Transplantation
Copyright © 1997 American Diabetes Association 



Diabetes sometimes damages kidneys so badly that they no longer work. When 
kidneys fail, the person needs a way to replace their function, cleaning the 
blood. The options are dialysis and kidney transplantation. 
In dialysis, a solution placed in the abdomen or a machine connected to the 
bloodstream cleans the blood. In a kidney transplant, a new kidney replaces the 
damaged ones. 
Sometimes a person receiving a kidney transplant also gets a new pancreas at the 
same time. If the transplanted pancreas "takes," the person's diabetes is cured. 
In the future, instead of transplanting entire pancreases, doctors may 
transplant the islets, the cells that make insuli n. 



Diabetic Kidney Disease
Nephropathy, diabetic kidney disease, strikes a third or more of people who have 
had type 1 diabetes for at least 20 years. Perhaps 10 percent of people with 
type 2 diabetes also get nephropathy. 
The kidneys are vital organs that clean wastes from the blood. When nephropathy 
develops, the kidneys lose their ability to remove these waste products from the 
body. 
The first signs of nephropathy are small amounts of protein in the urine and 
elevated levels of creatinine (a waste product) in the blood. There are no 
symptoms at this stage. When the kidneys lose too much function, the condition 
is called end-stage renal disease. At this point, the person does not feel well, 
and treatment is required to replace kidney function. 



Kidney Transplantation
One option for the person with end-stage renal disease is a new kidney. 
Transplants are most successful when the kidney comes from a living relative. 
Another option is a cadaver kidney (a kidney from an unrealated person who has 
just died). 
One year after getting a kidney from a living relative, about 9 in 10 people 
with diabetes are still alive. After 5 years, the number is 8 in 10. For people 
who get cadaver kidneys, about 8 in 10 are still alive after 1 year and 6 in 10 
after 5 years. 
These numbers may sound scary, but people who have kidney failure are certain to 
die without treatment. For those who choose dialysis, only about one-third are 
still alive 5 years later. So although kidney transplantation is a serious 
operation, it offers people with end-stage kidney disease their best chance for 
survival. 
The body has a complex system for telling its own parts from foreign parts. To 
fool the body into accepting the donor organ, doctors try to match donor and 
recipient for a blood protein called human leukocyte antigen (HLA) type. 
A good match is most important when using a kidney from a living donor. The 
evidence for the value of HLA matching with cadaver kidneys is less clear. Some 
doctors believe that, at least in blacks, cadaver kidneys all "take" equally 
well. 
Unfortunately, there are too few kidneys for all the people who need them. Not 
enough people sign up to be organ donors. Of the 23,000 Americans who wait for a 
cadaver kidney each year, only 8,000 get one. 
The shortage persists even though each person gets only one kidney at a time. 
Although the body normally has two kidneys, it can get by with just one as long 
as that kidney is healthy and working up to par. 
Federal law says that kidneys should be given out in a fair and efficient way. 
In the current system, a national list contains the names and HLA types of 
people who need cadaver kidneys. 
When a kidney donor's kidneys become available, doctors check the list to see 
whose HLA types best match that of the donor. If there are several people who 
match equally well, the two people waiting longest get the kidneys. Some people 
must wait years before a kidney becomes available. Those waiting use dialysis in 
the meantime. 
Despite the best HLA matching, the body may still not recognize the new kidney 
as part of itself. For this reason, people with kidney transplants must take 
certain drugs the rest of their lives. These drugs are called 
immunosuppressants, because they suppress the immune system to keep it from 
fighting the new organ. 
These drugs include azathioprine and cyclosporin A. Despite these drugs, some 
kidney transplants fail. When the body attacks the new organ as foreign, it is 
called rejection. 
Immunosuppressant drugs pose dangers. Although suppressing the immune system 
keeps it from noticing the foreign organ, it also keeps the immune system from 
noticing infections. As a result, the person gets sick more easily. These drugs 
also have many side effects. 
A new kidney does not cure diabetes, and the disease may damage the new kidney 
just as it did the original ones. But it took many years for the person's own 
kidneys to fail. If the new kidney does develop diabetic nephropathy, it too 
will take many years to fail. 



