Pancreas transplantation in diabetic patients

The influence of combined kidney-pancreas transplantation on the progression of diabetic retinopathy. A case series

PURPOSE

To evaluate the impact of combined kidney and pancreas transplantation on the progression of advanced diabetic retinopathy.

METHODS

The changes in diabetic retinopathy severity in patients with insulin-dependent diabetes mellitus who had kidney-pancreas transplantation (n = 51) and in those who had kidney transplantation only (n = 21) were compared. Patients were invited to baseline and 1 year follow-up examinations. Fundus photographs were graded in a masked fashion using standardized protocols.

RESULTS

The mean age and duration of diabetes were similar for both groups. After combined transplantation, none of the patients used insulin, and their mean glycosylated hemoglobin was significantly lower (6.4% versus 10.6%) than those who underwent only kidney transplantation. There was a nonsignificant difference in overall progression of retinopathy for combined transplantation compared with kidney transplantation only (risk ratio = 0.73; 95% confidence interval, 0.31, 1.71).

CONCLUSION

The authors found no evidence that the normalization of glycemia associated with a combined kidney-pancreas transplantation in patients with advanced proliferative diabetic retinopathy (mostly treated with photocoagulation) accelerated retinopathy progression. These data suggest that the normalization of glycemia associated with a combined kidney-pancreas transplantation does not have beneficial influence on the progression of advanced diabetic retinopathy.

Update of pancreatic transplantation

Pancreatic transplantation for the treatment of diabetes mellitus in man has proved increasingly successful. Between December 1966 and August 1990 2735 pancreas transplants from 141 institutions were reported to the International Pancreas Transplant Registry. For the period 1986 to 1989 the one year graft survival rate in 1,200 patients was almost 70%, a significant improvement over the preceding five years. The commonest techniques for the diversion of pancreatic secretions are bladder drainage, intestinal drainage and duct occlusion with synthetic polymers. The survival rate of pancreas grafts is significantly higher in recipients of simultaneous pancreas and kidney transplants than in recipients of pancreas transplants after kidney transplants and transplants of the pancreas alone. For this reason pancreas transplantation is mainly indicated as an adjunct to kidney transplantation, when the patient must be given immunosuppressive treatment in any case. A steady decline in the rate of technical failures and of serious adverse reactions as a result of immunosuppressive treatment will undoubtedly widen the present indications. In most recipients of a pancreas graft the blood glucose and hemoglobin A1c levels become normal or near normal. No convincing evidence of an ameliorating effect on microangiopathic and neuropathic complications has been obtained so far. On the other hand, it is established that pancreas transplantation may prevent the development of glomerular lesions in a simultaneously grafted kidney. Previously, transplantation of pancreas islets in man has not been successful. In 1990, however, in several insulin-dependent, diabetic subjects the intraportal transplantation of islets isolated from cadaver pancreas resulted in significant insulin production, and, in a few patients, it was possible to stop insulin treatment.(ABSTRACT TRUNCATED AT 250 WORDS)