autoimmune process that might destroy pancreatic islet cells again. 1 The immunosuppressive regimens have significant side effects whose frequency and severity must be weighed against the benefits. 1

Quality of Life and Complication Benefits

Successful pancreas transplantation significantly improves quality of life by: 1

• Eliminating the need for exogenous insulin 1
• Eliminating frequent daily blood glucose measurements 1
• Removing many dietary restrictions 1
• Eliminating acute complications like hypoglycemia and hyperglycemia 1

However, pancreas transplantation is only partially successful in reversing long-term renal and neural complications of diabetes, particularly since the procedure is usually performed after 20 years of established diabetes. 1

Transplant Center Requirements

Pancreas transplantation should only be performed in tertiary care centers with an active kidney transplant program that are equipped to handle the complex medical and psychosocial needs of transplant patients long-term. 1 Program guidelines for objective multidisciplinary evaluation of patient eligibility must be established and followed. 1

Islet Cell Transplantation Status

Pancreatic islet cell transplants remain experimental and should only be performed within controlled research studies, despite holding potential advantages over whole-gland transplants. 1 They also require systemic immunosuppression. 1

Type 2 Diabetes Consideration

While pancreas transplantation is primarily indicated for type 1 diabetes, selected patients with type 2 diabetes who have severe glycemic dysregulation with life-threatening sequelae (severe hypoglycemia, kidney failure) may be considered, though this remains controversial. 2