Pancreas Transplantation
In people with type 1 diabetes, the islet cells in the pancreas no longer 
produce insulin. So it seems logical that giving new pancreases to people with 
type 1 diabetes would cure their disease. Usually it does. 
But the cure can be worse than the disease. The side effects of 
immunosuppressive drugs are usually worse than the problems caused by diabetes. 
And the operation is serious. One to two people in 10 die within a year of 
getting a pancreas transplant. 
Sometimes a person has such serious complications from diabetes that taking 
these drugs is no worse. People with kidney transplants have to use these drugs 
anyway. For these people, pancreas transplants can be worthwhile. 
A person can receive either half a pancreas from a relative or an entire cadaver 
pancreas. There are not enough cadaver pancreases to go around. Not enough 
people sign up to be organ donors, and the pancreases must meet strict 
guidelines. Success seems higher when patients and donors are matched for HLA 
types. 
When the transplant takes, the person no longer has diabetes and is unlikely to 
get it again. Insulin shots and frequent blood glucose testing are no longer 
necessary. Restoring normal blood glucose levels may stop complications from 
worsening, although many more studies are needed. 
Pancreas transplants can be rejected, and roughly half of them are. However, a 
pancreas transplanted along with a kidney is less likely to fail than a pancreas 
transplanted alone. 
Pancreases attached so that they drain into the bladder are rejected less often 
than pancreases attached in other body sites. When a transplant fails, the 
person gets diabetes again. 
Remember that pancreas transplants work only for people with type 1 diabetes. 
The major problem in people with type 2 diabetes isn't a failing pancreas, but 
the body's inability to respond to insulin the right way. 



Dangers and Risks
Kidney and pancreas transplants are safest in people who do not have heart or 
blood vessel disease. Before you get a transplant, your doctor will check your 
circulatory system to see if it is healthy enough to risk the operation. 
As with any operation, the healthier you are, the better you can withstand the 
physical stress of surgery. Possible side effects of surgery include bleeding 
and infection. 
Immunosuppressive drugs are hard on the body, but people who get transplants 
must take these drugs the rest of their lives. Azathioprine and cyclosporine, 
two commonly used drugs, make it easier for you to get infections. 
You will need to avoid people who have infections, such as a cold or the flu. 
Also, you should not be immunized without first checking with your doctor. Both 
drugs can damage the kidneys. They have other side effects as well. Using either 
of these medicines for many years could increase your risk for some cancers. 
Because of these risks, kidney transplants are done only in people whose kidneys 
are failing. Pancreas transplants are done only in people with type 1 diabetes 
who are getting or already have a transplanted kidney, and with a few people 
whose diabetes is very serious. 



The Future Of Islet Transplantation
If scientists can develop safe immunosuppressants that always work, then many 
people with type 1 diabetes may choose to have pancreas transplants. 
But many doctors think islet transplants are a better option. Islets are 
clusters of cells in the pancreas that make insulin. In people with type 1 
diabetes, islets cells are destroyed. Only 1 to 2 percent of the pancreas is 
made up of islet cells. 
Transplanting islet cells has several advantages over transplanting a pancreas. 
First, unlike the pancreas transplant, it is a minor surgical procedure, is less 
expensive, and is probably safer. 
Second, scientists may learn to protect these cells from attack by the immune 
system. Several methods are already under study. If any work, the person with an 
islet transplant would not need to take immunosuppressants. Surgery would then 
be practical for many people with type 1 diabetes. 
Third, it may be possible to transplant animal islets. If so, then people who 
need islet transplants would not need to wait for cadaver donors. 
Islet transplants are still experimental. Doctors do not yet know how many 
islets it takes for the transplant to work. Researchers are still working on 
ways to protect islets from the immune system. Some doctors place the islets in 
a vein in the liver, while others place the islets in the kidney or the spleen. 
More studies are needed to decide which location is best. 



 
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