La transplantation combinée rein-pancréas : quel prix, quels bénéfices, quels bénéficiaires ?

As the requirement for immunosuppressive therapy after pancreas transplantation for insulin-dependant diabetes, which has compromised its use in non-uremic patient, cannot be avoided in uremic patients undergoing kidney transplantation, the benefits of combined kidney-pancreas transplantation might be sufficient to counterbalance the risks of the procedure. The International Pancreas Transplant Registry has collected data on over 7000 combined transplantations, allowing evaluation of the risks involved, assessment of patient benefit and identification of indications. Compared with renal graft alone, survival after combined transplantation is equivalent in patients under 45 years of age, but decreases in older patients and those with a history of heart failure. Actuarial survival of the pancreas graft, defined as absence of insulinotherapy, is currently 78% at 1 year and 65% at 5 years. Although combined transplantation may not reach early expectations regarding its affect on the progression of diasets complications patients quality of life is greatly improved after successful grafting as the daily constraints of regular meals, insulin injections and glycemia controls disappear at the same time as the burden of dialysis treatment Combining a pancreas graft with a kidney graft inevitably increases morbidity during the postoperative months, but experience has shown that many young patients are very willing to pay the price in order to benefit from a combined graft. We currently propose combined transplantation in patients under 45 who are free of severe cardiovascular disease and accept to reconsider candidates after myo cardial revascularization. The recent introduction of new immunosuppressive drugs such as tacrolimus and myco-phenolate offer hope for further improvement in success rates. Despite currently disappointing clinical results, pancreatic islet-cell transplantation provides exci-tivy perspectives.