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 strict 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

This is a much more restrictive indication because pancreas-only transplants require lifelong immunosuppression to prevent graft rejection and potential recurrence of the autoimmune process that could destroy pancreatic islet cells. 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

Important limitation: Pancreas transplantation is only partially successful in reversing long-term renal and neural complications of diabetes, likely because the procedure is usually performed after 20 years of established diabetes. 1

Procedural Requirements

All pancreas transplantations should 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 An objective multidisciplinary evaluation of the patient's condition and eligibility must be established and followed. 1

Islet Cell Transplantation Status

Pancreatic islet cell transplants are experimental and should only be performed within controlled research studies, as they also require systemic immunosuppression. 1