Introduction: As islet transplantation (tx) remains an experimental and uninsured procedure, there are no established protocols to achieve insulin independence following failure of the islet transplant. The options are further limited by potential sensititization following exposure to multiple HLA antigens during islet infusions. We reviewed the long term success of solitary pancreas tx after failed islet tx.

Methods: Between 2006 and 2011, 6 PAI were performed in preuremic Type I diabetic recipients with prior history of hypoglycemic unawareness. Pancreas tx were performed with portal and enteric drainage. Immunosuppression included: thymoglobulin induction (6 mg/kg), maintenance with low dose tacrolimus (trough 5-7 ng/ml), MMF 1 gm/d, low-dose sirolimus (trough 5-7 ng/ml), and prednisone 5 mg/d. Protocol pancreas biopsies were performed between 3-4 months, or for clinical indication.

Results: All six recipients achieved insulin independence which was maintained in 100% of PAI at mean follow-up of approximately 5 years (69.3 months). Hgb AIC levels remained normalized (Table 1). Rejection episodes occured in 3/6 (50%) of the recipients.

Conclusions: Rigorous immunosuppression and close monitoring with protocol biopsies resulted in excellent outcomes in this new category of PAI. Insulin independence and normalized Hbg A1C was achieved in all recipients regardless of pre-tx sensitization. Minimization of calcineurin inhibitors prevented deterioration of native renal function. PAI provides a succesfful strategy for achieving insulin independence in preuremic Type I diabetic patients with prior hypoglycemic unawareness and failed islet allografts.

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