**4. Conclusion**

The current gold standard IS therapy for all three categories of pancreas transplantation includes induction with polyclonal antibodies and for the maintenance therapy, association of Tac with either MMF or Rapa, the last drug being less popular at least during the first postoperative period due to its possible side-effects (Fig 19).

Based on that potent IS therapy, functional results and patient survival rates of PT are coming closer to those currently achieved in kidney transplantation (Fig 20).

SPK transplantation remains the best therapeutic approach for type 1 diabetic recipients with (pre) end-stage renal failure (creatinine clearance < 50ml/min), up to 55 years of age, without any cardiovascular risk. They have three options: either waiting for the 2 grafts coming from the same -cadaver or live- donor, or one graft –usually the kidney – coming from a live donor who is in stand-by while waiting for the pancreas from a cadaver donor.

PAK can be offered to diabetic recipients who had the opportunity of having a live donor for kidney transplantation.

PTA should be considered for selected type 1 diabetic candidate without nephropathy, with hypoglycemia unawareness syndrom, with proliferative retinopathy. These candidates could be also candidates for islet transplantation, knowing the fact that they will be submitted to the same IS therapy and its long term deleterious side-effects in both options, they might also know

**Figure 20.** International Pancreas Transplant Registry\* Panel (a): Patient survival in US primary pancreas transplants between 1/1/2007 and 12/31/2011. Panel (b): Pancreas graft function in all 3 categories (SPK, PAK, PTA). Panel (c): One year pancreas and kidney graft function in US primary pancreas transplants, between 10/1/1988 and

that, with islet insulin independence is not always achieved.

(a)

*Category n 1Yr Surv.* **PTA 465 97.4% PAK 947 96.8% SPK 4,155 95.5%**

\*By courtesy from A.E. Gruessner Department of Surgery,

University of Arizona, Tucson, USA.

12/31/2011.

0 6 12 18 24 30 36

**Months Posttransplant**

*Patient Survival* **USA Primary DD Pancreas Transplants 1/ 1/ 2007 – 12/ 31/ 2011**

**%**

**IPTR/UNOS**

*1-Year Pancreas/Kidney Graft Function* **USA Primary DD Pancreas Transplants, 10/ 1/ 1988 – 12/ 31/ 2011**

(c)

**SPK 4,146 85% PAK 947 79%** 

**%**

Kidney and Pancreas Transplantation: The History of Surgical Techniques and Immunosuppression

**IPTR/UNOS**

**PAK PTA** 269

*Pancreas Graft Function* **USA DD Primary Pancreas Transplants 1/ 1/ 2007 – 12/ 31/ 2011**

http://dx.doi.org/10.5772/55347

0 6 12 18 24 30 36

**PTA <sup>465</sup> 78% p < 0.0001**

**SPK** *Cat. <sup>n</sup> 1Yr Fxn*

Months Posttransplant

(b)

**IPTR/UNOS**

**PAK PTA SPK Px SPK Kd**

For other type 1 diabetic recipients, with (pre) end-stage renal failure, more than 55 years of age, with cardiovascular risk factors, they have 2 options: either receiving a kidney transplant alone (and eventually waiting for islet cells) or waiting for a simultaneous islet and kidney transplantation from the same cadaveric donor.

Kidney and Pancreas Transplantation: The History of Surgical Techniques and Immunosuppression http://dx.doi.org/10.5772/55347 269

\*By courtesy from A.E. Gruessner Department of Surgery, University of Arizona, Tucson, USA.

There were no differences in 3-year kidney pancreas or patient survival between the 0-3 and 4-6 HLA antigen mismatch (MM) groups. Significantly more patients with 0-3 MM (66 %) were rejection-free at 3 years compared to those with 4-6 MM (41 %; p = 0.003). The relative risk of acute rejection was 2.6 times higher among patients with 4-6 MM than among those with 0-3

In summary the Euro-SPK study findings provided evidence to support the use of Tac in

A second SPK study addressed the issue of the choice of the antiproliferative agent which could be associated to Tac, either MMF or rapamycine (Rapa). Preliminary one and three year results demonstrated more frequent study withdrawal in the Rapa group, due to toxicity [59].

More than 60 % of those patients were rejection free at 1 year. Adequate kidney and pancreas functions were also achieved in both groups while the serum creatinine level was significantly lower in the Rapa group from month 2, the price to pay being hyperlipidemia, delayed wound

Corticosteroid withdrawal was possible in both studies in 70 % and 50 % of recipients respectively. Therefore, it can be concluded that steroid withdrawal is feasible in SPK trans‐ plantation but not in all patients; further studies must be designed to address that issue

The current gold standard IS therapy for all three categories of pancreas transplantation includes induction with polyclonal antibodies and for the maintenance therapy, association of Tac with either MMF or Rapa, the last drug being less popular at least during the first

Based on that potent IS therapy, functional results and patient survival rates of PT are coming

SPK transplantation remains the best therapeutic approach for type 1 diabetic recipients with (pre) end-stage renal failure (creatinine clearance < 50ml/min), up to 55 years of age, without any cardiovascular risk. They have three options: either waiting for the 2 grafts coming from the same -cadaver or live- donor, or one graft –usually the kidney – coming from a live donor

PAK can be offered to diabetic recipients who had the opportunity of having a live donor for

For other type 1 diabetic recipients, with (pre) end-stage renal failure, more than 55 years of age, with cardiovascular risk factors, they have 2 options: either receiving a kidney transplant alone (and eventually waiting for islet cells) or waiting for a simultaneous islet and kidney

postoperative period due to its possible side-effects (Fig 19).

closer to those currently achieved in kidney transplantation (Fig 20).

who is in stand-by while waiting for the pancreas from a cadaver donor.

MM [48].

completely.

**4. Conclusion**

kidney transplantation.

transplantation from the same cadaveric donor.

patients undergoing SPK transplantation.

268 Current Issues and Future Direction in Kidney Transplantation

healing, lymphocoele or hernia.

**Figure 20.** International Pancreas Transplant Registry\* Panel (a): Patient survival in US primary pancreas transplants between 1/1/2007 and 12/31/2011. Panel (b): Pancreas graft function in all 3 categories (SPK, PAK, PTA). Panel (c): One year pancreas and kidney graft function in US primary pancreas transplants, between 10/1/1988 and 12/31/2011.

PTA should be considered for selected type 1 diabetic candidate without nephropathy, with hypoglycemia unawareness syndrom, with proliferative retinopathy. These candidates could be also candidates for islet transplantation, knowing the fact that they will be submitted to the same IS therapy and its long term deleterious side-effects in both options, they might also know that, with islet insulin independence is not always achieved.
