The case for pancreas transplantation.

More than 6,000 pancreas transplants had been performed by the end of 1994. Insulin-independence currently persists for more than one year in over 75% of diabetic recipients of simultaneous pancreas-kidney transplants, and in approximately 50% of recipients of a pancreas transplant alone. As kidney recipients are obligated to undergo immunosuppression in conjunction with this operation, the addition of a pancreas transplant entails only extra surgery. For non-uremic recipients of a pancreas transplant alone, immunosuppression itself is the trade-off for correction of diabetes. The problems of diabetes must be of a magnitude to justify the use of anti-rejection drugs. Thus, the main pancreas transplant applications have been in patients who are extremely labile or experience hypoglycaemic unawareness syndrome. Application to non-uremic patients without current problems would require randomisation to determine whether the probability of freedom from problems or the occurrence of complications differs over years of follow-up between a non-diabetic condition on immunosuppression and a diabetic status off immunosuppression. In the meantime, pancreas transplantation should be applied routinely to diabetic recipients of a kidney transplant or those whose quality of life is poor because of lability.